Electronic Letters to:
|
|
eLetters: Electronic letters published:
-
![[Read eLetter]](/icons/misc/sectionDOWN.gif)
Interesting times for personality disorder services
- Timothy Agnew (31 October 2008)
|
|
|||
|
Timothy Agnew, specialist registrar in general psychiatry
Send letter to journal:
timothy.agnew{at}nhs.net Timothy Agnew
|
The recent Delphi study (Crawford, 2008) assessing opinion on community-based services for personality disorder (PD) was a welcome attempt to identify important components of PD service provision. Perhaps unsurprisingly, consensus within and between the three stakeholder groups was attained for only a minority of the questionnaire’s 49 items, probably reflecting the rudimentary experience of service provision for personality disorder and the limited evidence base that exists to support development of such services. While many of the consensus items reflect the heartening shift in attitudes towards personality disorder over the past few years, some responses were slightly surprising. For example, panellists reached consensus that most people with personality disorder require dedicated services to help them cope with their problems. When this is considered in light of the estimate that 4% of the population have a personality disorder (Coid, 2006), and that “interventions aimed at helping people with PD develop better coping strategies need to be delivered over years not months”, the economic implications appear daunting. To contend that most people with personality disorder require dedicated services is to overlook factors such as severity and the issue of treatment-seeking versus treatment-resistance in PD (Tyrer, 2003). These factors are of prime importance in informing management on an individual level, but also in service planning. Many people with PD are treatment-resistant and, of those who are treatment-seeking, many will have a disorder of a severity which can be appropriately managed in primary care or in general mental health services. Furthermore, while lengthy interventions may be required for many people with PD, treatment should be guided by an individual case formulation which may indicate a less intensive intervention. Another thought-provoking finding was that expert authors and service users agreed that dedicated PD services should be open to self-referral; service providers disagreed. It would be unusual for an individual with PD to have problems severe enough to warrant specialist input and not first to come to the attention of general services. Professionals in general services and primary care frequently possess considerable skills in the management of PD, and it should be for them to make the decision of when to involve PD services. Allowing general services to be bypassed by self-referral could cause resentment towards PD services, especially if general services continue to hold overall clinical responsibility while receiving unsolicited and unwanted input from a specialist PD service. Needless to say, fragmentation of care in this patient group should be avoided at all costs. This paper highlighted the need both for evidence gathering in this field and also for careful consideration of how to use all-too-finite resources most effectively. Realistically, most personality disordered individuals will continue to be managed in primary care or general mental health services. PD services have an important role to play in supporting, educating, and delivering specialist input where needed. However, care needs to be taken to integrate sensitively and effectively with existing services. How these fledgling services meet the challenges ahead will influence attitudes not only towards PD services, but to PD itself. Coid J. et al. (2006) Prevalence and correlates of personality disorder in Great Britain. The British Journal Psychiatry. 188: 423 -31. Crawford M.J. et al. (2008) Dedicated community-based services for adults with personality disorder: Delphi study. The British Journal of Psychiatry. 193: 342 - 343. Tyrer, P. et al. (2003) Treatment-rejecting and treatment-seeking personality disorders: Type R and Type S. Journal of Personality Disorders. 17, 265–270. Declaration of interest: None. Dr Timothy Agnew MBchB MRCPsych PGDipCBP Specialist Registar in General Psychiatry Psychotherapy Department Larch house Stonneyfield Business Park Inverness IV2 7PA Telephone 01463 253667 Fax 01463 718303 |
|||