Ashley Smith:BPD in our Community

Ronald Fraser, MD, CSPQ, FRCPCAssistant Professor

Department of PsychiatryMcGill University

Dalhousie University

Disclosure

Disclosure

Ashley Smith

History• Ashley Smith born

January 29, 1989 in NB, adopted at age 5 days

• Reportedly uneventful childhood

• Age 13-14: distinct behavioral change

• By age 15: 14 appearances before juvenile court for petty crimes

• Multiple suspensions from school

History

• Initial assessment in March 2002 – no evidence of mental illness

• Second assessment in March 2003:– ADHD– Learning Disability– Borderline Personality Disorder with Narcissistic

traits

History

• 2003-2006 – remanded numerous times to NB Youth Center– Initial charge at age 14 for throwing crab apples– Assaulting guards, pranks like setting off sprinklers

and fire alarms – 50 additional charges• > 800 incidents and minimum of 150 attempts

to self-harm– Self-strangulation and self-mutilation

History

• February 23, 2005 – enters system for the final time at age 17

• January 2006, she turned 18• October 2006 – transferred to adult

correctional system

History

• October 5, 2006 – SJRCC – mostly in segregation due to out of control behavior– Tasered twice, pepper sprayed once

• October 26, 2006 – transferred to federal system and Nova Institute

• Over the next 11 months she was transferred 17 times amongst 8 federal institutions

Ashley Smith at Age 19

History

• October 16, 2007 –she requested transfer to a psychiatric facility

• October 18, 2007 – placed on suicide watch• October 19, 2007 – died in custody

• 2011 Inquest• 2012 Inquest– Homicide but no liability

What is Borderline Personality Disorder?

Symptoms of BPD• Erratic mood swings; intense anger

– Living without an “emotional skin”

• Chaotic relationships; interpersonal problems • Self-mutilation & suicide• Substances, gambling, reckless driving, sex• Distortions in thinking; transient paranoia

Etiology• Bio-psycho-social vulnerability factors– Biological – Psychosocial

• Diagnosed in adolescence, early adulthood• 75% in treatment for BPD are women

Prognosis• The bad news: – Can be among the most difficult disorders to

treat because common sense approaches can backfire

• The good news: – Individuals with BPD get better when treated

with evidence-base therapies and interventions– True in clinical contexts and in the community

Community prevalence• 10-13% prevalence of personality disorders• 2% BPD (American Psychiatric Association, 2000)

• In Quebec, estimation of 84,000 citizens

In mental health services• 10-15% in emergency • 40% in inpatient services • Increased drugs & alcohol abuse• Self-mutilation – 24,437 seen in Ontario emergencies (Stats Canada, 2009)

• Suicides involving a diagnosis of BPD – 25% of adult suicides – 33% of youth suicides

Psychosocial services• Youth protection services

– 50% of mothers with BPD traits (Perepletchikova et al., 2010)

• 360 mothers in Centre jeunesse de Montreal only

– Many adolescents followed by protective services

Judicial system• 2.2 million youths arrested in 2003• 60% in court procedure have mental illness– the majority, personality disorders

• 70-85% of crimes involve a personality disorder diagnosis• Familicide in Quebec 1986-2000 (Léveillé et al., 2007)

– 37.5% BPD traits– 18.8% had BPD

Other family

Parents

84,000 Québecois with BPD

ConjointConjoint

Conjoint

Siblings

Children

Patient

FriendsCo-workers

Mental Health Professionals

EmergencyStaff

GeneralPractitioners

ChildPsychiatrists

Teachers

YPSworkers

Judges

JudgesPolice

Lawyers

Tel jeuneinterveners

Women’sShelterworkers

SOS suicideintervenersCommunity

workers

Unionreps

and millions affected

Why is BPD so costly?

BPD costs economy millionsThe personal costs of BPD have a domino

effect

How?

Familial Costs

• Divorce• Child custody cases• Domestic abuse, child abuse/neglect• Childhood psychiatric problems

BPD costs economy millionsHow?

Medical &

Psychiatric Costs

• Emergency visits• Inpatient care, hospitalizations• Increased use of addiction services• Premature death• Misdiagnosis

34% wrong diagnosis, 74% never diagnosed

• Medication 67% on medications, 33% more than 1

*** None have demonstrated clear benefit ***

BPD costs economy millions

How?

Legal &

PsychosocialCosts

• Crime• Police involvement (domestic disputes)• Court procedures• Prison services • Judicial recidivism• Malpractice suits

BPD costs economy millions

How?

Lost Productivity Costs

• Unemployment• Underemployment• Absenteeism• Leave of absence • Dependency on public support

BPD costs economy millions“The social costs and disruptions caused by PDs is disproportionate to the amount of attention this disorder gets in public consciousness, in government research and clinical funding, in medical and graduate school, and in psychiatric residency training”

Frances, Paris, & Reugg, 2006

Case vignette

Case vignette: Chantal

1999 (26 years old) • Begins heavy resource use• Numerous ER visits• Multiple hospitalizations• Numerous psychotherapies• Poly medications

1995 - 2005

Medications• Risperidal, Zyprexa, Seroquel, Largactil, Haldol, Nozinan

• Remeron, Effexor, Parnate, Nardil, Prozac, Paxil, Celexa, Wellbutrin, Serzone, Nortriptyline, Imipramine

• Lithium, Epival, Tegretol, Topamax, Neurontin, Lamictal

• Ritalin, Ativan, Rivotril, Valium

Case vignette: 1995 - 2005

Case vignette: Chantal1995 - 2005

• Treatments– ECT– Weekly individual psychotherapy – Twice weekly group psychotherapy – Extremely close psychiatric follow-up

Case vignette: Chantal2005-2008• Entered specialized BPD program– Weekly individual and group therapy

• Psychiatric follow-up each 2-4 weeks • 3 medications – Clozapine, Mipramine, Seroquel

Case vignette: Chantal

Cost2002 – 2005

$272,0002006 – 2008$0

Case vignette: Chantal

Cost2002 – 2005

$17,0002006 – 2008$0

Case vignette: ChantalSince discharge in August 2008• No psychotherapy• Psychiatric follow-up each 4-8 weeks

Allan Memorial Institute

MUHC patients with BPD

2004 2008

Cost related to emergency room visits $96,500 $12,000

Number of patients hospitalized 34 5

Cost related to days of hospitalization $432,000 $69,000

Before and after specialized program

What is the solution?

What is needed?• Knowledge • Skills • Teaching and Training• Research

Or, a website that provides a doorway to all of the above

Who can benefit?• Health providers and clinicians• Students

– 30% of continuing medical education via Internet (2008)

– Effective

– Cost efficient

– Evidence-based medical decision making

– Formal E-learning virtually nil in BPD

– Language issue

Who can benefit?• Police, legal practitioners

• Youth Protection Services interveners• Community workers• Schools• Unions• Government agencies and others

How can it benefit?• Change perceptions of BPD• Training to deliver superior services• Help all those that interface with BPD• Help streamline service delivery systems• Increase knowledge at all levels• Save money

Return on investment• A web site is cost-effective• Implication for the plan d’action• National & international potential• Quebec as innovative leader

Why are we the best• Clinical expertise– experience– outcomes– excellence

• Teaching excellence• McGill: a leader in RUIS standards of care• McGill’s international reputation• McGill has done this before

Thank You