Satheesh Gangadharan

Psychological treatments in intellectual disability: the challenges of building a good evidence base

Psychological treatments are widely used for the management of mental health and behavioural problems in people with intellectual disabilities. The evidence base, including the cost-effectiveness of such interventions, is limited. This editorial explores the current evidence base and analyses its strengths and limitations. The editorial also highlights current problems in conducting randomised controlled trials in this area and suggests a way forward.

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.

Delayed discharge from intellectual disability in-patient units

Aims and method We undertook a cross-sectional service evaluation of the reasons and extent of delay in the discharge process in an intellectual disability hospital over a 12-month period. Delays at each stage of the discharge process are also quantified in this study. Results We found that discharge was delayed for 29% of patients during the study period. The majority (78.5%) was due to awaiting completion of assessment of future care needs and waiting for public funding. Clinical implications Commissioners (health and social), provider trusts, regulators and community providers should consider the reasons for delay in the discharge process and adopt a whole systems approach to discharge planning. This is highly relevant in light of recommendations by the Department of Health following the Winterbourne View scandal, which has raised concern about patients staying in intellectual disability in-patient units too long and for the wrong reasons.

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.

CASE REPORT: ASSOCIATION OF WAARDENBURG SYNDROME WITH INTELLECTUAL DISABILITY, AUTISTIC SPECTRUM DISORDER AND UNPROVOKED AGGRESSIVE OUTBURSTS: A NEW BEHAVIOURAL PHENOTYPE?

(2007). Case Report: Association of Waardenburg Syndrome with Intellectual Disability, Autistic Spectrum Disorder and Unprovoked Aggressive Outbursts: A New Behavioural Phenotype? The British Journal of Development Disabilities: Vol. 53, No. 104, pp. 53-62.

A Lithium Register for Adults with Intellectual Disabilities – Can It Work?

*Dr Sabyasachi Bhaumik MB BS DPM FRCPsych Consultant in Learning Disability Psychiatry, Leicestershire Partnership NHS Trust, Leicester Frith Hospital, Groby Road, Leicester, LE3 9QF, UK Honorary Senior Lecturer, University of Leicester, UK Email: bhaumikuk@yahoo.co.uk Tel: + 44 (0) 166 225 5310 Fax: + 44 (0) 166 225 5202 Dr Joanna M Watson MA MB BChir FFPH Associate Specialist in Learning Disability Psychiatry, Leicestershire Partnership NHS Trust, Leicester Frith Hospital, Groby Road, Leicester, LE3 9QF, UK Research Associate, University of Leicester, UK James F Falconer Smith DM FRCP FRCPath Consultant Chemical Pathologist, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Groby Road, Leicester, LE3 9QP Sanyogita Nadkarni MB BS MRCPsych Former Staff Grade in Learning Disability Psychiatry, Leicestershire Partnership NHS Trust, Leicester Frith Hospital, Groby Road, Leicester, LE3 9QF, UK Asit Biswas MD MRCPsych DPM MMedSci Consultant in Learning Disability Psychiatry, Leicestershire Partnership NHS Trust, Leicester Frith Hospital, Groby Road, Leicester, LE3 9QF, UK Satheesh Kumar Gangadharan MRCPsych MD (Psych) Consultant in Learning Disability Psychiatry, Leicestershire Partnership NHS Trust, Leicester Frith Hospital, Groby Road, Leicester, LE3 9QF, UK * For Correspondence Introduction

Characteristics and outcomes of patients with intellectual disability admitted to a specialist inpatient rehabilitation service

Rehabilitation services for people with mental illnesses have been extensively researched. However, services with similar aims and specifications for patients with intellectual disabilities (IDs) have had little focus. This study describes the characteristics and outcomes of 21 patients admitted to a specialist ID rehabilitation service over an 8-year time frame. Rather that solely accepting ‘step-down’ referrals, some patients were referred from community settings. During the study, 20 patients were discharged, 80% to lower levels of service restriction, while 14.3% to higher levels. The study suggested that rehabilitation services have an important role within the wider service model for people with ID. Within the service studied, patients were referred from both higher and lower levels of restriction, suggesting the rehabilitation service ‘bridged the gap’ between inpatient and community settings, supporting the aim of caring for patients in the least restrictive setting for their needs.

Safety I and Safety II for suicide prevention – Lessons from how things go wrong and how things go right in community-based mental health services [Abstract]

Prevention of patient suicide is a major challenge for mental health services. This study applied both safety I and safety II approaches to gain an understanding of the detection and response process for suicide prevention in community mental health care in order to compare/contrast outputs from each approach. For safety I, 41 suicide incident reports were analysed using a systemic analysis approach. For safety II, interviews with 20 community-based mental health practitioners and managers were conducted asking their know-hows to successful suicide risk detection and response. The five key issues found from the Safety I approach were: (i) an inherent weakness in the interactions between patient and clinician with the presence of uncertainty in the risk detection; (ii) Poor patients’ engagement with services; (iii) Reliance on patients self-presenting in crisis and declining the offered support options; (iv) Delay in treating new patients; (v) Coordination, communication and process issues. On the other hand, the safety II approach revealed a complex decision-making process with the presence of uncertainty and trade-offs between patient clinical need, patient desire, legal and procedural obligations, and resource considerations. It also revealed a strong theme on the importance of peer-support. The results of this study indicate that safety II approach provides valuable insights into how to strengthen the system performance without challenging systemic issues, while system I approach identifies systemic issues and raise questions how to address them. These findings suggest the potential benefit of applying both approaches to quality and safety improvement in healthcare.

Intellectual disability psychiatry: a competency-based framework for psychiatrists

ABSTRACT This paper is aimed at establishing a competency-based framework for undergraduate, graduate trainee and practicing psychiatrists and has evolved from the initial work of World Psychiatric Association (WPA) on outcome-based parity and human rights-based equity for people with intellectual disability and mental health problems.