Psychiatry (Abingdon, England)最新文献

Research in mental health learning disabilities has advanced significantly in recent years. Many important papers have helped to change practice and to pursue innovative ideas that cut across the nature/nurture divide. Several new journals have been launched that cover an array of subjects from basic sciences to policy and practice. The advent of evidence-based practice has been slow to develop in mental health learning disabilities but rigorous epidemiological studies and related developments such as the more precise calibration of diagnostic tools have been some of the notable outcomes. The scope of this article, written from the perspective of a clinical academic in the psychiatry of learning disability, is not to report on the whole of the research field in learning disabilities and so, inevitably, there will be important omissions. The aim is to discuss scientific enquiry as it pertains to mental health issues in this population and to consider some of the future drivers that show promise in helping to deliver high-quality care to our service users.

Here, we review the role of carers in general and specifically within the learning disability services. The role of carers is recognized but not always appreciated by the healthcare services despite guidance from the Department of Health and the Royal College of Psychiatrists. Service users in learning disability have complex needs, and carers provide life-long care. Carers have reported positive and negative experiences in their caring role; however, the negative experiences of caring can be minimized by providing better support and education to the carers. The resources available to provide this support are not equally accessible to all carers, e.g. respite care. Carers will have to go through many changes in service provisions. In return for the care they provide, carers would like services to listen to them. Regular carers' needs should be assessed and person-centred support must be offered to carers by responsible services.

Epilepsy, the experience of learning disability and the experience of mental health problems frequently occur in the same individual and can cause severe disadvantage, distress and vulnerability to the individual, together with a burden of care on families or carers. The challenges posed to clinicians include unpicking the complexities involved in understanding symptoms and presentations as well as the very limited evidence-based guiding management strategies. While evidence for service provision, care giving, and specific treatments is very limited, there are some themes that emerge from a review of the literature. The evidence that does exist indicates that the combination of these experiences is common, and attention must be paid to individual circumstances if one is to effectively understand and manage problems that arise. Certain clinical scenarios lead to specific treatment choices and the most popular anti-epileptic drugs prescribed seem to have both mood stabilizing and anti-epileptic effect profiles.

Although psychiatry in the United States owes its origins to the treatment of persons with intellectual disabilities (ID) and developmental disabilities (DD), over the past 50 years, clinical services, education of professionals and research in psychiatry of ID have consistently lagged behind other fields in psychiatry. The historical and contemporary reasons for this development are discussed with recommendations for establishment of a fully credentialed subspecialty of Psychiatry of Intellectual and Developmental Disabilities in the United States.

Challenging behaviours amongst people with learning disabilities are a major concern for carers, clinicians, and policy-makers. Services frequently fail to deliver optimum care practices for this user group, yet there is now considerable evidence as to what components are required to constitute an effective service. This article promotes positive behavioural support as an over-arching service model, and describes how it can help address the needs of members of this population and those who support them.

With the increase in lifespan, age-related mental and physical health problems have become evident in people with learning disability. Owing to the heterogeneity of the population, the nature and extent of age-related changes has not been explored fully. This article describes the mental health problems in older adults with learning disabilities with a focus on dementia, and highlights current evidence-based practice. To date, the main focus of research and service initiatives related to ageing has been on dementia in Down syndrome, despite the fact that a substantial proportion of older people with learning disabilities in general suffer from a variety of health problems. Clinical practice varies considerably within UK, and the link between community learning disability teams and mental health services for older people is not well established in many areas. The clinical challenges are related to a lack of standardized assessment processes and difficulties in carrying out the full range of investigations in some cases. The recently published national guideline on dementia in people with learning disabilities has now set the expected service standards and provides an audit tool against which quality of care can be measured. It is to be hoped that this will encourage the development of a dementia care pathway, removing the barriers in access to services for older people with learning disabilities.

A learning disability is a lifelong condition. Mental ill-health is common in people with learning disabilities, and several epidemiological studies have shown higher rates of psychiatric disorder in people with learning disabilities compared with the population as a whole. Biological, psychological, and social influences may account for this excess of mental ill-health. Presentation of symptoms differs across the range of learning disabilities. Nevertheless, there are several understudied areas, especially in the epidemiology (prevalence and incidence) of various types of mental disorder and the predictors of those disorders. Further investigation into the aetiology and course of mental ill-health may lead to better care and suitable interventions for this population.

Autism spectrum disorders (ASDs) are characterized by restricted, repetitive behaviour and abnormalities in social interaction and communication. A prevalence rate of ASD of up to 116/10,000 has been reported. The prevalence and range of psychiatric disorders are increased in people with ASD, including those with intellectual disability. Risk factors for psychiatric disorders in this group include genetic factors, communication problems, loneliness and low self-esteem. Mental health problems may be difficult to assess, and range from attention deficit hyperactivity disorder (ADHD) and tic disorders to psychotic and mood disorders, and catatonia. Prevalence of ADHD and tic disorders is increased in people with ASD. While the presentation of depressive and bipolar disorders may be similar to that in the general populations, depression may be associated with onset of or increase in maladaptive behaviour. In contrast to checking, cleaning or counting compulsions seen in people with obsessive–compulsive disorder (OCD), people with ASD may engage in repeating, hoarding, touching and tapping behaviour. ASD has been proposed as a non-specific neurodevelopmental marker for childhood-onset schizophrenia and it is recognized that psychotic symptoms may be difficult to establish in the presence of ASD. Interestingly, catatonia has been reported in up to 17% of young people with ASD referred to a national centre. It is important to disseminate available evidence on psychiatric treatment for people with ASD, while recognizing the need for further research on treatment and outcome measures.

Cognitive behavioural therapy (CBT) assumes that psychological disorders are characterized by distorted or dysfunctional thinking, and can be treated by working with the patient to modify thinking in the direction of more realistic or adaptive evaluations of events. CBT has been evaluated extensively and is now the first-line treatment of choice for many psychological disorders. It is increasingly being used with people with learning disabilities, although the evidence base with this population is relatively weak, consisting largely of case studies and case series. There are also controlled trials in anger and depression, for which all published studies report significant clinical improvements that are well maintained over 3–6-month follow-up periods. There are many barriers to engagement with CBT for people with learning disabilities, which reflect limitations of ability and motivation. The limitations of ability reflect the fact that people with learning disabilities have to cope with cognitive deficits in addition to the cognitive distortions that are the target of CBT interventions. If barriers to treatment are recognized, significant steps can be taken to increase accessibility by adapting the therapy. Adaptations include involving carers, simplifications of the delivery of therapy (e.g. by using simple language and a slower pace), and simplifications of the model (e.g. by the therapist adopting a more directive, less collaborative, approach). If the current policy of increasing access to psychological therapies is extended to people with learning disabilities, it is likely that evidence will also accrue to support the use of other psychotherapeutic approaches.

Epidemiological studies confirm that children and adolescents with learning disabilities are at risk of developing a range of mental health or behavioural problems. The presentation of these problems is complicated by a variety of factors including the child's level of cognitive functioning, diagnostic overshadowing, and psychiatric comorbidities. Expert multidisciplinary assessment is required in order to understand the underlying aetiology of the child's problems and the nature of any psychopathological processes. Appropriate interventions can then be planned and implemented. Child and adolescent mental health services and commissioners need to ensure that a comprehensive package of services is developed for this group of children as any unassessed and untreated problems are likely to have a significant impact on the quality of the child's life and the lives of family members and carers.