Psychiatric Disorders For Use Research Articles

A journey through psychiatry - A personal perspective.

A journey through psychiatry - A personal perspective.

Comparing psychopathology rates across autism spectrum disorders and intellectual disabilities

PurposeThe purpose of this paper is to compare the rates and patterns of comorbid anxiety, depression and ADHD across people with: autism spectrum disorder (ASD) plus intellectual disability (ID), ASD/no ID (AS/HFA) and ID only.Design/methodology/approachData were obtained using structured file review and two psychometric screening instruments. File reviews used a modified version of the Case Review Protocol from the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities. Screening employed the Reiss Screen for Maladaptive Behaviour and the ASD-Comorbidity-Adults scale.FindingsLevels of anxiety, depression and ADHD were high for all three groups, and greater than in general population studies. Between groups, the AS/HFA sample had significantly higher anxiety, while the ASD/ID group had significantly greater ADHD. Groups did not differ on measures of depression or total psychopathology. Levels of ADHD, but not anxiety or depression, increased with severity of ID and ASD symptoms.Research limitations/implicationsMore research is needed on the relationship between ASD and both anxiety and ADHD, particularly the identification of these comorbid conditions and their treatment.Practical implicationsRigorous screening for comorbid mental health conditions is required to achieve the best outcomes for adults with ASD.Originality/valueThe study used a broader community-based sample than previous comorbidity research. Including adults with ID but without ASD enabled a comparison of types and rates of disorder across three distinct but related groups with neurodevelopmental disorders.

Behavioural activation versus guided self-help for depression in adults with learning disabilities: the BeatIt RCT.

Depression is the most prevalent mental health problem among people with learning disabilities. The trial investigated the clinical effectiveness and cost-effectiveness of behavioural activation for depression experienced by people with mild to moderate learning disabilities. The intervention was compared with a guided self-help intervention. A multicentre, single-blind, randomised controlled trial, with follow-up at 4, 8 and 12 months post randomisation. There was a nested qualitative study. Participants were recruited from community learning disability teams and services and from Improving Access to Psychological Therapies services in Scotland, England and Wales. Participants were aged ≥ 18 years, with clinically significant depression, assessed using the Diagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities. Participants had to be able to give informed consent and a supporter could accompany them to therapy. BeatIt was a manualised behavioural activation intervention, adapted for people with learning disabilities and depression. StepUp was an adapted guided self-help intervention. The primary outcome measure was the Glasgow Depression Scale for people with a Learning Disability (GDS-LD). Secondary outcomes included carer ratings of depressive symptoms and aggressiveness, self-reporting of anxiety symptoms, social support, activity and adaptive behaviour, relationships, quality of life (QoL) and life events, and resource and medication use. There were 161 participants randomised (BeatIt, n = 84; StepUp, n = 77). Participant retention was strong, with 141 completing the trial. Most completed therapy (BeatIt: 86%; StepUp: 82%). At baseline, 63% of BeatIt participants and 66% of StepUp participants were prescribed antidepressants. There was no statistically significant difference in GDS-LD scores between the StepUp (12.94 points) and BeatIt (11.91 points) groups at the 12-month primary outcome point. However, both groups improved during the trial. Other psychological and QoL outcomes followed a similar pattern. There were no treatment group differences, but there was improvement in both groups. There was no economic evidence suggesting that BeatIt may be more cost-effective than StepUp. However, treatment costs for both groups were approximately only 4-6.5% of the total support costs. Results of the qualitative research with participants, supporters and therapists were in concert with the quantitative findings. Both treatments were perceived as active interventions and were valued in terms of their structure, content and perceived impact. A significant limitation was the absence of a treatment-as-usual (TAU) comparison. Primary and secondary outcomes, economic data and qualitative results all clearly demonstrate that there was no evidence for BeatIt being more effective than StepUp. Comparisons against TAU are required to determine whether or not these interventions had any effect. Current Controlled Trials ISRCTN09753005. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 53. See the NIHR Journals Library website for further project information.

