To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Racial microaggressions occur when subtle or often automatic exchanges of aversive and covert racism are directed towards people identifying as racialized groups. Consequently, affecting individuals' mental and physical health. Healthcare professionals are a vulnerable group to the effects of racial microaggressions, given the high prevalence of burnout. The aim of the review was to explore healthcare professionals and students' experience of racial microaggressions in healthcare settings
A PROSPERO registered scoping review was conducted using the PRISMA extension for scoping review guidelines. The literature search was undertaken in August 2020, of five databases, MEDLINE, EMBASE, CINAHL, PsycINFO, EMCARE and we also searched the ‘grey literature.’ Studies featuring primary data on racialized or migrant microaggressions towards professionals or students in healthcare settings were included. We excluded studies that were not in English. QDA Miner was used to analyse the data, using a non-essentialist perspective, which suggests that ‘culture’ is a movable concept used by different people at different times to suit purposes of identity, politics and science.
Our search identified 8 papers (5 qualitative, 2 mixed and 1 quantitative) on the experience of microaggressions towards healthcare professionals and students (n = 602). Almost all (87.5%) were conducted in North America and only one (12.5%) in the UK. The primary themes were as follows:
Intersectionality: Individual and group social categorizations of race, class, and gender were described as interconnected, leading to interdependent systems of discrimination or disadvantage. Healthcare professionals indicated that increasing diversity and racial representation can reduce bias and thus microaggressions among stakeholders in the culture of work.
Workplace culture and lack of senior support: The healthcare curriculum, and the manner of its delivery were found to propagate ideas encouraging racial microaggressions. Seniors behaving as role-models by challenging microaggressions could encourage an open and accountable environment. Supervision was a tool for allyship that reduced the threat of negative race-related incidents.
Intervention: Acknowledging racial microaggressions within healthcare, as well as quantifying their presence with tools, encouraged a stronger and more effective response from institutions. Teaching curriculum also served as a useful platform to teach and address microaggressions.
Racial microaggressions were experienced as having a detrimental impact on healthcare professionals’ well-being and mental health. Consequently, this affected the efficiency, the workplace culture, patient outcomes and job satisfaction. Given the multifaceted nature of racial microaggressions, tackling them requires a complex and wide-ranging response from institutions.
Brain in Hand (BIH) is a UK-based digital self-support system for managing anxiety and social functioning.
To identify the impact of BIH on the psychological and social functioning of adults with autism.
Adults with diagnosed or suspected DSM-5 (level 1) autism, identified by seven NHS autism services in England and Wales, were recruited for a 12-week prospective mixed-methods cohort study. The primary quantitative outcome measures were the Health of the Nation Outcome Scales for People with Learning Disabilities (HONOS-LD) and the Hospital Anxiety and Depression Scale (HADS). Fisher's exact test explored sociodemographic associations. Paired t-test was utilised for pre–post analysis of overall effectiveness of BIH. Multivariable linear regression models, univariable pre–post analysis, Wilcoxon signed-rank test, logistic regression analysis, Bonferroni correction and normative analysis were used to give confidence in changes identified. A thematic analysis of semi-structured exist interviews following Braun and Clarke's six-step process of 10% of participants who completed the study was undertaken.
Sixty-six of 99 participants completed the study. There was significant reduction in mean HONOS-LD scores, with 0.65 s.d. decrease in those who used BIH for 12 weeks. Significant positive changes were identified in HONOS-LD subdomains of ‘self-injurious behaviours’, ‘memory and orientation’, ‘communication problems in understanding’, ‘occupation and activities’ and ‘problems with relationship’. A significant reduction in the anxiety, but not depression, component of the HADS scores was identified. Thematic analysis showed high confidence in BIH.
BIH improved anxiety and other clinical, social and functioning outcomes of adults with autism.
Almost a quarter of people with intellectual disabilities have epilepsy. This life-long condition adversely affects their health, safety and well-being and carries an increased risk of sudden unexpected death in epilepsy (SUDEP) in this population. This commentary considers what not only health and social services but also communities and people with intellectual disabilities themselves can do to improve outcomes.
Antiseizure medications (ASMs) are the second most widely prescribed psychotropic for people with intellectual disabilities in England. Multiple psychotropic prescribing is prevalent in almost half of people with intellectual disabilities on ASMs. This analysis identifies limited evidence of ASM benefit in challenging behaviour management and suggests improvements needed to inform clinical practice.
