Regi Alexander

Referrals to a forensic service in the psychiatry of learning disability

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.

Substance misuse among offenders in a forensic intellectual disability service

Purpose – There have been few studies about the prevalence of substance abuse and links to offending behaviour among those with intellectual disabilities. This paper aims to address this issue.Design/methodology/approach – This baseline audit describes: the prevalence of alcohol and substance misuse in patients within a forensic intellectual disability service; and the introduction of a Drug and Alcohol Awareness Course. In total, 74 patients were included in the audit.Findings – Roughly half of the patients audited had co‐morbid harmful use or dependence with the problem being equally prevalent in men and women. Whilst alcohol and cannabis were the commonest drugs of abuse, cocaine, stimulants and opiates were abused by a small but significant number. Of those with harmful use or dependence, 35 per cent had used the drug in the immediate lead up to their index offence. A diagnosis of personality disorder and past history of convictions for violent offences was significantly more likely to be present in t...

The Clinical, Forensic and Treatment Outcome Factors of Patients with Autism Spectrum Disorder Treated in a Forensic Intellectual Disability Service

BACKGROUND To describe the characteristics of those with autism spectrum disorder (ASD) treated within a forensic intellectual disability hospital and to compare them with those without ASD. METHOD Service evaluation of a cohort of 138 patients treated over a 6-year period. RESULTS Of the 138, 42 had an ASD. Personality disorders and harmful use or dependence on drugs were significantly lower in the ASD group. The ASD group was less likely to be subject to criminal sections or restriction orders. Self-harm was significantly higher in the ASD group. There were no differences in the length of stay and direction of care pathway. CONCLUSIONS Although the ASD and non-ASD groups differ on clinical and forensic characteristics, their treatment outcomes appear similar. This suggests that the diagnostic category of ASD alone may be inadequate in predicting the treatment outcome. There is a case to identify distinct typologies within the ASD group.

“Why can’t they be in the community?” A policy and practice analysis of transforming care for offenders with intellectual disability

Purpose – 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. Design/methodology/approach – 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. Findings – 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 t...

Arson or fire setting in offenders with intellectual disability: Clinical characteristics, forensic histories, and treatment outcomes

Abstract Background Although many with intellectual disability come to the attention of services for fire setting, research in this area is scarce, which poses challenges for management. Method In this paper we examined those with a fire-setting history (n = 30), identified from a sample of 138 patients treated in a UK forensic intellectual disability service. Those with a fire-setting history were compared to those without this history on various clinical, forensic, and treatment outcome variables. Results Fire-setting was associated with significant psychopathology, including psychosis and personality disorders. Only half of the fire setters had a formal arson conviction. Fire setters were more likely to have a violence conviction and criminal sections/restriction orders. Conclusions Half of those with fire-setting histories did not have formal arson convictions, highlighting the need for thorough history taking. Prevalent comorbidity suggests interventions should focus on treating psychopathology before commencing offence-specific arson therapies.

Tiered model of learning disability forensic service provision

Purpose – 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.Design/methodology/approach – 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...

Impact of care pathway-based approach on outcomes in a specialist intellectual disability inpatient unit

Specialist intellectual disability inpatient units have come under increased scrutiny, leading to questions about the quality of service provision in this sector. A care pathway-based approach was implemented in such a unit and its impact on outcome variables was measured. The care pathway-based approach resulted in the turnover of more patients, increased capacity for admissions to the unit, reduced lengths of stay in hospital, timely assessments and treatments, which resulted in better outcomes in patients. Care pathway-based approach to service provision provides not only better outcomes in patients but also a reliable way of ensuring true multi-agency working and accountability. If used widely, it can reduce the variability in the quality of current service provision.

Challenges and pitfalls of antipsychotic prescribing in people with learning disability.

In this opinion piece we highlight the current concerns of prescribing antipsychotics to people with learning disability (PWLD) and propose a system of monitoring of antipsychotic prescribing in general practice that, we argue, will reduce inappropriate antipsychotic use. Learning disability, synonymous with the term ‘intellectual disabilities’,1 affects about 1–2% of the general population2 and is characterised by significant impairments of both intellectual and adaptive functioning, and an onset before 18 years.3 PWLD have high rates of ‘challenging behaviour’ (CB) — for instance, acts of aggression towards people or property, self-neglect, and self-harm — and risk exploitation.2 CB is a social construct to enumerate a behavioural or mental pattern that may cause suffering or a poor ability to function in life. It is best understood based on learning theory and the principles of applied behavioural analysis. Mental illness is a structured diagnostic concept that encompasses a large range of recognised emotional and behavioural disorders and its diagnosis requires robust application of the diagnostic schedules. It is reasonable to state that most PWLD with mental illness have CB but the majority of PWLD with CB might not satisfy criteria for mental illness. Therefore, the therapeutic approach to CB can be very different from a diagnostic one. However, there is significant overlap between CB and the presence of mental illnesses, with the latter also being higher in PWLD than in the general population. Deficits in communication, atypical clinical presentations, and differences in diagnostic coding methods mean that mental illness can be under-recorded, particularly in those with severe degrees of learning disability.1,4 This means that the clinician needs to be aware not just of what is observed behaviourally, but also whether there is something underlying diagnostically. A formulation based …

Heterogeneity within Autism Spectrum Disorder in Forensic Mental Health: The Introduction of Typologies

Individuals with diagnoses of autism spectrum disorder (ASD) within criminal justice settings are a highly heterogeneous group. Although studies have examined differences between those with and without ASD in such settings, there has been no examination of differences within the ASD group. The paper aims to discuss these issues.,Drawing on the findings of a service evaluation project, this paper introduces a typology of ASD within forensic mental health and intellectual disability settings.,The eight subtypes that are described draw on clinical variables including psychopathy, psychosis and intensity/frequency of problem behaviours that co-occur with the ASD. The initial assessment of inter-rater reliability on the current version of the typology revealed excellent agreement, multirater Kfree =0.90.,The proposed typology could improve understanding of the relationship between ASD and forensic risk, identify the most appropriate interventions and provide prognostic information about length of stay. Further research to refine and validate the typology is ongoing.,This paper introduces a novel, typology-based approach which aims to better serve people with ASD within criminal justice settings.

Intellectual disability and the ICD-11: towards clinical utility?

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 worlds 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.