Validity of Criteria for Dementia in Older People With Intellectual Disability

Valid definitions of dementia should discriminate dementia from other forms of cognitive impairment such as intellectual disability (ID). We aimed to evaluate the usefulness of criteria for dementia and mild cognitive impairment (MCI) in ID, including predictive validity, and inter-rater reliability. We assessed 222 participants in a survey of older adults with ID without Down syndrome at two time points for dementia (T1 and T2). Mean follow-up period was 2.9 years. Dementia diagnoses were made according to International Classification of Diseases, Tenth Revision, Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), Diagnostic criteria for psychiatric disorders for use with adults with learning disabilities (DC-LD) criteria. At follow-up (T2), raters were blind to initial diagnosis. Predictive validity was determined by comparing odds ratios (ORs) of death, or of having a "poor outcome" (i.e., either dying or being diagnosed with dementia at T2). All dementia criteria showed substantial inter-rater reliability (κ > 0.68) and high specificity (~95%). Dementia cases at T1 were more likely to have died at T2 than those with no dementia (33.3% versus 14.9%; OR: 2.85; 95% confidence interval (95% CI): 1.12-7.22) and to have a "poor outcome" (77.8% versus 27.6%; OR: 9.18; 95% CI: 3.43-24.53). At least two dementia cases at T1 were false positives. Those with "MCI" at T1 were similar to "no dementia" cases in terms of poor outcomes at T2. Dementia diagnostic criteria show substantial reliability and satisfactory validity in ID. The diagnoses were, however, less stable than in the general population and some caution is advisable in those with more severe ID or additional sensory disability. MCI definitions require further consideration in the ID population.

Application of DC‐LD to an intellectual disability population

Purpose – The Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC‐LD) was introduced in 2003 in an attempt to improve accuracy of diagnosis in the intellectual disability population. The paper aims to apply this system to a sample of a population with intellectual disability to further investigate its usefulness in the clinical setting.

Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group

Recognition of the significance of anxiety disorders in older adults is growing. The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a timely opportunity to consider potential improvements to diagnostic criteria for psychiatric disorders for use with older people. The authors of this paper comprise the Advisory Committee to the DSM5 Lifespan Disorders Work Group, the purpose of which was to generate informative responses from individuals with clinical and research expertise in the field of late-life anxiety disorders. This paper reviews the unique features of anxiety in later life and synthesizes the work of the Advisory Committee. Suggestions are offered for refining our understanding of the effects of aging on anxiety and other disorders (e.g., mood disorders) and changes to the DSM5 criteria and text that could facilitate more accurate recognition and diagnosis of anxiety disorders in older adults. Several of the recommendations are not limited to the study of anxiety but rather are applicable across the broader field of geriatric mental health. DSM5 should provide guidelines for the thorough assessment of avoidance, excessiveness, and comorbid conditions (e.g., depression, medical illness, cognitive impairment) in anxious older adults.

Adults with intellectual disabilities: prevalence, incidence and remission of aggressive behaviour and related factors

Aggressive behaviours can be disabling for adults with intellectual disabilities (ID), with negative consequences for the adult, their family and paid carers. It is surprising how little research has been conducted into the epidemiology of these needs, given the impact they can have. This study investigates point prevalence, 2-year incidence and 2-year remission rates for aggressive behaviour (physically aggressive, destructive and verbally aggressive), and it investigates which factors are independently associated with aggressive behaviour. All adults with ID - within a geographically defined area of Scotland, UK - were recruited to a longitudinal cohort. At baseline, assessments were undertaken of demography, lifestyle, supports, development, problem behaviours, disabilities and physical and mental health. These were repeated for a 2-year period. At baseline, the participation rate was 1023 (65.5%). After 2 years, the cohort retention was 651 adults. The point prevalence of Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) aggressive behaviour was 9.8% (95% confidence interval = 8.0-11.8%), 2-year incidence was 1.8%, and 2-year remission rate from all types of aggressive behaviour meeting DC-LD criteria was 27.7%. The factors independently associated with aggressive behaviours were lower ability, female gender, not living with a family carer, not having Down syndrome, having attention-deficit hyperactivity disorder and having urinary incontinence. Incidence of aggressive behaviour meeting DC-LD criteria in adult life is similar to that for each of psychotic, anxiety and organic disorders. Aggressive behaviour is common among adults with ID, but contrary to previous suggestions, more than a quarter remit within the short to medium term. This is important knowledge for professionals as well as the person and her/his family and paid carers. There is much yet to learn about the mechanisms underpinning aetiology and maintenance of aggressive behaviour in this population, and exploratory epidemiological investigations such as this have a role to play in progressing research towards further hypothesis testing and trials to influence clinical practice, service development and policy.

