Disability Psychiatry Research Articles

Interface between community intellectual disability and general adult psychiatry services

SUMMARYPeople with intellectual disability can have a range of common mental health difficulties that sit at the interface of two psychiatry subspecialties: intellectual disability and general adult psychiatry. Clinical presentations, comorbidities and complexities can affect the setting of boundaries between the two disciplines. This article touches on current concepts, drives for inclusion of people with intellectual disability in mainstream psychiatry services and some of the difficulties at the interface. It focuses on potential solutions for managing this interface between the two subspecialties.

Mutual associations between intellectual disability and epilepsy-related psychiatry disability: Population-based study.

Epilepsy is the third-leading cause of psychiatry disability in China, and intellectual disability (ID) is also 1 major type of disabilities in China. This study estimates the prevalence of comorbidities with ID and epilepsy-related psychiatry disability (EPD) and examines mutual associations within ID and EPD.Data were taken from the Second China National Sample Survey on Disability, which was a nationally representative, population-based survey. To derive a nationally representative sample, the survey used multistage, stratified, cluster random sampling with probability proportional to size. The disabled people who had ID and EPD based on the World Health Organization International Classification of Functioning, Disability, and Health and the International Statistical Classification of Diseases. The cox-proportional hazards model was used to examine the associations between ID and EPD considering the happened sequence of ID and EPD.The prevalence of ID with EPD was 0.14 (95% confidence interval: 0.09–0.19) per 1000 people. Age was strongly associated with the risk of EPD, which was diagnosed after ID, especially among young ID population. Except for age, other variables were also associated between ID and EPD considering sequence of ID and EPD.This study is the first national study to explore mutual associations with ID and EPD and highlights the young ID children with high risk of development of epilepsy. To address the challenge of ID with EPD disability in China, the government should adjust its strategies for healthcare systems to prevent disability.

Inequities and psychiatry disability in transition among the elderly population from 1987 to 2006 in China: Data based on national surveys.

The world will be facing huge population aged 65 and older, accounting for 13% of the total population in the future. Significant disabilities rates reflect an accumulation of health risks. Psychiatry disability is one of the most significant disabilities, because it manifests in cognitive, affective, and behavior disorders that limit one's daily life and restrict their participations. Very few studies have explored the 20 years associations between demographic factors and psychiatry disability among older people in China.In this study, we investigated psychiatry disability transitional association behind China rapid development from 1987 to 2006 among the 60 and older population. Data used 2 nationally represented, population-based data from the China National Sample Surveys on Disability, conducted in 1987 and 2006. The sample size of the current study was 140,008 in 1987 and 354,859 in 2006, respectively. Associations between socioeconomic factors and psychiatry disability were determined by using a logistic regression model.The prevalence of psychiatric disabilities increased from 1987 to 2006. In both surveys, the most common psychiatric disabilities were schizophrenia, schizotypal, and delusional disorders, and they presented the same associations with age increase. Socioeconomic inequities, such as current employment status and marital status, were associated with psychiatry disability in both surveys. These associations remained even after these 2 surveys were combined.The rapidly rising prevalence of psychiatric disorders expected warrants strategies to reduce the burden of these disabilities among females and rural residents.

Governing Madness – Transforming Psychiatry Disability History and the Formation of Cultural Knowledge in West Germany in the 1970s and 1980s

In 1975, the German Bundestag published the Psychiatrie-Enquete, a 1,800 pages report, which had been produced over five years by more than 200 experts under the auspices of Aktion psychisch Kranke e.V. The reform movement, which throughout the following 20 years established institutional standards of social psychiatry in the Federal Republic of Germany (FRG), was strongly influenced by the principles of welfare politics implemented in the states of Northern Europe. However, some minor trajectories of knowledge can be detected and will be discussed in this article. On the level of therapeutic and anthropological thinking, the ongoing and fierce critique of institutionalised psychiatric exclusion in different European countries was accompanied by new arguments of social research and critical theory. On the level of historical awareness, the emerging knowledge of the Nazi genocide and euthanasia led to a memory turn in 1979. Historical research on the so-called forgotten victims supported the acknowledgement and emancipation of psychiatric patients during the 1980s, which could be realised under the new social psychiatry frame. On the level of democratisation, patients’ self-help and -advocacy as well as their networks of support established a strong voice in the public, which since then has to be heard in political decision-making. These three trajectories of (marginalised) knowledge strongly affected cultural democratisation as the necessary platform or general heaven for moving social institutions and political realities. The aim of this paper is to get a clearer image of their conceptual influences on Western Germany’s intellectual and political consciousness in moving social imagination and the democratisation of interactions. The study will work with the de/constructionist cultural approach to disability in order to expound the problems of knowledge discourses and their effects on the constructions of normativity and inequality.

