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)

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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

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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

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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

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Emergency Department presentations significantly reduced

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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

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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.

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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

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Mental Health Staff Resources: Pyramid of care

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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

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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

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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