Search results

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.

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 purpose of this paper is to examine the trend of admissions and inpatient characteristics in a NHS intellectual disability hospital from 1975 to 2013, in particular looking at the effect following the Winterbourne View scandal.

A retrospective review of all admissions over a three-year period (January 2011-January 2013) was completed. This information was compared with admissions to the same hospital in three-year period over the last four decades (1975-1977, 1985-1987, 1995-1997, and 2003-2006). Number of admissions, gender, age, source of admission, length of stay, reasons for admission, type of admission, and diagnosis of psychiatric illnesses were included.

There were 87 admissions (including 29 from out of area) in the study period of 2011-2013. The number of admissions had varied over the years but male admissions were consistently higher than female. A majority of people stayed over six months. For the first time in five decades, there were more formal inpatients than informal ones. The diagnosis of Autism Spectrum Disorder (ASD) and of Attention Deficit Hyperactivity Disorder had increased.

This study has examined admission trends over five decades. It has highlighted that the Mental Health Act legislation is being used more frequently and that co-morbid mental disorders, such as ASD are commonly associated with those admitted to hospital. A well planned-out community health care system, as well as adequate social provision are keys to maintain people with intellectual disability in the community. Furthermore, a better understanding of the symptomology of challenging behaviours, and appropriate use of mental health legislation are crucial in providing a high-quality service that has clear treatment goals and values. Some of these issues have contributed to the failure of the recent initiative to reduce the size of the inpatient intellectual disability following Winterbourne View scandal.

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.

The purpose of this paper is to evaluate the impact of a changing commissioning landscape on the provision of specialist acute inpatient care from the perspective of a small category 2 unit in London.

The authors conducted a retrospective survey of all referrals to the unit in 2012 and 2013.

There has been an increase in the referrals and admissions to the unit with referrals covering a wider catchment area. This has resulted in a doubling of the average distance between the unit and the respective catchment areas that patients and their relatives have to travel. The majority of admissions were transfers from mainstream mental health services. There has been a reduction in the mean length of stay.

This survey looks at trends in one category 2 unit in an outer London Borough and therefore, limits generalisability. The data collection was retrospective and there was no information on patients requiring admission but not being referred to the unit.

There continues to be a need for category 2 admission units to serve the needs of a small group of patients with intellectual disability presenting with mental health needs and behavioural problems. Consideration needs to be given to the entire mental health and challenging behaviour care pathway, including the small but crucial element of specialist inpatient management if services are to remain local and responsive to the needs of this group of patients and their carers.

An ill-planned reduction in the number of specialist inpatient units without viable community services, risks perpetuating a situation where patients and their relatives have to travel long distances to obtain appropriate specialist help. Longer geographical distances could also potentially hamper closer liaison between the unit and the community services, thereby reducing the degree of oversight and prolonging the transition and discharge process.

This survey highlights the impact of recent commissioning and service changes on delivery of specialist in patient services for adults with intellectual disability in the immediate aftermath of the Winterbourne Review.

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 to describe the use and value of therapeutic communties (TCs) in services for people with intellectual disabilities (IDs) and complex needs.

A structured literature review of TC in ID services.

TCs have been used in a range of in-patient services for people with IDs. Although outcome studies are scarce, those that exist offer promising indications of such service designs.

TCs have seen a recent increase of interest in ID services. This paper provides an overview of these services and outlines the benefits that such a residential culture can offer for both service users and staff members.