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The purpose of this paper is to describe the views and experiences of Improving Access to Psychological Therapies (IAPT) practitioners in providing therapy to patients who have an intellectual disability in order to support IAPT services in increasing their capability in this area.

An online survey was conducted of IAPT practitioners in four IAPT services in the north of England. The survey collected respondents demographic information and their experience, confidence and attitudes to working with people with intellectual disabilities. Qualitative responses regarding respondents attitudes, views of barriers, problems, successes and possible solutions to the delivery of therapy to people with intellectual disabilities within IAPT services were collected. The survey results were interpreted by thematic and statistical analysis.

The majority of respondents report having worked with people with intellectual disabilities and identify the need to adapt therapy, but also believe that such therapy should be offered within mainstream services. Thematic analysis identifies the needs for support in training, therapy adaptation and adjustment to pathways. However, the majority of respondents could identify positive outcomes and experiences.

This data supports the further development of pathways and offers some broad frameworks for the focus of training and development work for people with intellectual disabilities within IAPT.

This project has identified a positive attitude and willingness to consider adaptation of therapy for people with intellectual disabilities in practitioners working within IAPT services.

Until now the views and experiences of IAPT practitioners in working with this patient group were relatively unknown.

The purpose of this paper is to explore use of community treatment orders (CTOs) in adults with intellectual disability (ID) and mental health problems across England and Wales.

A web-based exploratory survey was sent to 359 consultants on the database of the Faculty of the Psychiatry of ID, Royal College of Psychiatrists who had declared ID as their main speciality. Socio-demographic details of responding consultants, clinical characteristics of adults with ID on CTO, subjective views of consultants on using CTOs in people with ID were collected and analysed.

In total, 94 consultant questionnaires were returned providing information on 115 patients detained under CTO. More than 75 per cent of the respondents had used CTO in their clinical practice. Patients subject to CTO were generally young, white males with mild ID and living in supported accommodation. CTOs were primarily used in situations of non-engagement (52.2 per cent), non-compliance with medication (47 per cent) or non-compliance with social care supports (49.6 per cent).

Responding consultants expressed concerns about encroachment of civil liberties and ethics of using CTOs in people with ID who may lack capacity and stressed that decision to use CTOs needs to be therefore done on individual basis.

This is the first national study to examine the practice of applying CTOs in adults with ID and mental disorders. Current practice is based on evidence from research done in adults with normal intelligence. Further research is needed to investigate the utility of CTOs in routine clinical practice in adults with ID and mental disorders.

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.

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.

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.

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.

The purpose of this paper is to assess the prevalence and nature of presentation of unipolar depression in individuals with Down syndrome (DS).

The PRISMA (2009) checklist for systematic review was followed where possible.

Eight studies were included in the qualitative synthesis from a total of 634 records identified. The quality of the studies was then assessed: the studies all scored either 5 or 6 out of 6. The incidence of depression ranged between studies from 5 to 13 per cent. It was found that depression is more common in DS than the general intellectual disability population; this on a background of mental ill health of all causes being less common in DS. It was suggested that, excluding organic disorders, depression is the most common psychiatric problem in DS. In terms of the nature of depression, the evidence was less clear. Various “vegetative” and biological symptoms were observed, with no fixed pattern. There was evidence for withdrawal symptoms and psychosis.

The small number of studies included in this review, and their heterogeneity, highlights the need for further original research in this field.

An increased awareness of the frequency of depression in individuals with DS will aid in a timely diagnosis, therefore reduce psychiatric morbidity. Clinicians should be aware of the varied presentation, with no clear clinical picture, in order to maintain a high index of suspicion in an individual presenting with “atypical” symptoms.

This review has provided preliminary evidence that depression may be the most commonly experienced psychiatric disorder in DS.

The range of prevalence of personality disorder (PD) found in people with intellectual disability (ID) has been reported as vast, and has included data from dissimilar settings. The purpose of this paper is to review the reported prevalence of PD in the general population of people with ID, and to consider how different and changing ideas about PD have affected these rates.

Cross-sectional studies of the prevalence of PD in people with ID were identified. The quality of the studies was considered, along with how cases of PD were identified.

Six studies were included. The reported prevalence of PD in people known to have ID ranged from 0.7 to 35 per cent. Possible reasons for this wide range included different views of PD and methods of assessment.

The wide range of findings suggests that methodological differences are significant. Consideration to how clinicians should respond to the overlap of impairment between ID and PD may improve the conceptual clarity of PD, informing future epidemiological research.

This review was limited to studies of samples likely to be representative of the general ID population. The range of prevalence estimates was narrower than previously reported, and more likely to reflect the true prevalence rate of PD amongst people who have ID. Consideration was also given to how different ideas of PD led to different methods and may have contributed to variance in the results.

There is little published literature about the number of home visits provided to patients within forensic intellectual disability units, and there is no published data on variables that affect home visits. There is a need for a baseline audit that can formulate standards for future practice. The paper aims to discuss these issues.

