Summary of the impact

People with personality disorders (PD) have enduring and serious difficulties in relating to others and their treatment remains one of the most challenging areas in psychiatry. Until recently, service provision for such individuals was extremely variable in both quality and quantity. Research at King's College London (KCL) has helped highlight the considerable public health and economic impacts of personality disorders and has had a significant impact on current treatment guidelines in the UK. KCL research also led to the development of a brief and simple screening test for personality disorders — the Standard Assessment of Personality Abbreviated Scale (SAPAS) — which is now recommended for use in the UK Government's Improving Access to Psychological Therapies initiative, under which nearly a million patients a year are seen.

Underpinning research

Individuals with a personality disorder (PD) show an enduring pattern of inner experience and behaviour that deviates markedly from cultural expectations. The term `personality disorder' covers a broad diagnostic group and several subtypes of individuals with PD are recognised. These individuals differ with respect to symptom profiles but share the common defining feature of having enduring and serious difficulties in relating to others. Between 1998 and 2000, research carried out at Institute of Psychiatry, King's College London (KCL) by Dr Paul Moran (2001-present, Clinical Senior Lecturer) and colleagues under the supervision of Prof Anthony Mann (1983-2013, Professor of Epidemiological Psychiatry) determined the prevalence and health outcomes of personality disorder (PD) and helped bring a neglected area of mental health into sharp focus.

KCL research highlights the prevalence of PD in primary care attenders

In 2000, KCL researchers led the first study of PD in primary care attenders, an important population since most mental health disorders are managed in primary care. Out of 303 UK primary care attenders studied, 24% met research criteria for PD (including PD categories of obsessive-compulsive, impulsive, paranoid and anxious) and were significantly more likely to have depression and anxiety and to attend GP surgeries on an emergency basis (1). At one year follow-up, a research rating of PD was associated with a doubling in the odds of frequent attendance to general practice (2). A KCL-led economic evaluation of the same cohort showed that over the course of a year, the mean total cost for patients with PD was £3,094 compared to £1,633 for those without PD. A significant interaction was found between the presence of PD and common mental disorder, with the presence of both conditions leading to significantly elevated economic costs (3).

PD association with unmet needs and the development of a simple PD screening test

Subsequent research by KCL investigated the level of unmet need, physical health problems, violence and suicidal behaviour amongst individuals with PD. In a 2006 study of 153 psychiatric inpatients in four acute hospital wards (54% of whom had a PD), the presence of PD was significantly associated with greater unmet need (4). A study of 8,580 adults aged 16-74 showed that the odds of reporting a stroke were almost doubled among individuals with any type of PD (5). KCL researchers screened 670 patients with psychotic illness for PD and evaluated their behaviour over a 2-year period. Over a quarter were rated as having co-morbid PD and these individuals were significantly more likely to behave violently (6) and to attempt or complete suicide (7) over the follow-up period, even after accounting for the effects of known risk factors for violence and suicide.

KCL researchers recognised the need for a brief and simple screening test for PD that can be used in routine psychiatric assessments and led the development and validity testing of the Standard Assessment of Personality Abbreviated Scale (SAPAS). The SAPAS was tested in 60 psychiatric patients and found to correctly predict the presence of PD in 90% of participants with a high level of sensitivity and specificity (8).

References to the research

Grants

• A Mann (PI). The added burden of personality disorder in primary care. NHS Executive 1999-2000. £43,486

• Studentship for Alison Rendu (primary supervisor: Prof A Mann). Medical Research Council. 1998-2001. £33,490.

• P Moran, G Thornicroft (PI). Postdoctoral fellowship for Dr Moran: differential access to services for individuals with severe personality disorder. Department of Health. 2001-2004. £186,073

Details of the impact

As a result of the research conducted at King's College London (KCL), personality disorders (PD) are now recognised as major mental health problems associated with considerable public health burden. The body of epidemiological research into these disorders led by KCL has been influential in helping to shape Government policy and service development for people with PD.

KCL research impacts national treatment guidelines

Research by KCL contributed to the two current NICE guidelines on personality disorders. The 2009 NICE guideline on the treatment of Borderline Personality Disorder cites the research on the prevalence of PD in primary care, the levels of service use and economic impact (Moran et al. 2000; Moran et al. 2001; Rendu et al. 2002). Dr Moran was also a member of the Guideline Development Group (1a). In addition, the epidemiological research of Moran et al. 2000 is cited in the 2010 NICE guideline on the treatment, management and prevention of Antisocial Personality Disorder (1b). Both guidelines have had a significant impact on the treatment and care that individuals with PD receive from the NHS and have been used to implement services, for example the NHS Forth Valley Integrated Care Pathway for Borderline Personality Disorder (1c) and the Norfolk and Suffolk personality disorder strategy which references both NICE guidelines (1d).

KCL research impacts on policy

In 2008, Dr Moran authored the UK Government's `State of Science Review' on personality disorders as part of the Government's Office for Science Foresight project on Mental Capital and Wellbeing. The KCL primary care research and the accompanying economic analysis (Moran et al. 2000; Moran P et al. 2001; Rendu et al. 2002) were all cited in the Foresight review (2a). This document provides an independent review of the latest scientific evidence to help policy makers tackle complex issues. For example, the review of personality disorders, commissioned by the Health and Social Care Board at the Public Health Agency in Northern Ireland cites the State of Science Review as evidence (2b).

In 2008, the King's Fund, a leading UK healthcare think tank, published a major review of mental health expenditure in England to 2026. The Report uses KCL research on the economic impact of PD in primary care (Rendu et al. 2002) to calculate the projected total service costs for PD which they estimate to rise from £704m for those in contact with primary care to £1.1b in 2026 (3).

