Introduction
People diagnosed with personality disorders have enduring difficulties in their ways of thinking, feeling, and behaving that cause serious disruption to their ability to function in society and usually a significant degree of distress. There is increasing recognition of the need for trauma-informed care in Ireland, and the role of childhood trauma in the development of personality disorders is well documented (Zanarini and Frankenburg, Reference Zanarini and Frankenburg1997). Historically people with personality disorders have been stigmatised and treated at the margins of health services, often ineffectually. Ireland’s current National Mental Health Policy, ‘Sharing the Vision’, launched in 2020, does not refer to services for individuals diagnosed with personality disorder at all. There is no national treatment programme (College of Psychiatrists of Ireland (CPSYCHI) 2021), and the national suicide prevention strategy and programme for self-harm (Department of Health, 2014) do not explicitly address these needs beyond suggesting Dialectical Behaviour Therapy (DBT) for self-harm. This gap in recognition and service provision persists despite significant advancements in effective treatments for people with personality disorder over the last few decades (Chanen et al. Reference Chanen, Sharp and Hoffman2017). Personality disorders are the fourth leading cause of disease burden among all mental disorders across all ages (Chanen et al. Reference Chanen, Betts, Jackson, Cotton, Gleeson, Davey, Thompson, Perera, Rayner, Chong and McCuthcheon2022). Families of people with personality disorder struggle with significantly elevated levels of distress, negative caregiving experiences and maladaptive coping strategies (Seigerman et al. Reference Seigerman, Betts, Hulbert, McKechnie, Rayner, Jovev, Cotton, McCuthcheon, McNab, Burke and Chanen2020). Those diagnosed with borderline personality disorder have a 10% lifetime mortality from suicide, which is greater than that for depression (Paris and Zweig Frank, Reference Paris and Zweig Frank2001).
Ireland’s previous mental health policy ‘A Vision for Change’ did make specific suggestions for treatment of borderline personality disorder (BPD). It suggested that centralised services be established for severe BPD and that this could be in the form of dedicated DBT teams (Department of Health, 2006). The National DBT Project was established in 2013 with the main objective to implement DBT in community mental health services across Ireland (The National DBT Project 2013). It is unfortunate that our current mental health policy does not attempt to build on this progress. A Model of Care for talking therapies was published in 2021 by the Health Service Executive (HSE) Mental Health Services. It recommends collaborative multi-layered delivery of therapies, with highly specialised interventions for patients with severe and complex presentations such as personality disorder. However, it does not make any specific therapy recommendations or broader suggestions for service delivery (HSE Mental Health Services, 2021).
In 2021, the College of Psychiatrists of Ireland approved a position paper on ‘The development of services for treatment of personality disorder in Adult Mental Health Services’ prepared by the college’s Personality Disorders Special Interest Group (PDSIG). The paper recommended that the HSE develop a national strategy to provide evidence-based treatment for personality disorders; however, the PDSIG has had limited engagement from the HSE since its publication. The PDSIG now aims to build on the position paper by developing proposals for a national treatment strategy. As part of this effort, we examined international evidence and guidelines for personality disorder treatment. This included key review papers and policies and guidelines developed in other English-speaking countries specifically Northern Ireland, England, Australia and the USA. The focus of this examination was on how to develop and deliver personality disorder services more so than specific treatment modalities. This editorial will highlight our key findings from the literature, which are also summarised in Table 1 below.
England
The UK was one of the first countries in Europe to develop a policy document on the development of national personality disorder services. In 2003, the National Institute for Mental Health in England (NIMH(E)) published ‘Personality Disorder: no longer a diagnosis of exclusion’ (NIMHE, 2003). This report highlighted the lack of dedicated services for personality disorders in England and recommended the establishment of specialist community services (Zhan Yuen Wong et al. Reference Zhan Yuen Wong, Barnett, Sheridan Rains, Johnson and Billings2023). Since its publication, various reports, policies, strategies, and frameworks focusing on personality disorders have followed in the UK (Dale et al. Reference Dale, Sethi, Stanton, Evans, Barnicot, Sedgwick, Goldsack, Doran, Shoolbred, Samele, Urquia, Haigh and Moran2017). In 2009 specific guidelines on borderline personality disorder and antisocial personality disorder were published in England by the National Institute for Health and Clinical Excellence (NICE, 2009). Services in England are regularly reviewed with a national survey in 2017 finding an overall increase in service provision but variability in access to services (Royal College of Psychiatrists (RCPsych), 2020). Similar to our college, in 2020, the Royal College of Psychiatrists in the UK issued a position statement titled ‘Services for people diagnosable with personality disorder’, which outlined further necessary services to deliver high-quality treatment. The premise of this statement is that personality disorder services should be tiered, depending on diagnosis severity, with increasing intensity of intervention and reducing number of patients in the consecutively higher tiers (RCPsych, 2020).
Northern Ireland
Influenced by developments in the rest of the UK, Northern Ireland first published a strategy document in 2010 titled ‘Personality Disorder: A Diagnosis for Inclusion’ (Department of Health Social Services and Public Safety, 2010). It also proposed a tiered model of care for personality disorders. Tiered service provision, joint regional training and a care pathway were subsequently established (McCartan and Davidson, Reference McCartan and Davidson2020). Similar to England, these services are regularly reviewed. In 2020 the Department of Health advised the 2010 strategy be closed and the ongoing need for service development would be included in a new 10-year Mental Health Strategy for Northern Ireland. (McCartan and Davidson, Reference McCartan and Davidson2020).