This paper describes the home visit programme within a forensic intellectual disability service, and a baseline audit of the programme. The audit measured the number of home visits, any factors that adversely affect home visits, and the extent of family contact. The authors propose audit standards for evaluation of good practice in this area.

The audit involved 63 patients over a one-year period. In total, 81 per cent of patients had some form of family contact and 54 per cent of patients at least one home visit. However, 19 per cent of patients had no contact with their family due to a variety of reasons. There were no significant differences in the number of home visits between men and women, patients on civil vs criminal sections or those treated “within area” or “out of area”. Patients in rehabilitation wards had significantly more visits than those in low or medium secure.

Conventional wisdom is that reduced family contact is the direct result of patients being placed “out of area”. The results of this audit suggest that, at least in this group, the reasons may be much more nuanced and that the current definition of “out of area” has to be improved to incorporate the actual distance between the patient’s current family home and the service. Audit standards have been proposed to monitor family contact and home visits. Future work should focus on the relationship between family contact and treatment outcomes.

The purpose of this paper is twofold. First to ascertain the efficacy of current police reception screening to detect detainees with intellectual disability (ID). Second to assess the validity of a short targeted screen for ID among police custody detainees.

The study comprised three stages. First, 248 police custody detainees were assessed for a range of health morbidities, including a pragmatic clinical evaluation of ID. For those with suspected ID, the police custody screens were scrutinised for evidence that this had been detected. Second, a new police health screen, incorporating a short screen for ID, was piloted. Totally, 351 detainees were assessed in the same way as in part 1 with the new screens being scrutinised for evidence that ID had been detected where relevant. Third, the new police screen for ID was validated among a sample of 64 inpatients, some with ID and some without, from forensic inpatient services. Parts 1 and 2 were carried out in the Metropolitan Police Service, London. Part 3 took place in one NHS Trust.

In parts 1 and 2, the rate of detainees with suspected ID was 2-3 per cent. The standard police screen detected 25 per cent of these detainees in part 1. When the new screen was introduced in part 2, the sensitivity for ID increased to 83 per cent. However, there was no requisite improvement in the proportion of detainees with ID receiving an Appropriate Adult. In the inpatient study, the new screen showed a good level of sensitivity (91 per cent) and reasonable specificity (63 per cent).

It is possible to improve the detection rate of detainees with suspected ID by introducing a short ID screen into the police custody officers’ reception health screen.

The Health Screening of People in Police Custody (HELP-PC) study is a project evaluating screening for health morbidity among police custody detainees. Other data from this study have been reported elsewhere, but this is the first time the data pertaining to ID screening has been reported in detail.

Fire setters who have an intellectual disability (ID) are often identified as posing a particular danger to the community although relatively little is known about their characteristics, treatment and support needs. The paper aims to discuss this issue.

This study describes the characteristics of 134 residents of low, medium and high security ID facilities in the UK who have either an index offence of arson, a violent index offence or a sexual index offence.

Index arson offenders who had an ID had multiple prior convictions, a history of violent offending and a high likelihood of having a comorbid mental disorder. There were many shared characteristics across the three groups.

The current study suggests that offenders who have ID who set fires have treatment needs that are similar to those of violent and sex offenders. It follows that fire setters who have an ID may also benefit from participating in more established offending behaviour treatment programs, such as cognitive behaviour therapy programs, developed for other types of offender.

This study is one of the few which has investigated the characteristics and treatment needs of persons who have an ID who set fires. In particular, it is one of the first to compare the characteristics and treatment needs for persons with ID who set fires, to those who have committed violent and sexual offences.

The purpose of this paper is to gather epidemiologicalinformation concerning firesetters with intellectual disabilities (ID) in Denmark to identify the assessment and treatment needs of this population and inform further research in this area.

The records held by the Danish Ministry of Justice concerning all firesetters with ID convicted of deliberate firesetting were reviewed for the period January 2001 to December 2010 inclusive. File information was extracted for 83 offenders concerning: demographic and personal characteristics; mental health characteristics; offending behaviour; offence-specific factors; and motives for offending. A sub-group of seven offenders were interviewed to explore some of the themes that emerged from the file review.

The majority of study participants were male and were classified as having mild ID and around 50 per cent had additional mental health problems. Many came from disturbed and deprived backgrounds. Two-thirds had set more than one fire and over 60 per cent had convictions for offences other than firesetting. Alcohol was involved in the firesetting behaviour in a significant proportion of cases (25 per cent). The motives for setting fires were – in descending order – communication (of anger, frustration and distress), fire fascination and vandalism. Interviews with participants indicated the important communicative function of firesetting, the difficulties people had in talking about and acknowledging their firesetting behaviour, and lack of access to targeted interventions.

Interventions for Danish firesetters with ID, as for firesetters with ID elsewhere, need to target the communicative function of this behaviour, along with offenders’ lack of insight and initial reluctance to accept responsibility for their behaviour and associated risks. Adjunctive treatment is required to address the psychiatric comorbidity experienced by many of these offenders, along with the alcohol use/misuse that is associated with many of these offences.

This is the first study concerning nature and needs of firesetters with ID in Denmark.