Susan Benbow, Paul Kingston, Sabyasachi Bhaumik, Sarah Black, Satheesh Gangadharan and Suzanne Hardy
The Royal College of Psychiatrists set up an interface group to look at the interface between old age psychiatry and learning disability and, as part of its work, the group…
Abstract
The Royal College of Psychiatrists set up an interface group to look at the interface between old age psychiatry and learning disability and, as part of its work, the group commissioned a survey of learning disability and old age psychiatrists to investigate their experience of working across the boundary between the two specialities. This paper is based on the report produced. It summarises the findings of the survey and sets out eight recommendations to further the work. There was no clarity on how services should be provided to older people with a learning disability who develop a mental health problem in later life but the need for collaboration between the two specialities is compelling.
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John Devapriam, Catherine Thorp, Freya Tyrer, Satheesh Gangadharan, Lammata Raju and Sabyasachi Bhaumik
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…
Abstract
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.
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Regi Alexander, Jack Piachaud, Lola Odebiyi and Satheesh Gangadharan
This survey describes the socio‐demographic, clinical and forensic variables of all patients referred to a medium secure unit in the psychiatry of learning disability. Of the…
Abstract
This survey describes the socio‐demographic, clinical and forensic variables of all patients referred to a medium secure unit in the psychiatry of learning disability. Of the sample, 67.5% were referred following an index offence and 76.6% had at least one previous conviction. Just over half (50.6%) came from either prisons, special hospitals or medium secure units and the remainder from mental health/learning disability hospitals or community resources. The majority (91.7%) had prior contact with a mental health or learning disability team. Most (81.5%) had a mild or ‘borderline’ learning disability, 46.8% had either a psychosis or major mood disorder, 58.4% had personality disorders and 56.6% had a history of illicit substance abuse. Of the 79 referrals 29.1% were accepted for admission. Arson as an index offence and a previous conviction for arson were significantly associated with being accepted for admission.
Regi Alexander, Avinash Hiremath, Verity Chester, Fatima Green, Ignatius Gunaratna and Sudeep Hoare
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…
Abstract
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.
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Sherva Elizabeth Cooray, Sab Bhaumik, Ashok Roy, John Devapriam, Rahul Rai and Regi Alexander
The 11th revision of the International Classification of diseases which sets global standards for defining, reporting and managing health conditions is under way. The…
Abstract
Purpose
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).
Design/methodology/approach
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.
Findings
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.
Research limitations/implications
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.
Practical implications
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.
Social implications
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.
Originality/value
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.
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Reza Kiani, Asit Biswas, John Devapriam, Regi Tharian Alexander, Satheesh Kumar, Hayley Andrews and Samuel Joseph Tromans
Clozapine is a well-known antipsychotic medication licensed for treatment-resistant schizophrenia, but there is limited research available to suggest its efficacy in the context…
Abstract
Purpose
Clozapine is a well-known antipsychotic medication licensed for treatment-resistant schizophrenia, but there is limited research available to suggest its efficacy in the context of personality disorder and intellectual disabilities presenting with high-risk behaviour with or without psychotic symptoms. The purpose of this paper is to raise awareness of the benefits of using clozapine in patients with intellectual disabilities and personality disorder that present with a complex picture of serious risk of harm to both their life and the lives of others.
Design/methodology/approach
The authors present five patients with intellectual disabilities and serious life-threatening challenging behaviour whom were started on clozapine as part of their multidisciplinary treatment plan to manage their presentation. The authors completed baseline assessment of five main symptom domains and then repeated this assessment following treatment with clozapine.
Findings
In all five cases use of clozapine was objectively associated with an improvement in symptomatology, quality of life and a safe transfer to the community.
Originality/value
The findings suggest that judicious use of clozapine could be considered as one of the effective pharmacological strategies in the management of patients with intellectual disabilities and personality disorder who present with serious life-threatening challenging behaviours.