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 ( )
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Oft-quoted (but unpublished) study by Linehan does not suppport utility of skills training alone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)
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) 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 Disorders 20 (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 Psychiatry 48 (1991), pp. 1060–1064