The draft Mental Health Bill, which amends the Mental Health Act 1983 for England and Wales, proposes protections for people with intellectual disability and/or autism (ID/A) to prevent detention in hospital in the absence of mental illness. This editorial critically appraises the positive impact and unintended consequences of the proposed reforms for people with ID/A.
Psychological stress has an established bi-directional relationship with obesity. Mindfulness techniques reduce stress and improve eating behaviours, but their long-term impact remains untested. CALMPOD (Compassionate Approach to Living Mindfully for Prevention of Disease) is a psychoeducational mindfulness-based course evidenced to improve eating patterns across a 6-month period, possibly by reducing stress. However, no long-term evaluation of impact exists.
This study retrospectively evaluates 2-year outcomes of CALMPOD on patient engagement, weight and metabolic markers.
All adults with a body mass index >35 kg/m2 attending an UK obesity service during 2016–2020 were offered CALMPOD. Those who refused CALMPOD were offered standard lifestyle advice. Routine clinic data over 2 years, including age, gender, 6-monthly appointment attendance, weight, haemoglobin A1C and total cholesterol, were pooled and analysed to evaluate CALMPOD.
Of 289 patients, 163 participated in the CALMPOD course and 126 did not. No baseline demographic differences existed between the participating and non-participating groups. The CALMPOD group had improved attendance across all 6-monthly appointments compared with the non-CALMPOD group (P < 0.05). Mean body weight reduction at 2 years was 5.6 kg (s.d. 11.2, P < 0.001) for the CALMPOD group compared with 3.9 kg (s.d. 10.5, P < 0.001) for the non-CALMPOD group. No differences in haemoglobin A1C and fasting serum total cholesterol were identified between the groups.
The retrospective evaluation of CALMPOD suggests potential for mindfulness and compassion-based group educational techniques to improve longer-term patient and clinical outcomes. Prospective large-scale studies are needed to evaluate the impact of stress on obesity and the true impact of CALMPOD.
There is growing evidence for the use of pharmacogenomics in psychotropic prescribing. People with intellectual disabilities are disproportionately prescribed psychotropics and are at risk of polypharmacy. There is an urgent need for safeguards to prevent psychotropic overprescribing but it is equally crucial that this population is not left behind in such exciting initiatives. Understanding how genetic variations affect medications is a step towards personalised medicine. This may improve personalised prescribing for people with intellectual disabilities, especially given the high rate of psychiatric and behavioural problems in this population. Our editorial explores opportunities and challenges that pharmacogenomics offers for the challenges of polypharmacy and overprescribing of psychotropics in people with intellectual disabilities.
An area of interest presently is the lingering symptoms after COVID-19, i.e. post-COVID-19 syndrome (PCS). Specifics of diagnosis and management of PCS are emerging. However, vulnerable populations such as those with intellectual disabilities, who were disproportionately affected by the pandemic, risk being ‘left behind’ from these considerations.
People living with intellectual and developmental disabilities (IDD) have suffered disproportionately in health outcomes and general well-being during the COVID-19 pandemic. There is emerging evidence of increased psychological distress. Increased strain has also fallen on clinicians managing the psychological needs of people with IDD, in the context of learning new technologies, staff shortages, reduced services and paused training opportunities.
To examine clinicians’ experiences of patient care, clinical management and the impact of care delivery.
A mixed fixed-response and free-text survey comprising 28 questions covering four areas (responder demographics, clinical practice, changes to local services and clinician experiences) was developed, using the STROBE guidance. It was disseminated through an exponential snowballing technique to clinicians in seven high-income countries. Quantitative data were analysed and presented with Microsoft Excel. Qualitative data were coded and thematically analysed, and presented with in-text quotations.
There were 139 respondents, mostly senior physicians (71%). Two-thirds reported over 10 years working in the field. Quantitative findings include increased clinician stress (77%), referrals (53%), patient distress presentations (>70%), patient isolation (73%) and carer burden (89%), and reduced patient participation in daily activities (86%). A third reported increased psychotropic prescribing. Qualitative analysis outlined changes to clinical practice, particularly the emergence and impact of telehealth.
In the countries surveyed, the pandemic has not only had a significant impact on people with IDD, but also their carers and clinicians. A proactive, holistic international response is needed in preparedness for future public health emergencies.
The prescribing of psychotropic medications for people with an intellectual disability has changed. In many locations across England, antidepressants have become the most widely prescribed psychotropic. In the context of the current NHS England STOMP programme to reduce inappropriate psychotropic prescribing for people with intellectual disability, there is an urgent need to understand whether this change reflects evidence-based use of the medications involved. There has been little analysis into the benefits or problems associated with the change and whether it is of concern. This paper offers a variety of possible explanations and opportunities to improve clinical practice and policy.
