A realist evaluation of an enhanced court-based liaison and diversion service for defendants with neurodevelopmental disorders

BACKGROUND

In England, court-based mental health liaison and diversion (L&D) services work across courts and police stations to support those with severe mental illness and other vulnerabilities. However, the evidence around how such services support those with neurodevelopmental disorders (NDs) is limited.

AIMS

This study aimed to evaluate, through the lens of court and clinical staff, the introduction of a L&D service for defendants with NDs, designed to complement the existing L&D service.

METHODS

A realist evaluation was undertaken involving multiple agencies based within an inner-city Magistrates' Court in London, England. We developed a logic model based on the initial programme theory focusing on component parts of the new enhanced service, specifically training, screening, signposting and interventions. We conducted semi-structured interviews with the court staff, judiciary and clinicians from the L&D service.

RESULTS

The L&D service for defendants with NDs was successful in identifying and supporting the needs of those defendants. Benefits of this service included knowledge sharing, awareness raising and promoting good practice such as making reasonable adjustments. However, there were challenges for the court practitioners and clinicians in finding and accessing local specialist community services.

CONCLUSION

A L&D service developed for defendants with NDs is feasible and beneficial to staff and clinicians who worked in the court setting leading to good practice being in place for the defendants. Going forward, a local care pathway would need to be agreed between commissioners and stakeholders including the judiciary to ensure timely and equitable access to local services by both defendants and practitioners working across diversion services for individuals with NDs.

Severe mental illness, common mental disorders, and neurodevelopmental conditions amongst 9088 lower court attendees in London, UK

BACKGROUND

Court Mental Health Liaison and Diversion Services (CMHLDS) have developed in some countries as a response to the over-representation of mental illness and other vulnerabilities amongst defendants presenting to criminal justice (or correctional) systems. This study examined the characteristics and rates of mental disorder of 9088 defendants referred to CMHLDS.

METHOD

The study analysed service level data, obtained from the National Health Service's mental health data set, to examine characteristics relating to gender, ethnicity and comorbidity of common mental and neurodevelopmental disorders at five CMHLDS across London between September 2015 and April 2017.

RESULTS

The sample included 7186 males (79.1%) and 1719 females (18.9%), the gender of 183 (2%) were not recorded. Of those referred, 6616 (72.8%) presented with an identifiable mental disorder and 503 (5.5%) with a neurodevelopmental disorder (NDD). Significantly higher rates of schizophrenia were reported amongst Black defendants (n = 681; 37.2%) and Asian defendants (n = 315; 29%), while higher rates of depression were found amongst White defendants (n = 1007; 22.1%). Substance misuse was reported amongst 2813 defendants (31%), and alcohol misuse amongst 2111 (23.2%), with significantly high rates of substance and alcohol misuse amongst defendants presenting with schizophrenia or personality disorder.

CONCLUSIONS

This is one of the largest studies to examine mental health needs and vulnerabilities amongst defendants presenting to CMHLDS. It will enable an improved understanding of the required service designs and resources required to manage the healthcare pathways for people attending CMHLDS.

Evaluation of a liaison and diversion Court Mental Health Service for defendants with neurodevelopmental disorders

AIM

Neurodevelopmental disorders (NDD) may present as neuropsychiatric problems as well as impairments of motor, cognitive, social and communication functioning. This study describes the introduction of a specialist service with expertise in NDD into an existing court mental health liaison and diversion service to determine if the service would impact on the health needs or disposal outcomes of defendants.

METHODS

We examined referrals of defendants with NDD disorders over 30-months at a London Magistrates' Court. The pre-existing Court Mental Health (CMH) service was enhanced to provide additional expertise and hereafter referred to as the CMH + NDD Service. Baseline data including gender, ethnicity, remands and the rates of mental disorders was collected from the CMH Service using the existing minimum mental health service dataset. This was compared with data collected from the CMH + NDD Service.

RESULTS

We found the following rates of NDD 9.5 % (n = 43) for the CMH service, and 9.5 % (n = 79) for the CMH + NDD service. Although overall the rates were the same the number of defendants with a single NDD diagnosis was increased in the CMH + NDD service with ADHD 10 %, ASD and ID 4% higher, the rates of comorbid NDD decreased in the CMH + NDD service compared to baseline. Specific disorders such as depression were recorded at higher rates for NDD defendants in both phases, however, this did not reach significance. In contrast, schizophrenia and delusional disorders, alcohol and substance use were observed at much higher in the non-NDD defendants during both phases of the study. The rates of diagnosis of schizophrenia and delusional disorders increased for the NDD group within the CMH + NDD service. Following the first court appearance, there was a 10 % reduction in custodial remands for defendants with NDD who were seen by the CMH + NDD service (34.2 %, n = 25 in the CMH + NDD service vs 43.8 %, n = 14 in the CMH service).

CONCLUSION

The study found it is possible to successfully integrate practitioners with expertise of NDD into existing liaison and diversion services. This service enhancement demonstrated modest evidence of service effectiveness, including an increase in the detection of comorbid mental illness and a reduction in custodial remands for defendants with NDD. Further work needs to be completed to examine how this model can be rolled out across multiple courts and in particular, a cost-benefit analysis is required to understand whether an approach involving a cluster of Courts, as opposed to a single site is the most effective approach for this group of defendants.

