Developing secure personality disorder pathways

Dr Dan BealesConsultant Psychiatrist in Forensic Psychotherapy

Assertive Case Management TeamThe Pathfinder Service

Avon and Wiltshire Mental Health Partnership NHS Trust

Assertive Case Management: a way of managing the risk of personality disorder

acting as a diagnosis ofexclusion?

Pathfinder

Tier 4 Forensic Personality Disorder Service, based in Bristol, covering the South West:assessment, consultation and liaison with community mental health teamstreatment programmeOPD probation partnerships: Bristol, Bath, Glos, Somerset, WiltsNational NPS MBT ASPD PilotIRiS: Bristol high risk offender partnership with police and probationPathfinder Nexus - HMP Eastwood Park

Assertive Case Management Team Consultant Psychiatrist in Forensic

Psychotherapy Clinical Psychologist

Ceri Jones Community Forensic Nurse

Jeff Roche Assistant Psychologist

Lauren Stead

Assertive Case Management Team

gate keeping low and medium secure specialist personality disorder placements

liaison with prison and probations services to support OPD and alternatives to admission to hospital

case managing and supporting patient pathways

What would a good pathway look like?

Sample

4 NHS services– 2 Local

Fromeside: 90 bed medium secure unit Wickham Unit: 29 bed low secure unit

– 2 National Broadmoor: male high secure Rampton: female high secure

13 different out of area placements

Locations

Caseload

 Level of Security 

 Male

N=16 (%) 

 Female

N=15 (%)

 % Total Sample

N=31

 Low

 

 4 (25)

 6 (40)

 32

 Medium

 

 5 (31)

 8 (53)

 42

 High

 

 7 (44)

 1 (7)

 26

Co-morbid diagnoses

 

N = 31

 

MaleN=16 (%)

 

 

FemaleN=15(%)

 

% Total Sample

 Psychotic illness 

  6 (38)

  6 (40)

 38

 Mood disorder 

 0

  5 (33)

 16

 Other* 

  5 (31)

  5 (33)

 32

* includes PTSD, mental and behavioural disorder resulting from drug use, ASD, anorexia nervosa and ADHD

Use of medication

 Medication

 Male

 Female

 % Total

 

 Any medication

 

 12

 

 11 

71 

 Anti-psychotic

 8 

8 

52 

 Benzodiazepines

 4 

2 

19 

 Mood stabiliser

 2 

0 

6 

 Anti-depressant

 3 

4 

23 

Polypharmacy

  

 Male

 

 Female

 

 Total

 

 Anti-psychotic polypharmacy

 3  

2  

5  

 Any polypharmacy

 

 7

 

 6

 

 13

 

 % total sample

any polypharmacy (N=31)

 

  

  

  

42%

Clozapine

   

Male 

 

Female

 

Gender 

 

4 

 

4 

 

PD only 

 

3

 

2

 

PD + co-morbid disorder 

 

1

 

2

% total sample (N=31) on clozapine = 26%

What would a good pathway look like?

NHS England(2015)

Effective secure mental health services will ensure:

placement in the lowest level of security appropriate for the shortest appropriate period of time necessary to improve

mental health and reduce risk to the levels needed for discharge with only appropriate transitions between admission and

discharge to the community as close to home as possible

engagement of their local community mental health teams services provision of the most appropriate and evidence based

treatment interventions

A diagnosis of exclusion?

Research and clinical guidanceProfessional confusion and ambivalenceCommissioning

Diagnosis and Classification

Comorbidity as an artefact of categorical diagnoses.

Jaspers(1923)

Wing (2011)

When nature draws a line it immediately smudges it.

Role of psychiatrists

Interaction with categorical approaches:

Prototypical diagnosis: “a PD”> binary thinking

Livesley(2011)

Pathoplastic interactions

Comorbidity Mental illness <> personality disorder

Role of substance misuse “Drug induced psychosis” (Maden, 2007)

Pathoplastic interactions?

Atypical mental illness? intrusive thoughts “pseudohallucinations”

what does transient mean?

lack of negative symptoms clozapine?

Medication

Role of trials of medication Role of medication free trials Role of clozapine Research POMH

rationale review physical health

Commissioning

Challenging small numbers – high cost distributed geographically variable access to local services research and professional uncertainty

...parallels to non-forensic out of area placements?

Commissioning

Consultants leading the pilot personality disorder services report that it is exceptionally difficult to provide treatment...(for) patients within mainstream services.

RCPsych (2003)

What would a good pathway look like?

Solutions

clarification of national picture regional variation

integrated commissioning of pathways across NHSE and CCGs

Solutions

improved joint working between local and out-of area services

use of audit and service user/service peer review eg secure services Quality Network Prescribing Observatory Mental Health

(POMH)

Locations

Conclusion

local snapshot a model work in progress

what does assertive mean?

develop reciprocal quality assurance/improvement role clarity re pathway with services

...keeping the service user in mind.

Daniel.Beales@nhs.net

Thank you