Psychiatry (Abingdon, England)最新文献

Mental capacity is a difficult yet fundamental concept that is becoming more influential in psychiatric practice. Assessment of mental capacity for research purposes has proven possible but empirical research into this area is relatively new. I report on empirical studies that have assessed the reliability of capacity assessments and the associations with psychopathology. Such information can help to guide decision-making both at a clinician–patient level and also at a policy level. The decision-making at issue is some of the most fundamental we face in medicine.

Policies and procedures for ‘adult safeguarding’ aim to protect adults against the harm posed to them by other individuals. In England, safeguarding adults from abuse is a public duty, and psychiatrists have an important role to play in upholding this duty through their involvement in this process. Here, we outline ethical, legal and social issues raised by current procedures for adult safeguarding in England and consider proposals for policy reform alongside parallel developments in the law in Scotland. Addressing these issues adequately involves (a) clarifying who will require the support of safeguarding services, (b) defining the nature of the putative harm they face, (c) determining which interventions are justifiable, and (d) ascertaining the circumstances in which these interventions can be initiated. In line with other recent developments in mental health and mental capacity law, the major challenge facing the development of adult safeguarding policy and practice is to find an appropriate balance between protection and empowerment.

Truth-telling has been part of one of the great bioethical shifts of the 20th century, from medical paternalism to respect for patient autonomy. Some argue that there are psychiatric cases where truth-telling is less necessary, however. The three standard justifications for medical deception – that the truth can be anti-therapeutic, that patients don't want to know the truth, and that telling the truth is ultimately impossible – seem to be more compelling in psychiatry, and there are additional justifications that apply when psychiatric patients lack the capacity to make their own decisions. Here, I consider those justifications, and argue that truth-telling is paramount even in psychiatry.

This contribution reviews recent developments in the law and policy of healthcare decision-making by, with and for adults with learning disabilities. In particular, it considers the impact of the Mental Capacity Act 2005 and the reforms outlined in the Department of Health's (2005) White Paper Our Health, Our Care, Our Say: A New Direction for Community Services, and the Local Authority Circular (2008) Transforming Social Care. Pressing issues such as the concept of choice for vulnerable adults and the challenges for professionals in assessing decision-making ability are assumed within these policy frameworks. Other issues, such as the importance of creating time to engage and involve vulnerable adults in decision-making about their health, continue to present challenges for healthcare policy and practice.

For many people with learning disabilities, the presence of ill health may impair their ability to achieve the best possible quality of life. The attainment of a good standard of health (at least as good as the rest of the population) is a reasonable goal. Primary care teams are central to the provision of good-quality healthcare. This provision is based on an ability to assess, investigate and manage a range of common and complex conditions, which requires an awareness of the specific needs of this population. The expected health needs of people with learning disabilities in the community and how best to identify and address these needs are described here. These needs include improved access to health promotion, identification of common but unidentified illness and the common comorbidities of people with a learning disability such as epilepsy. The organization of care is also reviewed, in particular the need for structured care delivery through health checks.

Choices, rights and control are aspects of healthcare that most take for granted. For many people with a learning disability, however, these are not a reality, with them being denied choice, their rights and control over the healthcare that they are given. Following on from the Mencap report Death by Indifference, which highlighted some of the shortfalls in the provision of healthcare for people with learning disability, it was the Royal College of Psychiatrist's Service User Group's intention to look into a more personalised account of experiences of accessing healthcare services. To do this, the group garnered the views of the pan-UK membership of the group, asking them about their experiences of healthcare. We wanted them to share both good and bad practice of receiving services, and also areas such as staff attitude and how much they were listened to. From the research and consultation, it was found that, in many instances, people with learning disability who access healthcare services are denied their choices in that they are not consulted on the type of care they should expect. This is specifically true for aspects such as medication. It was also found that people with learning disability can often be denied their rights, such as the right to be treated like an adult and not be patronised, the right to privacy and to be fully informed about making decisions. The third main theme to emerge from the group's work was that people with learning disability often feel they have little-to-no control over the services they receive from healthcare professionals. The findings are that, when people are consulted and fully informed of their healthcare, it leads to good practice and better outcomes. Healthcare professionals need to make the most basic reasonable adjustments to ensure that they cover everyone's needs.

Specific traumas, such as abuse and bereavement, and overall extent of potentially stressful life experiences are associated with increased levels of a range of behavioural and affective difficulties in people with learning disabilities. Although causality is probably complex and variable across diagnostic groups, evidence for a causal role for life events in the incidence of mental ill-health is growing. Even salient events, however, may not be perceived by carers as relevant to emotional and behavioural disturbance. Preventative strategies including use of social stories may reduce distress when life events can be anticipated. Supportive groupwork and a number of behavioural and cognitive–behavioural interventions offer promising interventions to reduce affective and other symptoms subsequent to traumatic life events.

Since the 1990s, many publications have provided a description of the status of care for persons with intellectual disability in Europe. This set of documents constitutes a unique case of international description and follow-up of care systems for intellectual disabilities in a single world region. The main information sources on care systems for persons with intellectual disability in Europe are presented with a special focus on projects funded by the European Commission during the past 15 years, which incorporate information on care systems (MEROPE, IDRESNET, POMONA, DECLOC). Following this knowledge base, a set of priorities has been identified as regards to training, care planning and provision, assessment and monitoring, empowerment and other related issues. These European projects highlight the fact that inequalities in the care of persons with intellectual disability persist to date, although these differences are decreasing particularly in Western Europe, and care reforms are also in progress in those Eastern European countries which have joined the European Union. The inequalities regarding people with intellectual disabilities exceed the differences found in other health sectors, such as adult mental health care, and therefore healthcare for people with intellectual disabilities should be placed as a main priority focus within equity of care strategies in Europe.

Research with representative samples of children with intellectual disabilities and their parents has consistently demonstrated much higher levels of psychopathology and poorer well-being amongst both children with intellectual disabilities and their parents compared with those without intellectual disabilities. Although these differences in psychopathology are often assumed to be an inevitable consequence of the child's intellectual disability and therefore to result in an inherently stressful parenting role, here, we briefly review the research evidence for an alternative proposition, namely that poverty and socio-economic position may play an important part in the development and maintenance of psychopathology in both children with intellectual disabilities and their parents. We review evidence that families with a child with intellectual disabilities are more likely to be living in poverty, and that differences in socio-economic position between families with a child with or without intellectual disabilities can substantially account for differences in child and parent psychopathology. Potential mechanisms linking poor socio-economic position to family psychopathology are outlined, together with some brief implications for policy and practice.