Substance and Alcohol Misuse, Drug Pathways, and Offending Behaviors in Association With ADHD in Prison Inmates

Objective: The objective of the study is to quantify the extent of specific polysubstance use, drug transitions to current substances, and describe the association with alcohol use disorders among inmates with ADHD. We also examined health risk behaviors and patterns of offending in relation with ADHD. Method: A total of 387 male British prison inmates were screened and interviewed via the Diagnostic Interview for ADHD in Adults 2.0 (DIVA-2). Results: Male prisoners with ADHD endorse more methadone and amphetamine use. There was a significantly higher linear trend among those with ADHD for the number of substances ever used. ADHD was positively associated with increasing levels of alcohol use disorder severity, and with alcohol dependence. Transition along the pathways of substance misuse and persistence of drug misuse was better explained by the presence of conduct disorder/antisocial personality traits. Conclusion: Higher rates of alcohol dependence and stimulant-cocaine misuse suggest these inmates have maladaptive coping mechanisms, such as self-medication behaviors.

Needs of Adolescents and Young Adults with Neurodevelopmental Disorders: Comparisons of Young People and Parent Perspectives

This study used the Camberwell Assessment of Need for adults with Developmental and Intellectual Disabilities (CANDID) to examine the social, physical health and mental health needs of 168 young people (aged 14-24 years) with neurodevelopmental disorders and compared young person and parent ratings of need. Agreement was poor in 21 out of 25 domains. Parents consistently reported higher levels of need than young people in the majority of domains although young people with ADHD reported significantly more needs in physical health, eyesight/hearing, seizures, other mental health problems and safety of others than their parents. Both parent and young person perspectives of needs are necessary to ensure that needs that are predictive of current or future poor outcomes are not missed.

Socioeconomic crisis and aggressive behaviour of Greek adolescents

BACKGROUND

Aggressive behaviours are common during adolescence. In Greece, adolescents and their families experience a severe and enduring recession with potentially adverse impact on mental health.

AIM

This study aimed to examine the correlation between adolescents' aggressive behaviour and economic factors.

METHODS

The Buss-Perry Aggression Questionnaire (AQ) was used to measure aggression. Reduction in pocket money and three items of the Household Food Insecurity Access Scale were used to measure material deprivation as a result of the economic crisis. The questionnaires were administrated to a sample of 2,159 adolescent students of the Greater Athens Metropolitan Area.

RESULTS

Students who during the previous 4 weeks had experienced household food insecurity (anxiety/uncertainty about food, insufficient food quality or insufficient food intake) or had their pocket money decreased within the last 6 months scored on average significantly higher in the AQ compared to their counterparts who did not.

CONCLUSION

The shortage in basic goods due to the actual Greek economic crisis seems to be related to aggressive behaviours during adolescence and we should take this into account in clinical practice.

Clinical service use as people with Attention Deficit Hyperactivity Disorder transition into adolescence and adulthood: a prospective longitudinal study

Background

While Attention Deficit Hyperactivity Disorder (ADHD) often persists into adulthood, little is known about the needs and service use among adolescents and young adults with ADHD. The present study followed-up a cohort diagnosed with ADHD as children and assessed their: 1) needs, 2) correlates of contact with clinical services, and 3) experiences of transition from child to adult health services.

Methods

Ninety one young people aged 14–24 were recruited from the UK subset of the International Multi-Centre ADHD Genetics (IMAGE) Project. Affected young people and parents conducted face-to-face interviews and self-completion questionnaires including a modified version of the Client Services Receipt Inventory, The Barkley’s ADHD rating scale, The Clinical Interview Schedule-Revised, and the Zarit Burden Interview. Changes in key need characteristics (e.g. ADHD symptoms and impairments) over a 3-year period were examined using fixed effect models. Generalised Estimating Equations (GEE) were used to explore how key characteristics (such as ADHD symptoms) were associated with contact with clinical services across the three years.

Results

At baseline 62 % met diagnostic criteria for ADHD and presented with a range of ADHD related impairments, psychiatric comorbidities, and significant caregiver burden. While ADHD symptoms and related impairments lessened significantly over the three years, psychiatric comorbidities and caregiver burden remained stable. The strongest correlate of contact with clinical services was age (OR 0.65 95 % CI 0.49–0.84) with the odds of reported contact with clinical services decreasing by 35 % for each year increase in age at baseline and by 25 % for each year increase in age over time. Only 9 % of the sample had experienced a transfer to adult services, with the majority reporting unmet needs in healthcare transition.

Conclusions

Despite continuing needs, few were in contact with adult health services or had received sufficient help with transition between child and adult health services. The main determinant of health service use for adolescents and young adults with ADHD is age – not needs. Service models should address the needs of ADHD individuals who are no longer children.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1509-0) contains supplementary material, which is available to authorized users.

Demographic correlates of anxiety and depression symptoms in chronic sinonasal diseases

OBJECTIVES

To explore mental health of patients with olfactory loss due to chronic sinonasal diseases and investigate the effects of age-, gender-, and socio-economic variables on anxiety and depression symptoms.

