Challenges facing us

Given the fact that we have a population prevalence of at least 1% of BPD, we have at the minimum 240, 000 people with BPD needing urgent care and evidence based treatments.

We have a mental health workforce that is poorly trained in the management and treatment of BPD using specific therapies. The Australian Mental Health Services are not ideally set up for managing BPD. They were set up to treat major psychotic and mood disorders predominantly with pharmacotherapy.

Most people with BPD get management and not evidence based psychological treatments in mental health services. People with BPD and their families face significant stigma and discrimination and are frequently excluded when they attempt to access services from emergency departments and mental health services.

It is appreciated that the mental health services are struggling with inadequate resources and it is people with a diagnosis of BPD who are most heavily impacted by this. Given the high rate of suicide and self-harm characteristics of BPD and the national intent to decrease the suicide rate, attention must be given to responding more positively to people with BPD.

NHMRC guidelines suggest making a diagnosis of BPD after age 12. Unfortunately most adolescents who suffer BPD do not get diagnosed with BPD until age 18. This means precious opportunity for early interventions is lost. Prof Chanen, one of the leading global experts on BPD has demonstrated that adolescents with BPD can be treated with treatments that are appropriately developed for them.

According to the NHMRC Clinical Practice Guidelines for the Management of BPD:
‘in people aged 12-18, the presence of any of the following features indicates the need for a full assessment for BPD: frequent suicidal or self-harming behaviour, marked emotional instability, other psychiatric conditions (e.g. mood disorders, substance abuse disorders, disruptive behaviour disorders or anxiety disorders), non-response to established treatments for current symptoms, high level of impairment in general psychosocial functioning, self-care, and peer relationships and family relationships.

Although some clinicians have been concerned that it may be inappropriate to diagnose a personality disorder in a young person whose brain is still developing, current evidence shows that diagnostic criteria for BPD in a person under 18 years are as reliable and valid as in adults and the diagnosis is similarly stable over time as for adults. BPD diagnosed in adolescence is associated with serious and persistent morbidity in adulthood. Accordingly, the diagnosis can be made with reasonable confidence when a person aged 12-18 years meets diagnostic criteria for BPD.

The issue of whether or not to tell an adolescent that they have BPD has been controversial. Some health professionals have preferred to withhold the diagnosis, or even when confident of its accuracy, due to concerns about stigma and discrimination the person may experience as a result of the BPD label. However, prompt disclosure of the diagnosis has potential benefits. Young people often experience relief when they learn that the difficulties they have been experiencing can be attributed to an identified syndrome and that effective treatment is available’

The guideline document further states that:
‘Increased rates of identification of people with features of BPD, including adolescents with early features of BPD in primary care and emergency departments could result in early referral to a specialist, specialised and allied health services for thorough assessment and earlier diagnosis, in turn leading to prompt treatment.

Effective identification and referral to people with features of BPD would necessitate adequate access to referral services in all regions, and effective referral pathways would need to be established within each service or organisation.

The availability and affordability of such services varies across and within jurisdictions.

Early detection might lead to higher rates of BPD diagnosis and treatment. The care of people with BPD will require investment in resources, additional training and services. However, early referral to effective treatment, particularly for adolescents and young people, is likely to improve long term clinical outcomes and result in decreased utilisation of health services over the person’s lifetime. In contrast, delayed or incorrect diagnosis is likely to delay effective treatment and result in high use of health services.

The diagnosis of BPD in an adolescent of young person requires youth mental health experience and expertise. Early detection is likely to lead to higher rates of BPD diagnosis and treatment among adolescents and young adults, who will required access to appropriate youth-oriented treatment services. Increased demand may result in a requirement for expansion of youth-oriented treatment services and more health professionals maybe required to undergo specific training’.

There are very few specialist personality disorder services that can advocate for BPD, educate and train mental health workforce in the treatment and management of BPD. Even well-established state-wide specialist services such as Spectrum, personality disorder service for Victoria can only provide some care for about 500 people with BPD in a year. Given the context most BPD patients are and will always be, treated within generalist rather than specialist mental health treatment settings.

There is a huge unmet treatment need for BPD. Primary care sector is again not equipped to adequately detect and manage BPD. Even if detected, general practitioners (GP)are faced with a paucity of specialist psychologists, psychiatrists and other mental health clinicians who are willing and able to take on the care and treatment of BPD both in public and private health settings. Private psychologists are not adequately covered under the Medicare to provide the comprehensive and long term psychotherapy that BPD patients require. The “Better access to mental health care” initiative was not set up to adequately service the needs of people with BPD, although expanding its scope can go a long way in servicing the needs of people with BPD.

There are several evidence based treatments for BPD, but the “big four” are the most popular ones. The big four treatments include the Dialectical Behaviour Therapy (DBT), Mentalization Based Treatment (MBT), Schema Therapy (ST) and the Transference Focused Therapy. The most evidenced based treatment of all BPD treatments is DBT. It is likely that majority of clinicians who are currently treating BPD patients in Australian setting with evidence based treatments use a DBT approach. MBT and ST are also popular. Unfortunately, DBT is an expensive treatment costing $ 687/month and a total of $ 8,000 per patient. If we were to organise DBT for every single Australian with BPD (taking 1% prevalence rates and 24 million populations) we need about $ 2 billion.

Although it has been well demonstrated internationally that it is cost effective to treat rather than not treat BPD, it is not easy to convince the funding bodies to come up with a new funding of $ 2 billion to treat BPD with treatments such as DBT. It is also unclear if DBT should be the treatment of choice as it is not a treatment accepted by all patients or clinicians.

We now have some evidence that there may be other less expensive treatments that are equally effective (e.g. Good Clinical Care, Structured Clinical Management, General Psychiatric Management etc.). However some experts believe that we should stick to well established evidenced based treatments such as DBT, MBT etc.

Further we do not have well-articulated models of care for management and treatment of BPD. In its absence patients often receive chaotic and non-evidence based care.

Tolkien II Report (by Gavin Andrews 2010 for WHO) stated that we currently treat 15% of BPD patients and in a chaotic manner. The report suggested that ideal treatment would be with a 30% coverage using a stepped care approach from GP to Specialist care. However this recommendation is less ambitious.

In summary BPD patients face stigma, discrimination, rejection and labelling. Care is usually limited to management in Emergency Departments, psychiatry in-patient facilities and CATT teams. People diagnosed with BPD are also often excluded from treatment at Emergency Departments and crisis services leaving their families to struggle on their own which often jeopardizes the health and well-being of families/carers. Of those who are able to access Emergency Departments, psychiatric in-patient facilities and CATT teams they often receive management only and not psychotherapeutic treatments that have the capacity to actually help them recover.

Please email your thoughts, comments, and feedback to bpd_national_strategy@bpdfoundation.org.au

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