There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.
There has been an increase in the development and application of serious games to support management of mental ill health, but their full impact is unclear.
Evaluation of the current evidence of acceptability and effectiveness of serious games in improving mental health disorders.
A PRISMA-guided scoping review was conducted, using a predefined criteria and a relevant word combination on three databases: EMBASE, Medline and PsycINFO. Each included study was examined for game format, study type, number of participants, basic demographics, disorder targeted, recruitment, setting, control conditions, duration and follow-up, study attrition, primary outcomes and their results. Each study was given a Grading of Recommendations, Assessment, Development and Evaluations rating for quality.
Fourteen out of 513 studies met the inclusion criteria. The serious games focused on symptoms of anxiety (n = 4), attention-deficit hyperactivity disorder (n = 3), depression (n = 2), schizophrenia (n = 2), alcohol use disorder (n = 2) and bipolar disorder (n = 1). There were multiple significant outcomes favouring serious games across conditions covered in the review. Study quality varied, with studies rated high (n = 3), moderate (n = 6), low (n = 3) and very low (n = 2).
The available evidence suggests that serious games could be an effective format for an intervention to reduce mental health symptoms and improve outcomes of individuals. Better designed studies would further develop confidence in this area. This is a potential vehicle of change to deliver some of the much-needed psychiatric support to both economically developed and developing regions in a resource-utilitarian manner. Partnerships between the gaming industry, researchers and health services may benefit patients.
Coronavirus disease 2019 (COVID-19) has had a disproportionate impact on people with intellectual disability (PwID). PwID are at higher risk of mental illness and receive psychotropic prescribing ‘off licence' also, to manage distress behaviour. The lockdown and reduction of multidisciplinary face-to-face appointments had an impact on care delivery, the recourse possibly being psychotropic prescribing. It is imperative to comprehend the influence the pandemic had on psychotropic prescribing patterns to enable future planning.
The aim was to understand the impact of the pandemic by comparing psychotropic prescribing patterns during the England lockdown with the prescribing patterns before lockdown in specialist urban and rural psychiatric services for PwID.
Data was collected from Cornwall (rural) and London (urban) intellectual disability services in England as a service evaluation project to rationalise psychotropic prescribing. PwID in both services open across January 2020 to January 2021 were included. Baseline patient demographics including age, gender, ethnicity, intellectual disability level and neurodevelopmental and psychological comorbidities were collected. Baseline psychotropic prescribing and subsequent % change for each psychotropic group for the two services was compared using Pearson's chi-square and z-statistic (two tailed) with significance taken at P < 0.05.
The two centres London (n = 113) and Cornwall (n = 97) were largely comparable but for baseline differences in terms of presence of severe mental illness (37 v. 86, P < 0.001), challenging behaviour (44 v. 57, P < 0.05) and attention-deficit hyperactivity disorder (37 v. 3, P < 0.001). There was an overall increase in psychotropic prescribing during lockdown in urban as compared with rural settings (11% v. 2%).
The pandemic caused an increase in psychotropic prescribing associated with lockdown severity and urban settings. Team structures could have played a role.
Attention-deficit hyperactivity disorder (ADHD) is common among people with intellectual disability. Diagnosing ADHD in this clinically and cognitively complex and diverse group is difficult, given the overlapping psychiatric and behavioural presentations. Underdiagnoses and misdiagnoses leading to irrational polypharmacy and worse health and social outcomes are common. Diagnostic interviews exist, but are cumbersome and not in regular clinical use.
We aimed to develop a screening tool to help identify people with intellectual disability and ADHD.
A prospective cross-sectional study, using STROBE guidance, invited all carers of people with intellectual disability aged 18–50 years open to the review of the psychiatric team in a single UK intellectual disability service (catchment population: 150 000). A ten-item questionnaire based on the DSM-V ADHD criteria was circulated. All respondents’ baseline clinical characteristics were recorded, and the DIVA-5-ID was administered blinded to the individual questionnaire result. Fisher exact and multiple logistic regressions were conducted to identify relevant questionnaire items and the combinations that afforded best sensitivity and specificity for predicting ADHD.
Of 78 people invited, 39 responded (26 men, 13 women), of whom 30 had moderate-to-profound intellectual disability and 38 had associated comorbidities and on were medication, including 22 on psychotropics. Thirty-six screened positive for ADHD, and 24 were diagnosed (16 men, eight women). Analysis showed two positive responses on three specific questions to have 88% sensitivity and 87% specificity, and be the best predictor of ADHD.
