Developing secure personality disorder pathways Dr Dan Beales Consultant Psychiatrist in Forensic Psychotherapy Assertive Case Management Team The 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 of exclusion?

Pathfinder Tier 4 Forensic Personality Disorder Service, based in Bristol, covering the South West:  assessment, consultation and liaison with community mental health teams  treatment programme  OPD probation partnerships: Bristol, Bath, Glos, Somerset, Wilts  National NPS MBT ASPD Pilot  IRiS: Bristol high risk offender partnership with police and probation  Pathfinder 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 Male N=16 (%) Female N=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 Anti-psychotic Benzodiazepines Mood stabiliser Anti-depressant

Polypharmacy Male Female Total Anti-psychotic polypharmacy Any polypharmacy % 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 guidance  Professional confusion and ambivalence  Commissioning

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.

Thank you