Beyond A Beautiful Mind: Schizophrenia and Bioethics in the Classroom

This essay focuses on specific teaching assignments, strategies, and resources designed to help undergraduate students think critically about key concepts in bioethics—such as autonomy, paternalism, informed consent, and competency—using examples and case studies involving people diagnosed with schizophrenia. The assignments described below are disability-rights inspired interventions into the students' career-focused mindsets and training; one of my main strategies is social decentering, or having students examine a situation from a variety of theoretical and subjective perspectives. Exposing students to online talks by people diagnosed with schizophrenia and similar primary sources helps those students without first-hand experience to better understand these different points of view. While these assignments are primarily geared toward bioethics classes, they include resources and ideas for class activities that might be useful in other courses within disability studies, mad studies, psychiatry, literature, or film.

Excellence in Training – What Makes a Good Psychiatrist?

Psychiatry is part of the medical discipline and a key medical specialty which deals with mental illness and mental, emotional and behavioural disorders in the presence or absence of physical disorders. Psychiatric disorders include a number of problems starting from childhood to older age as well as chronic severe mental illness and common mental disorders and psychiatry of learning disability. Biopsychosocial models of aetiology and management are generally followed. Thus the psychiatrist needs to be aware of medical interventions, social care and psychological therapies along with spiritual and anthropological aspects of care. They may not provide these directly but must be aware of where help should be sought from. There are various models of training and frameworks for what are the roles and responsibilities of psychiatrists. First and foremost psychiatrists need to be clinicians along with abilities to be a professional, have academic abilities, be able to communicate and manage resources. Being a team player is an essential criterion. A good psychiatrist should be able to synthesise all the information including biological, psychological, social and spiritual and cultural factors in making sense of the patient’s distress emotional and behavioural experiences. A good psychiatrist can manage uncertainty and deal with ambiguity. They must be able to help patients and their families navigate the complex health care systems. Working with families and working as an advocate for patients and their families is a critical but often unappreciated aspect of the role of the psychiatrist. In these changing times, good psychiatrists will also engage in public mental health agenda.

Lauren Slater and the Experts: Malingering, Masquerade, and the Disciplinary Control of Diagnosis.

The work of psychologist and author Lauren Slater has elicited strong reactions from both medical professionals and disability studies theorists, ranging from criticism to high praise. Attending to these responses, I argue that her work, in perhaps perverse fashion, can provide a narrative touch point for attempts from both fields to complicate the outdated binary division of the medical and social models. I illustrate the need for this collaboration through the example of malingering, suggesting that reading Slater's work through the lens of Tobin Siebers's theory of "masquerade" can open progressive conversations about "illness deception," which is an issue of central importance in disability rights, psychiatry, and political conversations. By using Slater's work and research on malingering as a test case, I point to potentially productive convergences among academic, medical, and social fields.

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 world's 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.

Education and Training in Psychiatry in the U.K.

Recent training and education changes have raised important issues in delivery of psychiatric education at all levels. In this article, the authors describe the current status of mental health education in the training of all doctors and postgraduate training and education in psychiatry in the U.K. The authors explore and describe some of the initiatives that are being used in order to increase exposure to mental health placements in the Foundation Program, and they then describe the existing specific mental health opportunities within general practice and other specialist training programs. After graduation from medical school, a two-year Foundation training program is a must, and, at the end of the first year, trainees become eligible for full registration with the "regulator," the General Medical Council; after finishing the second year, they become eligible to undertake specialist training. Psychiatry training takes up to 6 years, and six specialties are recognized as leading to certificates for completion of training before independent practice. These six specialties are 1) general and community; 2) child and adolescent; 3) medical psychotherapy; 4) forensic psychiatry; 5) psychiatry of old age; and 6) psychiatry of learning disability. Also, three subspecialties-liaison psychiatry, addictions, and rehabilitation-form a part of the training in general and community psychiatry. The authors discuss advantages and disadvantages of such an approach and raise key issues related to ongoing work to improve recruitment, progression, and retention of trainee psychiatrists.

