Post on 22-May-2020
Step-down Integrative Relational Models in Mental Health Services
Brin Grenyer grenyer@uow.edu.au
Project Air Advisory Committee
Expert Project Consultants
Project Governance
NSW Health Priority
1. Improve the capacity of mainstream mental health services to manage and treat personality disorders
2. Expand specialist treatment options including improved referral pathways between generic and specialist treatment
3. Deliver well constructed and supported education
4. Evaluate expert intervention models to provide guidance for future service development
The broader context…
• Relational model : • Relationships to focus on:
– between person and themselves** – between person and therapist** – between person and carers – between person and health service – between person and workplace – between person and wider social environment
**All therapy models
What do Health Services need to plan better personality disorder services?
Step down models and the Project Air Strategy implementation
20 years of research progress…
25 RCTs DBT Dialectical Behaviour Therapy
CBT plus treatment as usual
SFT Schema-Focused Therapy
TFP Transference-Focused Psychotherapy
MBT Mentalisation Based Therapy
TEC Therapy by experts in the community
GPM General Psychiatric Management
CAT Cognitive Analytic Therapy
Psychological Treatment works Most treatments are one to three years in duration but we don’t know what is optimal Treatments require specific training and supervision
APA American Psychiatric Association Guidelines 2001
UK National Centre for
Clinical Excellence
2009#
11
NHMRC Clinical Practice
Guideline – Released 15 March 2013
NHMRC Guideline in numbers • 63 Recommendations • 166 pages • 278 scientific references • 11 Members of multidisciplinary guideline
development committee • 1 Methodologist – ADAPTE and AGREE
methods (NICE+updated meta-analyses+NHMRC grading criteria)
• 49 submissions to public consultation 2012 • 3 independent clinicians reviewed • 8 key recommendations
8 Key Recommendations 1. BPD is legitimate diagnosis for healthcare services 2. Structured psychological therapies should be provided 3. Medicines should not be used as primary therapy 4. Treatment should occur mostly in the community 5. Adolescents should get structured psychological
therapies 6. Consumers should be offered a choice of psychological
therapies 7. Families and carers should be offered support 8. Young people with emerging symptoms should be
assessed for possible BPD
Can guidelines be adapted as a clinical approach to treatment?
General Psychiatric Management
• Professor John Gunderson, Harvard Professor of Psychiatry
• Chaired the DSM-IV Personality Disorders Workgroup
• Developed the diagnosis of BPD
• Gunderson & Links, A Clinical Guide (2008)
Guideline-based treatment
1. Once a week individual meetings
2. Focus on person's priorities (not specifically targeting self-harm and suicidal thinking)
3. Psychoeducation about problems
4. Here and now focus 5. Emotion focus 6. Relationship focus 7. Hospitalisation if helpful
Research not done by Linehan or Gunderson, but both support its validity and findings.
Common Factors
Weinberg I, Ronningstam E, Goldblatt MJ, Schechter M, Maltsberger JT. Curr Psychiatry Rep. 2011 Feb;13(1):60-8. Individual therapies for BPD all have: 1. focus on treatment relationship 2. active therapist 3. attention to affect 4. exploratory change-oriented interventions
Step-down models
Why do we need step-down approaches?
The Need …
• 6.5% of the population: 1.5 million Australians have a diagnosable personality disorder
• 1.1% of the population have schizophrenia (i.e. 285,000 people in Australia)
0
5
10
15
20
25
30
35
Who presents to Emergency and Hospital with mental health problems?
Source: all mental health ED presentations Nov 2008 - Nov 2012 Illawarra Shoalhaven LHD (N=1988) Personality disorders and related conditions = 26% of presentations
0
5
10
15
20
25
30
35 Emergency
Source: all mental health inpatient presentations Nov 2008 - Nov 2012 Illawarra Shoalhaven LHD (N=6338) Personality disorders and related conditions = 25% of presentations
Inpatient admission
The size of the need • Approximately 14,000 people living in the
Illawara region have a personality disorder • Illawarra LHD: of 6338 inpatients, 1,584 unique
people with a personality disorder presented over 4 years
• 396 per year (one gets hospitalised per day) • 3694 people were admitted to hospitals in NSW
for personality disorders • 450 unique people seen in MHS had a BPD
diagnosis in one year
How do you provide treatment for 365 ? • 1 client presents per day • DBT and other intensive programs • - 8 staff (2 programs) - 40 clients graduate (5
per staff) per year • Brief interventions • - 16 staff (3 programs, 2 places/week) 450
places available – uptake by 325 clients (20 per staff) per year
• - Acute care staff – emergency clinical review • Combining acute, short and longer term options
matched to the treatment readiness of the client
Mental Health Clinical Resources: Pyramid of care
!
What is a brief intervention?
• Offer an appointment within 1-3 days of first presentation, or re-presentation with immediate treatment needs, or hospital discharge
• Act as an intermediate point between acute settings and longer-term treatment programs
• Increase compliance with follow-up after discharge • Promote treatment engagement and retention in longer-
term treatment programs • Provide brief, time-limited interventions aimed at
psychological factors and lifestyle (both of which are found to contribute to self-harm).
