Personality Disorder Services in NHS Highland: Challenges and Developments

1. Personality Disorder Services in NHS Highland: Challenges and Developments Dr Tim Agnew, Consultant Psychiatrist and Lead in NHS Highland Personality Disorder Service.

2. Overview • NHS Highland • Services available as of 2009 • Challenges • Recent developments • Future developments • Questions

3. NHS Highland • 41% of landmass of Scotland • 33,000km² • Only 6% of Scottish population (300 000) • Two thirds in very low population densities • Biggest centre of population Inverness (40 000) • Difficult terrain • Limited infrastructure

4. NHS Highland • 4 Community Health Partnerships (CHPs) • Services for North, Mid and South-East Highland CHPs • Argyll and Bute CHP has its own major process of service redesign ongoing including psychological therapy services

5. Situation in 2009 in 3 Northern CHPs • Specific services for Borderline PD • Generic services for all other PDs

6. Specific services for BPD • Structured admission program • Dialectical Behaviour Therapy (DBT) • CBT-BPD (Davidson)

7. Services for all PDs • Clinical psychology • Primary care • CMHTs • In-patient services • Liaison psychiatry

8. DBT service • DBT has been mainstay for BPD • First group of therapists trained in 2006 • Three groups trained to date (24 in total) • 18 therapists amounting to 2 WTE • Anyone meeting DSM IV criteria offered 1 year of DBT • Very intensive

9. DBT service • Problems with increasing waiting times • Limited capacity, large referral numbers • Situation unsustainable

10. DBT Service • BPD is a polymorphic disorder • 256 varieties • Severity was measured using number of DSM IV criteria • DBT is over-intensive intervention for some

11. DBT service • Evidence suggests DBT is best at reducing parasuicidal behaviour and hospital admissions • Stage 1 DBT – behavioural stabilisation • Decided to prioritise on basis of: • parasuicidal behaviour • psychiatric hospital admissions

12. DBT service • Allows quicker response for these individuals • What to offer everyone else? • Some patients seemed to prefer skills groups to individual work • Skills group work twice as efficient in terms of therapist time as individual work

13. What about a skills group standalone? • Oft-quoted (but unpublished) study by Linehan does not suppport utility of skills training alone • Some emerging evidence for DBT-ST (Soler, 2009) • Single centre, randomised, two-group trial • DBT-ST or “Standard Group Therapy” for 13 weeks • 63 patients • Seemed to have an impact on affective symptoms • No effect on parasuicidal behaviour

14. Other considerations • STEPPS (Systems Training for Emotional Predictability and Problem Solving) RCT • All DBT therapists already trained to deliver skills groups • Existing supervision system (DBT consult groups) • Theoretical coherence

15. Drawbacks • No really robust evidence for approach • No individual therapy • Formulation • Skills generalisation • Validation • Dialectics • Problem solving

16. No individual therapist • 4 individual sessions before group work • Crisis plan • Written formulation • Extra module (Foundation module) • Psycho-education • Validation, dialectics, problem solving • 3 final group sessions • Agenda set by group

17. No RCT evidence • Service-based evidence • Same regular assessment/ outcome tools as full DBT • Pilot only • Re-evaluate after one run-through

18. Skills Training Program (STP) • Starts next week • 33 week run (plus 4 weeks individual work) • Closed group of 8 patients • 2 skills trainers • Good feedback for individual sessions

19. Personality Disorder Service • Name change from DBT service • PDS offers: • DBT • STP • CBT-BPD • Still only for people with BPD as primary presentation • Allows flexibility to develop further

20. Life after DBT • Some feedback from individuals that there is a service gap after completion of DBT • What is available after finishing DBT? • User-led “graduate” group not active • Possible DBT skills informed “graduate” group, CPN input • Some people wish to move away from this type of service after completing DBT

21. Other perspectives • Recent visit by Tom Mullen • Multidisciplinary and service user attendance • Stakeholders meeting planned • OTs keen to adapt Journey program locally • Multidisciplinary visit to Leeds being planned • Volunteering Highland

22. Future • PDS to expand educational role to CMHTs, primary care and in-patient wards • PDS to offer consultation service to CMHTs, in-patient wards • Expand CBT-PD provision within PDS • Specific provision in the localities • Training in other approaches

23. Don’t forget • Administration • Overhaul of referral process • Overhaul assessment process • Revised prioritisation • Standardised admin guidance • New computerised database

24. Main challenges • Too much geography • Not enough therapists with not enough time • Increasing referrals

25. Main developments • Revision of prioritising factors • Skills Training Program • Database and admin overhaul

26. Thank you • Questions or comments?

27. Reference • Soler J. et al, Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial. Behaviour Research and Therapy 47 (2009) 353-358 • Blum et al., Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Outpatients With Borderline Personality Disorder A Randomized Controlled Trial and 1-Year Follow-Up. American Journal of Psychiatry 165 (4) 468 -- Am J Psychiatry • K. Davidson, J. Norrie, P. Tyrer, A. Gumley, P. Tata and H. Murray et al., The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial, Journal of Personality Disorders20 (2006), pp. 450–465. • M.M. Linehan, H.E. Amstrong, A. Suarez, D. Allmon and H.L. Heard, Cognitive-behavioral treatment of chronically parasuicidal borderline patients, Archives of General Psychiatry48 (1991), pp. 1060–1064