Barriers and facilitators to the implementation of a stepped care intervention for personality disorder in mental health services

The evaluation of a stepped care approach for early intervention of borderline personality disorder

BACKGROUND

The current study evaluated the stepped care approach applied in AtR!Sk; a specialized outpatient clinic for adolescents with BPD features that offers a brief psychotherapeutic intervention (Cutting Down Program; CDP) to all patients, followed by a more intensive Dialectical Behavioral Therapy for Adolescents (DBT-A) for those whose symptoms persist.

METHODS

The sample consisted of 127 patients recruited from two AtR!Sk clinics. The number of BPD criteria, psychosocial functioning, severity of overall psychopathology, number of days with non-suicidal self-injury (NSSI; past month), and the number of suicide attempts (last 3 months) were assessed at clinic entry (T0), after CDP (T1), and at 1- and 2-year follow-up (T2, T3). Based on the T1 assessment (decision criteria for DBT-A: ≥ 3 BPD criteria & ZAN-BPD ≥ 6), participants were allocated into three groups; CDP only (n = 74), CDP + DBT-A (eligible and accepted; n = 36), CDP no DBT-A (eligible, but declined; n = 17).

RESULTS

CDP only showed significantly fewer BPD criteria (T2: β = 3.42, p < 0.001; T3: β = 1.97, p = 0.008), higher levels of psychosocial functioning (T2: β = -1.23, p < 0.001; T3: β = -1.66, p < 0.001), and lower severity of overall psychopathology (T2: β = 1.47, p < 0.001; T3: β = 1.43, p = 0.002) over two years compared with CDP no DBT-A, while no group differences were found with regard to NSSI and suicide attempts. There were no group differences between CDP + DBT-A and CDP no DBT-A, neither at T2 nor at T3.

DISCUSSION

The findings support the decision criterion for the offer of a more intense therapy after CDP. However, there was no evidence for the efficacy of additional DBT-A, which might be explained by insufficient statistical power in the current analysis.

Implementing a whole-of-service stepped care approach to personality disorder treatment: Impact of training and service redesign on clinician attitudes and skills

Personality disorders are a highly prevalent mental health condition. Historically, clinician attitudes have been negative, and only a small number have specialised training. This study evaluated clinician attitudes and confidence in working with people with personality disorder following the combination of training and implementation of a stepped care whole-of-service approach. A total of 102 multidisciplinary mental health clinicians were trained to implement the stepped care approach, and completed surveys prior to implementation and at 12 months follow up. Clinicians delivered manualised structured psychological therapy as part of the model. Measures assessed changes in attitudes and confidence, and impact of the service changes and therapy approach. Qualitative responses elucidated core themes. Evaluation at 12 months post training and service redesign showed improvements in clinician skills, confidence, theoretical knowledge and attitudes. Qualitative thematic analysis found core themes of improved understanding, clinical skills and improvements in the accessibility and timeliness of treatment. Implementing a whole-of-service model featuring stepped care therapies enhanced clinician attitudes, confidence, skills and knowledge in working with people with personality disorders. Clinicians identified that the whole-of-service model also improved accessibility to treatment, and quality of clinical care to the consumer and their carers.

A State-Wide Initiative to Improve Health System Responses to People With Borderline Personality Disorder Symptoms in Crisis: A Retrospective Audit

Gold Card SA is a four-session structured psychological intervention offered soon after an acute crisis presentation to people with symptoms characteristic of borderline personality disorder. This study describes individual and system-level outcomes from a large-scale health-care improvement initiative to implement Gold Card SA across South Australia. An uncontrolled pre-post study design was utilized examining service user (n = 332) patient-reported outcome measures and hospital service utilization records (6 months before and after Gold Card SA). Mixed-effects negative binomial regression analysis revealed a significant decrease in rates of service utilization across emergency department presentations (63%), mental health-related inpatient admissions (65%), and bed days (82%). Linear mixed-effect regression indicated large reductions in borderline symptoms and nonspecific psychological distress, and small to moderate improvements in psychosocial functioning. People presenting with or experiencing borderline personality disorder symptoms may benefit from a brief crisis intervention embedded within a stepped care model.

Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review

BACKGROUND

People with Borderline Personality Disorder (BPD) and their carers/families continue to experience structural stigma when accessing health services. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and wellbeing of people living with attributes that are the object of stigma. BPD is a serious mental illness characterized by pervasive psychosocial dysfunction including, problems regulating emotions and suicidality. This scoping review aimed to identify, map, and explore the international literature on structural stigma associated with BPD and its impact on healthcare for consumers with BPD, their carers/families, and health practitioners.

