Evidence-based psychological interventions for borderline personality disorder in the United Kingdom. Who falls through the gaps?

Over the past fifteenyears, access to evidence-based psychological interventions (EBPIs) for borderline personality disorder has dramatically increasedin the United Kingdom. However, some patients continue to fall through the gaps. This paper presents a novel analysis of evidence on patients who are currently unable to benefit from EBPIs and explores possible solutions, with particular reference to dialectical behaviour therapy and mentalization based therapy.At one end of the spectrum, patients with less severe difficulties often do not meet the threshold for receiving EBPIs in dedicated personality disorder services. The nascent evidence base for a possible solution —implementation of streamlined versions of EBPIs in generic mental health or even primary care services —is reviewed. At the other end, asizeable minority of patients receiving long-term EBPIs discontinue treatment prematurely and/or experience poor outcomes. This is a highly distressing experience with potential for iatrogenesis—yet the evidence base for what to do next is non-existent and follow-on treatment pathways in services are unclear. Difficulties in the therapeutic alliance, a failure to overcome epistemic hypervigilance, and therapist non-adherence to the model are reviewed as possible contributing factors. The importance of understanding the patient perspective on what happened, considering the role of both patient and therapist in contributing to difficulties, and offering patients a choice in specifying their onward treatment, is discussed. Finally, increasing access to trauma-focussed EBPIs for post-traumatic stress disorderis recommended as an avenue for the future

Conclusions and questions from a non-randomised comparison of routine clinical services implementing different treatment models for borderline personality disorder

Our study (Barnicot & Crawford 2018) was a non-randomised comparison of outcomes in routine clinical services implementing different treatment models for borderline personality disorder (BPD): mentalization-based therapy (MBT) and dialectical behaviour therapy (DBT). Our study’s contribution lies primarily in its novelty as currently the only head-to-head comparison of these treatment models, and its potential to generate exploratory findings for further testing in a definitive randomised controlled trial. We thank Luyten and colleagues for their useful commentary

Dialectical behaviour therapy v. mentalisation-based therapy for borderline personality disorder

Background: Dialectical behaviour therapy (DBT) and mentalisation-based therapy (MBT) are both widely used evidence-based treatments for borderline personality disorder (BPD), yet a head-to-head comparison of outcomes has never been conducted. The present study therefore aimed to compare the clinical outcomes of DBT v. MBT in patients with BPD. Methods: A non-randomised comparison of clinical outcomes in N = 90 patients with BPD receiving either DBT or MBT over a 12-month period. Results: After adjusting for potentially confounding differences between participants, participants receiving DBT reported a significantly steeper decline over time in incidents of self-harm (adjusted IRR = 0.93, 95% CI 0.87–0.99, p = 0.02) and in emotional dysregulation (adjusted β = −1.94, 95% CI −3.37 to −0.51, p < 0.01) than participants receiving MBT. Differences in treatment dropout and use of crisis services were no longer significant after adjusting for confounding, and there were no significant differences in BPD symptoms or interpersonal problems. Conclusions: Within this sample of people using specialist personality disorder treatment services, reductions in self-harm and improvements in emotional regulation at 12 months were greater amongst those receiving DBT than amongst those receiving MBT. Experimental studies assessing outcomes beyond 12 months are needed to examine whether these findings represent differences in the clinical effectiveness of these therapies

Loss of relational continuity of care in schizophrenia: associations with patient satisfaction and quality of care

BACKGROUND: Users of mental health service are concerned about changes in clinicians providing their care, but little is known about their impact. AIMS: To examine associations between changes in staff, and patient satisfaction and quality of care. METHOD: A national cross-sectional survey of 3379 people aged 18 or over treated in secondary care for schizophrenia or schizoaffective disorder. RESULTS: Nearly 41.9% reported at least one change in their key worker during the previous 12 months and 10.5% reported multiple changes. Those reporting multiple changes were less satisfied with their treatment and less likely to report having a care plan, knowing how to obtain help when in a crisis or to have had recommended physical health assessments. CONCLUSIONS: Frequent changes in staff providing care for people with psychosis are associated with poorer quality of care. Greater efforts need to be made to protect relational continuity of care for such patients. DECLARATION OF INTEREST: M.J.C. was co-chair of the expert advisory group on the NICE quality standard on Service User Experience in Adult Mental Health. S.J.C. has previously been a member of the Health and Social Care Board Northern Ireland Formulary Committee. D.S. received a speaker's fee from Janssen Cilag in 2011. He is a topic expert on NICE guideline for psychosis and schizophrenia in children and young people and a board member of National Collaborating Centre for Mental Health. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license

Psychological interventions for acute psychiatric inpatients with schizophrenia-spectrum disorders: A systematic review and meta-analysis

