Title: Low-intensity intervention for people with personality disorder: development of a practice-based protocol and feasibility study.
Funder: Department of Health and Social Care

Abstract: Background to the research Personality disorders are long-term mental health conditions which can lead to social exclusion, suicidal behaviour and impaired quality of life. Costs of caring for people with personality are high as a result of attendance at emergency departments and inpatient treatment during emotional crises or following deliberate self-harm. No drugs are licensed for personality disorder; instead current national guidelines recommend intensive psychological treatments delivered over a 12 or 18 month period. Few people are able to access these treatments and many of those that do, drop out of them before they have been completed. In recent years evidence from other countries has suggested that less intensive interventions based on psychoeducation, psychological support and promoting self-management can help people with personality disorder. Mental health services in the UK have started to deliver less intensive interventions but it is unclear what the optimal content of these are, and evidence to support their delivery in the NHS does not exist. Study aims (the questions to be addressed) This study will examine the optimal form and content of a low-intensity intervention for people with personality disorder and examine the feasibility of conducting a randomized trial to examine the clinical and cost effectiveness of this intervention. The study will generate information about what works best for people with personality disorder who are referred to mental health services and will provide data needed to design a future trial of this promising approach to helping people with this condition. Plan of investigation A researcher with lived experience of using services for people with personality disorder will collect data from staff, patients and carers at four different Trusts in London that are already delivering low intensity interventions for people with this condition. We will present these data alongside the results of extant research to an expert panel of patients, carers and front-line staff who will develop consensus-based recommendations on the optimal form and content of a low-intensity intervention for people with personality disorder. In a subsequent feasibility study, six mental health teams will be randomized to an active (low-intensity intervention) or control (usual care) arm of the trial. Staff who are already working with people with personality disorder will be trained to deliver the low-intensity intervention. Patients meeting study inclusion criteria will be assessed at baseline and three and six months later using measures of mental health, social functioning, health-related quality of life and service utilisation. Qualitative and quantitative data collected during the trial will be used to examine the acceptability of study methods and the feasibility of the study design. Summary of the potential benefits to patients and the NHS This study will generate a practice-based protocol for a low intensity intervention for people with personality disorder that builds on the best features of existing interventions. The study will also establish the feasibility of a randomised trial of this intervention. If the feasibility study achieves pre-specified progression criteria we will seek funding for a full-scale trial of a promising intervention which has the potential to increase the proportion of people with personality disorder who receive an evidence based intervention that improves mental health and quality of life and reduce costs of care for people with this long term condition.

Lay abstract: Personality disorder is a long-term condition characterised by difficulties in relationships, poor mental health and social exclusion. People with personality disorder have high levels of contact with health services but the care they receive is frequently poor. For other mental health conditions a stepped-care approach is often used in which people receive short-term interventions and only those who do not benefit from these are referred on for more intensive and costly treatments. However, for people with personality disorder, we do not know what the best approach is to delivering these low-intensity interventions. While long-term psychological treatment helps some people with personality disorder, most people are unable to commit to attending these lengthy and intensive treatment programmes. Research conducted in the United States suggests that less intensive interventions based on psychoeducation and psychological support can also be helpful, but we do not know if this approach works for people using NHS services. We are a group of clinicians, researchers and service users who have designed a study that would generate guidance on the best approach to delivering a low intensity intervention for people with personality disorder. We will interview patients, carers and front-line staff about their experiences of what is most helpful and present this information to an expert panel who will help us generate guidelines on how low intensity interventions are best delivered. We will then test whether a clinical trial can be used to examine the effectiveness of this intervention. If shown to be effective this approach could greatly increase the number of people with personality disorder who receive an evidence based intervention. This study has the potential to improve people s health and quality of life and reduce the high costs associated with helping people with this common and disabling condition.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH