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Ledden S, Rains LS, Schlief M, Barnett P, Ching BCF, Hallam B, Günak MM, Steare T, Parker J, Labovitch S, Oram S, Pilling S, Johnson S. Current state of the evidence on community treatments for people with complex emotional needs: a scoping review. BMC Psychiatry 2022; 22:589. [PMID: 36064337 PMCID: PMC9442944 DOI: 10.1186/s12888-022-04171-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN. METHODS We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020. RESULTS We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services. CONCLUSIONS Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.
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Affiliation(s)
- Sarah Ledden
- Division of Psychiatry, University College London, London, UK
| | - Luke Sheridan Rains
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Merle Schlief
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK.
| | - Phoebe Barnett
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Brian Chi Fung Ching
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Brendan Hallam
- Division of Psychiatry, University College London, London, UK
- Research Department of Primary Care & Population Health, University College London, London, UK
| | - Mia Maria Günak
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Department of Psychology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Thomas Steare
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Jennie Parker
- NIHR Mental Health Policy Research Unit Co-Production Group, University College London, London, UK
| | - Sarah Labovitch
- NIHR Mental Health Policy Research Unit Co-Production Group, University College London, London, UK
- West London NHS Trust, London, UK
| | - Sian Oram
- NIHR Mental Health Policy Research Unit, Department of Health Service and Population Research, King's College London, London, UK
| | - Steve Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
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Morgan M, Hunt DF, Trueman H, Vincent C, Maughan D. Improving personality disorder care across mental health services: a system-wide approach. BMJ Open Qual 2022. [PMCID: PMC9445797 DOI: 10.1136/bmjoq-2022-001979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Improving personality disorder (PD) care across a healthcare system is an important but complex task and one that has been endeavoured by many organisations. Oxford Health National Health Service (NHS) Foundation Trust recently received funding from the NHS Long Term Plan’s Community Mental Health Framework to improve PD care across Buckinghamshire mental health services. Therefore, Oxford Healthcare Improvement performed a system-wide diagnostic assessment of gaps in the provision of care for patients with PD and produced a list of recommendations to aid future improvement work. We used a robust and systematic approach that included, a range of quality improvement methods, the mapping of patient pathways, collection of quantitative data on the utilisation of these pathways and focus groups with staff, patients and carers. This paper summarises our mixed-method approach to show how the first stage of improving a complex mental health system could be approached. It also outlines potential areas for improvement associated with the care and treatment of patients with PD and change ideas to address these areas. These include, ensuring a specialised approach to triage and assessment for patients with PD, upskilling the workforce across the system and utilising a variety of evidence-based practices to best support the range of patient needs. As well as introducing a leadership structure to ensure and support improvement work associated with PD care and treatment. We believe our methodological approach could be used beyond improving PD care and we hope that sharing our methods will aid organisations when approaching system-wide improvement work.
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Affiliation(s)
- Mia Morgan
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - David Francis Hunt
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Hayley Trueman
- Patient Safety, Oxford Academic Health Science Network, Oxford, UK
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Daniel Maughan
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
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Abstract
PURPOSE OF REVIEW This review examines the prevalence of personality disorder in those with mental state disorder. Some challenges disentangling these psychopathologies are delineated and advances in understanding broadly are reviewed. RECENT FINDINGS Recent taxonomic changes to a dimensionally based classification system in the ICD-11 and DSM of mental disorders-V's alternative model of personality disorder include requiring cut offs to examine clinical outcomes akin to those in hypertension. These new criteria affect personality disorder prevalence where it is comorbid with mental state disorder, although more robust the dimensional approach complicates understanding both theoretically and practically. Such issues include: deciding the cut off for 'pathology', understanding if psychopathology is related to mental state disorder, personality disorder or both, and consideration of the clinical value of comorbidity. SUMMARY There is overlap between personality pathology and all types of mental state disorder. However, the shift to a dimensional framework of personality pathology means new methods to define and measure this comorbidity are needed. Dimensional conceptualisation of personality pathology challenges the underlying ontology of comorbidity in this area.
