BackgroundBorderline personality disorder (BPD) is challenging for family members who are often required to fulfil multiple roles such as those of advocate, caregiver, coach and guardian. To date, two uncontrolled studies by the treatment developers suggest that Family Connections (FC) is an effective programme to support, educate and teach skills to family members of individuals with BPD. However, such studies have been limited by lack of comparison to other treatment approaches. This study aimed to compare the effectiveness of FC with an optimised treatment-as-usual (OTAU) programme for family members of individuals with BPD. A secondary aim was to introduce a long term follow-up to investigate if positive gains from the intervention would be maintained following programme completion.MethodsThis study was a non-randomised controlled study, with assessment of outcomes at baseline (pre-intervention) and end of programme (post-intervention) for both FC and OTAU groups, and at follow-up (3 months post-intervention; 12 or 19 months post-intervention) for the FC group. Eighty family members participated in the FC (n = 51) and the OTAU (n = 29) programmes. Outcome measures included burden, grief, depression and mastery. Linear mixed-effects models were used to assess baseline differences in the outcome measures by gender, age group and type of relationship to the individual with BPD. Linear mixed-effects models were also used to estimate the treatment effect (FC versus OTAU) utilising all available data from baseline and end of programme.ResultsThe FC group showed changes indicating significant improvement with respect to all four outcome measures (p < 0.001). The OTAU group showed changes in the same direction as the intervention group but none of the changes were statistically significant. The intervention effect was statistically significant for total burden (including both subscales; p = .02 for subjective burden and p = .048 for objective burden) and grief (p = 0.013). Improvements were maintained at follow-up for FC participants.ConclusionsThe findings of the current study indicate that FC results in statistically significant improvements on key measures while OTAU does not yield comparable changes. Lack of significant change on all measures for OTAU suggests that a three session psycho-education programme is of limited benefit. Further research is warranted on programme components and long-term supports for family members.

Background Dialectical behaviour therapy for adolescents (DBT‐A) is an intervention with a growing evidence base for treating adolescents with emotional and behavioural dysregulation. This study describes the implementation and effectiveness of 16‐week DBT‐A across multiple sites in publicly funded child/adolescent mental health services (CAMHS) in Ireland. Method The Consolidated Framework for Implementation Research was used to guide this national implementation. Fifty‐four clinicians from seven CAMHS teams completed DBT training and delivered the 16‐week DBT‐A programme. Eighty‐four adolescents with emotional and behavioural dysregulation participated in the intervention and outcome measures were administered at preintervention, postintervention and 16‐week follow‐up. Results Significant reductions on all outcome measures were observed for DBT‐A participants including presence and frequency of self‐harm, suicidal ideation and depression. Reductions in the number of acute inpatient admissions, bed days and emergency department visits were also reported. Conclusions DBT‐A can be successfully implemented in CAMHS settings and yield positive outcomes for adolescents with emotional and behavioural dysregulation.

BackgroundDialectical behaviour therapy (DBT) is noted to be an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with borderline personality disorder (BPD). Evidence for the effectiveness of DBT in publicly funded community mental health settings is lacking however. No study to our knowledge has been published on the effectiveness of a 12 month standard DBT programme without adaptations for individuals with BPD in a publicly funded community mental health setting and no study has included data across multiple time-points. The main objective of the current study was to determine if completion of a 12 month DBT programme is associated with improved outcomes in terms of borderline symptoms, anxiety, hopelessness, suicidal ideation, depression and quality of life. A secondary objective includes assessing client progress across multiple time-points throughout the treatment.MethodsFifty-four adult participants with BPD completed the standard DBT programme across four sites in community mental health settings in the Republic of Ireland. Data was collected by the DBT therapists working with participants and took place at 8 week intervals across the 12 month programme. To explore the effects of the intervention for participants, linear mixed-effects models were used to estimate change utilising data available from all time-points.ResultsAt the end of the 12 month programme, significant reductions in borderline symptoms, anxiety, hopelessness, suicidal ideation and depression were observed. Increases in overall quality of life were also noted. In particular, gains were made during the first 6 months of the programme. There was a tendency for scores to slightly regress after the six-month mark which marks the start of the second delivery of the group skills cycles.ConclusionsThe current study provides evidence for the effectiveness of standard DBT in publicly funded community mental health settings. As participants were assessed at the end of every module, it was possible to observe trends in symptom reduction during each stage of the intervention. Despite real-world limitations of applying DBT in community settings, the results of this study are comparable with more tightly controlled studies.Trial registrationClinicalTrials.gov ID: NCT03166579; Registered May 24th 2017 ‘retrospectively registered’Electronic supplementary materialThe online version of this article (doi:10.1186/s40479-017-0070-8) contains supplementary material, which is available to authorized users.