METHODOLOGY

One hundred and eight patients (62 males; mean age: 39.78 ± 16.11 years), suffering from olfactory impairment due to chronic rhinosinusitis and allergic rhinitis and 30 healthy subjects (16 males; mean age, 37.03 ± 13.09 years) were studied. Olfactory function was evaluated using "Sniffin' Sticks" test. All patients completed four validated questionnaires specific for assessing anxiety and depression (Zung Anxiety Scale, State-Trait Anxiety Inventory-STAI, Zung Depression Scale, and Beck Depression Inventory-BDI).

RESULTS

We found significantly more severe anxiety and depression symptoms in anosmic (all p < 0.001) and hyposmic patients compared to healthy controls. No significant differences were observed between normosmic patients and controls. Scores in all psychological measures were significantly higher in elderly and female patients as well as in low, compared to high, socio-economic status patients. No significant differences were found between low and medium socio-economic level.

CONCLUSIONS

Olfactory loss in chronic sinonasal diseases was found to be associated with anxiety and depression symptoms. Moreover, anxiety was correlated with depression. With regard to patients' demographics, female gender and low socioeconomic status proved to be independently correlated with anxiety and depression levels.

Psychosocial support and cognitive deficits in adults with schizophrenia

BACKGROUND

In recent decades there has been an increasing interest in cognitive deficits in schizophrenia. However, only a few studies have examined the impact of psychosocial support on the prevention of cognitive deterioration in patients who suffer from schizophrenia.

AIM

The aims of the present study are: (1) to confirm the presence of cognitive deficits among patients with schizophrenia; (2) to explore any correlations between such deficits and a range of clinical and/or demographic characteristics of the patients; and (3) to investigate any association between cognitive deficits and psychosocial support.

METHOD

A total of 118 patients with schizophrenia (the patient group) and 102 healthy volunteers (the control group) had a cognitive assessment using a battery of neuropsychological tests. The patients were allocated to one of the following groups: (1) patients under routine outpatient follow-up; or (2) patients receiving or having recently received intensive psychosocial support, in addition to follow-up. This included daily participation in vocational and recreational activities provided by dedicated mental health day centers. The findings of the neuropsychological testing of individuals in all groups were compared, after controlling for clinical or demographic factors.

RESULTS

The scores in the neuropsychological tests were lower overall in the patients group compared to healthy volunteers. Within the patients group, those receiving/having received psychosocial support had higher scores compared to those on routine follow-up alone. There were no significant differences between patients currently receiving psychosocial support and those having received it in the past. Lower education, age and illness duration (but not severity of positive or negative symptoms) were factors associated with lower test scores.

CONCLUSIONS

The study provides some evidence that psychosocial support may be beneficial for the cognitive functioning of patients with schizophrenia and this benefit may be a lasting one.

Glutamate/glutamine and neuronal integrity in adults with ADHD: a proton MRS study

There is increasing evidence that abnormalities in glutamate signalling may contribute to the pathophysiology of attention-deficit hyperactivity disorder (ADHD). Proton magnetic resonance spectroscopy ([1H]MRS) can be used to measure glutamate, and also its metabolite glutamine, in vivo. However, few studies have investigated glutamate in the brain of adults with ADHD naive to stimulant medication. Therefore, we used [1H]MRS to measure the combined signal of glutamate and glutamine (Glu+Gln; abbreviated as Glx) along with other neurometabolites such as creatine (Cr), N-acetylaspartate (NAA) and choline. Data were acquired from three brain regions, including two implicated in ADHD-the basal ganglia (caudate/striatum) and the dorsolateral prefrontal cortex (DLPFC)-and one 'control' region-the medial parietal cortex. We compared 40 adults with ADHD, of whom 24 were naive for ADHD medication, whereas 16 were currently on stimulants, against 20 age, sex and IQ-matched healthy controls. We found that compared with controls, adult ADHD participants had a significantly lower concentration of Glx, Cr and NAA in the basal ganglia and Cr in the DLPFC, after correction for multiple comparisons. There were no differences between stimulant-treated and treatment-naive ADHD participants. In people with untreated ADHD, lower basal ganglia Glx was significantly associated with more severe symptoms of inattention. There were no significant differences in the parietal 'control' region. We suggest that subcortical glutamate and glutamine have a modulatory role in ADHD adults; and that differences in glutamate-glutamine levels are not explained by use of stimulant medication.

Victimization of the severely mentally ill in Greece: the extent of the problem

BACKGROUND

In contrast to extensive research on psychiatric patients' dangerousness, very few studies have examined their victimization.

AIM

The aim of our study is to record reported victimization of seriously mentally ill outpatients in Greece and compare them with healthy controls.

METHOD

We interviewed 150 severely mentally ill outpatients and a matched group of healthy controls using a semi-structured interview. This recorded incidents of victimization and perceived discrimination during the previous year. Logistic regression models were used to examine the influence of demographic parameters on both victimization and discrimination.

