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This commentary examines the autonomy‐control argument in public mental health and how services have developed over the years from prejudiced asylums, to community‐based care. Peter Tyrer discusses how people with mental ill health, who have struggled to gain independence and autonomy of their lives, are finally enjoying their emancipation.

English governance has repeatedly had a tendency to veer between national, regional and local centres of power and influence. This has often led to profound disagreements, sometimes even open conflict. National policy guidance is usually helpful, if developed through consultation, to steer a clear, coherent direction for the system. But a narrow, excessively top‐down, mechanistic target‐driven approach can lead to a prevailing culture of ticking boxes at the expense of real patient priorities. Government ministers and civil servants, however, are often caught in a tension between being too dogmatic, or alternatively too flexible and giving responsibility to local agencies, whereupon people may complain about a ‘postcode lottery’ in services. Balancing perspectives and narratives in a coherent way for policy development and implementation and service improvement is a major challenge of leadership. The creation of the National Institute for Mental Health in England (NIMHE) was designed to bring together the local, regional and the national in a form that would see policy and practice mutually developed and nurtured at all levels of governance.

The debate as to whether intellectual disability (ID) should be conceptualized as a health condition or as a disability has intensified as the revision of World Health Organization’s (WHO’s) International Classification of Diseases (ICD) is being finalized. Defining ID as a health condition is central to retaining it in ICD, with significant implications for health policy and access to health services. The purpose of this paper is to include some reflections on the consensus document produced by the first WHO Working Group on the Classification of MR (WHO WG-MR) and on the process that was followed to realize it. The consensus report was the basis for the development of official recommendations sent to the WHO Advisory Group for ICD-11.

A mixed qualitative approach was followed in a series of meetings leading to the final consensus report submitted to the WHO Advisory group. These recommendations combined prior expert knowledge with available evidence; a nominal approach was followed throughout with face-to-face conferences.

The WG recommended a synonym set (“synset”) ontological approach to the conceptualisation of this health condition underlying a clinical rationale for its diagnosis. It proposed replacing MR with Intellectual Developmental Disorders (IDD) in ICD-11, defined as “a group of developmental conditions characterized by a significant impairment of cognitive functions, which are associated with limitations of learning, adaptive behaviour and skills”. The WG further advised that IDD be included under the parent category of neurodevelopmental disorders, that current distinctions (mild, moderate, severe and profound) be continued as severity qualifiers, and that problem behaviours removed from its core classification structure and instead described as associated features.

Within the ID/IDD synset two different names combine distinct aspects under a single construct that describes its clinical as well as social, educational and policy utilities. The single construct incorporates IDD as a clinical meta-syndrome, and ID as its functioning and disability counterpart. IDD and ID are not synonymous or mirror concepts as they have different scientific, social and policy applications. New diagnostic criteria for IDD should be based on a developmental approach, which accounts for the complex causal factors known to impact the acquisition of specific cognitive abilities and adaptive behaviours. The paper focuses on a new clinical framework for the diagnosis of IDD that also includes and complements the existing social, educational and policy components inherent in ID.

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.

Dual‐diagnosis strategies are developing in medium secure services in response to both government policies and clinical need and there has been a move towards integrated services for this patient group. Substance use that has been a feature of the index offence must be taken into account as much as psychosis or the offending behaviour. Treatment of dual diagnosis relies heavily on cognitive‐behavioural therapies. Relapse in either psychosis or substance use increases risk and re‐admission rates to medium security. This paper reviews the literature on family interventions in dual diagnosis and its applicability to forensic mental health inpatient services. As there appeared to be limited direct evidence, various domains were examined and extrapolated to a forensic setting as appropriate. The review indicates the potential for positive outcomes for families following family interventions in dual diagnosis, which may be beneficial in a forensic setting in lowering risk.

Alongside teachers, community nurses have been identified as having an important role to play in the provision of school‐based personal, social and health education (PSHE) and sex and relationships education (SRE). However, there currently exist few programmes of preparation for this work that recognise the specific contribution of community nurses to SRE. This paper reports on findings from a formative evaluation of a pilot certification scheme for community nurses involved in SRE provision and recently implemented in England. The evaluation sought specifically to access views about the value of the educational experience in preparing school nurses to better fulfil their SRE role.

During the implementation of the pilot scheme, 124 semi‐structured interviews were conducted with a range of stakeholders, including national players, local scheme support leads, nurses participating in the pilot scheme, nurse managers and other colleagues. Data gathering adopted a close‐focus, largely qualitative approach. Partial transcription took place and a thematic analysis was carried out using constant comparative method.

Findings suggest that a well‐designed scheme of the type described is likely to be well received by community nurses, but that ways need to be found to ensure good synergy between local health and education services in the support of SRE in schools. At the same time, there is a need to respect the unique contribution of community nurses and the skills that they bring to this work.

This paper raises awareness and highlights issues surrounding a pilot certification scheme for community nurses involved in sex and relationships in education.

As part of the work leading to the development of the National Healthy Schools Scheme, an audit was carried out of existing healthy schools schemes in England. This, together with an evaluation of healthy schools activities within eight pilot healthy schools partnerships throughout England funded by the Department of Health and the Department for Education and Employment, formed part of the research underpinning the creation of a National Healthy Schools Standard. Principles for effective working are identified, as well as difficulties likely to be encountered in creating and promoting such a standard.

With permission, this paper is an edited and abridged version of an article written by Richards, Doyle and Cook for The British Journal of Forensic Practice (Richards et al, 2009), detailing their literature review on family interventions in dual diagnosis and with reference to forensic mental health care. There appeared to be limited direct evidence, therefore various domains were examined and extrapolated to a forensic setting as appropriate. The review indicates the potential for positive outcomes for families following family interventions in dual diagnosis, which may be beneficial in a forensic setting in lowering risk.

The UK Government has been planning changes to mental health legislation for at least eight years. On 23 March 2006, the Department of Health announced that many of these plans would proceed ‐ although through amendments to the 1983 Mental Health Act rather than a substantive Bill. These proposed reforms are significant but controversial. This paper sets out some of the reasons for welcoming the proposed changes. It is argued that the proposals to replace the responsible medical officer with a clinical supervisor are in keeping with best quality mental health care, and allow for proper multidisciplinary practice. Such an approach explicitly permits proper use of the skills and competencies of the workforce ‐ including psychologists. A second controversial aspect of the proposed reforms ‐ supervised community treatment orders, permitting compulsory care outside of hospitals ‐ represent not a violation of human rights, but a specific defence of ‘Article 8’ rights to protection of family and personal life. Finally, it is argued that the proposed amendments are important because mental health legislation dominates mental health care and the present 1983 Mental Health Act inappropriately consolidates the status of the medical model and the role of the responsible medical officer (and hence psychiatry). It is argued that the proposed changes are imperfect; in particular they lack inclusion of an ‘impaired judgement’ criterion, but it is suggested that necessary role and service redesign needs such amendments to allow the new ways of working programme to ‘bite’.