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To describe characteristics of adults with intellectual disability (ID) and/or autism spectrum disorder (ASD) accessing care in one mental health Trust.
To explore factors associated with in-patient admission/risk of re-admission within 12 months of discharge.
There is concern that adults with intellectual disability and those with autism spectrum disorder are frequently admitted to mental health hospitals. The evidence from NHS datasets suggests that this remains a significant issue and is associated with personal, social and economic costs.
Adults (≥ 18 years) with ICD-10 diagnosis of “mental retardation” and/or autism who had accessed care in the Camden and Islington Foundation Trust were identified using the Clinical Record Interactive Search (CRIS). The identification process was validated through cross checking of free text in the electronic clinical notes. We compared demographic and clinical characteristics and service use, including length of admission, of 315 individuals with ASD and 339 with ID (with or without ASD). Logistic regression was used to explore factors associated with in-patient admission and re-admission within 12 months of discharge.
A greater proportion of adults with ID (with or without ASD) had a diagnosis of psychosis, substance misuse, or dementia whereas diagnosis of anxiety disorder was greater in those with ASD. Antipsychotics and other psychotropics were twice as likely to be prescribed for the ID ± group. Admission to psychiatric in-patient care was greater in those with ID ± ASD (adjusted OR 4.00, 95% confidence interval (CI) 2.41-6.63), men (aOR 2.28, 95%CI 1.39-3.75), younger adults (aOR 0.98, 95%CI 0.97-1.00), and in those with a diagnosis of schizophrenia spectrum disorder (aOR 5.08, 95%CI 3.00-8.61), affective disorder (aOR 2.23, 95%CI 1.29-3.83), personality disorder (aOR 1.94, 95%CI 1.02-3.68), and record of previous inpatient admission (aOR 2.18, 95%CI 1.17-4.05). Having ASD alone was associated with a greater risk of re-admission within one year of discharge, although this difference was not statistically significant (aOR 0.70, 95% CI 0.32-1.52). Comorbid diagnoses of affective disorder or personality disorder were the only significant associations with re-admission (aOR 3.11, 95%CI 1.34-7.23 and aOR 8.28, 95%CI 2.85-24.04, respectively).
These findings provide the first longitudinal investigation into the acute care pathway for adults with ID and/or ASD in the NHS. Replication in other trusts is now needed to inform “at risk of admission” registers and guide targeted interventions to prevent admission.
Mental health services have changed the way they operate during the COVID-19 pandemic. We investigated the challenges and innovations reported by staff working in services for people with intellectual disability and/or autism in National Health Service (NHS) and non-NHS sectors, and in in-patient and community settings.
Data were drawn from 648 staff who participated in a UK-wide online survey. Issues around infection risk and mitigation were more important to those working in the NHS and in-patient settings. Community staff were more likely to express concern about the practicalities of a rapid shift to remote working and engaging patients remotely. Qualitative data revealed support for maintaining remote staff working and remote service provision post-pandemic.
Given the current emphasis on community support for people with intellectual disability and/or autism, the focus of research and clinical practice should be the development of accessible and effective models of remote service provision.
Adults with intellectual disability or autism are at risk of psychiatric admission which carries personal, social and economic costs. We identified 654 adults with intellectual disability or autism in the electronic clinical records of one mental health trust. We investigated the demographic and clinical factors associated with admission and readmission after discharge. Young male patients with intellectual disability, schizophrenia and previous admissions are most at risk of the former, whereas affective and personality disorders predict the latter. Both community intellectual disability services and mental health crisis care must focus on providing effective support for those patients.
Although the research base on mental health in intellectual disabilities is advancing, there are long-standing barriers that hinder successful completion of funded studies. A variety of stakeholders hold the key to mitigating the challenges and arriving at sustainable solutions that involve researchers, experts by experience, clinicians and many others in the research pathway. Lessons learned during the COVID-19 pandemic can also contribute to improvements in the conduct of research in the medium to long term. People with an intellectual disability and mental health conditions deserve high standards of evidence-based care.
Out of area treatments (OAT) are expensive and contribute to social isolation of individuals with intellectual disabilities and challenging behaviour.
To identify the needs of those service users who are in OATs with the view of developing a process of assessment and relocation of those service users locally where possible. Finally we aim to reinvest financial flow in each locality to develop high quality services.