Mental Disorders and Problem Behavior in a Community Sample of Adults with Intellectual Disability: Three-Month Prevalence and Comorbidity

The aim of this study was to investigate the prevalence of mental disorders in a Norwegian sample of adults with intellectual disability (ID) using the Psychopathology Checklists for Adults With Intellectual Disability (P-AID; Hove & Havik, 2008), a screening instrument adopting diagnostic criteria from the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Intellectual Disability/Mental Retardation (DC-LD; Royal College of Psychiatrists, 2001). The P-AID checklists, comprising 10 psychiatric diagnoses and 8 types of problem behaviors, were completed by staff at community-based homes for adults with ID in Western Norway. One in three adults with ID showed indices of a mental disorder. Problem behavior was the most prevalent single diagnosis next to anxiety and affective disorder, and there was a high frequency of comorbidity among the disorders. The findings extend previous reports on mental disorders and comorbidity and support the use of DC-LD in epidemiological research.

The prevalence and incidence of mental ill‐health in adults with Down syndrome

While there is considerable literature on adults with Down syndrome who have dementia, there is little published on the epidemiology of other types of mental ill-health in this population. Longitudinal cohort study of adults with Down syndrome who received detailed psychiatric assessment (n = 186 at the first time point; n = 134 at the second time point, 2 years later). The prevalence of Down syndrome for the 16 years and over population was 5.9 per 10 000 general population. Point prevalence of mental ill-health of any type, excluding specific phobias, was 23.7% by clinical, 19.9% by Diagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities/Mental Retardation (DC-LD), 11.3% by ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research (DCR-ICD-10) and 10.8% by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Revised (DSM-IV-TR) criteria. Two-year incidence of mental ill-health of any type was 14.9% by clinical and DC-LD, 9.0% by DCR-ICD-10 and 3.7% by DSM-IV-TR criteria. The highest incidence was for depressive episode (5.2%) and dementia/delirium (5.2%). Compared with persons with intellectual disabilities (ID) of all causes, the standardized rate for prevalence of mental ill-health was 0.6 (0.4-0.8), or 0.4 (0.3-0.6) if organic disorders are excluded, and the standardized incidence ratio for mental ill-health was 0.9 (0.6-1.4), or 0.7 (0.4-1.2) if organic disorders are excluded. Urinary incontinence was independently associated with mental ill-health, whereas other personal factors, lifestyle and supports, and other types of health needs and disabilities were not. Mental ill-health is less prevalent in adults with Down syndrome than for other adults with ID. The pattern of associated factors differs from that is found for other adults with ID, with few associations found. This suggests that the protection against mental ill-health is biologically determined in this population, or that there are other factors protective for mental ill-health yet to be identified for the population with Down syndrome.

The Prevalence, Incidence, and Factors Predictive of Mental Ill‐Health in Adults with Profound Intellectual Disabilities

Background There are no previous studies of the prevalence and incidence of mental ill‐health in adults with profound intellectual disabilities.Method In this population‐based prospective cohort study, adults with profound intellectual disabilities underwent psychiatric assessment (n = 184), with further assessment after 2 years (n = 131).Results Point prevalence of mental ill‐health was 52.2% by clinical, 45.1% by Diagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities (DC‐LD), 10.9% by the ICD‐10 Classification of Mental and Behavioural Disorders Diagnostic Criteria for Research (1993) (DCR‐ICD‐10) and 11.4% by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2004) (DSM‐IV‐TR) criteria. The highest 2‐year incidence rates were for affective disorders (6.1%) and problem behaviours (6.1%). Type of accommodation/support, and the number of preceding life events were predictive of incidents of mental ill‐health, but age, gender, living in areas of greatest deprivation, and having special communication needs were not.Conclusions Mental ill‐health is more commonly experienced by adults with profound intellectual disabilities than the general population, or other adults with intellectual disabilities, warranting proactive supports/interventions. Predictive factors differ, compared with the general population.

