Collaborative Care for patients with severe personality disorders: a comparative multiple case study on process and outcomes.

A personality disorder is a severe and complex psychiatric disorder. The
lifetime prevalence of personality disorders is 9-14% in the general
population, whereas as much as 60% of patients in specialized mental health
care and 56% of patients with an addiction have at least one personality
disorder (Multidisciplinaire Richtlijn Persoonlijkheidsstoornissen, 2008; Tyrer
& Mulder, 2006).
Structured psychotherapy is recommended as the preferred treatment of
personality disorders since studies mainly report modest positive results
(Bateman & Fonagy, 2008, 2001; Linehan e.a., 2006; Binks e.a., 2006;
Giesen-Bloo e.a., 2006; Van de Bosch, 2005; Leichsenring & Leibing, 2003;
Verheul e.a., 2003). Although these therapies are aimed at the complex problems
of personality disorders, a substantial group of patients does not benefit.
These patients have a chronic and unstable course of illness with disruptive
behaviour and addiction problems. They experience severe suffering, especially
those who have been treated with several (unsuccessful) therapies and with an
elevated risk of suicide (van Luyn, 2007; Paris, 2007). They often receive long
lasting care in specialized mental health care institutes (Koekkoek e.a., 2007;
van Meekeren, 2009).
However, these patients may benefit from Collaborative Care; a structured
approach, with a central role for the nurse, with emphasis on the quality of
the communication and the reduction of health care needs, problems and
problematic behaviour. We expect that this intervention strategy will improve
quality of life and coping with (chronic) suicidal behaviour, psychiatric
illness, addiction and daily problems (De Bie e.a., 2009; Koekkoek e.a.,
2009).

The objective of this study is to describe the process of application as well
as the outcomes of a Collaborative Care program provided for patients with
severe personality disorders in specialized mental health care.
The following research questions are formulated:
A. What are the results of a Collaborative Care program for patients with a
personality disorder with regard to suicidality, self harm, addiction,
psychosocial functioning and quality of life?
B. What are the experiences of patients, family members and nurses with the
Collaborative Care program?
C. Which factors hamper or foster the application of a Collaborative Care
program, as described by patients, family and nurses?

The present study is a comparative multiple case study conducted within the
specialized mental health care institute GGZ inGeest, located in Amsterdam and
surrounding areas, and contains an experimental group in which the
Collaborative Care program is provided and a control group in which Care as
Usual is provided. A distinctive feature of a multiple case study is, that data
are collected and analyzed at the individual level as well as the group level.
Different types of data collection will be used: questionnaires, dossier
research and interviews. By means of data triangulation a profound
understanding will be obtained of the results and the processes of the
Collaborative Care program.

Collaborative Care is a care arrangement in which a collaborative care manager
(nurse) has a central role in optimizing coordination and continuation of care.
The strong emphasis on collaboration in all stages of the care process * with
the active involvement of the patient * should empower the patient in coping
with his illness and life in general. *Contracting* is used to reach a shared
decision on treatment goals and working methods. The treatment components which
are provided within Collaborative Care enhance problem solving skills regarding
rumination, impulsivity and emotion-management. (Para) suicidal behaviour will
be systematically registered and discussed with the patient. The mental
condition of the individual patient will be monitored by means of Routine
Outcome Monitoring (ROM).
Nurses in the experimental group will be trained in their role as collaborative
care manager and in the application of these special Collaborative Care
interventions. The application of the intervention will be supported with
intervision and coaching.

Possible advantages of participation in this study
We expect that patients will be better able to cope with their problems and
illness. We do not know for sure that this outcome will be obtained: that is
the reason to conduct this research.

Disadvantages of participation in this study
Patients will be asked to complete questionnaires three times during the study.
This will cost 4 hours during the first session, during the second (after 6
months) and third session (after 12 months) this will cost 1,5 hours. Partly
the questionnaires will be completed with the help of a research assistent,
partly the patient can complete the questionnaires in their home setting in
their preferred time. In the experimental group a questionnaire will be
completed every session, this will cost a very limited amount of time and
effort.