We undertook a scoping project over one year in five London boroughs. We reviewed the existing literature, surveyed mental health and challenging behaviour needs of sample, reviewed current treatment and run focus groups with various stakeholders. We presented a business case
205 service users were identified costing over £1300 per week. 65.4% were in OATs costing an estimated £403,740 a week across the five boroughs. High expenditure was associated with increased perceived severity of mental illness, complex physical disabilities and presence of autism. Those detained under the Mental Health Act were also in more expensive placements. Private sector placements were used in the majority of cases.
Despite the lack of high level evidence for specialist services for challenging behaviour, a multi-stranded approach with both inpatient spot purchasing, rehabilitation facilities and high quality accommodation with flexible community with variable purchasing patterns and specialist community input could substantially reduce the financial burden.
Associations have been described between lower IQ and serious mental illness. Associations between common mental disorders (CMDs) and IQ have received little research. The objective of this study was to investigate the association between verbal IQ and CMD symptoms and diagnoses, and to investigate the role of potential mediating and confounding factors.
Data were analysed from a British national survey with an analysed sample of 8054 people aged 16–74 years. Associations between verbal IQ (NART) and mental symptoms/disorders (CIS-R) were analysed with covariates including education, social class, income, debt, problem drinking, life events, physical health and relationship quality.
CMD was associated with lower IQ. This association was stronger for depressive disorder/symptoms than for generalised anxiety disorder/symptoms. The most important covariates were education, social class, income and relationship quality.
The association between lower IQ and CMD is partly accounted for by adverse social/socioeconomic conditions. Stronger associations for depression than anxiety may indicate an effect of IQ on the way mental distress is communicated.
To carry out a three year randomised controlled trial of a specialist behaviour therapy service for adults with learning disabilities compared with treatment as usual, within South Essex Partnership NHS Trust. The study is funded by the South Essex Partnership NHS Trust (ISRCTN62134865).
Challenging behaviour is common in people with intellectual disabilities, but there is a paucity of specialist services in most areas. Currently, most of the care is provided by local community based intellectual disabilities teams whilst specialist care is usually hospital based and situated away from the clients' residence. South Essex Partnership NHS Trust provides such a specialist service to people with intellectual disabilities and challenging behaviour within a five sector locality.
68 participants will be randomly assigned either to specialist intervention or treatment as usual group. Structured interviews are conducted with clients and their carers at baseline and at three and six month follow-up. Main outcome is reduction in challenging behaviour. Secondary outcomes are reduction in carer burden and costs.
Will report on the first 2 years of a 3-year trial.
Intervention research is very scarce if not completely lacking in the field of intellectual disabilities mental health. We anticipate that the data from this study will provide evidence not only for further research but also for service developments and improvement in patient care.
Extended brief interventions (EBIs) are effective in targeting alcohol misuse in the general population. However, little is known on the effects of EBI in adults with intellectual (also known as learning disabilities).
In this feasibility trial we compared EBI with usual care for alcohol misuse in adults with mild to moderate intellectual disability (ID).
The study took place in three community ID services in England. Participants aged 18–65 years with reported alcohol problems, a score > 8 on the alcohol use disorder identification test (AUDIT), and IQ < 70 (+/5% CI) were recruited and were randomly allocated to either EBI (5 weekly sessions and 1 follow-up at 8 weeks) and usual care or usual care alone. Research assessments took place at baseline, two and three months.
Thirty individuals were randomised (15 in each arm). In regard to harmful drinking, at baseline, all the participants exceeded the relevant threshold. At 8 weeks, the proportion of participants with harmful drinking decreased to 60% for both groups, at 12 weeks it was decreased by 66.7% and 46.7% for the intervention and the control group respectively. The unit cost for the delivery of EBI is £ 430.
Recruitment to this trial has been proven challenging as prevalence of alcohol misuse in the targeted population was lower than anticipated. EBI may provide an effective low intensity treatment for this population. Participants’ and carers’ feedback on their experience was overall positive.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Approximately 18% of adults with intellectual disabilities living in the community display behaviours that challenge. Intensive support teams (ISTs) have been recommended to provide high-quality responsive care aimed at avoiding unnecessary admissions and reducing lengthy in-patient stays.
To identify and describe the geographical distribution and characteristics of ISTs, and to develop a typology of IST service models in England.
We undertook a national cross-sectional survey of 73 ISTs. A hierarchical cluster analysis was performed based on six prespecified grouping factors (mode of referrals, size of case-load, use of outcome measures, staff composition, hours of operation and setting of service). A simplified form of thematic analysis was used to explore free-text responses.
