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The Enhance Study: Effectiveness of a Clinical Pathway for the Acute Inpatient Care of Patients with Emotionally Unstable Personality Disorder
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The purpose of this report is to review current evidence-based practice, service availability and experiences of treatment for Australians with lived experience of personality disorder, regardless of their circumstances. An overarching aim of this body of work is to improve management of and access to effective treatment and support services for these people.
This project was commissioned by the National Mental Health Commission to identify treatment and support availability and access through three components: a literature review, an environmental scan and a qualitative study.
Participants typically described long, non-linear journeys with treatment and support services, which they perceived to be impacted by stigma and discrimination. Participants reported frustration with financial barriers, waiting lists and availability of specialist support.
Based on the results of the literature review, environmental scan and qualitative study, 11 recommendations were developed. These recommendations relate to the availability of and access to support services; strategies to improve clinician training and reduce stigma from health professionals; and research directions.
Unlabelled:
Aim Integrated care pathways (ICP) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities. ICPs are now being implemented across international healthcare arena, but evidence to support their use is equivocal. The aim of this study was to identify the circumstances in which ICPs are effective, for whom and in what contexts. Methods A systematic review of high-quality randomised controlled trials published between 1980 and 2008 (March) evaluating ICP use in child and adult populations in the full range of healthcare settings.
Results:
1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. 3 ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. 4 ICPs can be effective in improving physician agreement about treatment options. 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide. 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. 7 Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established. 10 Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others. 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. 13 ICP documentation can introduce scope for new kinds of error. Conclusions ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.
Psychotherapy for borderline personality disorder (BPD) has been associated with problematically low treatment completion rates.
PsycInfo and Medline were systematically searched to identify studies providing information on treatment completion in psychotherapy models that have been shown to be effective for BPD. A meta-analysis of treatment completion rates and a narrative analysis of factors predicting dropout were conducted.
Forty-one studies were included, with completion rates ranging from 36% to 100%- a substantial between-study heterogeneity. Random effects meta-analyses yielded an overall completion rate of 75% (95% CI: 68-82%) for interventions of <12 months duration, and 71% (95% CI: 65-76%) for longer interventions. Egger's test for publication bias was significant for both analyses (P ≤ 0.01). Study characteristics such as treatment model and treatment setting did not explain between-study heterogeneity. In individual studies, factors predicting dropout status included commitment to change, the therapeutic relationship and impulsivity, whilst sociodemographics were consistently non-predictive.
Borderline personality disorder should no longer be associated with high rates of dropout from treatment. However, the substantial variation in completion rates between studies remains unexplained. Research on the psychological processes involved in dropping out of treatment could further improve dropout rates.
This paper presents an implementation of matching estimators for average treatment effects in Stata. The nnmatch command allows you to estimate the average effect for all units or only for the treated or control units; to choose the number of matches; to specify the distance metric; to select a bias adjustment; and to use heteroskedastic-robust variance estimators. Copyright 2004 by StataCorp LP.
The Patients' Charter for Mental Health Services (DOH, 1997) states that a patient is entitled to both know and understand his or her diagnosis. Despite this, personality disordered clients are not always well informed about their disorder. Some will not be told their diagnosis because of concern that to do so would damage the therapeutic alliance.
To test the hypothesis that the therapeutic alliance is not compromised by engaging in a psychoeducation programme that informs about personality disorder.
Pilot study, pre-post design.
Eighteen forensic in-patients and 16 community out-patients separately participated in a 4-session individual programme that focused on personality, personality disorder, and their own diagnosis. Understanding of these concepts was explored in a brief structured interview. Therapeutic alliance was assessed pre- and post-intervention using the Agnew relationship measure.
For both samples, participation in the intervention resulted in a positive change in four of the five measured components of the therapeutic alliance. This change was rated more strongly by clients than therapists, and reached statistical significance for bond, partnership, and confidence subscales. Participants demonstrated improved knowledge of their disorder following the intervention, and all but one gave positive feedback.
These findings support the hypothesis and suggest the therapeutic relationship is not impaired when a diagnosis of personality disorder is imparted using this psychoeducation programme.
This study compared psychosocial functioning and treatment utilization in 130 participants who were diagnosed with a borderline personality disorder (BPD), a non-BPD personality disorder (OPD), a mood and/or anxiety disorder (MAD), or had no current psychiatric diagnosis and served as a healthy comparison group. Diagnostic and Statistical Manual of Mental Disorders (4th Edition) diagnoses, psychosocial functioning, and treatment utilization were determined by using well-established semistructured research interviews conducted by trained doctoral-level clinicians. Analysis of variance revealed the most severe deficits in functioning characterized the BPD group across areas of global functioning with more moderate impairments in functioning occurring in OPD and MAD groups. The BPD group was characterized by significantly greater psychiatric and nonpsychiatric treatment utilization than the other groups. These findings indicate that BPD as well as other personality disorders are a source of considerable psychologic distress and functional impairment equivalent to, and at times exceeding, the distress found in mood and anxiety disorders. The public health impact of BPD diagnosis is highlighted by the high rates of psychiatric and nonpsychiatric treatment utilization.
Matching estimators for average treatment effects are widely used in evaluation research despite the fact that their large sample properties have not been established in many cases. In this article, we develop a new framework to analyze the properties of matching estimators and establish a number of new results. First, we show that matching estimators include a conditional bias term which may not vanish at a rate faster than root-N when more than one continuous variable is used for matching. As a result, matching estimators may not be root-N-consistent. Second, we show that even after removing the conditional bias, matching estimators with a fixed number of matches do not reach the semiparametric efficiency bound for average treatment effects, although the efficiency loss may be small. Third, we propose a bias-correction that removes the conditional bias asymptotically, making matching estimators root-N-consistent. Fourth, we provide a new estimator for the conditional variance that does not require consistent nonparametric estimation of unknown functions. We apply the bias-corrected matching estimators to the study of the effects of a labor market program previously analyzed by Lalonde (1986). We also carry out a small simulation study based on Lalonde's example where a simple implementation of the biascorrected matching estimator performs well compared to both simple matching estimators and to regression estimators in terms of bias and root-mean-squared-error. Software for implementing the proposed estimators in STATA and Matlab is available from the authors on the web.
The bipolar spectrum-the shaping of a new paradigm in psychiatry
- H S Akiskal
Akiskal, H. S. (2002). The bipolar spectrum-the shaping of a new paradigm in
psychiatry. Current Psychiatry Reports, 4(1), 1-3. doi:10.1007/s11920-0020001-1
Doubly robust estimation in missing data and causal inference models Retrieved from https://pdfs.semanticscholar.org/a85a Development of an inpatient cognitive-behavioral treatment program for borderline personality disorder
- H Bang
- J M W D Robins
- S E Buie
- E W Peterson
- A S Hollingsworth
- M Griva
- S C Hickerson
Bang, H., & Robins, J. M. (2005). Doubly robust estimation in missing data and causal
inference models. Biometrics, 61(4),962-973. Retrieved from
https://pdfs.semanticscholar.org/a85a/cbe6ff39173031d877eaf79af3ca52bbc20f.
pdf
Barley, W. D., Buie, S. E., Peterson, E. W., Hollingsworth, A. S., Griva, M., Hickerson,
S. C., et al. (1993). Development of an inpatient cognitive-behavioral treatment
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7(3), 232-240. doi:10.1521/pedi.1993.7.3.232