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