METHODS

A comprehensive search of the literature encompassed MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 28th 2022). The search strategy also included grey literature searches and handsearching the references of included studies. Eligibility criteria included citations relevant to structural stigma associated with BPD and health and crisis care services. Quality appraisal of included citations were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18), the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool, and the AGREE II: advancing guideline development, reporting, and evaluation in health care tool. Thematic Analysis was used to inform data extraction, analysis, interpretation, and synthesis of the data.

RESULTS

A total of 57 citations were included in the review comprising empirical peer-reviewed articles (n = 55), and reports (n = 2). Studies included quantitative, qualitative, mixed methods, and systematic review designs. Review findings identified several extant macro- and micro-level structural mechanisms, challenges, and barriers contributing to BPD-related stigma in health systems. These structural factors have a substantial impact on health service access and care for BPD. Key themes that emerged from the data comprised: structural stigma and the BPD diagnosis and BPD-related stigma surrounding health and crisis care services.

CONCLUSION

Narrative synthesis of the findings provide evidence about the impact of structural stigma on healthcare for BPD. It is anticipated that results of this review will inform future research, policy, and practice to address BPD-related stigma in health systems, as well as approaches for improving the delivery of responsive health services and care for consumers with BPD and their carers/families.

REVIEW REGISTRATION

Open Science Framework ( https://osf.io/bhpg4 ).

Key stakeholders’ experiences and expectations of the care system for individuals affected by borderline personality disorder: An interpretative phenomenological analysis towards co-production of care

Background

The diagnosis of borderline personality disorder (BPD) consists of extreme emotional dysregulation and long-term disability when left untreated. It is associated with ineffective use of health care systems and mismanaged care in emergency departments, which can result in a revolving door phenomenon of urgent system usage, poor treatment outcomes, or patients falling out of care entirely–all of which primarily affect patients with BPD as well as their caregivers and clinicians. This crisis must be addressed with a comprehensive understanding of key stakeholder perspectives on the challenges of the system and potential solutions.

Objective

This study explored the perspectives of three key stakeholder groups (i.e., patients, clinicians, and caregivers) in relation to their experiences with and future expectations of the care system for those affected by BPD.

Methods

Four patients with BPD, three generalist clinicians with experience treating BPD, and three caregivers of individuals with BPD participated in individual semi-structured interviews. Participants were asked about their experiences with the current healthcare system and their suggestions for improvement. Responses were analyzed using interpretative phenomenological analysis.

Findings

In-depth analysis of the qualitative data revealed twelve shared themes and three themes that were unique to each key stakeholder group. These themes are discussed and used to inform recommendations for promising practices, policies, and training in this area.

Conclusion

Findings support the importance of a comprehensive mental health system approach for improving the accessibility, effectiveness, and acceptability of the management and treatment of BPD.

The impact of educational interventions on modifying health practitioners' attitudes and practice in treating people with borderline personality disorder: an integrative review

BACKGROUND

The rising prevalence of Borderline Personality Disorder (BPD) and suicidality represents substantial health burden worldwide. People with BPD experience high rates of crisis presentations and stigma when accessing health services. Educational interventions designed to modify health practitioners' attitudes and practice in treating people with BPD may assist in addressing this stigma. The current review aimed to identify and explore existing educational interventions designed to modify health practitioners' attitudes and practice in BPD; and determine what impact educational interventions have on improving health practitioners' responses towards people with BPD.

METHODS

A comprehensive search of the literature was undertaken in MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 2022). Secondary sources of literature included grey literature searches and handsearching the references of included studies as part of the comprehensive search strategy. The eligibility criteria included peer-reviewed empirical studies examining BPD-related educational interventions aimed at modifying health practitioners' attitudes and practice in treating people with BPD. Quality appraisal of the included studies were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18) or the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool. Thematic Analysis informed data extraction, analysis, interpretation, and narrative synthesis of the data.

RESULTS

A total of nine papers containing 991 participants across a diverse range of studies including, quantitative, qualitative, mixed methods, and a systematic review were included in this integrative review. Several BPD-related educational interventions designed to modify health practitioners' attitudes and practice in BPD exist. Findings suggest that training health practitioners in BPD-related educational interventions can enhance positive attitudes and change practice towards people with BPD; however, more high-quality studies are needed to confirm these conclusions.

CONCLUSIONS

This review collated and summarized findings from studies examining the impact of BPD-related educational interventions on changing health practitioners' attitudes and practice in treating this population. Results from this review may help inform future research, policy, and practice in stigma-reduction strategies which would improve the delivery of responsive health services and care for people with BPD.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework ( https://osf.io/7p6ez/ ).