RESULTS

In this study 59.3% of patients and 46.0 % of controls (p = .02) reported being victims of a criminal act at least once and 52.0% of patients and 24.0 % of controls (p < .001) reported experiencing discrimination during the previous year. Patients, in comparison to controls, were more likely to report being victims of any kind of victimization (OR = 1.85, 95% CI = 1.07-3.21), of assault/threat (OR = 4.62, 95% CI = (2.32-9.19) and of discrimination (OR = 3.34, 95% CI = (2.1-5.62). In addition, patients reported experiencing higher distress in assault/threat crime compared to controls (p = .03).

CONCLUSIONS

Patients with serious mental illness are more likely than the general population to report being victims of criminal acts and experiencing discrimination.

Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units

BACKGROUND

ADHD is a common childhood onset mental health disorder that persists into adulthood in two-thirds of cases. One of the most prevalent and impairing comorbidities of ADHD in adults are substance use disorders. We estimate rates of ADHD in patients with substance abuse disorders and delineate impairment in the co-morbid group.

METHOD

Screening for ADHD followed by a research diagnostic interview in people attending in-patient drug and alcohol detoxification units.

RESULTS

We estimated prevalence of undiagnosed ADHD within substance use disorder in-patients in South London around 12%. Those individuals with substance use disorders and ADHD had significantly higher self-rated impairments across several domains of daily life; and higher rates of substance abuse and alcohol consumption, suicide attempts, and depression recorded in their case records.

CONCLUSIONS

This study demonstrates the high rates of untreated ADHD within substance use disorder populations and the association of ADHD in such patients with greater levels of impairment. These are likely to be a source of additional impairment to patients and represent an increased burden on clinical services.

Adults with attention deficit hyperactivity disorder: an investigation of age-related differences in behavioural symptoms, neuropsychological function and co-morbidity

BACKGROUND

The outcomes of attention deficit hyperactivity disorder (ADHD) have been studied extensively in the first decades of life, but less is known about ADHD in adulthood. Hence we investigated cross-sectional age-related differences in behavioural symptoms, neuropsychological function and severity of co-morbid disorders within a clinically referred adult ADHD population.

METHOD

We subdivided 439 referrals of individuals with ADHD (aged 16-50 years) into four groups based on decade of life and matched for childhood ADHD severity. We compared the groups on measures of self- and informant-rated current behavioural ADHD symptoms, neuropsychological performance, and self-rated co-morbid mood and anxiety symptoms.

RESULTS

There was a significant age-related reduction in the severity of all ADHD symptoms based on informant-ratings. In contrast, according to self-ratings, inattentive symptoms increased with age. Neuropsychological function improved across age groups on measures of selective attention and response inhibition. There was a mild correlation between the severity of depression symptoms and increasing age.

CONCLUSIONS

This observational study suggests that, in adulthood, ADHD symptoms as measured using informant-ratings and neuropsychological measures continue to improve with increasing age. However the subjective experience of people with ADHD is that their symptoms worsen. This dichotomy may be partially explained by the presence of co-morbid affective symptoms. The main limitation of the study is that it is cross-sectional rather than longitudinal, and the latter design would provide more conclusive evidence regarding age-related changes in an adult ADHD population.

Caregiver burden as people with autism spectrum disorder and attention-deficit/hyperactivity disorder transition into adolescence and adulthood in the United Kingdom

OBJECTIVE

There is increasing recognition that autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are associated with significant costs and burdens. However, research on their impact has focused mostly on the caregivers of young children; few studies have examined caregiver burden as children transition into adolescence and young adulthood, and no one has compared the impact of ASD to other neurodevelopmental disorders (e.g., ADHD).

METHOD

We conducted an observational study of 192 families caring for a young person (aged 14 to 24 years) with a childhood diagnosis of ASD or ADHD (n = 101 and n = 91, respectively) in the United Kingdom. A modified stress-appraisal model was used to investigate the correlates of caregiver burden as a function of family background (parental education), primary stressors (symptoms), primary appraisal (need), and resources (use of services).

RESULTS

Both disorders were associated with a high level of caregiver burden, but it was significantly greater in ASD. In both groups, caregiver burden was mainly explained by the affected young person's unmet need. Domains of unmet need most associated with caregiver burden in both groups included depression/anxiety and inappropriate behavior. Specific to ASD were significant associations between burden and unmet needs in domains such as social relationships and major mental health problems.

CONCLUSIONS

Adolescence and young adulthood are associated with high levels of caregiver burden in both disorders; in ASD, the level is comparable to that reported by persons caring for individuals with a brain injury. Interventions are required to reduce caregiver burden in this population.

Group psychosocial interventions for adults with schizophrenia and bipolar illness: the evidence base in the light of publications between 1986 and 2006

AIM

The treatment of major mental disorders usually combines medical and psychosocial interventions. The present study reviews research pertaining to the efficacy of group psychosocial interventions for people with psychotic illness.

METHOD

An electronic search was conducted through Medline and PsychINFO to identify articles relevant to group therapy for people with schizophrenia and bipolar affective disorder. Articles published in the English language, between January 1986 and May 2006, were considered. Studies were included if they had a control group and at least 20 participants. The search resulted in 23 articles concerning patients with schizophrenia and five concerning patients with bipolar affective disorder.

RESULTS AND CONCLUSION

The therapeutic approach in the majority of the studies was along the lines of cognitive behaviour therapy and psychoeducation. All studies reported improvement in at least one parameter. Most of them report improvement in skills and overall functioning.

