Can investing in therapy cost less than traditional case management for dissociative identity disorders, asks Cheshire and Wirral Partnership FT clinical psychologist Dr Mike Lloyd.
Dissociative identity disorder (DID) is a steadily growing diagnostic label that appears to be just outside the reach of many mainstream NHS services. Many people with the condition have multiple prior diagnoses (personality disorders, psychosis and schizophrenia are common) and cost the NHS a great deal in crisis and inpatient management while waiting for treatment. International guidelines do exist for psychotherapy, but are not part of NICE.
This article is an attempt to describe one example of DID from the joint perspective of clinical work in a therapeutic setting and how the finances behind setting up a care package are applied as an outcome measure.
This single case study revolves around a mother in her fifties, “Anne”, who was diagnosed with DID over a year ago, after 13 years of misdiagnosis within the psychiatric system. Her daughter gained the support of a recognised specialist after great effort, and the local trust, Cheshire and Wirral Partnership Foundation Trust, provided therapy and training to meet the need once identified.
The ICD-10 classification of mental and behavioural disorders describes such conditions as “a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of body movements” (F44: Dissociative (conversion) Disorders).
Anne was physically and sexually abused by her father from the age of four years old, eventually fleeing the family home at 15. She worked and raised a family until being sexually assaulted at work, which led to her current presentation. Since then she has been in the NHS mental health system and ended up with dissociation and agoraphobia, frightened to leave the house in the last three years.
The task of the commissioned therapy was to treat Anne and demonstrate that the therapeutic approach to her trauma would be more effective than offering purely care co-ordination within the community mental health team (CMHT), crisis intervention, medication and admission.
At the beginning of 2010, therapy began within Cheshire and Wirral, during which time I got to know Anne and her various alters (different personality states). Clinically, the improvements were apparent. Prior to therapy commencing, Anne had not been in her adult, communicative state for at least six months, with only brief glimpses of who she used to be. She had effectively been replaced with a procession of her alters and needed to be watched constantly as would a child with risk of self-harm.
After six months I could talk with Anne, she could leave the house and take care of herself with ongoing support from family and agencies.
As part of the review, data was collected from Cheshire and Wirral’s records, with Anne’s full permission, regarding her admissions, CMHT, consultant and crisis team contacts. The data set available was from 2006 – 2010 with weekly therapy.
Cheshire and Wirral Partnership and the local primary care trust agreed to fund a two-year development programme, whereby I would be trained and supervised to specialist level while seeing Anne and other clients referred with DID, so the data will reflect the cost of one session per week of a principal clinical psychologist for the sake of comparison.
For each year, the number of CMHT and Crisis Team face-to-face and phone contacts were counted, as well as any consultant contact or inpatient episode. This data is presented in Tables 1-3.
Table 1: Team contacts by year and cost
|Year||All Contacts||Cost £||All Contacts||Cost £|
Table 2: Ward and Therapy contacts by year and cost
|Ward / Consultant||Psychology|
|Year||All Days / contacts||Cost £||All Contacts||Cost £|
(n.b. psychology time has been costed at one session per week for 52 weeks)
Table 3: Overall costs by year comparison
Anne’s therapy began at the start of January 2010, and by mid-February she was discharged from the crisis team. The care co-ordinator continues to support Anne with regular phone calls and home visits, much like any other client on the team. Anne’s therapy has continued with weekly sessions, and although there have been setbacks, she has not been admitted or refused to attend any appointments.
One year after starting therapy, Anne still has not had a single admission, and has needed only occasional crisis team contacts.
The average cost per year of Anne’s care package for face to face/phone contacts and admissions has been £29,492, prior to therapy beginning. Since therapy started, the cost of the care package has dropped to £10,695, representing a saving of £18,797.
What is clear from the data collected is that more money has been saved by offering therapy than the therapy actually cost. The money saved is used to fund services and bed days for other clients while the client with DID is able to focus more on how to manage the condition and begin exploring how to go about life on a more meaningful level than purely survival.
Using this approach, more clients with DID are now being seen, and similar figures are becoming available. Anne’s case successfully demonstrates the need and usefulness of delivering therapeutic services rather than cutting them back, both for quality of life and efficient use of budgets.