Transcript Beales D Assertive Case Management

Developing secure personality
disorder pathways
Assertive Case Management: a way of
managing the risk of personality disorder
acting as a diagnosis of
exclusion?
Dr Dan Beales
Consultant Psychiatrist in Forensic Psychotherapy
Assertive Case Management Team
The Pathfinder Service
Avon and Wiltshire Mental Health Partnership NHS Trust
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
Psychotic illness
Mood disorder
Other*
Male
N=16 (%)
6 (38)
0
5 (31)
Female
N=15(%)
% Total Sample
6 (40)
38
5 (33)
16
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
12
11
71
Anti-psychotic
8
8
52
Benzodiazepines
4
2
19
Mood stabiliser
2
0
6
Anti-depressant
3
4
23
Polypharmacy
Anti-psychotic
polypharmacy
Any polypharmacy
% total sample
any polypharmacy
(N=31)
Male
Female
Total
3
2
5
7
6
13
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
(2015)
England
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
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
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
Role of trials of medication
Role of medication free trials
Role of clozapine
Research
POMH
 rationale
 review
 physical health
Commissioning
 Challenging


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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.
[email protected]
Thank you