The interface between learning disability and old age psychiatry: two specialties travelling alone or travelling together?

The Royal College of Psychiatrists set up an interface group to look at the interface between old age psychiatry and learning disability and, as part of its work, the group commissioned a survey of learning disability and old age psychiatrists to investigate their experience of working across the boundary between the two specialities. This paper is based on the report produced. It summarises the findings of the survey and sets out eight recommendations to further the work. There was no clarity on how services should be provided to older people with a learning disability who develop a mental health problem in later life but the need for collaboration between the two specialities is compelling.

Developmental Neuropsychiatry: A New Model of Psychiatry for Young People With and Without Intellectual Disability?

Deinstitutionalization of young people with intellectual disability means that they are now cared for by families and served by community-based professionals. Normalization, which has been the guiding philosophy for this re-integration, has challenged child psychiatry to accept its responsibility for the mental health of this special needs group. It is argued that this group, with its special mental health needs, has had an influence on the conceptual framework of child psychiatry, particularly our understanding of development. This article examines the influence of the psychiatry of intellectual disability on child psychiatry and the influence of child psychiatry on the understanding of the mental health needs of those with intellectual disability. In particular, the management of young people with intellectual disability has required child psychiatry to expand its understanding of a biopsychosocial approach. Some of the resulting changes and challenges are presented to illustrate the benefits for both child psychiatry and the psychiatry of intellectual disability. The interaction of different conceptual biases has led to a new and broader conceptual spectrum of developmental neuropsychiatry. Developmental neuropsychiatry recognizes the need to integrate social science and preventative strategies at one end of the spectrum, with the genetics, molecular biology of human behaviour and targeted pharmacology at the other, and consider the developmental and interactive nature of such models. This article argues that this emerging, dynamic and broader conceptual framework of developmental neuropsychiatry enhances our understanding of the child mental health of all children. The article looks at some of the implications for assessment, diagnosis and treatment. As mental health needs become a greater public health priority, the advances in basic sciences will reinvigorate this medical specialty and training programmes will need to reflect these.

A survey of consultants in the psychiatry of learning disability

Aims and MethodAll 208 consultant members of the Faculty for the Psychiatry of Learning Disability were contacted and asked to complete a questionnaire to provide qualitative and quantitative information about their work and experiences.ResultsOne hundred and thirty-six consultants responded, giving a 64% response rate. They reported a wide range of clinical, academic and management skills, with 72 having registration in other specialities. Insufficient in-patient provision and problems with discharge were cited by 85% of respondents. There was a wide disparity in the provision of mental health services for children and adolescents with learning disabilities and 12 areas reported no services from any source. Although most respondents showed satisfaction with clinical work and professional relationships, there were many concerns about management, commissioning and planning of services.Clinical ImplicationsConsultant psychiatrists in the field of learning disability are a broadly skilled group of clinicians with a wide range of responsibilities and areas of expertise, but many are working in services that they see as under-resourced and poorly managed, planned and commissioned. Overall levels of satisfaction are good, particularly in relation to clinical work, peer support and study/academic work.

Psychiatry of learning disability – a future with mental health?

Aims and MethodA postal survey was sent to all consultants in the psychiatry of learning disability from four English regions. Their views on job satisfaction, their core roles and the management re-structuring of services were elicited.ResultsThe proportion agreeing or strongly agreeing with each management option was 79% for integrated mental health–learning disability trusts, 61% for specialist learning disability trusts, 47% for care trusts, 10% for primary care trusts and 5% for social services. Only 34% felt consulted or able to influence the process of change and only 33% were satisfied with the current management changes within their trust but 67% were satisfied overall with their jobs.Clinical ImplicationsManagement from integrated mental health–learning disability trusts is the most preferred option for psychiatrists in learning disability. A large number of consultants, though otherwise satisfied with their jobs, feel excluded or unable to influence the current changes in management structures. A model of integrated service provision in line with the government's learning disability strategy is presented.

What is the future of the psychiatry of learning disability?