Cluster analysis identified two models of IST provision: (a) independent and (b) enhanced provision based around a community intellectual disability service. ISTs aspire to adopt person-centred care, mostly use the framework of positive behaviour support for behaviour that challenges, and report concerns about organisational and wider context issues.
This is the first study to examine the delivery of intensive support to people with intellectual disability and behaviour that challenges. A two-cluster model of ISTs was found to have statistical validity and clinical utility. The clinical heterogeneity indicates that further evaluation of these service models is needed to establish their clinical and cost-effectiveness.
Behaviour that challenges in people with intellectual disability is associated with higher healthcare, social care and societal costs. Although behavioural therapies are widely used, there is limited evidence regarding the cost and quality-adjusted life-years (QALYs).
We aimed to assess the incremental cost per QALY gained of therapist training in positive behaviour support (PBS) and treatment as usual (TAU) compared with TAU using data from a cluster randomised controlled trial (Clinical Trials.gov registration: NCT01680276).
We conducted a cost-utility analysis (cost per QALY gained) of 23 teams randomised to PBS or TAU, with a total of 246 participants followed up over 36 months. The primary analysis was from a healthcare cost perspective with a secondary analysis from a societal cost perspective.
Over 36 months the intervention resulted in an additional 0.175 QALYs (discounted and adjusted 95% CI −0.068 to 0.418). The total cost of training in and delivery of PBS is £1598 per participant plus an additional cost of healthcare of £399 (discounted and adjusted 95% CI −603 to 1724). From a healthcare cost perspective there is an 85% probability that the intervention is cost-effective compared with TAU at a £30 000 willingness to pay for a QALY threshold.
There was a high probability that training in PBS is cost-effective as the cost of training and delivery of PBS is balanced out by modest improvements in quality of life. However, staff training in PBS is not supported given we found no evidence for clinical effectiveness.
At the beginning of 1941 Britain decided to provide military aid to Greece, which was facing an ongoing war against Italy and was expecting a German invasion. This article discusses the impressions and experiences of the British soldiers who took part in the campaign, using their letters, diaries and their – mostly unpublished – reminiscences. It examines their perception of Greece and its inhabitants, as well of their fellow allies and their enemies; their venture in military operations, or captivity; and their daily routine. Furthermore, it comments on their retrospective assessments of the campaign.
There is little evidence to guide pharmacological treatment in adults with Down syndrome and Alzheimer's disease.
To investigate the effect of cholinesterase inhibitors or memantine on survival and function in adults with Down syndrome and Alzheimer's disease.
This was a naturalistic longitudinal follow-up of a clinical cohort of 310 people with Down syndrome diagnosed with Alzheimer's disease collected from specialist community services in England.
Median survival time (5.59 years, 95% CI 4.67–6.67) for those on medication (n = 145, mainly cholinesterase inhibitors) was significantly greater than for those not prescribed medication (n = 165) (3.45 years, 95% CI 2.91–4.13, log-rank test P<0.001). Sequential assessments demonstrated an early effect in maintaining cognitive function.
Cholinesterase inhibitors appear to offer benefit for people with Down syndrome and Alzheimer's disease that is comparable with sporadic Alzheimer's disease; a trial to test the effect of earlier treatment (prodromal Alzheimer's disease) in Down syndrome may be indicated.
Declaration of interest
A.S. has undertaken consulting for Ono Pharmaceuticals, outside the submitted work. Z.W. has received a consultancy fee and grant from GE Healthcare, outside the submitted work.
People with intellectual disability have high mental and physical healthcare needs, which must be addressed on individual, local and national levels. Policy interventions informed by research and stakeholder views and extending beyond a focus on health are needed to reduce inequities in this group.
Staff training in positive behaviour support (PBS) is a widespread treatment approach for challenging behaviour in adults with intellectual disability.
To evaluate whether such training is clinically effective in reducing challenging behaviour during routine care (trial registration: NCT01680276).
We carried out a multicentre, cluster randomised controlled trial involving 23 community intellectual disability services in England, randomly allocated to manual-assisted staff training in PBS (n = 11) or treatment as usual (TAU, n = 12). Data were collected from 246 adult participants.
No treatment effects were found for the primary outcome (challenging behaviour over 12 months, adjusted mean difference = −2.14, 95% CI: −8.79, 4.51) or secondary outcomes.
Staff training in PBS, as applied in this study, did not reduce challenging behaviour. Further research should tackle implementation issues and endeavour to identify other interventions that can reduce challenging behaviour.