Clinician perspectives on what constitutes good practice in community services for people with complex emotional needs: A qualitative thematic meta-synthesis

INTRODUCTION

The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood.

AIM

To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN.

METHODS

Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies.

RESULTS

Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate.

DISCUSSION

Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support.

A qualitative exploration of pharmacovigilance policy implementation in Jordan, Oman, and Kuwait using Matland's ambiguity-conflict model

Background

As Arab countries seek to implement the ‘Guideline on Good Pharmacovigilance Practice (GVP) for Arab countries’, understanding policy implementation mechanisms and the factors impacting it can inform best implementation practice. This study aimed to explore the mechanisms of and factors influencing pharmacovigilance policy implementation in Arab countries with more established pharmacovigilance systems (Jordan, Oman), to inform policy implementation in a country with a nascent pharmacovigilance system (Kuwait).

Results

Matland’s ambiguity-conflict model served to frame data analysis from 56 face-to-face interviews, which showed that policy ambiguity and conflict were low in Jordan and Oman, suggesting an “administrative implementation” pathway. In Kuwait, policy ambiguity was high while sentiments about policy conflict were varied, suggesting a mixture between “experimental implementation” and “symbolic implementation”. Factors reducing policy ambiguity in Jordan and Oman included: decision-makers’ guidance to implementors, stakeholder involvement in the policy’s development and implementation, training of policy implementors throughout the implementation process, clearly outlined policy goals and means, and presence of a strategic implementation plan with appropriate timelines as well as a monitoring mechanism. In contrast, policy ambiguity in Kuwait stemmed from the absence or lack of attention to these factors. Factors reducing policy conflict included: the policy’s compliance with internationally recognised standards and the policy’s fit with local capabilities (all three countries), decision-makers’ cooperation with and support of the national centre as well as stakeholders’ agreement on policy goals and means (Jordan and Oman) and adopting a stepwise approach to implementation (Jordan).

Conclusions

Using Matland’s model, both the mechanism of and factors impacting successful pharmacovigilance policy implementation were identified. This informed recommendations for best implementation practice in Arab as well as other countries with nascent pharmacovigilance systems, including increased managerial engagement and support, greater stakeholder involvement in policy development and implementation, and undertaking more detailed implementation planning.

Searching in the dark: Shining a light on some predictors of non-response to psychotherapy for borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) is a prevalent and serious mental health condition. People can experience recovery or remission after receiving psychotherapy for BPD; however, it is estimated that about 45% of people in well conducted treatment trials do not respond adequately to current psychological treatments.

AIM

To further advance psychotherapies for BPD by identifying the factors that contribute to the problem of non-response.

METHOD

184 consecutive participants with BPD in community treatment were naturalistically followed up over 12 months and measures of personality and social functioning were examined. Logistic regressions were used to determine which baseline factors were associated with the likelihood of being a non-responder after 12 months of psychotherapy. After 12 months, 48.4% of participants were classed as non-responders due to a lack of reduction in BPD symptoms according to the Reliable Change Index (RCI) method.

RESULTS

At baseline intake, patients who endorsed an adult preoccupied attachment relationship style and increased anger were more likely to be a non-responder regarding BPD symptoms at 12 months. In addition, those with preoccupied attachment patterns in their adult relationships were more likely to be non-responders regarding general psychological distress at follow up. Higher baseline levels of paranoia and endorsement of a dismissive adult relationship style was associated with being a non-responder in regard to global functioning.

CONCLUSIONS

Consistent with previous research, almost half of the sample did not achieve reliable change at 12-month follow up. A relationship style characterised by preoccupied insecurity and high anger seemed to be particularly challenging in being able to benefit from psychotherapy. This style may have affected both relationships outside, but also inside therapy, complicating treatment engagement and alliance with the therapist. Early identification and modification of treatment based on challenges from these relationship styles may be one way to improve psychotherapy outcomes for BPD.

Barriers to care for adolescents with borderline personality disorder

Intervention for borderline personality disorder (BPD) in adolescence is crucial as early onset of the disorder predicts more severe course, and intervention 'late' in the course of the disorder is associated with more negative outcomes. In spite of this, access to services is poor. This is because several unique barriers to accessing care exist for adolescents with BPD. In this article we highlight key barriers to care for adolescents with BPD utilizing a conceptual model for understanding health care access that emphasizes the interaction between patient and health care system characteristics. We conclude with proposed recommendations to address these identified barriers.