Two surveys about learning disability service organisation and psychiatric staffing appear in this issue. Smiley et al ( [2002][1], this issue) had a 100% response from Scottish service providers to their survey looking at the relationship between psychiatric staffing levels, other resources and

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.

Psychiatry of learning disability

Psychiatry of learning disability

The dual diagnosis facility: a renewed engagement with the psychiatry of intellectual disability?

A case study of a pilot residential facility for intellectually disabled adults who also suffer the effects of mental illness I presented in the context of the emergent debate surrounding the issue of dual diagnosis and co-morbidity. The innovative role of nurses in the establishment if this new service is discussed in terms of the beginning of a renewed engagement with the psychiatry of intellectual disability and it’s implications for nursing practice and practice arrangements.

Audit on Letters from Psychiatrists to General Practitioners Following Assessment of Patients with Learning Disabilities in Follow-Up Clinics

The quality of communication between psychiatrists and General Practitioners reflect the quality of care provided to patients (Prasher et al., 1992). Most studies in this area have focused on the General Adult Psychiatrists describing their first assessment of patients following a GP referral (Pullen and Yellowlees, 1985; Pether et al., 1993; Blakely et al., 1997). GPs identified five key items namely diagnosis, treatment recommended, follow-up arrangements, prognosis and concise explanations of the patient’s condition as items which should be present in a psychiatrist’s letter, the length of which they preferred to be one page (Pullen and Yellowlees, 1985). There has been only one audit which focused on letters following an initial assessment of patients with learning disabilities (Markar and Mahadeshwar, 1998). They found that when dealing with learning disability patients, GPs preferred longer letters with specific subheadings according to the guidelines set out by the Institute of Psychiatry. These include reason for referral, complaints, present illness, family history, personal history, medical history, previous psychiatric history, alcohol and drug history, forensic history, premorbid personality, mental state examination and physical examination. There have not been any published studies or audits which have focused exclusively on letters from follow-up clinics in the Psychiatry of Learning Disability.

Trainee attitudes within the Faculty of the Psychiatry of Learning Disability

Aims and methodRecruitment of trainees and consultants into psychiatry is a major concern. A questionnaire survey of trainees within the psychiatry of learning disability was conducted to highlight attitudes about training and career issues.ResultsNinety per cent of trainees decided on a career in learning disability as a result of completing a junior post in this speciality. Forty-three per cent were seeking dual accreditation and nearly half of these were experiencing problems relating to this; 84% expressed fears about becoming a consultant; and 63% felt they needed more advice on how to find a consultant post.Clinical implicationsIncreased exposure to learning disability at the basic training grade is required to ensure recruitment. In addition issues related to dual accreditation and anxieties about consultant posts need to be addressed.

Primary Health Care and Health Gain for People with a Learning Disability

OCTOBER 1998 © Pavilion Publishing (Brighton) Limited 15 with a brief to facilitate communication with the GPs of clients referred to the specialist learning disability health care team, to advocate on the behalf of clients, and to offer postgraduate education. Our approach was to identify all the clients known to the specialist team or the local learning disability register who were registered with a practice, and to visit that practice with information about each of the identified clients. This was supplemented with laminated checklists intended to act as prompts whenever the identified patient visited the doctor. Although these checklists were welcomed by many of the GPs, there is no evidence that they have improved the quality of care provided by GPs. The major problem we have found is that their service is reactive rather than proactive. Although people visit their doctor three or four times a year on average, and although GPs are the most frequently consulted professionals and the ones who are most likely to know the person over many years, any hope that opportunistic screening will take place seems to be based on a false premise. This is well illustrated by a conversation I had with a fundholding GP. He told me that his practice register enabled him to know who the people with learning disabilities were. He said he knew that there were several people with Down’s syndrome. When he checked the register to confirm this, he discovered that no-one was identified as having Down’s syndrome. His explanation was that they consult their doctor with coughs and colds and thus the aetiology of their learning disability, and even the fact of their learning disability, is irrelevant. My experience as a GP in practice in South London for several years, and now as a consultant in psychiatry of learning disability for 17 years, is that neither facilitation nor opportunistic screening nor postgraduate education in the local GP centre has had much impact on improving awareness of the Primary Health Care and Health Gain for People with a Learning Disability