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

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

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

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

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

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

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

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

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

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

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

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

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 Oft-quoted (but unpublished) study by Linehan does not suppport utility of skills training alone Some emerging evidence for DBT-ST (Soler, 2009) Single centre, randomised, two-group trial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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you Questions or comments?

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 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