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Affiliation(s)
| | - Sara Austin
- Northwestern University, Evanston, Illinois, USA
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Sheridan Rains L, Echave A, Rees J, Scott HR, Lever Taylor B, Broeckelmann E, Steare T, Barnett P, Cooper C, Jeynes T, Russell J, Oram S, Rowe S, Johnson S. Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis. PLoS One 2021; 16:e0248316. [PMID: 33914750 PMCID: PMC8084224 DOI: 10.1371/journal.pone.0248316] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/24/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is a recognised need to develop clear service models and pathways to provide high quality care in the community for people with complex emotional needs, who may have been given a "personality disorder" diagnosis. Services should be informed by the views of people with these experiences. AIMS To identify and synthesise qualitative studies on service user experiences of community mental health care for Complex Emotional Needs. METHODS We searched six bibliographic databases for papers published since 2003. We included peer reviewed studies reporting data on service user experiences and views about good care from community-based mental health services for adults with CEN, including generic mental health services and specialist "personality disorder" services. Studies using any qualitative method were included and thematic synthesis used to identify over-arching themes. RESULTS Forty-seven papers were included. Main themes were: 1) The need for a long-term perspective on treatment journeys; 2) The need for individualised and holistic care; 3) Large variations in accessibility and quality of mental health services; 4) The centrality of therapeutic relationships; 5) Impacts of 'personality disorder' diagnosis. Themes tended to recur across studies from different countries and years. DISCUSSION Recurrent major themes included wanting support that is individualised and holistic, provides continuity over long journeys towards recovery, and that is delivered by empathetic and well-informed clinicians who are hopeful but realistic about the prospects of treatment. Care that met these simple and clearly stated priorities tended to be restricted to often limited periods of treatment by specialist "personality disorder" services: generic and primary care services were often reported as far from adequate. There is an urgent need to co-design and test strategies for improving long-term support and treatment care for people with "personality disorders" throughout the mental health care system.
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Affiliation(s)
- Luke Sheridan Rains
- Division of Psychiatry, NIHR Mental Health Policy Research Unit, University College London, London, United Kingdom
| | - Athena Echave
- Division of Psychiatry, University College London, London, United Kingdom
| | - Jessica Rees
- Division of Psychiatry, University College London, London, United Kingdom
| | | | - Billie Lever Taylor
- Division of Psychiatry, NIHR Mental Health Policy Research Unit, University College London, London, United Kingdom
| | - Eva Broeckelmann
- Health Service and Population Research Department, NIHR Mental Health Policy Research Unit Complex Emotional Needs Lived Experience Working Group, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Thomas Steare
- Division of Psychiatry, NIHR Mental Health Policy Research Unit, University College London, London, United Kingdom
| | - Phoebe Barnett
- Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
| | - Chris Cooper
- Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
| | - Tamar Jeynes
- Health Service and Population Research Department, NIHR Mental Health Policy Research Unit Complex Emotional Needs Lived Experience Working Group, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Jessica Russell
- Health Service and Population Research Department, NIHR Mental Health Policy Research Unit Complex Emotional Needs Lived Experience Working Group, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Sian Oram
- Health Service and Population Research Department, NIHR Mental Health Policy Research Unit, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Sarah Rowe
- Division of Psychiatry, University College London, London, United Kingdom
| | - Sonia Johnson
- Division of Psychiatry, NIHR Mental Health Policy Research Unit, University College London, London, United Kingdom
- Camden and Islington NHS Foundation Trust, London, United Kingdom
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Mortality in mental health patients of the Emilia-Romagna region of Italy: A registry-based study. Psychiatry Res 2021; 296:113702. [PMID: 33418461 DOI: 10.1016/j.psychres.2020.113702] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/29/2020] [Indexed: 12/21/2022]
Abstract
Evidence from previous research demonstrated a gap in mortality between patients with mental disorders and the general population. However, a more exhaustive assessment is required to address this public health issue. The aim of this study was to provide comprehensive analysis of mortality examining all causes of death and all psychiatric diagnoses. We conducted a 10-year retrospective cohort study, including all in and out patients registered in the Mental Health Registry of Emilia-Romagna, Italy. Standardized mortality ratios (SMRs) were calculated. The cohort consisted of 137,351 patients 11,236 of whom died during the study period and the overall SMR was 1.99. 85.9 % of excess mortality was attributable to a broad range of natural causes. Diseases of circulatory and respiratory systems as well as neoplasms were the principal contributors to the mortality gap. All psychiatric conditions led to a higher risk of death. The greatest excess was due to neoplasms in depressed and neurotic patients and to cardiovascular diseases in patients with schizophrenia and personality disorders. Our results highlight the need for close collaboration between mental and primary health care services with the aim of reducing excess mortality as a result of medical diseases among all patients suffering from psychiatric condition.