The three-question screening is an important development for identifying ADHD in people with intellectual disability. It needs larger-scale replication to generate generalisable results.
Differential attainment (DA) amongst Black and Minority Ethnic (BAME) medical students and postgraduate trainees including Psychiatry trainees has been extensively documented in medical education, with non-white medical students being 2.5 times more likely to fail high-stake examinations compared to their White counterparts. The Equality Act 2010 places a responsibility on public bodies such as Royal Colleges to address discrimination in training and assessment. Understanding DA in undergraduate medical education can help understand DA in the postgraduate setting. Consequently, this systematic review aims to detect the processes that enable and impede DA in UK undergraduate medical education.
Seven online databases including PubMed, Scopus, PyschInfo, and ERIC were searched. A formal grey literature search was also conducted. Inclusion criteria comprised studies dated from January 1995 to present and included UK undergraduate medical students. We present the preliminary findings from 13 papers, analysed to create a conceptual framework for a further mixed methods analysis. The studies were critically appraised for methodological quality.
Five key themes emerged from the preliminary analysis of 13 papers. BAME students experienced:
Being ‘divergent’: Not feeling part of the current organisational learning milieu
Lack of social capital: Difficulty in being absorbed into existing ‘networks’ of relationships in a manner that is ‘approachable’ and not ‘intimidating’
Continuum of discrimination: ‘Indirect’ impact of subtle communication processes in the learning environment undermining individual ‘belief’ in own performance
Institutional discriminatory factors: Culture, rules, norms, and behavioural routines of educators that lead to differential outcomes for learners
Lack of external support: Relative lack of interventions tackling DA.
The key finding of this review is that British BAME undergraduate medical students experience discriminatory behaviours early in medical schools that impact on personal, educational, and professional outcomes. These factors may need to be borne in mind by postgraduate training organisations such as the Royal College of Psychiatrists as they commence the challenging task of addressing DA.
A significant number of people with autism require in-patient psychiatric care. Although the requirement to adequately meet the needs of people with autism in these settings is enshrined in UK law and supported by national guidelines, little information is available on current practice.
To describe characteristics of UK in-patient psychiatric settings admitting people with autism. Also to examine psychiatric units for their suitability, and the resultant impact on admission length and restrictive interventions.
Multiple-choice questions about in-patient settings and their ability to meet the needs of people with autism and the impact on their outcomes were developed as a cross-sectional study co-designed with a national autism charity. The survey was distributed nationally, using an exponential and non-discriminatory snowballing technique, to in-patient unit clinicians to provide a current practice snapshot.
Eighty responses were analysed after excluding duplications, from across the UK. Significant variation between units across all enquired parameters exist. Lack of autism-related training and skills across staff groups was identified, this becoming disproportionate when comparing intellectual disability units with general mental health units particularly regarding psychiatrists working in these units (psychiatrists: 94% specialist skills in intellectual disability units versus 6% specialist skills in general mental health units). In total, 28% of survey respondents felt people with autism are more likely to be subject to seclusion and 40% believed in-patients with autism are likely to end in segregation.
There is no systematic approach to supporting people with autism who are admitted to in-patient psychiatric units. Significant concerns are highlighted of lack of professional training and skill sets resulting in variable clinical practice and care delivery underpinned by policy deficiency. This could account for the reported in-patient outcomes of longer stay and segregation experienced by people with autism.
People with neurodevelopmental disorders often present with challenging behaviours and psychiatric illnesses. Diagnosis and treatment require patients, families and healthcare professionals to work closely together in partnership, acknowledging their respective areas of expertise. Good treatment outcomes should also be underpinned by robust research evidence. Key research priorities are highlighted.
The approach taken to support individuals during the coronavirus disease 2019 (COVID-19) pandemic needs to take into account the requirements of people with intellectual disabilities and/or autism, who represent a major vulnerable group, with higher rates of co-occurring health conditions and a greater risk of dying prematurely. To date, little evidence on COVID-related concerns have been produced and no report has provided structured feedback from the point of view of people with intellectual disabilities and/or autism or of their family/carers.
To provide systemised evidence-based information of the priority concerns for people with intellectual disabilities and/or autism regarding the COVID-19 pandemic.