Collective trauma transmission and traumatic reactions among descendants of Armenian refugees

BACKGROUND

It has been suggested, mainly by case reports, that the collective trauma generated by mass calamities may be transmitted to, and have long-lasting effects on, new generations.

AIMS

To investigate the psychological impact on contemporary Armenians of traumatic events suffered by Armenians during the period 1914-1918.

METHODS

A descriptive, cross-sectional study investigating demographic and cultural characteristics of a population of 689 people of Armenian origin, residents of Greece and Cyprus. Subjects were recruited during a range of Armenian cultural, athletic or charitable events. The participants completed a version of the Post-Traumatic Stress Disorder (PTSD) (Self-Rating) Scale and a questionnaire including ad hoc questions regarding their relationship to the Armenian community, their attitudes and their source of information about the 1914-1918 events.

RESULTS

Over a third (35.7%) of participants presented at least sub-clinical forms of such reactions during long periods of their lives. Women, older people, participants with a close relative lost during the events and those with strong connections to the Armenian community were more vulnerable.

CONCLUSION

The results are indicative of a long-lasting (though gradually fading) cross-generational traumatizing effect of the discussed events. Clinicians having to deal with patients belonging to cultural or ethnic groups that suffered persecutions in the past should take into account the probable effects caused by a trauma-transmission mechanism.

Prefrontal cortex dysfunction and 'Jumping to Conclusions': bias or deficit?

The 'beads task' is used to measure the cognitive basis of delusions, namely the 'Jumping to Conclusions' (JTC) reasoning bias. However, it is not clear whether the task merely taps executive dysfunction - known to be impaired in patients with schizophrenia - such as planning and resistance to impulse. To study this, 19 individuals with neurosurgical excisions to the prefrontal cortex, 21 unmedicated adults with Attention Deficit Hyperactivity Disorder (ADHD), and 25 healthy controls completed two conditions of the beads task, in addition to tests of memory and executive function as well as control tests of probabilistic reasoning ability. The results indicated that the prefrontal lobe group (in particular, those with left-sided lesions) demonstrated a JTC bias relative to the ADHD and control groups. Further exploratory analyses indicated that JTC on the beads task was associated with poorer performance in certain executive domains. The results are discussed in terms of the executive demands of the beads task and possible implications for the model of psychotic delusions based on the JTC bias.

ADHD symptom presentation and trajectory in adults with borderline and mild intellectual disability

BACKGROUND

This study examined symptoms and lifetime course of Attention Deficit Hyperactivity Disorder (ADHD) in adults with borderline and mild Intellectual Disability (ID).

METHOD

A total of 48 adults with ID and ADHD were compared with 221 adults with ADHD without ID using the informant Barkley scale for childhood and adulthood symptoms.

RESULTS

The ADHD/ID group presented with greater severity of (adult and childhood) symptoms compared with the non-ID group. For the ADHD/non-ID group, most symptoms improved significantly from childhood to adulthood, whereas only two symptoms changed significantly for the ID group. Principal component analysis revealed scattered loading of different items into five components for the ADHD/ID group that were not consistent with the classic clusters of inattentive, hyperactive and impulsive symptoms. A negative correlation was found between severity of symptoms and IQ.

CONCLUSIONS

ADHD in adults with ID may have a more severe presentation and an uneven and less favourable pattern of improvement across the lifespan in comparison with adults without ID.

Executive functioning differences between adults with attention deficit hyperactivity disorder and autistic spectrum disorder in initiation, planning and strategy formation

Executive functioning deficits characterize the neuropsychological profiles of the childhood neurodevelopmental disorders of attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD). This study sought to determine whether similar impairments exist in adults with ADHD (N = 53) and ASD (N = 45) in comparison with a healthy control group (N = 31), whether the two disorders can be distinguished on the basis of their executive functioning features, and whether these impairments are related to symptom severity. Both clinical groups were found to exhibit executive functioning deficits. The ADHD group had difficulty withholding a response, with relative preservation of initiation and planning abilities. In contrast, the ASD group exhibited significant impairments in initiation, planning and strategy formation. The specific executive functioning deficits were related to severity of response inhibition impairments in ADHD and stereotyped, repetitive behaviours in ASD. These findings suggest the pattern of executive functioning deficits follows a consistent trajectory into adulthood.

Neuropsychological characteristics of adults with comorbid ADHD and borderline/mild intellectual disability

This study aimed to characterise the neuropsychological functioning of adults with comorbid attention deficit hyperactivity disorder (ADHD) and intellectual disability. Individuals with ADHD and mild-borderline range intelligence (N=59) and individuals with ADHD and normal intellectual functioning (N=95) were compared on attentional and response inhibition tasks. The comorbid group had significantly lower scores on the majority of measures in comparison with the ADHD alone group. These differences remained significant after co-varying for level of intellectual functioning for variables measuring selective attention and errors of commission during sustained attention. This suggests that individuals with comorbid ADHD and intellectual disability may be vulnerable to a 'double deficit' from both disorders in certain aspects of cognitive functioning.