BACKGROUND: Acute inpatient psychiatric wards are important yet challenging environments in which to implement psychological interventions for people with schizophrenia-spectrum disorders. No meta-analysis to date has evaluated whether psychological interventions are effective in this context. METHODS: We systematically searched Embase, Medline and PsycInfo databases for randomised controlled trials (RCTs) of psychological interventions implemented in acute inpatient psychiatric settings with individuals with schizophrenia-spectrum disorders. We conducted random effects meta-analyses of between-groups outcomes at post-intervention and relapse/re-hospitalisation rates by follow-up. RESULTS: Twenty-nine trials were suitable for meta-analysis. Psychological interventions improved post-intervention positive symptoms, social functioning and treatment compliance and reduced the risk of relapse/ re-hospitalisation, relative to control conditions. Analyses of specific intervention effects found positive effects of psychoeducation on several key outcomes (power > 80%) and preliminary evidence for positive effects of acceptance and commitment therapy (ACT), cognitive behaviour therapy (CBT) and metacognitive training (MCT) on some outcomes (power < 80%). CONCLUSION: Psychological interventions can be helpful for acute inpatients with schizophrenia-spectrum disorders. However, risk of bias was often high or unclear, and some analyses were underpowered. Further research should use more rigorous RCT designs and publish meta-analysable data on positive symptoms, general psychopathology, relapse/ re-hospitalisation, social functioning and treatment compliance

Factors influencing use of community treatment orders and quality of care that people receive: results of a national survey in England and Wales.

Aims and method: We conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive. RESULTS: Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive-behavioural therapy.Clinical implicationsCTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care. Declaration of interest: None

Exploring the prevalence of personality disorder and the feasibility of using the SAPAS as a screening tool for personality disorder in an emergency department in India

BACKGROUND: Personality disorders (PD) lead to frequent emergency department (ED) visits. Existing studies have evaluated high-risk ED populations in Western settings. PD screening tools, such as the Standardized Assessment of Personality - Abbreviated Scale (SAPAS), have thus far only been validated in Western populations. AIMS: This study aimed to establish the screened prevalence of PD, and to evaluate the performance of the SAPAS as a screening tool within an ED setting in India. METHODS: The study took place in the ED of a private multi-speciality hospital in Kolkata, India. All attendees were approached during two days per week over three months, except those who were medically unfit to participate. The SAPAS and the International Personality Disorder Examination (IPDE) were translated into Bengali and then used as screening tools for PD and as the reference standard for PD diagnosis. RESULTS: Out of 120 ED attendees approached, 97 participated (48 men and 49 women), of whom 24% met the criteria for a diagnosis of PD. A cut-off score of 4 on the SAPAS provided the best trade-off between sensitivity and specificity for detecting PD. CONCLUSION: The prevalence of PD was similar to Western samples, and the SAPAS showed promise for use in a non-Western setting

A Systematic Review of Training Interventions for Emergency Department Providers and Psychosocial Interventions delivered by Emergency Department Providers for Patients who self-harm

Objectives People who self-harm frequently present to the emergency department (ED) and are treated by generalist healthcare staff with no specialist mental health training. We systematically reviewed (i) training interventions for generalist ED providers and (ii) psychosocial interventions delivered predominantly by generalist ED providers for people who self-harm. Method Five databases were searched for studies reporting on training interventions for generalist ED staff (at least 50% of the sample needed to be generalist ED staff) or psychosocial interventions for people who self-harm delivered predominantly by generalist ED staff. No limitations were placed regarding study design/country. Narrative synthesis was conducted. Results Fifteen studies from high-income countries were included. Nine studies of moderate methodological quality evaluated training for generalist ED providers (n = 1587). Six studies of good methodological quality evaluated psychosocial interventions for adults who self-harm (n = 3133). Only one randomized controlled trial was identified. Training was linked with pre-post improvements in staff knowledge, and less consistently with improvement in skills, attitudes, and confidence. Evidence on patient outcomes was lacking. Patient-level interventions involving common suicide prevention strategies—safety planning and follow-up contact—were consistently linked to pre-post reductions in suicide attempts. Effects on treatment engagement and psychiatric admissions were unclear. Conclusions There is a clear need for further RCTs to improve the evidence base for ED generalist providers managing patients with self-harm. Evidence supports potential benefits of training for improving staff knowledge, attitudes, and skills, and of safety planning and follow-up contact for reducing repeat suicide attempts. • More RCTs are needed to improve the evidence base for ED providers managing self-harm • Safety planning and follow up contacts are linked to reductions in repeat suicide attempts • Future research should investigate the impact of staff training on patient outcome

Overcoming Barriers to Skills Training in Borderline Personality Disorder: A Qualitative Interview Study

Despite evidence suggesting that skills training is an important mechanism of change in dialectical behaviour therapy, little research exploring facilitators and barriers to this process has been conducted. The study aimed to explore clients’ experiences of barriers to dialectical behaviour therapy skills training and how they felt they overcame these barriers, and to compare experiences between treatment completers and dropouts. In-depth qualitative interviews were conducted with 40 clients with borderline personality disorder who had attended a dialectical behaviour therapy programme. A thematic analysis of participants’ reported experiences found that key barriers to learning the skills were anxiety during the skills groups and difficulty understanding the material. Key barriers to using the skills were overwhelming emotions which left participants feeling unable or unwilling to use them. Key ways in which participants reported overcoming barriers to skills training were by sustaining their commitment to attending therapy and practising the skills, personalising the way they used them, and practising them so often that they became an integral part of their behavioural repertoire. Participants also highlighted a number of key ways in which they were supported with their skills training by other skills group members, the group therapists, their individual therapist, friends and family. Treatment dropouts were more likely than completers to describe anxiety during the skills groups as a barrier to learning, and were less likely to report overcoming barriers to skills training via the key processes outlined above. The findings of this qualitative study require replication, but could be used to generate hypotheses for testing in further research on barriers to skills training, how these relate to dropout, and how they can be overcome. The paper outlines several such suggestions for further research