Australia
The Mental Health Commission in Australia commissioned a report to identify treatment and support availability for people with personality disorders nationally in 2018 (Carrotte and Blanchard, Reference Carrotte and Blanchard2018). This report made recommendations on research, policy and practice efforts to support Australians affected by personality disorder. A statewide model of care for personality disorder was published for Western Australia in 2020. This model of care was developed through a co-design process led by people with lived experience and drew on findings of a literature review, stakeholder engagement and service mapping (Western Australian Association for Mental Health (WAAMH), 2020).
United States of America
The USA does not have an identifiable national treatment strategy for personality disorder. The American Psychiatric Association (APA) published updated guidelines for the treatment of borderline personality disorder in October 2023 (APA, 2023). It includes recommendations for the assessment, treatment, prevention and screening of personality disorders. Key recommendations include comprehensive assessment, quantification of severity, collaboration with patients, person-centred treatment plans, psychoeducation, evidence-based structured psychotherapy and early intervention.
Published literature
We searched bibliographic databases for original research on models of care for personality disorders but found few papers. A few relevant literature reviews have been completed. A 2022 scoping review found limited evidence on providing quality treatment for people with ‘complex emotional needs (CEN)’, an alternative term used for those with personality disorders. It advocated for more research on overall service delivery models, not just specialist therapies (Ledden et al. Reference Ledden, Rains, Schliff, Barnett, Ching, Hallam, Gunak, Steare, Parker, Labovitch, Oram, Pilling and Johnson2022).
The European Society for the Study of Personality Disorders (ESSPD) completed a review of European guidelines on personality disorder treatment in 2018. It identified inconsistencies between guidelines, attributing this to lack of methodological rigour in their development. It made recommendations for future guideline development, including evidence-based recommendations, capturing patient and carer views, focus on all types of personality disorder and cross-collaboration in Europe (Simonsen et al. Reference Simonsen, Bateman, Bohus, Dalewijk, Doering, Kaera, Moran, Renneberg, Ribaudi, Taubner, Wilberg and Mehlum2019).
A systematic review was conducted in 2023 by Zhan Yuen Wong et al., summarising guidelines for personality disorder treatment and management from the UK, Australia, Netherlands, Spain, USA, Denmark, Finland, Switzerland, Italy, Canada and Sweden. It summarised consensus recommendations from these guidelines under four domains as follows:
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Recipients of services: Highlighting the importance of continuity of care and planned transitions between services, ensuring early intervention and equity of access to services.
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Service delivery: Emphasising developing specialist services to manage complex cases and provide training to other services and wider public education. These services should be multidisciplinary trauma-informed, offer out-of-hours access and collaborate with patients and families.
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Staff: Staff should be adequately trained, skilled in forming therapeutic relationships and receive support and supervision.
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Treatment: Services should adopt a tiered model of care with treatments that are evidence-based and flexible to meet patient’s needs and preferences. Interventions should be routinely reviewed for effectiveness. Pharmacotherapy is not recommended to treat personality disorders on its own.
Conclusion
Many countries have developed a national treatment strategy for personality disorders at government level. The process of developing a strategy is extensive and involves literature review, service user and carer input, key stakeholder engagement, evaluation of the current service landscape and regular review. The Irish government is lagging behind other developed nations in its lack of acknowledgement of personality disorder as a public health issue in current policy and delivery of a national treatment strategy. Although progress has been made through the National DBT Project and the Model of Care for Talking Therapies, evidence suggests there needs to be more attention on models of service delivery rather than simply focusing on specific psychotherapies (Ledden et al. Reference Ledden, Rains, Schliff, Barnett, Ching, Hallam, Gunak, Steare, Parker, Labovitch, Oram, Pilling and Johnson2022).
Recognising the deficits in service provision, the College of Psychiatrists of Ireland published a position paper recommending developing a national evidence-based strategy for personality disorders in line with the guidance and landscape of services available internationally (CPSYCHI, 2021). Unfortunately, since the position paper was published the College of Psychiatrists of Ireland has had limited engagement from the HSE and has received no support or funding in its efforts to develop a national treatment strategy. Despite this, the College of Psychiatrists of Ireland is committed to progressing this objective, and we next plan to repeat a survey of existing services for personality disorder in adult mental health services in Ireland. The PDSIG then plans to develop a proposed national treatment strategy informed by the results of the survey and evidence from the literature.
Comprehensive literature reviews have evaluated international guidance on treatment of personality disorders and report a gap in research in this area, particularly regarding holistic models of care (Bateman and Tyrer, Reference Bateman and Tyrer2004). Although there is no internationally agreed consensus on the best treatment pathways for people with personality disorders, a systematic review by Zhan Yuen Wong et al. (Reference Zhan Yuen Wong, Barnett, Sheridan Rains, Johnson and Billings2023) has summarised common themes from international guidelines. These themes include access to services, continuity of care, a multidisciplinary approach, a tiered model of care, service-user collaboration in treatment, staff training and supervision, and delivery of evidence-based interventions. These should serve as the basis for developing a national treatment strategy in Ireland.
Summary of key treatment strategies from national and international literature
Funding statement
There are no relevant financial or non-financial competing interests to report in preparation of this editorial.
Competing interests
There are no conflicts of interest to report.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
