A number of studies have demonstrated reductions in the utilisation of psychiatric services, especially acute inpatient admissions, following therapeutic community treatment of personality disorder. These studies have, however, been of limited duration (1 year) and follow-up has not always been complete.

To identify hospital admissions before and after therapeutic community treatment of personality disorder.

A naturalistic clinical cohort of patients admitted between January 1993 and December 1995 was followed up for 3 years. All subjects were traced to their current consultant psychiatrist, general practitioner or death.

All patients were traced at 3-year follow-up. The significant reduction in in-patient admissions seen in the first year was maintained over 3 years. Those with the poorest outcomes, suicide, accidental death or prolonged admission were all in the quartile with the shortest admissions (under 42 days) to the therapeutic community.

Previously reported reductions in psychiatric admissions following therapeutic community treatment of personality disorder are maintained over 3 years.

Though contentious, the diagnosis of personality disorders in persons with learning disability is clinically relevant because it affects many aspects of management.

To examine published literature on the diagnosis of personality disorders in learning disability.

Selective review with computerised (Medline, Embase and PsychInfo) and manual literature searches.

The variation in the cooccurrence of personality disorder in learning disability, with prevalence ranging from less than 1% to 91% in a community setting and 22% to 92% in hospital settings, is very great and too large to be explained by real differences.

The diagnosis of personality disorders in learning disability is complex and difficult, particularly in those with severe disability Developing consensus diagnostic criteria, specific for various developmental levels, is one way forward. Such criteria may need to include objective proxy measures such as behavioural observations and informant accounts.

The Global Assessment of Function (GAF) scale is widely used in adult psychiatric practice and research but it has not often been used in learning disability, which is inherently more complex.

To evaluate the reliability of GAF in the assessment of learning disability.

GAF reliability was tested by simultaneous multiple rating of unselected case vignettes (n=19–25) from health professionals of different disciplines, under controlled conditions. Analysis of reliability was made with the intraclass correlation coefficient (R1) with separate assessments to determine rater bias and individual performance of raters.

The results of three data-sets showed generally poor overall levels of agreement, with R1 levels of 0.35 and 0.28 and somewhat better levels for current GAF scores (R1=0.49). However, a subset of raters was identified that achieved much higher levels (R1=0.54 to 0.74).

The GAF, in its current format, is not reliable enough to be used in the routine assessment of learning disability A subgroup of raters, however, have ratings that are, by current biostatistical criteria, sufficiently reliable.