Background Borderline personality disorder (BPD) is considered to be a challenging condition for clinicians to treat. Clinicians routinely working with individuals who experience severe emotional dysregulation often do not receive appropriate training and support to work with this client group. This article describes an intervention, Clinician Connections (CC), which was developed to support practitioners who work with individuals with BPD. CC aims to increase practitioner’s knowledge of BPD, develop a skillset to work with emotionally dysregulated individuals and enhance practitioner’s self-efficacy with regard to working effectively with this client group. The aim of this study is to investigate the perceived utility and acceptability of CC, and identify areas for further development of the intervention. Method A seven-hour CC workshop was provided to Emergency Department and community mental health clinicians. Three focus groups were completed following completion of the intervention with 13 clinicians (12 female; 1 male) and were audio recorded. The study utilised a thematic analysis framework. Results Six master themes emerged from the focus group data which included 10 subordinate themes. The master themes identified were: the need for training; a new understanding; validation; barriers to applying new skills; overcoming barriers to skill application; and future direction: practical application of skills. Participants reflected on how their new understanding of transactions and their own experiences affects their practice. They also noted improved client interactions and client relationships resulting from the use of validation. While there was an increase in participants’ self-efficacy in working with individuals with BPD, a need for further skills and practice was also highlighted. Conclusion The evidence presented here suggests that CC is both beneficial and feasible. Qualitative feedback suggests there is a need for further support in the strengthening and generalisation of skills. Suggestions were made by practitioners regarding potential improvements to the delivery of the workshop. Future research could evaluate the changes made to CC and focus on a quantitative approach to quantify the impact of CC.

The National Dialectical Behaviour Therapy (DBT) Project, Ireland was established in 2013 in the Republic of Ireland. The aims of the project were twofold: to implement DBT in Community Mental Health Services across Ireland and to evaluate this coordinated implementation of DBT at a national level. This chapter describes the process of implementing DBT in the public health system in Ireland. It first describes how the need emerged for a coordinated national implementation, and the framework put in place to establish and put this coordinated initiative into action. It then considers challenges to a national implementation of an evidence-based treatment such as DBT and approaches that were employed to overcome such challenges. The chapter concludes with a summary of implementation outcomes and key learnings from this initiative as well as recommendations and considerations for DBT implementation and ongoing sustainability in community mental health services.

BackgroundIn the Republic of Ireland, borderline personality disorder (BPD) is a feature of approximately 11–20% of clinical presentations to outpatient clinics within mental health services. These estimates are similar to other countries including the UK and USA. Dialectical behaviour therapy (DBT) is an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with BPD. While a number of randomised controlled trials (RCTs) have demonstrated the efficacy of DBT, there is limited research which evaluates the effectiveness of this model when applied to real world settings. Funding was secured to co-ordinate DBT training in public community-based mental health services across Ireland. As no other study has evaluated a co-ordinated national implementation of DBT, the current study proposes to investigate the effectiveness of DBT in both adult and child/adolescent community mental health services across Ireland, evaluate the coordinated implementation of DBT at a national level, and complete a comprehensive economic evaluation comparing DBT versus treatment-as-usual.Methods/ designThis study takes the form of a quasi-experimental design. Individuals attending community mental health services who meet criteria for participation in the DBT programme will be allocated to the intervention group. Individuals who live in areas in Ireland where DBT is not yet available, and individuals who choose not to participate in the intervention, will be invited to participate in a treatment-as-usual comparison group. Self-report clinical measures and health service use questionnaires for DBT participants (and parent/guardians as appropriate) will be administered at pre-, mid- and post-intervention, as well as follow-up for participants who complete the intervention. Survey and interview data for DBT therapists will be gathered at three time points: prior to DBT training, 6 months after teams begin delivery of the intervention, and 2 years following training completion.DiscussionIt is anticipated that the results of this study will provide evidence for the effectiveness of DBT for patients, and report on recommendations regarding best practice guidelines for implementation of DBT and its economic merit in a publicly funded service.Trial registrationClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 ‘retrospectively registered’.

Objectives. Borderline personality disorder (BPD) is characterised by recurring crises, hospitalisations, self-harm, suicide attempts, addictions, episodes of depression, anxiety and aggression and lost productivity. The objective of this study is to determine the use of direct health care resources by persons with BPD in Ireland and the corresponding costs.Methods. This prevalence-based micro-costing study was undertaken on a sample of 196 individuals with BPD attending publicly funded mental health services in Ireland. All health care costs were assessed using a resource utilisation questionnaire completed by mental health practitioners. A probabilistic sensitivity analysis, using a Monte Carlo simulation, was performed to examine uncertainty.Results. Total direct healthcare cost per individual was €10 844 annually (ranging from 5228 to 20 609). Based on a prevalence of 1% and an adult population (18-65 years) of 2.87 million, we derived that there were 28 725 individuals with BPD in Ireland. Total yearly cost of illness was calculated to be up to €311.5 million.Conclusions. There is a dearth of data on health care resource use and costs of community mental health services in Ireland. The absence of this data is a considerable constraint to research and decision-making in the area of community mental health services. This paper contributes to the limited literature on resource use and costs in community mental health services in Ireland. The absence of productivity loss data (e.g. absenteeism and presenteeism), non-health care costs (e.g. addiction treatment), and indirect costs (e.g. informal care) from study participants is a limitation of this study.

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