Risperidone for attention-deficit hyperactivity disorder in people with intellectual disabilities

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is increasingly recognised as occurring in people with intellectual disability (ID), although treatment of ADHD in this population has not ben tested widely. Risperidone has been used to treat ADHD in people with ID, although the evidence for its effectiveness is unclear.

OBJECTIVES

To examine the effectiveness of risperidone for the treatment of attention deficit hyperactivity disorder in people with intellectual disabilities.

SEARCH STRATEGY

In February 2009, MEDLINE, PsycINFO, EMBASE, AMED, ISI Web of Science and WorldCat Dissertations were searched using an extensive list of synonyms for ADHD and ID. CENTRAL, CCDPLP, Current Controlled Trials meta-register (mRCT), CenterWatch, NHS National Research Register, clinicaltrials.gov were searched, pharmaceutical companies and experts in the field were contacted. Reference lists of review articles were examined and citation searches were performed in ISI Web of Knowledge.

SELECTION CRITERIA

All randomised controlled trials (RCTs), both published and unpublished, in any language, in which children or adults with ADHD and ID were treated with risperidone.

DATA COLLECTION AND ANALYSIS

Data collection and analyses were planned but not performed due to a lack of suitable studies.

MAIN RESULTS

Eleven studies were considered but none were suitable for inclusion.

AUTHORS' CONCLUSIONS

There is no evidence from RCTs that risperidone is effective for the treatment of ADHD in people with ID. Prescribing in this population can only be based on open-label studies or extrapolation from research in people with autism and disruptive behaviour disorders; however these studies have not investigated people with ID separately so there are reservations regarding the applicability of these findings. Research into effectiveness and tolerability is urgently needed.

Evaluation of group cognitive behavioral therapy for adults with ADHD

OBJECTIVE

A brief cognitive behavioral therapy (CBT) group intervention was designed to treat comorbid anxiety, depression, and low self-esteem and self-efficacy in adults with ADHD. It was hypothesised that participants would gain knowledge about ADHD, experience a reduction in comorbid symptoms, and benefit from the supportive aspect of group treatment.

METHOD

Participants in the study formed a CBT treatment group that attended six workshops and a waiting list control group. The intervention was evaluated with measures assessing knowledge about ADHD, psychological symptoms, and support received. The groups were compared using repeated measures ANOVAs.

RESULTS

The CBT group had significantly greater improvement on measures of knowledge about ADHD, self-efficacy, and self-esteem than the control group. Participants' evaluations of the sessions suggested that sharing personal experiences with other adults with ADHD was an important aspect of the intervention.

CONCLUSION

Brief CBT group treatments may be an acceptable and cost-effective intervention for adults with ADHD.

Amfetamine for attention deficit hyperactivity disorder in people with intellectual disabilities

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is increasingly recognised as occurring in people with intellectual disability (ID), although treatment of ADHD in this population has not been tested widely. Amfetamine has been used to treat ADHD in people with and without ID, although the evidence for its efficacy in people with ID is unclear.

OBJECTIVES

To examine the effectiveness of amfetamine for the treatment of attention deficit hyperactivity disorder in people with intellectual disabilities.

SEARCH STRATEGY

MEDLINE, PsycINFO, EMBASE, AMED, ISI Web of Science and WorldCat Dissertations were searched using an extensive list of synonyms for ADHD and ID. CENTRAL, Current Controlled Trials meta-register (mRCT), CenterWatch, NHS National Research Register, clinicaltrials.gov were searched in August 2007. Pharmaceutical companies and experts in the field were contacted. Reference lists of review articles were examined and citation searches were performed in ISI Web of Knowledge.

SELECTION CRITERIA

All randomised controlled studies, both published and unpublished, in any language, in which children or adults with ADHD and ID were treated with amfetamine.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers using a standardised extraction sheet. Risk of bias was assessed by two authors using a standardised framework. Meta-analyses were planned but were not performed due to a lack of suitable studies.

MAIN RESULTS

Only one study was suitable for inclusion. This was a cross-over study in 15 children with ADHD, ID and Fragile X syndrome. Duration of treatment was only one week. No significant difference was reported between amfetamine and placebo for any of the ADHD measures, but significantly more side effects were reported while taking amfetamine, mainly mood lability and irritability.

AUTHORS' CONCLUSIONS

There is very little evidence for the effectiveness of amfetamine for ADHD in people with ID . Prescribing in this population is based on extrapolation of research in people without ID. More research into effectiveness and tolerability is urgently needed.

The prevalence of intellectual disabilities among 12,000 prisoners - a systematic review

There are 9 million prisoners worldwide, but it is uncertain what proportion have intellectual disabilities. Such prisoners have been identified as a vulnerable group at risk of victimization and mental illness. Psychiatric surveys based on interviews of unselected prison populations were sought, involving diagnoses of intellectual disabilities. The search was performed by computer-assisted searches, scanning of relevant reference lists, hand-searching of journals, and correspondence with authors of relevant reports. Prevalence rates of intellectual disabilities by gender and other potentially relevant study characteristics were abstracted from publications, supplemented by information from authors of reports. Ten relevant surveys from four different countries were identified that included a total of 11,969 prisoners (mean age: 29 years; 92% male; 23% violent offenders). No formal calculation of a summary estimate of prevalence was undertaken due to substantial heterogeneity. The results suggest that typically 0.5-1.5% of prisoners were diagnosed with intellectual disabilities (range 0% to 2.8% across studies). We conclude that the number of prisoners with intellectual disabilities is considerable and discuss implications for policy and practice.