Refining diagnoses: applying the DC‐LD to an Irish population with intellectual disability

The diagnostic criteria for psychiatric disorders for use with adults with learning disabilities/mental retardation (DC-LD) is a diagnostic tool developed in 2001 to improve upon existing classification systems for adults with learning disability. The aim of this study was to apply the classification system described by the DC-LD to a residential intellectual disability (ID) population to examine whether it improved our diagnostic understanding of residents. Chart reviews of 113 of 178 people in a residential ID service were conducted. For each resident, information was recorded according to the DC-LD multi-axial system. Each resident's case was then discussed with a member of nursing staff familiar with the resident. If diagnosis was unclear, the case was discussed with a senior clinical psychiatrist. The percentage of residents with a moderate to profound ID was 87.6%. In total, 94 diagnoses of psychiatric illness (Axis III, Level B, DC-LD) were made. Of those 94 diagnoses, seven new diagnoses were found because of DC-LD criteria. Of the total number of psychiatric diagnoses made, 72.3% were non-specific, residual category diagnoses. A total of 79 residents (69.9%) had at least one behaviour problem diagnosed on Axis III, Level D, Problem behaviours. Fifty-six (49.6%) of residents in this sample had co-morbid epilepsy. In people with moderate to profound learning disabilities, diagnosis continues to be challenging. The DC-LD is a useful tool in helping to clarify diagnoses in this population by providing revised criteria and a system to classify problem behaviours. The DC-LD would be more helpful if specific axes were included to document medical and psychosocial problems independently from other diagnoses. Further research is warranted to determine whether the DC-LD hierarchical approach to diagnosis improves diagnostic validity.

Diagnosis and classification of eating disorders in adults with intellectual disability: the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) approach.

Previous classifications of eating disorders [EDs] employed a narrower concept of EDs. They did not include the wide range of abnormal eating behaviours [AEBs], persistent feeding disorders and EDs psychopathology, aetiological and comorbidity factors seen in adults with intellectual disability [ID]. The International Classification of Diseases--10 [ICD-10], ICD-10-MR, Diagnostic and Statistical Manual--IV [DSM-IV] and Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation[DC-LD] diagnostic approaches to EDs in adults with ID are compared. The DC-LD encourages conceptually clearer and systematic hierarchical differential diagnostic classification of AEBs and EDs. The DC-LD also allows consideration of relevant aetiological and comorbidity issues. DC-LD-based multi-axial case formulation supports the multimodal clinical assessment of AEBs and EDs. Further research should develop similar systematic and evidence-based multicomponent clinical diagnostic, management and service models for adults with ID and EDs.

The classification of problem behaviour in Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD).

Problem behaviour is common among adults with learning disabilities, often to an extent that it impacts upon the functioning and social inclusion of the individual, and of the individual's family and immediate social network. However, most approaches to the classification and diagnosis of psychiatric disorder among people with learning disability do not deal with problem behaviour as a diagnosis. The recent innovation of the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) includes diagnostic criteria for problem behaviour. The background and the thinking behind these criteria are reviewed. It is proposed that the adoption of such criteria offers the possibility of improved services for the individuals concerned, with resultant improvements in their adaptation and social inclusion.

Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) and the diagnosis of anxiety disorders: a review.

During the development of Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities[DC-LD] a literature review of diagnostic issues in anxiety disorders in adults with intellectual disability (ID) was undertaken using electronic and hand searching of journals. Relevant general concepts in the general population are reviewed briefly before those related specifically to adults with ID. The literature relating to the diagnosis of specific anxiety disorders is reviewed, although with the exception of obsessive compulsive disorder this consists mainly of case reports. Difficulties in the use of diagnostic systems developed for the general population for the diagnosis of anxiety disorders in adults with ID are frequently commented upon. It is concluded that anxiety disorders are well recognized in adults with ID, although their prevalence is uncertain, and that the use of modified diagnostic criteria may aid further research in this area.

Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) and psychiatric phenotypes.

The concept of behavioural phenotypes is reviewed, with emphasis on the need to research reasons for heterogeneity. The classification of emotional, behavioural, linguistic and cognitive abnormalities associated with genetic disorders may be improved through the use of the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation. Examples of such abnormalities are discussed, showing how more accurate descriptions can result in improved diagnosis and treatment.

Psychiatric diagnosis, intellectual disabilities and Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD).

Classification of psychopathology using operationalized diagnostic criteria is one component of psychiatric assessment. Previous literature has demonstrated that there are limitations in the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual-IV (DSM-IV) when used with adults with intellectual disabilities. A literature search using Medline, PsychLIT and hand searching of key journals identified the existing literature, which was reviewed by the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) Development Working Group. Key findings are integrated into this paper. This, together with expert consensus led to the development of DC-LD, a new psychiatric classificatory system devised specifically for use with adults with intellectual disabilities. The new diagnostic criteria and classification within DC-LD were piloted with 52 field investigators drawing on 709 clinical cases. Validity of DC-LD classification was measured by comparison between the criteria providing DC-LD diagnosis and the gold standard of learning disabilities psychiatric assessment. In 96.3% of cases, the DC-LD diagnosis was fully concordant with that of clinical opinion. The few discrepancies related to level of detail. DC-LD accommodates the pathoplastic effect of intellectual disabilities on psychopathology. Its use will hopefully improve clinical practice and facilitate research, but further work to determine its usefulness and limitations is required.

The Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC‐LD) papers

The Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC‐LD) papers

Attention deficit hyperactivity disorder: review of ADHD in learning disability: the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation[DC-LD] criteria for diagnosis.

Attention deficit hyperactivity disorder [ADHD)]is believed to be common among people with learning disabilities. Classification systems in current use have presented diagnostic difficulties in this area, when used for people with learning disability (particularly adults). A literature search using electronic databases was undertaken, and journals were hand-searched for articles relevant to the diagnosis of mental disorders in adults with intellectual disabilities. There is preliminary evidence that ADHD is more common in this population than among the non-learning-disabled population, and indeed that rates of hyperactivity increase with increasing severity of learning disability. There are also associations between ADHD and certain causal syndromes of learning disability. While available evidence suggests that ADHD may be common among children and adults with learning disabilities, research has been hindered by deficits in currently used diagnostic classification systems. With the recent development of criteria for the diagnosis of ADHD in learning-disabled adults, and the publication of these in Diagnostic Criteria for Learning Disabilities/Mental Retardation[DC-LD] there is scope for an increase in the level of interest in the study of ADHD among adults with learning disabilities.

A critique of the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) chapter on non-affective psychotic disorders.

There has been a longstanding interest in the study of psychotic disorders in adults with intellectual disability. The DC-LD chapter for non-affective psychotic disorders provides operationalised criteria for use with this population. A detailed, structured review of the literature was carried out. Relevant papers were reviewed to provide a framework for a critique of the DC-LD criteria. Most of the research literature focuses on psychotic disorders in adults with mild intellectural disability and suggests that this group experience clinical symptoms similar to those experienced by adults with average abilities. Although the DC-LD criteria for non-affective psychotic disorders are derived from the ICD-10 equivalent categories they are broader than other classification systems, which may affect their reliability, validity and utility. At this stage, it is important that the DC-LD criteria are used alongside established systems to gather information about their use for clinical and research purposes.

DC-LD (Diagnostic criteria for psychiatric disorders for use with adults with learning disabilities/mental retardation) . Royal College of Psychiatrists. London: Gaskell. 2001. 128 pp.

DC-LD (Diagnostic criteria for psychiatric disorders for use with adults with learning disabilities/mental retardation) . Royal College of Psychiatrists. London: Gaskell. 2001. 128 pp.