IAPT SMI (for Personality Disorder):

the first year as a demonstration site

Dr. Janet Feigenbaum and Oliver English

North East London NHS Foundation Trust

Contact: Janet.feigenbaum@nhs.net; 0300 555 1213

Improving Access to Psychological Therapies

for individuals with a Personality Disorder

Providing services for the treatment seeking population

Identifying strategies for engaging with the treatment reluctant population

Working within the current economic position

Improving Access means inclusivity

IMPART works with:

8 of the 10 DSM-IV Personality Disorders*

Older adults

mild learning disabilities

co-morbid substance abuse

high risk

* The clinical and business case for ASPD has been developed and

is being discussed with leadership and commissioners

Improving Access needs robust pathways

Mental

Health

Primary

Care

Local

Authority

Criminal

Justice

Weekly

Psychology

Referrals

Panels*

Psychology

Departments

IMPART

GP

Fewer assessments

Reduced waiting times CAMHS

IMPART Referrals Nov 2012 to Jan 2014

236 open cases on day of commencing IAPT SMI (1 Nov 2012)

830 new referrals

696 community (58/month)

134 Acute (11/ month)

Number offered steps 2/3 treatment: 511

Number started step 2 treatment: 389

235 cases open as of Jan 2014 (waiting list = 45)

27 – average caseload (current wte 8.6 – 3.0 vacant)

Demographics

OA: n=11

Gender

M 26%

F 74%

IAPT Stepped Care pathway

Step 1:

Screening assessment

Self help pack

Monthly phone call

Step 3:

Full assessment

Collaborative formulation

Motivational Interviewing

DBT or CBT (6m or 1y)

Step 2:

DBT or CBT

skills groups

Psychoeducational groups

MBCT Follow up:

Phone coaching

3 x follow up appointments

Top up sessions

Referral to

Appropriate

service

Not PD or risk

Supporters (carers) workshops and DBT skills training workshops

8-10 weeks

4-8 weeks

8-12 weeks

Activity by Type – 11/12-01/14

Activity Sessions

attended

Sessions DNA (%) Overall % activity

Assessments 907 223 (20) 15

Family meetings 32 0 0.4

CPA meetings 56 1 (2) 0 .7

CBT 1:1 1050 226 (18) 17

CBT group 271 63 (19) 4

CBT coaching (TC) 50 0.6

Crisis intervention 35 0 0.3

DBT 1:1 1777 331 (16) 28

DBT group 1805 403 (18) 29

DBT coaching (TC) 316 4

MBCT group 60 12 (20) 0.9

Motiv. Interv. 95 13 (12) 1.4

Psychoeduc. 25 3 (11) 0.3

Schema FT 68 7 (9) 1

Supportive Couns. 164 5 (3) 2.2

Indirect provision

• Training on working effectively with PD

Mental Health Services

Psychiatric Liaison and A&E staff

Housing workers

Social Services

Child protection services

Probation

Magistrates

GPs

Health visitors

Engaging with the treatment reluctant population

In-patient IMPART Therapist

assessments

facilitating pathways to community treatment

motivational enhancement

psychoeducation and coping skills

staff support groups

ward based DBT skills

What to measure - General Principles

The Five D’s:

• death

• disease

• disability

• discomfort

• dissatisfaction

Measuring Outcomes

IAPT Dataset

PHQ-9

IAPT employment status

WSAS (Work and Social Adjustment)

EQ-5D (Quality of Life)

WEMWBS (Warwick-Edinburgh Mental Well Being Scale)

SAPAS (Standardized Assessment of Personality)

Rates of self harm and suicide attempts

Service utilization

IMPART dataset

SCID I and II

Staxi (Speilberger Anger Scale)

Christo (modified drug/alcohol)

Treatment history (one year)

Outcomes (commissioning targets):

Amongst treatment completers (> 50% appts and agreed)

Q1 Q2 Q3

Bed days prior

to IMPART

233 82 95

Bed days

during IMPART

27 7 27

BED DAYS

reduced

206 75 68

Suicide

attempts

before

97 51 33

Suicide

attempts

during

5 10 7

% reduction in

self harm

frequency

89% 97% 94%

Challenges faced by IMPART

Demands to see individuals with ASPD

Care coordination – pressures on the system

Requests for more training /consultation/supervision

Continual restructuring – disrupted care pathways

Managing a wait list – high risk clients

Adopting a Dialectical Perspective

There is only one pie

and everyone wants it!

Trust Target Hierarchy

Risk

TIB

(Trust interfering behaviours)

Quality of Life

Will anyone die soon?

Interfere with management

Complaints

SUIs

Interfere with Targets

Contacts

Financial (e.g. bed days)

CQUINS

CQC/UQAT

NICE guideline compliance

Staff retention

Service User views

Fledgling IAPT SMI service

BPD with little comorbidity

Compliant with treatment

Out-patient

Good outcomes

Social network

Operational Manager

High risk

Revolving door

Long stay in-patient

High co-morbidity

High cost (e.g. ISA)

Isolated

Synthesize the dialectic

Issues relating to Cost Effectiveness / Health Economics:

• resources are limited

• decisions based on greatest outcome per unit of resource

employed

• economic burden of illness or psychological disorder

(without input/service)

• evaluate savings based on changes in service usage

• evaluate based on productivity

• may look at ‘dose dependent’ curve

i.e. number of sessions

• will need to examine initial severity as confounding factor