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Lester R, Prescott L, McCormack M, Sampson M. Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review. Personal Ment Health 2020; 14:263-283. [PMID: 32073223 DOI: 10.1002/pmh.1478] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/22/2020] [Accepted: 01/30/2020] [Indexed: 11/11/2022]
Abstract
There is ongoing controversy regarding the borderline personality disorder (BPD) diagnosis. Whilst the experiences of people living with BPD have been widely acknowledged, the process of receiving the diagnosis is poorly described. This systematic review aimed to synthesize the existing research exploring people's experiences of receiving a diagnosis of BPD, as well as examining what is considered best practice in the diagnostic delivery process. The findings from 12 qualitative studies were synthesized using thematic analysis, generating two overarching themes: negative and positive experiences of receiving a diagnosis of BPD. These themes were described using the following sub-themes: the communication of diagnosis and meaning made of it, validity around diagnosis and attitudes of others. Results indicate that there is a substantial difference between a well-delivered and poorly delivered diagnosis. The diagnostic delivery process is fundamental to how people understand and interpret the BPD diagnosis. The way in which the BPD diagnosis is shared with people can ultimately shape their views about hope for recovery and their subsequent engagement with services. © 2020 John Wiley & Sons, Ltd.
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Affiliation(s)
- R Lester
- St Helens Recovery Team, Harry Blackman House, Peasley Cross Hospital, St Helens, UK
| | - L Prescott
- Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - M McCormack
- St Helens Recovery Team, Harry Blackman House, Peasley Cross Hospital, St Helens, UK
| | - M Sampson
- St Helens Recovery Team, Harry Blackman House, Peasley Cross Hospital, St Helens, UK
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Flynn S, Graney J, Nyathi T, Raphael J, Abraham S, Singh-Dernevik S, Williams A, Kapur N, Appleby L, Shaw J. Clinical characteristics and care pathways of patients with personality disorder who died by suicide. BJPsych Open 2020; 6:e29. [PMID: 32183913 PMCID: PMC7176898 DOI: 10.1192/bjo.2020.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND It is estimated that 1 in 10 people have a personality disorder. People with emotionally unstable personality disorder are at high risk of suicide. Despite being frequent users of mental health services, there is often no clear pathway for patients to access effective treatments. AIMS To describe the characteristics of patients with personality disorder who died by suicide, examine clinical care pathways and explore whether the care adhered to National Institute for Health and Care Excellence guidance. METHOD National consecutive case series (1 January 2013 to 31 December 2013). The study examined the health records and serious incident reports of patients with personality disorder who died by suicide in the UK. RESULTS The majority had a diagnosis of borderline/emotionally unstable or antisocial personality disorder. A high proportion of patients had a history of self-harm (n = 146, 95%) and alcohol (n = 101, 66%) or drug misuse (n = 79, 52%). We found an extensive pattern of service contact in the year before death, with no clear pathway for patients. Care was inconsistent and there were gaps in service provision. In 99 (70%) of the 141 patients with data, the last episode of care followed a crisis. Access to specialised psychological therapies was limited; short-term in-patient admissions was adhered to; however, guidance on short-term prescribing for comorbid conditions was not followed for two-thirds of patients. CONCLUSIONS Continuity and stability of care is required to prevent, rather than respond to individuals in crisis. A comprehensive audit of services for people with personality disorder across the UK is recommended to assess the quality of care provided.
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Affiliation(s)
- Sandra Flynn
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, UK
| | - Jane Graney
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, UK
| | - Thabiso Nyathi
- Greater Manchester Mental Health NHS Foundation Trust, UK
| | - Jessica Raphael
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, UK
| | | | - Sandeep Singh-Dernevik
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, UK
| | - Alyson Williams
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, UK
| | - Nav Kapur
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, UK
| | - Louis Appleby
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, UK
| | - Jenny Shaw
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, UK
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