Mental health service use and costs associated with complex emotional needs and a diagnosis of personality disorder: analysis of routine data

AIMS AND METHOD

We aimed to estimate the costs of care for people with a personality disorder diagnosis and compare service use and costs for those receiving specialist input and those receiving generic care. Service use data were obtained from records and costs calculated. Comparisons were made between those who received care from specialist personality disorder teams and those who did not. Demographic and clinical predictors of costs were identified with regression modelling.

RESULTS

Mean total costs before diagnosis were £10 156 for the specialist group and £11 531 for the non-specialist group. Post-diagnosis costs were £24 017 and £22 266 respectively. Costs were associated with specialist care, comorbid conditions and living outside of London.

CLINICAL IMPLICATIONS

Receiving increased support from a specialist service may reduce the need for in-patient care. This may be clinically appropriate and results in a distribution of costs.

The prevalence and severity of loneliness and deficits in perceived social support among who have received a 'personality disorder' diagnosis or have relevant traits: a systematic review

BACKGROUND

Loneliness and struggles with unmet social needs are a common experience among people with 'personality disorder' diagnoses/traits. Given the impact of loneliness and poor perceived social support on mental health, and the importance of a sense of belonging for recovery, a systematic review examining the prevalence/severity of loneliness and deficits in perceived social support among people with 'personality disorder' diagnoses/traits is an essential step towards developing an intervention targeting the social needs of people with diagnoses/traits 'personality disorder'. Despite an extensive literature on loneliness and deficits of perceived social support among people with 'personality disorder' diagnosis/traits, to date there has been no systematic review of this evidence.

METHOD

We conducted a systematic review synthesising quantitative data on the prevalence/severity of loneliness and deficits of perceived social support among people with diagnoses/traits of 'personality disorder' in comparison with other clinical groups and the general population. We searched Medline, Embase, PsycINFO, Web of Social Science, Google scholar and Ethos British Library from inception to December 2021. We conducted quality appraisals using the Joanna Briggs Critical appraisal tools and rated the certainty of evidence using the Grading of Recommendation, Assessment, Development and Evaluation approach. A narrative synthesis was used describing the direction and strength of associations prioritising high quality studies.

FINDINGS

A final set of 70 studies are included in this review, most of which are cross-sectional studies (n = 55), based in the United States (51%) and focused on community samples. Our synthesis of evidence found that, across all types of 'personality disorders' (except 'narcissistic personality' traits), people with traits associated with 'personality disorder' or meeting criteria for a diagnosis of 'personality disorder', have higher levels of loneliness, lower perceived relationship satisfaction, and poorer social support than the general population or other clinical samples.

CONCLUSION

The quality of evidence is judged as low quality. However, given the distressing nature of loneliness and the known negative effects of loneliness on mental health and recovery, it is important for future research to explore mechanisms by which loneliness may exacerbate 'personality disorder' symptoms and the impact this has on recovery.

Crisis and acute mental health care for people who have been given a diagnosis of a 'personality disorder': a systematic review

BACKGROUND

People who have been given a diagnosis of a 'personality disorder' need access to good quality mental healthcare when in crisis, but the evidence underpinning crisis services for this group is limited. We synthesised quantitative studies reporting outcomes for people with a 'personality disorder' diagnosis using crisis and acute mental health services.

METHODS

We searched OVID Medline, PsycInfo, PsycExtra, Web of Science, HMIC, CINAHL Plus, Clinical Trials and Cochrane CENTRAL for randomised controlled trials (RCTs) and observational studies that reported at least one clinical or social outcome following use of crisis and acute care for people given a 'personality disorder' diagnosis. We performed a narrative synthesis of evidence for each model of care found.

RESULTS

We screened 16,953 records resulting in 35 studies included in the review. Studies were published between 1987-2022 and conducted in 13 countries. Six studies were RCTs, the remainder were non randomised controlled studies or cohort studies reporting change over time. Studies were found reporting outcomes for crisis teams, acute hospital admission, acute day units, brief admission, crisis-focused psychotherapies in a number of settings, Mother and Baby units, an early intervention service and joint crisis planning. The evidence for all models of care except brief admission and outpatient-based psychotherapies was assessed as low or very low certainty.

CONCLUSION

The literature found was sparse and of low quality. There were no high-quality studies that investigated outcomes following use of crisis team or hospital admission for this group. Studies investigating crisis-focused psychological interventions showed potentially promising results.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.