Background and objectivesPeople with personality disorders are prevalent in emergency and inpatient mental health services. We examined whether implementing a stepped care model of psychological therapy reduces demand on hospital units by people with personality disorder, in a cluster randomized controlled trial.MethodA total of 642 inpatients (average age 36.8, 50.5% female) with a primary ICD-10 personality disorder were recruited during 18 months baseline, then monitored during an 18 month active trial phase. In the active trial phase two equivalent sites were randomised to either treatment as usual (TAU), or a whole of service intervention that diverted people away from hospital and into stepped care psychological therapy clinics. The study design was cost neutral, with no additional staff or resources deployed between sites. A linear mixed models analysis evaluated outcomes.ResultsAs predicted, demand on hospital services reduced significantly in the intervention compared to TAU site. The intervention site evidenced shorter bed days, from an average of 13.46 days at baseline to 4.28 days per admission, and patients were 1.3 times less likely to re-present to the emergency department compared to TAU. Direct cost savings for implementing the approach was estimated at USD$2,720 per patient per year. Limitations included not directly comparing individual symptom changes.ConclusionsUsing a whole of service stepped care model of treatment for personality disorder significantly reduced demand on hospital services.
BackgroundThe relative burden and risk of readmission for people with personality disorders in hospital settings is unknown. AimsTo compare hospital use of people with personality disorder with that of people with other mental health diagnoses, such as psychoses and affective disorders. MethodNaturalistic study of hospital presentations for mental health in a large community catchment. Mixed-effects Cox regression and survival curves were generated to examine risk of readmission for each group. ResultsOf 2894 people presenting to hospital, patients with personality disorder represented 20.5% of emergency and 26.6% of inpatients. Patients with personality disorder or psychoses were 2.3 times (95% CI 1.79-2.99) more likely than others to re-present within 28 days. Personality disorder diagnosis increases rate of readmission by a factor of 8.7 (s.e. = 0.31), marginally lower than psychotic disorders (10.02, s.e. = 0.31). ConclusionsPersonality disorders place significant demands on in-patient and emergency departments, similar to that of psychoses in terms of presentation and risk of readmission. Declaration of interestNone.
The clinic achieved high rates of first session attendance. This may have been attributable to the use of a few specific strategies aimed at increasing compliance, such as the green card, next-day appointments and assertive follow-up of non-attenders. For repeat self-harmers, we advocate an approach aimed at 'lifestyle change' rather than based on current psychological stressors. The Green Card Clinic service, involving a range of interventions tailored to meet the multitude of presenting needs, appears to be an acceptable and flexible approach to brief intervention for DSH.
BACKGROUNDT he National Survey of Mental Health and Wellbeing 1 reported lifetime prevalence of suicidal ideation as 14.3% and rates of suicidal attempts as 3.1%. The highest rates for ideation were 2.9% for men and 5.3% for women from 18-24 years (with rates of 0.7% for men and 1.0% for women for suicide attempts), but rates for the 25 to 44 year group were almost as high. At least 10% of attempters will eventually die by suicide and at least half of those who complete suicide have had a previous attempt. 2 Not only does deliberate self harm (DSH) account for 1 to 5% of all public hospital admissions, 3 but there is increased (of up to 30%) risk of repeated attempts in the 12-18 months after an attempt. 2 A re-attempt is most likely in the subsequent ten days, 4 so that the first few days after an attempt provide a 'window of opportunity' when the precipitating issues are still in high profile. However, compliance for outpatient appointments is in the order of 25%-50% within 1 month of attempt. 5 Noncompliance may be for a number of reasons. These include disinterest by staff in Emergency Departments (ED), wish to forget about the attempt and attending circumstances, amnesia for the episode and referral for follow up due to effects of drugs taken (in overdose), alcohol or other substances consumed, lack of sleep or inadequate instructions being given at the time, and lags between assessment and appointment. Two steps are necessary to improve compliance: increased rates of referral for follow-up assessment 6-8 and provision of relevant interventions to those who present for follow-up after recent episodes of DSH. METHODTwo neighbouring Sydney hospitals (St Vincent's (SVH) and Prince of Wales (POW)) collaborated to introduce an intervention program for those presenting to the two EDs with DSH attempts over a period of 15 months from late 1998. The aims were to increase compliance of those referred for assessment after an attempt, by providing an accessible service within the short time span and some relevant time-limited strategies to those referred. Initially, there was an emphasis on education for medical and nursing staff in ED. This comprised talks on psychosocial history-taking, conducting mental state examinations and risk assessment, supplemented by continuing inservice education.People presenting to the EDs with DSH were given the 'usual' medical and psychiatric assessments. The psychiatry registrars then gave them a 'Green card', for the next clinic at the respective hospital. The card, a modification from another study 9 provided the appointment time and
The necessary conditions for an accountable, responsive, fair and transparent health culture are proposed.
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