Ashley Smith: BPD in our Community
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Transcript of Ashley Smith: BPD in our Community
Ashley Smith:BPD in our Community
Ronald Fraser, MD, CSPQ, FRCPCAssistant Professor
Department of PsychiatryMcGill University
Dalhousie University
History• Ashley Smith born
January 29, 1989 in NB, adopted at age 5 days
• Reportedly uneventful childhood
• Age 13-14: distinct behavioral change
• By age 15: 14 appearances before juvenile court for petty crimes
• Multiple suspensions from school
History
• Initial assessment in March 2002 – no evidence of mental illness
• Second assessment in March 2003:– ADHD– Learning Disability– Borderline Personality Disorder with Narcissistic
traits
History
• 2003-2006 – remanded numerous times to NB Youth Center– Initial charge at age 14 for throwing crab apples– Assaulting guards, pranks like setting off sprinklers
and fire alarms – 50 additional charges• > 800 incidents and minimum of 150 attempts
to self-harm– Self-strangulation and self-mutilation
History
• February 23, 2005 – enters system for the final time at age 17
• January 2006, she turned 18• October 2006 – transferred to adult
correctional system
History
• October 5, 2006 – SJRCC – mostly in segregation due to out of control behavior– Tasered twice, pepper sprayed once
• October 26, 2006 – transferred to federal system and Nova Institute
• Over the next 11 months she was transferred 17 times amongst 8 federal institutions
History
• October 16, 2007 –she requested transfer to a psychiatric facility
• October 18, 2007 – placed on suicide watch• October 19, 2007 – died in custody
• 2011 Inquest• 2012 Inquest– Homicide but no liability
What is Borderline Personality Disorder?
Symptoms of BPD• Erratic mood swings; intense anger
– Living without an “emotional skin”
• Chaotic relationships; interpersonal problems • Self-mutilation & suicide• Substances, gambling, reckless driving, sex• Distortions in thinking; transient paranoia
Etiology• Bio-psycho-social vulnerability factors– Biological – Psychosocial
• Diagnosed in adolescence, early adulthood• 75% in treatment for BPD are women
Prognosis• The bad news: – Can be among the most difficult disorders to
treat because common sense approaches can backfire
• The good news: – Individuals with BPD get better when treated
with evidence-base therapies and interventions– True in clinical contexts and in the community
Community prevalence• 10-13% prevalence of personality disorders• 2% BPD (American Psychiatric Association, 2000)
• In Quebec, estimation of 84,000 citizens
In mental health services• 10-15% in emergency • 40% in inpatient services • Increased drugs & alcohol abuse• Self-mutilation – 24,437 seen in Ontario emergencies (Stats Canada, 2009)
• Suicides involving a diagnosis of BPD – 25% of adult suicides – 33% of youth suicides
Psychosocial services• Youth protection services
– 50% of mothers with BPD traits (Perepletchikova et al., 2010)
• 360 mothers in Centre jeunesse de Montreal only
– Many adolescents followed by protective services
Judicial system• 2.2 million youths arrested in 2003
• 60% in court procedure have mental illness– the majority, personality disorders
• 70-85% of crimes involve a personality disorder diagnosis• Familicide in Quebec 1986-2000 (Léveillé et al., 2007)
– 37.5% BPD traits– 18.8% had BPD
Why is BPD so costly?
BPD costs economy millionsThe personal costs of BPD have a domino
effect
How?
Familial Costs
• Divorce• Child custody cases• Domestic abuse, child abuse/neglect• Childhood psychiatric problems
BPD costs economy millionsHow?
Medical &
Psychiatric Costs
• Emergency visits• Inpatient care, hospitalizations• Increased use of addiction services• Premature death• Misdiagnosis
34% wrong diagnosis, 74% never diagnosed
• Medication 67% on medications, 33% more than 1
*** None have demonstrated clear benefit ***
BPD costs economy millions
How?
Legal &
PsychosocialCosts
• Crime• Police involvement (domestic disputes)• Court procedures• Prison services • Judicial recidivism• Malpractice suits
BPD costs economy millions
How?
Lost Productivity Costs
• Unemployment• Underemployment• Absenteeism• Leave of absence • Dependency on public support
BPD costs economy millions“The social costs and disruptions caused by PDs is disproportionate to the amount of attention this disorder gets in public consciousness, in government research and clinical funding, in medical and graduate school, and in psychiatric residency training”
Frances, Paris, & Reugg, 2006
Case vignette
Case vignette: Chantal
1999 (26 years old) • Begins heavy resource use• Numerous ER visits• Multiple hospitalizations• Numerous psychotherapies• Poly medications
1995 - 2005
Medications• Risperidal, Zyprexa, Seroquel, Largactil, Haldol, Nozinan
• Remeron, Effexor, Parnate, Nardil, Prozac, Paxil, Celexa, Wellbutrin, Serzone, Nortriptyline, Imipramine
• Lithium, Epival, Tegretol, Topamax, Neurontin, Lamictal
• Ritalin, Ativan, Rivotril, Valium
Case vignette: 1995 - 2005
Case vignette: Chantal1995 - 2005
• Treatments– ECT– Weekly individual psychotherapy – Twice weekly group psychotherapy – Extremely close psychiatric follow-up
Case vignette: Chantal2005-2008• Entered specialized BPD program– Weekly individual and group therapy
• Psychiatric follow-up each 2-4 weeks • 3 medications – Clozapine, Mipramine, Seroquel
Case vignette: Chantal
Cost
2002 – 2005
$272,000
2006 – 2008
$0
Case vignette: Chantal
Cost
2002 – 2005
$17,000
2006 – 2008
$0
Case vignette: ChantalSince discharge in August 2008• No psychotherapy• Psychiatric follow-up each 4-8 weeks
MUHC patients with BPD
2004 2008
Cost related to emergency room visits
$96,500 $12,000
Number of patients hospitalized
34 5
Cost related to days of hospitalization
$432,000 $69,000
Before and after specialized program
What is the solution?
What is needed?• Knowledge • Skills • Teaching and Training• Research
Or, a website that provides a doorway to all of the above
Who can benefit?• Health providers and clinicians• Students
– 30% of continuing medical education via Internet (2008)
– Effective
– Cost efficient
– Evidence-based medical decision making
– Formal E-learning virtually nil in BPD
– Language issue
Who can benefit?• Police, legal practitioners
• Youth Protection Services interveners
• Community workers
• Schools
• Unions
• Government agencies and others
How can it benefit?• Change perceptions of BPD• Training to deliver superior services• Help all those that interface with BPD• Help streamline service delivery systems• Increase knowledge at all levels• Save money
Return on investment• A web site is cost-effective• Implication for the plan d’action• National & international potential• Quebec as innovative leader
Why are we the best• Clinical expertise– experience– outcomes– excellence
• Teaching excellence• McGill: a leader in RUIS standards of care• McGill’s international reputation• McGill has done this before
Thank You