developing secure personality disorder pathways dr dan beales consultant psychiatrist in forensic...
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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?
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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
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Assertive Case Management Team Consultant Psychiatrist in Forensic
Psychotherapy Clinical Psychologist
Ceri Jones Community Forensic Nurse
Jeff Roche Assistant Psychologist
Lauren Stead
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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
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What would a good pathway look like?
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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
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Locations
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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
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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
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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
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Polypharmacy
Male
Female
Total
Anti-psychotic polypharmacy
3
2
5
Any polypharmacy
7
6
13
% total sample
any polypharmacy (N=31)
42%
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Clozapine
Male
Female
Gender
4
4
PD only
3
2
PD + co-morbid disorder
1
2
% total sample (N=31) on clozapine = 26%
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What would a good pathway look like?
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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
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A diagnosis of exclusion?
Research and clinical guidanceProfessional confusion and ambivalenceCommissioning
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Diagnosis and Classification
Comorbidity as an artefact of categorical diagnoses.
Jaspers(1923)
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Wing (2011)
When nature draws a line it immediately smudges it.
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Role of psychiatrists
Interaction with categorical approaches:
Prototypical diagnosis: “a PD”> binary thinking
Livesley(2011)
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Pathoplastic interactions
Comorbidity Mental illness <> personality disorder
Role of substance misuse “Drug induced psychosis” (Maden, 2007)
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Pathoplastic interactions?
Atypical mental illness? intrusive thoughts “pseudohallucinations”
what does transient mean?
lack of negative symptoms clozapine?
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Medication
Role of trials of medication Role of medication free trials Role of clozapine Research POMH
rationale review physical health
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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?
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Commissioning
Consultants leading the pilot personality disorder services report that it is exceptionally difficult to provide treatment...(for) patients within mainstream services.
RCPsych (2003)
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What would a good pathway look like?
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Solutions
clarification of national picture regional variation
integrated commissioning of pathways across NHSE and CCGs
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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)
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Locations
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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.
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Thank you