Project Air Strategy Outcomes: Hospital use significantly reduced
Before Project Air: Average of 1.33 admissions to hospital & 9.30 days in hospital per person (Oct ’09 – Mar ‘11) After Project Air: Average of 0.36 admissions and 4.64 days per person (Apr ‘11 – Sept ‘12) Admissions – t(360) = 13.87, p = .000; Days = t(360) = 4.74, p = .000 Male = 49.6%, Female = 50.4%; Average age = 37.83 years (Range = 14 – 83). Data is Illawarra Shoalhaven LHD
0
100
200
300
400
500
600
Pre-‐Project Air Post-‐Project Air
Tota
l Num
ber o
f Hos
pita
l Adm
issi
ons
for 3
61 P
erso
ns
Tota
l Num
ber o
f Day
s Sp
ent i
n H
ospi
tal f
or 3
61 P
erso
ns
0 500 1000 1500 2000 2500 3000 3500 4000
Pre-‐Project Air Post-‐Project Air
Emergency Department presentations significantly reduced
0
20
40
60
80
100
120
140
Pre-‐Project Air Post-‐Project Air
Before Project Air: Average of 1.17 presentations to ED per person(Oct ’09 – Mar ‘11) After Project Air: Average of 0.31 presentations to ED per person (Apr ‘11 – Sept ‘12) t(99) = 8.39.87, p = .000 Data is Illawarra Shoalhaven LHD (excluding Nowra). Subset of N=361 inpatient sample.
Total Number of Emergency Department Presentations
for 100 Persons
People reduced their personality disorder symptoms & improved their quality of life over 12 months
t(45) = 6.81, p = .000
0
2
4
6
8
10
Pre Post
No. of B
PD sy
mptom
s
0 10 20 30 40 50 60 70
Pre Post
Qua
lity
of li
fe
Most clients at intake had at least 7 symptoms of borderline personality disorder, which had dropped to 4 after 12 months, as measured by clinical interview based on DSM-IV psychiatric criteria.
z(46) = -3.972, p = .000
Clients rating of quality of life increased significantly over 12 months, as did their satisfaction with their health, and ratings of overall health, as measured by the WHO-Quality of Life Scale.
People were much less depressed and less wanting to kill themself
t(43) = 4.34, p =.000 Most clients at intake had significant symptoms of depression (measured by the clinical cut-off on the mental health inventory SF-36), which had significantly reduced after 12 months.
0
20
40
60
80
100
Pre Post
% of p
a2en
ts
0
0.5
1
1.5
2
2.5
3
Pre Post
z(42) = -3.633, p = .000 Clients ratings of suicidal thoughts from the Beck suicide assessment significantly reduced after 12 months.
Depression Suicidal thoughts
People were more productive, with less days unable to work
The number of days that clients were totally unable to carry out their usual activities, or cut-back or reduced their usual activities, due to their health conditions decreased significantly, as measured by the WHO-Disability Assessment Scale. Disability days: t(40) = 2.867, p = .007 Cut-back days: t(37) = 2.323, p = .026
0
1
2
3
4
5
6
7
8
9
Pre Post
Num
ber o
f days
Disability Days
Cutback Days
Mental Health Staff Resources: Pyramid of care
!
Pyramid of training Level 3, 4 & 5 Workshops
Level Theme Content
Level 3 Assessment Pharmacotherapy
Assessment, measures and differential diagnosis; medication protocols and risk
Level 4 Treatment
Care planning, psychoed, psychological treatments, risk, young people, families and carers
Level 5
Psychotherapy Specific treatment skills, relationship management, challenges and supervision
Dr Louise McCutcheon Clinical Psychologist, Orygen Youth Health, Melbourne
Bernadette Jenner
Counselling Psychologist, Illawarra Health and Medical Research Institute
Associate Professor Andrew Chanen
Psychiatrist, Orygen Youth Health and Associate Professor, University of Melbourne
Professor Brin Grenyer Clinical Psychologist, Illawarra Health and Medical Research Institute.
Training Team
N=1764 staff trained
Shifting the skills and attitudes of staff
Z (49)= -3.18, p< 0.01, 12-month follow-up of 75 staff “… by having that specialist training and by having that support from the project … it’s given us the justification to work like this” – Mental Health Manager
2
2.1
2.2
2.3
2.4
2.5
2.6
Pre-‐training Post-‐training
Staff Confidence 2
2.1
2.2
2.3
2.4
2.5
2.6
Pre-‐training Post-‐training
Staff Skill
The benefit of working with families & carers… The group sessions have given me a language that I didn’t have before. I can now talk with my daughter about what she’s experiencing and with the professionals about what is best for her.
I have already put into practice things I’ve learned in the group … setting boundaries and self-care. I spoke about this with my daughter and she understood.
Attendees found useful:
• The interaction of the group
• Developing and putting into place a safety plan
• Not pushing in when the situation was not life threatening
• Hearing what others had to say about their experiences
Supporting families & carers to stay connected…
Carer workshops were all-day sessions with 15-30 participants
Willingness to remain a carer
Optimism for the person
with personality
disorder
Enthusiasm to care or
support the person with personality
disorder
Confidence in caring or
supporting the person with personality
disorder
0
10
20
30
40
50
60
70
80
90
100
Percen
tage
Satisfaction Helpfulness
Summary – step down care across a service
• Working with whole of service to enhance training, support and attitudes towards personality disorder clients
• Enhancing clinical pathways through reinforcing early brief psychological interventions as alternative to inpatient admission
• Strengthening longer-term treatment in the community by upgrading mental health caseworker skills
• Encouraging and protecting quality clinical practice e.g. DBT, MBT
• Working with services on complex case reviews of high risk clients who are intensive service users
• Providing family and carer workshops, brief sessions and group interventions
www.projectairstrategy.org ihmri.uow.edu.au/projectairstrategy