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The availability of personality disorder-specific interventions was assessed by determining whether services offered psychological therapies developed specifically for personality disorder. To address the secondary aims of the survey, logistic and linear regression was used to evaluate the effect of service type dedicated or generic on professional diversity, exclusion criteria, CPA usage, biopsychosocial provision, patient and carer involvement, and training, education and research activity.
Multilevel models, with a random effect for organisation, were used to adjust for the potential higher similarity between services within the same organisation than between services from different organisations. Robust standard errors were used for linear variables that did not conform to a normal distribution. Where significant differences between dedicated and generic services were found, multivariate models were used to adjust for the influence of potentially confounding service characteristics. The number of dedicated personality disorder services per organisation ranged from 1 to 5 mean 1.
Across the 52 English mental health NHS trusts, 71 dedicated personality disorder services and 48 generic services were described, a mean of 1.
The four independent service providers described ten dedicated personality disorder services; a mean of 2. Figure 1 compares the findings with the survey of To aid comparison, the independent sector organisations have been removed from the results so that only English NHS mental health trusts are referred to. Comparison between and survey results percentage change; English mental health NHS trusts only. Across services, teams varied widely in their multi-disciplinary composition Table 2. Within services, team make-up was significantly less diverse in dedicated than in generic services, with the latter utilising almost twice as many different types of professional on average dedicated personality disorder services mean 5.
This suggests that the less diverse workforce in dedicated services was not simply due to providing a more focused range of interventions. Almost all services used the CPA as their management framework. Across services, there was a fairly wide availability of a number of different biological, psychological and social interventions.
Table 3 includes the mean biopsychosocial ratings stratified by service type. Most services were involved in at least one of these activities Table 4. The rates of participation in these activities for dedicated services were approximately twice those of generic services, and dedicated services were significantly more likely than generic services to be involved in all three of these activities i. Table 5 contains the mean patient and carer ratings stratified by service type.
No services excluded individuals on the basis of a diagnosis of personality disorder. Across both dedicated and generic services, the most common exclusion criterion was uncontrolled substance misuse, followed by active risk to others Table 6. This national survey was the first of its kind and captured data provided by 56 relevant mental health organisations in England.
This quantifies the progress made in this area since and points to a fivefold increase in organisations providing dedicated personality disorder services. This represents substantial progress in a decade in which the economic landscape has been challenging.
The NIMHE publication formally introduced the concept of dedicated personality disorder service as distinguished from generic service, and this distinction has been further developed in the current paper. The survey methodology steered respondents to consider the concept of dedicated v. Analysis of the descriptive and statistical differences between the 81 dedicated and 51 generic services allows us to draw some conclusions about these two types of service provision.
For instance, we found that generic services draw from a wide range of professional disciplines, which is in line with their broader remit. Seemingly, dedicated services draw from a more restricted range of professional disciplines; this supports the notion that they are specialist, niche services. Contrary to our a priori hypothesis, dedicated services were no more likely to provide personality disorder-specific interventions when compared with generic services.
Furthermore, generic services provide a significantly wider range of biopsychosocial interventions than dedicated ones, although there was some suggestion that this was influenced by their employment of a significantly more diverse workforce and by their higher rates of medical professional leadership. The accessibility of these interventions and the quality of their delivery are unknown; however, NICE guidance stipulates that specialist interventions are best delivered by specialist services.
The delivery of developmental activities is a clear priority for dedicated services, with almost all involved in training, and significantly more dedicated than generic services involved, indicating that they deliver both training and education and research.
Dedicated services appear to show greater selectivity in patient choice than generic ones, as significantly more operate with exclusion criteria. The response rate for the independent providers should be treated with caution as it is subject to selection bias. Responses were self-reported and there may have been variation in the interpretation of what constituted a dedicated personality disorder service.
In the comparisons made with generic services, the respondents were asked to provide an overview of all of the generic services within their organisation. Although this was pragmatically necessary, given the large numbers of generic services within any organisation, this approach requires the reader to consider the comparisons with appropriate caution. In particular, the findings which relate to the personality disorder-specific interventions and range of staff within the multidisciplinary team will be skewed by this methodology. While this survey is able to give a good organisational-level description of service availability, mapping the local provision is achieved to a limited degree.
Perhaps the most important consideration is that the indicators used in this survey to consider the quality can only provide a broad brush-stroke indication, owing to necessary methodological trade-offs for pragmatic purposes. Understanding the consistency with which individual patients and carers can expect adherence to best practice and the timeliness of the interventions offered is beyond the scope of this survey.
We believe this body of work begins to elucidate the questions which need to be considered, but it is a long way from achieving that. Indeed, the largest limitation of this work is that at best it provides a broad overview of provision.see
Borderline Personality Disorder (BPD)
To properly understand what is actually delivered to those in need will require a more systematic and sustained effort to describe quality standards and ensure, perhaps through accreditation, that best practice is being followed. This paper charts the most systematic attempt to date at mapping the provision of care across England for those affected by personality disorder. What is clear is that the past decade or so has seen considerable progress in providing a service for this range of disorders. Despite this progress, data presented here provide evidence that there remains continued exclusion, variability of practice and inconsistencies in the availability of services.
The current NICE guidance, in step with the evidence base, supports the provision of a range of cost-effective interventions and the establishment of specialist services from which to deliver them. The initial offering presented here lends weight to the call for the establishment of authoritative commissioning guidance and service standards to ensure that patients and carers have access to the care that they need. A multidisciplinary group was formed with representations from psychiatry, psychology, psychotherapy and expertise through lived experience of personality disorder.
The project was granted approval as a service evaluation through the audit department of West London Mental Health Trust.
Personality disorder services in England: findings from a national survey
Declaration of interest None. National Center for Biotechnology Information , U. BJPsych Bull. Author information Article notes Copyright and License information Disclaimer.
Personality disorder services in England: findings from a national survey
Correspondence to Oliver Dale ku. This article has been cited by other articles in PMC.
Abstract Aims and method We aimed to evaluate the availability and nature of services for people affected by personality disorder in England by conducting a survey of English National Health Service NHS mental health trusts and independent organisations. Table 1 Summary of service characteristics.
Open in a separate window. CPA, care programme approach. Aims The primary aim of this study was to describe a number of organisations which provided care for those affected by personality disorder and whether this care was delivered through dedicated personality disorder services, generic services or both. The quality indicators evaluated were: Is there a multidisciplinary team available? Is care managed under the CPA process? Are services involved in education, training and research?
What level of patient and carer involvement do services employ? What exclusion criteria, if any, are applied by services? Method Survey design We conducted a cross-sectional survey of mental health organisations in England using a questionnaire designed for this study.