Senior representatives of major UK-based professional and service-user representative organisations with a stake in the care of people with intellectual disabilities and/or autism were contacted to provide a list of concerns across three domains: ‘mental health and challenging behaviour’, ‘physical health and epilepsy’ and ‘social circumstances and support’. The feedback was developed into statements on frequently reported priorities. These statements were then rated independently by expert clinicians. A video-conference meeting to reconcile outliers and to generate a consensus statement list was held.
Thirty-two organisations were contacted, of which 26 (81%) replied. From the respondent's data, 30 draft consensus statements were generated. Following expert clinician review, there was initially strong consensus for seven statements (23%), increasing to 27 statements (90%) following video conferencing.
These recommendations highlight the expectations of people with intellectual disabilities and/or autism in the current pandemic. This could support policymakers and professionals’ deliver and evidence person-centred care.
Rapid spread of coronavirus disease 2019 (COVID-19) has affected people with intellectual disability disproportionately. Existing data does not provide enough information to understand factors associated with increased deaths in those with intellectual disability. Establishing who is at high risk is important in developing prevention strategies, given risk factors or comorbidities in people with intellectual disability may be different to those in the general population.
To identify comorbidities, demographic and clinical factors of those individuals with intellectual disability who have died from COVID-19.
An observational descriptive case series looking at deaths because of COVID-19 in people with intellectual disability was conducted. Along with established risk factors observed in the general population, possible specific risk factors and comorbidities in people with intellectual disability for deaths related to COVID-19 were examined. Comparisons between mild and moderate-to-profound intellectual disability subcohorts were undertaken.
Data on 66 deaths in individuals with intellectual disability were analysed. This group was younger (mean age 64 years) compared with the age of death in the general population because of COVID-19. High rates of moderate-to-profound intellectual disability (n = 43), epilepsy (n = 29), mental illness (n = 29), dysphagia (n = 23), Down syndrome (n = 20) and dementia (n = 15) were observed.
This is the first study exploring associations between possible risk factors and comorbidities found in COVID-19 deaths in people with intellectual disability. Our data provides insight into possible factors for deaths in people with intellectual disability. Some of the factors varied between the mild and moderate-to-profound intellectual disability groups. This highlights an urgent need for further systemic inquiry and study of the possible cumulative impact of these factors and comorbidities given the possibility of COVID-19 resurgence.
Background: The multidrug-resistant fungus Candida auris is emerging as a major cause of healthcare-associated infection globally. Understanding the epidemiology of these infections in vulnerable groups such as cancer patients is important for hospital infection control and their effective management. In this report we present diagnostic, clinical, antifungal resistance and outcome data of 11 cases of C. auris infection from an oncology center in India. Methods:C. auris strains were identified by Sanger-based DNA sequencing of the internal transcriber spacer (ITS) gene. Antifungal susceptibility testing (AFST) was performed using the broth dilution method. Identification and AFST were checked by the WHO Collaborating Center for Reference & Research on Fungi of Medical Importance. Patients had both empirical as well as directed therapy with antifungal agents based on AFST results and clinical assessment. Results: Between November 2018 and March 2019, 11 cases of C. auris (8 from patients with solid-organ tumors and 3 from hematological malignancy) were detected. Two distinct genetic clusters were identified by ITS gene sequencing; one of these clusters showed 100% homology with a previously unknown C. auris isolate (GenBank accession no. MK881076) and the other cluster had a 100% identity score with isolates from Japan and South Korea (GenBank accession nos. MH071441, KY657027, and EU884189). All 11 strains were resistant to fluconazole. With voriconazole, 1 isolate was susceptible, 3 were resistant, and 7 showed dose-dependent susceptibility. Two isolates were resistant to amphotericin B. Resistance to caspofungin or anidulafungin was noted in 1 of 11 isolates (9%); most showed intermediate susceptibility (63% to caspofungin). Among all of the patients, 72% were from the intensive care unit (ICU) or the high-dependency unit. The 30-day all-cause mortality was 5 of 11 (45%) in the C. auris group and 4 of 11 (36%) the control group (ie, infections with other Candida spp during same period). Duration of ICU stay in the C. auris group was 12 days and in the control group it was 6 days. The median cost (in terms of hospital bill at the time of discharge or death) for management of Candida auris infection and the primary medical condition was US$10,121 for the C. auris groups and US$8,608 for the control group. Most cases (10 of 11) were detected in wards without isolation rooms, and 8 of the 11 C. auris cases (73%) were detected in patients in the intensive care unit. Conclusions: Morbidity, mortality, ICU stay, and healthcare costs are significant in C. auris infection.