دانلود رایگان مقاله انگلیسی مدل مدیریت بحران استاندارد برای خودزنی و خودکشی با چند معیار تشخیص اختلال شخصیت مرزی - NCBI 2017

Abstract

Background: Brief Admission is a crisis and risk management strategy in which self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder self-admit to hospital at times of increasing risk when other efforts to stay safe are failing. Standardized in the current randomized controlled trial, the intensity of Brief Admission Skåne is implemented in durations of three days, with a maximum frequency of three times a month. Brief Admission is integrated into existing treatment plans in advance of crises to prevent reliance on general psychiatric admissions for risk management, as these may be lengthy, unstructured, and of uncertain therapeutic value. Methods/design: The overall objective of the Brief Admission Skåne randomized controlled trial is to determine if Brief Admission can replace general psychiatric admission for self-harming and suicidal individuals with complex mental illness at times of escalating risk. Other objectives of the study are to evaluate whether Brief Admission increases daily functioning and enhances coping, reduces psychiatric symptoms including frequency and severity of self-harm and suicidal behaviours. A final objective is to determine if Brief Admission is an effective crisis management model for this population. Participants are randomized at an individual level to either Brief Admission Skåne plus Treatment as Usual or Treatment As Usual. Based on a priori power analyses, N = 124 participants will be recruited to the study. Data collection is in progress, and will continue until June 2018. All participant data are single-blinded and will be handled with intention-to-treat analysis. Discussion: Based on the combined clinical experience of our international research group, the Brief Admission Skåne randomized controlled trial upon which the current protocol is based represents the first initiative to standardize, implement and evaluate Brief Admission amongst self-harming and suicidal individuals, including those with borderline traits. Objectively measuring protocol fidelity and developing English-language Brief Admission study protocols and training materials are implementation and dissemination targets developed in order to facilitate adherent international export of Brief Admission Skåne.

Discussion

Brief Admission (BA) is an adjunctive treatment in which individuals can engage alongside specialized evidence-based psychotherapy offered on an outpatient basis. As a concurrent structured respite plan, BA has been well received by individuals and care providers for more than 20 years in the Netherlands [17] as a crisis management approach for individuals with a BPD. The Brief Admission Skåne (BAS) randomized controlled trial upon which the current protocol is based represents the first international effort to standardize, export, and implement BA into a different language, cultural setting, and country from which it was developed.

Implementing BA in a general psychiatric setting is an extensive and time-consuming process. All staff and management at the participating psychiatric wards, emergency departments and outpatient units must be informed of the availability of BA, be trained in the referral process, and understand BA parameters and implementation well enough to either explain it adequately to prospective participants or deliver BA themselves. Importantly, all professionals must also be willing to initiate and maintain good collaboration with the BA ward, the BAS PI and RA, and amongst each other.

Implementing BA to a novel setting outside of its country of origin has required regular informationsharing, education and consultation to each entire setting in which BAS has been implemented by a full-time PI and a part-time RA. Daily communication between the PI and RA and regular communication with the wards involved in BAS implementation was required in order to maintain adherent BA delivery, as well as to promptly solve problems as they arose. Regular (monthly, and if needed weekly) consultation as well as repeated (at least 2 times a year) training on BAS has been offered over the duration of the trial. Practical and clinical emergencies related to suicidality or other crises arising during BA were managed by direct clinical supervision with the PI, who is a psychiatrist, on an on-call basis. In more complex clinical situations, urgent consultation amongst the research team, the majority of who are also clinicians, was required so that adherent decisions could be made by consensus.