Reliability and validity of the Greek version of the Derogatis Psychiatric Rating Scale (DPRS)

BACKGROUND

The aim of this paper is to report on the Greek version of the Derogatis Psychiatric Rating Scale (DPRS) and its validity and reliability when administered to a Greek sample. The DPRS is a clinician-rated measure of psychiatric symptoms with nine basic and eight complementary symptom dimensions and a Global Pathology Index.

METHOD

The DPRS was translated into Greek and administered to 161 psychiatric patients and healthy volunteers. Its validity was assessed against the Semistructured Clinical Interview (SCID) and the Symptoms Checklist-90-Revised (SCL-90-R). The inter-rater reliability and test-retest reliability were also evaluated for each symptom dimension.

RESULTS

All the symptom dimensions of the DPRS, except euphoria, have concurrent validity with the SCID on the relevant symptom dimensions diagnoses set by the interview. At the cut-off point 2/3 the DPRS has a sensitivity of 98% and a specificity of 74% in indicating active psychiatric patients. The symptom dimensions of the DPRS also have strong correlations with the relevant dimensions of SCL-90-R. The range for inter-rater reliability was from 0.48 to 0.88, the range for test-retest reliability was from 0.25 to 0.85, and the internal consistency was 0.90.

CONCLUSION

The Greek version of the DPRS has acceptable psychometric properties, rendering it a useful screening instrument of global psychopathology as well as a multidimensional measure of some basic psychiatric symptoms.

Interpersonal Support Evaluation List (ISEL)--college version: validation and application in a Greek sample

OBJECTIVES

a) To validate the Interpersonal Support Evaluation List (ISEL)--college version in a Greek population sample and b) To test the hypothesis that students scoring high on the ISEL present stronger resistance to stressful experiences and fewer psychological or physical problems.

DESIGN

Rating scale assessment and analytical cross-sectional study.

METHOD

The ISEL was translated into Greek and then back-translated into English. A random sample of 145 students of the Faculty of Medicine completed: a) the translated version of the ISEL, b) the Symptom Check List 90-R (SCL-90-R), c) the Scale of Stressful Life Events (SSLE) and d) a questionnaire about physical health problems. Comparisons were conducted between the scores on the ISEL and the scores on the other measures. Correlations were also calculated between the scores on the Global Severity Index (GSI) of the SCL-90-R and SSLE, separately for students with high, fair and low social support, in order to assess the protective role of social support. The test-retest reliability and the internal consistency of the ISEL were also investigated.

RESULTS

The students with a lower score in social support reported more psychological and somatic symptoms. The students with a higher score in social support were protected against the harmful effect of stressful events. The ISEL presents good internal consistency (Cronbach's alpha: 0.452-0.752) and test-retest reliability (intraclass correlation coefficients (ICC): 0.631-0.847).

CONCLUSIONS

The ISEL is a valid and reliable instrument for measuring social support among Greek students. A higher score on the ISEL is correlated with a significant stress-buffering effect.

Prevalence of mental disorders and deliberate self-harm in Greek male prisoners

The aim of this survey was to determine the prevalence of current and lifetime mental disorder and deliberate self-harm among male prisoners in Greece. The subjects were 80 randomly selected remanded and sentenced prisoners in a Greek prison. They were assessed for mental disorder including suicidality and substance misuse using the Mini International Neuropsychiatric Interview (MINI). We also collected information regarding contact with psychiatric services, previous deliberate self-harm as well as physical health and conducted a brief assessment of their intellectual functioning. Mental disorder was diagnosed in 63 (78.7%) prisoners. The main diagnoses were: anxiety disorder, 30 (37.5%); major depression, 22 (27.5%); antisocial personality disorder, 30 (37.5%); alcohol dependence, 21 (26.3%) and opiate dependence 22 (27.5%) and schizophrenic or bipolar disorder 9 (11.2%). Deliberate self-harm prior to and during imprisonment was reported by 15% and 2.5% of prisoners, respectively, and 12 prisoners (15%) had IQ below 75. This survey identified a significant level of need for specialist mental health services in prison. Further studies are required to assess the specific needs of those patients who are too unwell to remain in prison, the need for specific treatments for substance misuse and improved assessment/treatment of common psychiatric disorders.

Social and psychological characteristics of Greek secondary school students with learning difficulties

In Greece there is an almost total lack of special education after the primary school (6th grade). This is a descriptive study that aimed to examine social, academic and psychological characteristics of secondary school students with a history of special placement during primary school. It compared 86 students with a placement (group A) with their 1284 schoolmates with no such placement history (group B) with respect to scores on School Adjustment Scale, Academic Motivation Self-Rating Inventory and Youth Self-Report. Group A presented more family social, academic and psychological problems such as: One-parent family, lower socioeconomic status, poor adjustment, low motivation and (especially for boys) high internalizing and externalizing scores. The high rates of failure and dropout of these students indicate that in Greece there is a need to set up appropriate services to help secondary school students with learning difficulties.

