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There is increasing emphasis on caring for people with intellectual disabilities in the least restrictive, ideally community settings. Therefore, the purpose of this paper is to explore the risk factors considered by clinicians involved in discharging people from secure services.

The views of five senior clinicians were sought in semi structured interviews. Data were analysed thematically.

Themes related to risk assessment, risk management, and multidisciplinary and multiagency working. Illustrative quotes are used to evidence themes.

This study described the risk assessment and management factors considered during the discharge of patients from secure to community services, which are of direct relevance to multiple stakeholders post-Winterbourne.

Challenges when facilitating discharge were highlighted, such as ongoing risk management issues, or unexpected discharge from tribunals, and how these were addressed, via the development of extensive risk assessment and management processes, and interdisciplinary and interagency working.

The purpose of this paper is to describe key policy and practice issues regarding a significant subgroup of people with intellectual disability – those with offending behaviour being treated in forensic hospitals.

The reasons why psychiatrists continue to be involved in the treatment of people with intellectual disability and mental health or behavioural problems and the factors that may lead to patients needing hospital admission are examined. Using two illustrative examples, three key questions – containment vs treatment, hospital care vs conditional discharge and hospital treatment vs using deprivation of liberty safeguards usage in the community are explored.

Patients with intellectual disability, mental health problems and offending behaviours who are treated within forensic inpatient units tend to have long lengths of stay. The key variable that mediates this length of stay is the risk that they pose to themselves or others. Clinicians work within the framework of mental health law and have to be mindful that pragmatic solutions to hasten discharge into the community may not fall within the law.

This paper makes practical suggestions for the future on how to best integrate hospital and community care for people with intellectual disability, mental health and offending behaviours.

People with learning disabilities have high dependency needs and high prevalence of physical, psychological and social morbidities. Some studies have shown that South Asian and white populations have a similar prevalence of learning disabilities and related psychological morbidity (McGrother et al, 2002), although other studies have shown an increased prevalence of severe levels of learning disabilities in the South Asian population (Emerson et al, 1997). The aim of this study was to compare stress levels and unmet service needs in informal carers of South Asian and white adults with learning disabilities.A sample of 742 informal carers was selected from the Leicestershire Learning Disability Register. Data on carers' and subjects' demographic details, stress levels and unmet service needs were analysed and compared using chi‐square tests and logistic regression analyses. Substantial differences were observed between the two groups. Carers of South Asian adults with learning disabilities reported significantly higher levels of care provision and unmet needs. Major stress was reported in 23% of carers. This was more common in carers with poor health, in those caring for younger adults, carers of adults with psychological symptoms, and in those with an expressed need for moral support or respite care.Stress is common among informal carers of adults with learning disabilities and inequalities, in reported care given and unmet needs, exist between carers of South Asian and white adults. Practitioners need to be aware of factors associated with stress when assessing carers in this population.

The prevalence rate of arson in offenders with intellectual disabilities (ID) has been reported to be higher than that in the general population. This retrospective study focuses on examining the characteristics of offenders with ID and the range of identified reasons for the index offence. The findings indicate a higher prevalence of arson in this population, along with the fact that the majority of people with ID who have committed arson tend to bypass the Criminal Justice System. A significant number are likely to repeat the behaviour and will also commit other offences. The most common reason for arson appears to be revenge, closely followed by suggestibility. The majority had an associated diagnosis of personality disorders along with an Axis 1 psychiatric diagnosis. Other factors include large family size, history of childhood psychiatric disorders, abuse, homelessness, unemployment and relationship difficulties.

Traditionally, services for people with learning disabilities (LD) and forensic needs are underdeveloped. This paper aims to describe the setting up of a tiered model of LD forensic service provision in Leicester, Leicestershire and Rutland, facilitated and driven by a core team of professionals who have the skills and expertise in this area.

With no dedicated funding, this team is virtual in nature and provides support for the community and in‐patient teams in the assessment and management of offenders with LD. A care pathway including a process map is included to represent a visual idea of the referral, assessment, intervention and disposal strategies across the four tiers of service delivery. The service has a unique partnership arrangement with the independent sector that allows for staff training in order to deliver quality outcomes. The virtual team can support patients with learning disabilities and forensic needs in the community and in‐patient settings, both by avoiding unnecessary in‐patient admissions and by improving the treatment outcomes of those discharged from in‐patient settings.

Further research is required to demonstrate the clinical and social outcomes for offenders with LD using the tiered model of care and care‐pathway.

The virtual team and the LD forensic care pathway were developed because of a gap in service that was identified as part of a mapping exercise and stakeholder discussion. In the current economic climate, additional resources to address this gap in service may not be readily available; therefore, an innovative way of addressing this gap in service was by developing a care pathway for use by community LD teams based on lean principles and evidence‐based medicine and the pooling of specialist skills to develop the virtual team to enable and support the implementation of the care pathway.

The aim of the project was to evaluate the short‐term treatment outcomes of patients treated in a medium secure service for people with intellectual disability. A total of 138 patients, 77 discharged and 61 current inpatients, treated over a six‐year period were included in the audit. Information on demographic and clinical variables was collected on a pre‐designed data collection tool and analysed using appropriate statistical methods. The median length of stay for the discharged group was 2.8 years. About 90% of this group were discharged to lower levels of security and about a third went directly to community placements. None of the clinical and forensic factors examined was significantly associated with length of stay for this group. There was a ‘difficult to discharge long‐stay’ group which had more patients with criminal sections, restriction orders, history of abuse, fire setting, personality disorders and substance misuse. However, when regression analysis was done, most of these factors were not predictive of the length of stay. Clinical diagnosis or offending behaviour categories are poor predictors of length of hospital stay, and there is a need to identify empirically derived patient clusters using a variety of clinical and forensic variables. Common datasets and multi‐centre audits are needed to drive this.