KCL measures improve screening for Personality Disorders around the world

On the basis of its ease of administration, good psychometric properties and clinical utility, the Standard Assessment of Personality Abbreviated Scale (SAPAS) has had a significant and wide reaching impact on practitioners and services. It has been translated into Danish (4a), Dutch (4b) and French (4c) and has been used in the 2013 Danish National Health Survey (4d). It has been recommended by BMJ Evidence Centre Best Practice (4e) as an appropriate PD screen for primary care patients with co-morbid psychiatric conditions. Following a study by colleagues at the University of Lincoln, the SAPAS was tested for validity in a probationer population (4f) and recommended by the UK Ministry of Justice in its practitioner's guide for personality disorders (4g). The SAPAS is also used in continuing professional development for nurse practitioners, for example in the USA (4h) through RN.com, a nursing resource provider whose training material cites KCL research (Moran P, et al. Br J Psychiatry, 2003).

Established in 2008, the UK's Improving Access to Psychological Therapies (IAPT) aimed to improve access to NICE compliant psychological interventions for people with common mental health problems, principally depression and anxiety disorders. In 2011, the programme broadened its remit to include the management of severe mental illness (SMI) including PD. Nearly a million UK patients a year are seen under the remit of IAPT. Chaired by the IAPT National Advisors for SMI, an event for 120 stakeholders highlighted the need for an appropriate screening tool, such as SAPAS, for practitioners to use. SAPAS was already in use in IAPT sites in London and the South West (5a) and was subsequently recommended as the ideal tool for adoption by the IAPT SMI national demonstration sites (5b).

Sources to corroborate the impact

1) NICE Guidelines

a. British Psychological Society & Royal College of Psychiatrists. Borderline Personality Disorder: The NICE Guideline on Treatment and Management. Leicester & London: British Psychological Society & Royal College of Psychiatrists; 2009.
http://www.nice.org.uk/nicemedia/live/12125/43045/43045.pdf

b. British Psychological Society & Royal College of Psychiatrists. Antisocial Personality Disorder: The NICE Guideline on Treatment and Management. Leicester & London: British Psychological Society & Royal College of Psychiatrists; 2010.
http://www.nice.org.uk/nicemedia/pdf/CG077FullGuideline.pdf

c. NHS Forth Valley Care Pathway for Borderline Personality Disorder (2011)
http://www.nhsforthvalley.com/__documents/qi/CE_Guideline_MentalHealth/BorderlinePersonal ityDisorderICP.pdf

d. Norfolk and Suffolk NHS Personality Disorder Strategy 2013-2017
http://www.nsft.nhs.uk/Global/About%20Us/Board%20of%20Directors'%20papers/2013%2 0Feb%20BoD/Att%20H%20-%20%20PD%20Strategy%2005%2002%2013%20Version%207.pdf

2) Foresight

a. UK Government's Foresight Project on Mental Capital & Wellbeing, 2008):
http://www.bis.gov.uk/assets/bispartners/foresight/docs/mental-capital/sr-b10_mcw.pdf

b. Rapid Review in Personality Disorders, Report commissioned by the HSC Research & Development Division, Public Health Agency; in conjunction with the Health and Social Care Board, and the Department of Health, Social Services and Public Safety (Northern Ireland)
http://www.publichealth.hscni.net/sites/default/files/Rapid%20Review%20Personality%20Di sorders_1.pdf

3) King's Fund: Paying the Price — The cost of mental health care in England to 2026 (2008): http://www.kingsfund.org.uk/sites/files/kf/Paying-the-Price-the-cost-of-mental-health-care-England- 2026-McCrone-Dhanasiri-Patel-Knapp-Lawton-Smith-Kings-Fund-May-2008_0.pdf

4) Impact of SAPAS

a. SAPAS used in Denmark: Hesse, M. et al. Standardised assessment of personality — a study of validity and reliability in substance abusers. BMC Psychiatry (2008) doi:10.1186/1471-244X-8-7

b. SAPAS used in The Netherlands: Germans S. et al. The Self-report Standardized Assessment of Personality-abbreviated Scale: Preliminary results of a brief screening test for personality disorders. Personality and Mental Health 2008;2:70-6. Doi: 10.1002/pmh.34

c. SAPAS used in France: Gorwood P. Treatment response in major depression: effects of personality dysfunction and prior depression. Br J Psychiatry 2010;196,139-142. doi: 10.1192/bjp.bp.109.067058

d. Danish National Health Survey 2013 — Hvordan har du det? (PDF available on request)

e. BMJ Evidence Centre: Best Practice — Personality Disorders:
http://bestpractice.bmj.com/best-practice/monograph/489/diagnosis/step-by-step.html

f. Pluck G, et al. Screening for personality disorder in probationers: Validation of the Standardised Assessment of Personality—Abbreviated Scale (SAPAS). Personal Ment Health 2012;6:61-8. Doi 10.1002/pmh.177

g. Ministry of Justice: Working with personality-disordered offenders, a practitioners guide:
http://www.justice.gov.uk/downloads/offenders/mentally-disordered-offenders/working-with- personality-disordered-offenders.pdf

h. Used in continuing professional development for nurse practitioners in the USA:
http://www.rn.com/getpdf.php/1734.pdf?Main_Session=d922441669a1cd6f1e2deda4d8a2b7e8

5) Improving Access to Psychological Therapies (IAPT) for Severe Mental Illness (SMI)

a. Reference to the adoption of the SAPAS in London and SW England at IAPT stakeholder event; 23^rd November 2011: http://www.iapt.nhs.uk/silo/files/smi-stakeholder-eventreport--final-version.pdf

b. Guide for SMI demonstration sites: http://www.iapt.nhs.uk/silo/files/guide-for-smi-demonstration-site-application.pdf