Mental health problems in the elderly in residential care in Greece--A pilot study

The aim of this study is to examine the mental health problems of older adults living in a residential home in a Greek rural area. A sample of 40 residents was compared with 40 matched controls attending a community open care centre for the elderly (OCCE). The following measures were used: Mini International Neuropsychiatric Interview (MINI), Geriatric Depression Screening Scale (GDSS), and the Mini Mental State Examination (MMSE). The group of the residents had a lower educational level and presented with a higher prevalence of depression and suicidality. Suicidal ideation was not significantly correlated to any of the examined independent social or psychological factors and was persistent during a period of two years follow-up. It is possible that, especially in rural areas, admission in the institution is per se a traumatic event precipitating suicidality. The issues of effective psychological care for older adults in residential care are discussed.

People with learning disabilities in a low secure in-patient unit: comparison of offenders and non-offenders

BACKGROUND

People with learning disability who exhibit challenging behaviour are frequently segregated from services and local teams are often reluctant to receive them back into their care. This situation is worse in those whose challenging behaviour includes a forensic history, but the difference between those labelled as challenging and those treated as offenders is not clear, and there is a lack of evidence about treatment effectiveness.

AIMS

To test between-group differences in aggression and treatment outcome in people with learning disability and challenging behaviour, with and without a forensic history.

METHOD

Clinical records of 86 former in-patients (45 offenders and 41 non-offenders) of a specialist unit were compared on measures of behavioural disturbance and placement outcome.

RESULTS

People in the offenders group were significantly less likely to be aggressive to others and to use weapons, but significantly more likely to harm themselves compared with the non-offenders group. Both groups had a significant reduction in their challenging behaviour during admission, and there was no significant difference in treatment outcome.

CONCLUSIONS

The negative reputation of people with learning disabilities who offend needs to be reconsidered.

Psychiatric inpatient care for adults with intellectual disabilities: generic or specialist units?

BACKGROUND

When adults with intellectual disabilities (ID) require a psychiatric admission, general adult mental health units are often used. Specialist units have emerged recently as a care option but there is only limited evidence of their effectiveness. Thus this study aims to describe and evaluate the effectiveness of a specialist inpatient unit and report on the utilization of generic and specialist inpatient services.

METHOD

All patients admitted to a specialist ID psychiatric unit were evaluated on admission and immediately after discharge on a number of outcome measures. In addition, they were compared with those admitted to general adult mental health units covering the same catchment area.

RESULTS

Significant improvements were demonstrated within the specialist unit cohort on measures including psychopathology, global level of functioning, behavioural impairment and severity of mental illness. The specialist unit patients had a longer length of inpatient stay but were less likely to be discharged to out-of-area residential placement.

CONCLUSIONS

Specialist units are an effective care option for this group of people.

Self-reported substance misuse in Greek male prisoners

The aim of this survey was to determine levels and severity of self-reported alcohol and drug misuse and associated physical and mental health problems in Greek male prisoners. The sample consisted of 80 randomly selected convicted and remanded male prisoners in a prison in northern Greece. The Mini International Neuropsychiatric Interview (MINI) was used to assess psychiatric disorders including substance abuse and dependence. All prisoners who participated completed the Alcohol Use Disorders Identification Test (AUDIT). Those who reported daily use of opiates and stimulants completed the Severity of Dependence Scale (SDS). Information was obtained from medical notes about the prisoners' hepatitis B and HIV status. The MINI identified 27.5% of the prisoners as dependent on opiates, 26.3% on alcohol and 73.8% as cannabis users, while 13.8% were misusing both alcohol and illicit drugs. Severity of dependence was rated, using SDS, as serious for all opiate and stimulant users. In terms of physical health examination of medical records indicated that no prisoner was HIV-positive but 26.5% were hepatitis-B-positive. Of those who had a previous history of substance misuse, 31.2% fulfilled the criteria for depression and 37.5% for antisocial personality disorder. Similarly, 15% of those misusing substances had a previous history of deliberate self-harm and 16% were assessed to have moderate to high suicide risk.

Reliability and validity of the CANDID--a needs assessment instrument for adults with learning disabilities and mental health problems

BACKGROUND

People with learning disabilities and mental health problems have complex needs. Care should be provided according to need.

AIM

To develop a standardised needs-assessment instrument for adults with learning disabilities and mental health problems.

METHOD

The Camberwell Assessment of Need for Adults with Developmental and Intellectual Disabilities (CANDID) was developed by modifying the Camberwell Assessment of Need (CAN). Concurrent validity was tested using the Global Assessment of Functioning (GAF) and the Disability Assessment Schedule (DAS). Test-retest and interrater reliability were investigated using 40 adults with learning disabilities and mental health problems.

RESULTS

CANDID scores were significantly correlated with both DAS (P < 0.05) and GAF scores (P < 0.01). Correlation coefficients for interrater reliability were 0.93 (user), 0.90 (career), and 0.97 (staff ratings); for test-retest reliability they were 0.71, 0.69 and 0.86 respectively. Mean interview duration was less than 30 minutes.

CONCLUSIONS

The CANDID is a brief, valid and reliable needs assessment instrument for adults with learning disabilities and mental health problems.