The purpose of this paper is to ascertain the current competencies and training needs for being an expert witness of trainees (CT3, ST4-6) and career grade psychiatrists (consultants and staff grade, associate specialist and specialty doctors) in a UK health and well-being Trust.

This was completed through an online survey, developed by the authors, of all career grade and trainee psychiatrists within the Trust.

Only 9 per cent of respondents reported that they felt they had adequate training to feel competent as an expert witness. Despite low levels of training and confidence, 73 per cent of respondents had written an expert report. As well as shortage of training opportunities for psychiatrics acting as expert witnesses, the findings indicated increasing fear of litigation and lack of direct experience of court proceedings during training.

Doctors need to be offered formal training opportunities including simulated training, ideally organised within Trust, Continuing Professional Development (CPD) committees or Education committees. Implementation of the RCPsych report guidance into speciality curricula and CPD opportunities for doctors would ensure a robust curriculum-based delivery of these essential skills.

A wealth of guidance is available for expert witnesses, but no previous study had identified the specific training issues and overall confidence in competency to act as an expert witness amongst psychiatrists. It will be valuable to all psychiatrists involved in court work and organisations involved in training psychiatrists, especially in light of recent relevant court cases and removal of expert witness immunity.

The 11th revision of the International Classification of diseases which sets global standards for defining, reporting and managing health conditions is under way. The International Classification of Diseases (ICD) underpinning principle of clinical utility is currently poor for persons with Disorders of Intellectual Development (DID) and mental disorders. This impedes access to healthcare resources; services and social inclusion thereby further aggravating their vulnerability. The purpose of this paper is to present a critical overview and evidence informed recommendations within the context of an international collaborative programme, undertaken by the Faculty of Psychiatry of Intellectual Disability, Royal College of Psychiatrists, UK with support from the World Health Organisation (WHO).

The authors carried out: first, a systematic review (SR) of literature, using PRISMA guidelines regarding the reliability, validity and utility of the ICD-10/Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria in people with DID (PWDID); second, a national and international consultation exercise with partners, stakeholders and experts; third, a multicentric survey of problem behaviours in PWDID; and finally, information dissemination/dialogues including presentations and workshops at key scientific events, consultation networking, data gathering and consensus building.

The SR revealed a dearth of robust studies – most consisting of weak research methodologies. Significant difficulties were highlighted regarding the application of diagnostic criteria in the current classificatory systems – particularly in people with severe/moderate DID. Recommendations supported the introduction WHERE APPROPRIATE of modifications based on observed phenomena (signs) in PWDID in lieu of reported symptoms to facilitate DIAGNOSIS AND better access to healthcare and the community. Heterogeneity precluded quantitative pooling and meta-analysis. The consensus building exercise globally revealed that problem behaviours were the commonest reasons for referral to healthcare services with significant numbers without a diagnosed mental disorder being prescribed psychoactive medication.

The consensus gathering exercise WAS SELECTIVE AND did not cover all of the 194 member states of WHO due to resource and time constraints and this constitutes the main limitation of our study. Based on the SR and expert consensus, the authors submitted evidence informed pragmatic proposals to the WHO aimed at addressing the shortcomings of the ICD-10. The key recommendations focused on improving clinical utility within the context of epistemic iteration which would consolidate and strengthen the future evidence base. It was also recommended that self-injurious behaviour should form a standalone sub category in view of its relevance for healthcare services and resources which underpin clinical utility.

The ICD-11 is a global, multidisciplinary and multilingual development for public health benefit with 70 per cent of the world's health expenditures assigned using this system for resource allocation. Currently mental disorders in PWDID can be misinterpreted, unrecognised and under reported resulting in barriers to access to treatment and healthcare resources. Conversely disorders may be over diagnosed when the inherent discrepancies between the chronological age and the developmental level of functioning are not considered. Conclusions and recommendations from this study will result in better diagnosis of mental disorders and healthcare resources in this population.

PWDID are a vulnerable sector of the population with an increased prevalence of mental health problems who are marginalised and discriminated by society. Early detection, treatment and management of these conditions will prevent further decompensation and stigmatisation.

To the best of the authors knowledge this is the first comprehensive, large-scale study which evaluates the ICD classificatory system within the context of clinical utility for PWDID, including experts and stakeholders from both lower/middle- and high-income countries. The international consultation/consensus building process culminating in the formulation of evidence informed recommendations, aimed at improving the clinical utility of the ICD-11 for this population, has the potential to improve access to appropriate healthcare and treatment and consequent enhancement of their quality of life.

Winterbourne and Mid-Staffordshire scandals have had a significant impact on how Care Quality Commission inspects and regulates intellectual disability services (IDS). The purpose of this paper is to describe the changes and development of regulation of these services and future work.

The paper is a descriptive paper.

A new regulatory model is currently implemented for IDS. It has been developed in consultation with patients, carers, providers and other stakeholders. There will be ongoing development and refinement of the inspection methodology.

This is an original descriptive paper which will provide useful information to readers on how the regulatory process works in IDS.