Transcript Haringey PD service
IAPT SMI Stakeholder Event: Haringey Personality Disorder Service
Barnet, Enfield and Haringey Mental Health NHS Trust Dr Tom Pennybacker
Halliwick Unit
Tottenham
Haringey
The Team
The Team
What do we do?
• Specialist assessment and treatment for people with personality disorder • Team based in local psychiatric services with clear referral pathways from primary and secondary care • Nurse-led liaison service • Introductory group (i-MBT) • Treatment program: Mentalisation Based Treatment (MBT) or Structured Clinical Management (SCM)
Guiding principles
Organisational support at all levels
• Explicit theoretical approach • Structured care and therapist supervision • Long-term psychological interventions (typically 18 months) • Treatment and service is data driven
How do we do it?
• Mentalisation is the capacity to understand oneself and others in terms of mental states • Sense of self, constructive social interaction, mutuality in relationships, sense of personal security • We are all vulnerable to collapses in our mentalising ability, people with personality disorder especially so • Aim of treatment is to increase the person ’ s capacity to recover and retain mentalising
Treatment vectors in re-establishing mentalizing in borderline personality disorder
Implicit Automatic Explicit Controlled Mental interior focused Cognitive agent:attitude propositions Imitative frontoparietal mirror neurone system Mental exterior focused Affective self:affect state propositions Belief-desire MPFC/ACC inhibitory system
Service Practicalities
• Standardised assessment (SCID) with identification of severity to determine treatment pathway: MBT or SCM • Introductory group (3 months) leading to structured treatment program with regular consultant-led CPA reviews • Active service user group combined with Patient Experience feedback and Quality Assurance system at Trust management level
Predictive Recovery by Axis II Pathology
Assessment Refer elsewhere Introductory Group (i-MBT) SCM If 2 or less Axis II diagnoses MBT If 2 or more Axis II diagnoses MBT+ Comorbid Drug use/Alcohol/ED
Data collection
• Focus of current developments in service • IAPT minimum data set • Patient Owned Database - POD • Historic and current data
Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months) N=62 2011-2012
MBT 120 100 80 60 40 20 0
.
Baseline Six Months Twelve Months Eighteen Months
Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months) N=74 2011-2012
SCM 120 100 80 60 40 20 0 Baseline Six Months Twelve Months Eighteen Months
Routine
data collection – why?
• It ’ s good!
• Patients in trials do better than patients with same treatment given in general services • Impact of individual therapists
Impact of individual therapists in routine practice
Okiishi et al. 2006 (J Clin Psychol 62:9, 1157) • 6,499 patients seen by 71 therapists • therapists had to see at least 15 clients (average 92) • Mean number of sessions: 8.7
• Equivalent clients in terms of disturbance & presentation • Recovery curves monitored
Clients of Some Therapists Improve Faster or Slower Than Others
Session number
Outcomes for Best and Worst Performing Therapists top 10% therapists bottom 10% therapists recovered 22.4% 10.6% improved 21.5% 17.4% deteriorated 5.2% 10.5%
Incidence of Harmful Effects • estimates are that 5-10% of therapy clients deteriorate • across all orientations, client groups, modalities • in RCTs of ‘ empirically supported treatments ’ • rates higher in active treatment than in control groups – NIMH reanalysis13/162 (8%) deteriorated, all in active treatments • therapists tend to be poor at: –
predicting
who will do badly –
recognising
failing therapies
MBT introductory group data
BDI
27 18 9 0 63 54 45 36 Beginning Middle
Time Point SCL-90
End 5 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 Beginning Middle
Time Point
End
Grouped data on POD
PHQ-9
27 24 21 18 15 12 9 6 3 0 1 2 3 4
Week
5
EuroQol VAS
6 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4
Week
5 6 7 7 8 Ряд1 15 10 5 0 40 35 30 25 20 40 35 30 25 20 15 10 5 0 1 1 2 2
WSAS
3 4
Week
5
MOAS
3
Week
4 6 5 7 6 8
27 24 21 18 15 12 9 6 3 0 1 100 90 80 70 60 50 40 30 20 10 0 1 2
Individual data on POD
PHQ-9 WSAS
40 35 30 25 20 15 10 5 0 1 2 3 4
Week
5
EuroQol VAS
6 7 8 2 3 4
Week
5
MOAS
15 10 5 0 40 35 30 25 20 3 4
Week
5 6 7 8 1 2 3
Week
6 7 8 4 5
Next Steps
• Comparative severity data • Site visits: starting 16 th April – BMJ Experience day – Future dates: 9 th May, 13 th June, 11 th July – Further dates will be arranged according to demand • Regional days with PD commissioning tool
PD Service Commissioning Tool
• Organisational requirements • commitment, management support • Service framework • clinical pathway, multiagency agreement • Treatment framework • defined programmes, coherence, structure • Quality monitoring • therapist competences, adherence, supervision, outcome monitoring
Regional meetings – for whom?
• Commissioners, managers, clinicians, service users • Local completion of commissioning tool • Identify and map organisational and service requirements • Links with local service user groups • Benchmarking local services • Define principles of clinical treatments for people with PD • Quality document • Introduce generic clinical skills for treatment of PD in mental health teams
The End
Thank You