Madness and society in Britain.

The fiftieth anniversary of the Royal College of Psychiatrists, and the publication of a detailed multidisciplinary social history of British psychiatry and mental health in recent decades have offered an opportunity to take a helicopter view and reflect on the relation between psychiatry and changing British society. We argue that the time has come to move on from the rhetoric of deinstitutionalisation and community mental healthcare to lead public debate and advocacy for the needs of the mentally ill in the new era of 'meta-community psychiatry and mental healthcare'. We need to respond effectively to the increasing awareness of mental health problems across society, aiming for a pluralist, integrated and well-funded reform led by joint professional and patient interests which could be unstoppable if we all work together.

From Community to Meta-Community Mental Health Care.

Since the 1960s, we have witnessed the development and growth of community mental health care that continues to dominate mental health policy and practice. Several high-income countries have implemented community mental health care programmes but for many others, including mostly low- and middle-income countries, it remains an aspiration. Although community mental health care has been positive for many service users, it has also had severe shortcomings. Expectations that it would lead to fuller social integration have not been fulfilled and many service users remain secluded in sheltered or custodial environments with limited social contacts and no prospect of work. Others receive little or no service at all. In today’s complex landscape of increasingly specialised services for people with mental health problems, the number of possible interfaces between services is increasing. Together with existing uneven financing systems and a context of constant change, these interfaces are challenging us to develop effective care pathways adjusted to the needs of service users and their carers. This discussion paper reviews the developments in community mental health care over the recent years and puts forward the concept of “Meta-Community Mental Health Care”. “Meta-Community Mental Health Care” embraces pluralism in understanding and treating psychiatric disorders, acknowledges the complexities of community provision, and reflects the realities and needs of the current era of care.

Hubris and Sciences.

There has been an increasing awareness of the importance of leadership and decision making, including scientists and academics, over recent times. By whom and how decisions are made can have serious implications across all levels of society. Several people have been successful in their life and have been inflicted by excessive pride and self-confidence. There are times when the manifestations of such behaviours demonstrate noticeable signs of narcissism and on extreme cases, hubris. Hubris is an old concept originated from the Greek mythology.  The risk of hubris affects politicians, leaders in business, scientists, academia, the military, entertainers, athletes and doctors (among many others). Power, especially absolute and unchecked power, is intoxicating and is manifested behaviourally in a variety of ways, ranging from amplified cognitive functions to lack of inhibition, poor judgment, extreme narcissism, deviant behaviour, and even cruelty. Hubristic behaviour of overconfidence, extreme pride together with an unwillingness to disregard advice makes powerful people in leadership positions to over-reach themselves with negative consequences for themselves and others. As the dangerous consequences of hubristic behaviours become more apparent and well described it is imperative that individuals, organisations and governments act to prevent such phenomena. Responsible leaders, including acclaimed scientists should exercise greater humility to the complexity and inherent uncertainty of their activities and strive to seek out and challenge hubristic behaviours.

Maudsley International: improving mental health and well-being around the world.

Maudsley International was set up to help improve people's mental health and well-being around the world. A variety of programmes have been developed by Maudsley International over the past 10 years, for planning and implementing services; building capacity; and training and evaluation to support organisations and individuals, professionals and managers to train and develop health and social care provisions. Maudsley International's model is based on collaboration, sharing expertise and cultural understanding with international partners.

Sustaining international careers: a peer group for psychiatrists working in global mental health.

Regular appraisal and revalidation are now a routine part of professional life for doctors in the UK. For British-trained psychiatrists working abroad (in either development/humanitarian or academic fields) this is a cause of insecurity, as most of the processes of revalidation are tailored to those working in the standard structures of the National Health Service. This article explores the degree to which a peer group for psychiatrists working abroad has achieved its aim of helping its members to fulfil their revalidation requirements. It gives recommendations for how those considering work abroad can maximise their chances of remaining recognised under the revalidation system.

How should community mental health of intellectual disability services evolve?

Services for people with Intellectual Disability (ID) and coexisting mental health problems remain undeveloped; research into their effectiveness has been lacking. Three linked recent studies in the UK have provided evidence on essential service provision from staff, service users and carers. Interfaces with mainstream mental health services were seen as problematic: the area of crisis response was seen as a particular problem. Further services' research is needed, focusing on service components rather than whole service configurations. There was not support for establishing more intensive mental health services for people with ID only. The way forward is in developing new ways of co-working with staff in "mainstream" mental health services. Mental health of ID staff might often be best situated directly within these services.

Evaluation of Greek psychiatric reforms: methodological issues.

Over the last three decades significant efforts have been made in many European countries to move away from a mental health system dominated by institutional care towards one whereby the main emphasis is on providing care and support within the community. Although the time of starting the reforms, their pace, the political context, and the exact objectives varies substantially across Europe, practically all countries have been undergoing such major reforms aimed at establishing services in the community to replace institutional based care. Each country makes its own decisions about the necessary mental health services taking into account a range of factors including population needs, level of resources, flexibility and coordination of organizational structures, as well as local culture. These factors become an integral element of a national mental health policy and action plan, closely linked with national public health strategies.Greece has been modernizing an outdated mental health system, which was based on institutional care, over the last 20 years, by developing community-based mental health care. This article describes the methodology used for the evaluation of the Psychargos programme of the mental health reforms in Greece. Various forms of community-based mental health services have been developed including supported living facilities, community mental health centres and employment opportunities.

Psychometric properties of the Disability Assessment Schedule (DAS) for behavior problems: an independent investigation.

The present study employed the Disability Assessment Schedule (DAS) to assess problem behaviors in a large sample of adults with ID (N=568) and evaluate the psychometric properties of this instrument. Although the DAS problem behaviors were found to be internally consistent (Cronbach's α=.87), item analysis revealed one weak item ('Objectional habits') with item-total biserial correlation of only .20. An exploratory factor analysis revealed two main factors. The first factor consisted of items relating to disruptive/distractive problems. The second factor consisted of items relating to antisocial/delinquent problems. Disruptive/distractive problems were specifically associated with low ID level. Antisocial/delinquent behaviors were specifically associated with male gender, schizophrenia, hospital admission and troubles with police. For patients who had both disruptive/distractive problems and antisocial/delinquent behaviors, personality disorders and autism were more frequent, where as anxiety and depression were less frequent. On the basis of the obtained results, two new DAS subscales for assessing challenging behavior were proposed. Both subscales had good levels of internal consistency, as well as face and criterion validity. Overall, the new DAS subscales were shown to have acceptable psychometric properties and have therefore potential for use in both research and clinical practice.

Epilepsy and intellectual disability: does epilepsy increase the likelihood of co-morbid psychopathology?

Although epilepsy is particularly common among people with intellectual disability (ID) it remains unclear whether it is associated with an increased likelihood of co-morbid psychopathology. We therefore investigated rates of mental health problems and other clinical characteristics in patients with ID and epilepsy (N = 156) as compared to patients with ID but no epilepsy (N = 596). All participants were consecutive referrals to specialist mental heath services. Specialist clinicians agreed on the mental health diagnoses by applying ICD-10 clinical criteria using information gained from interviews with key informants and the patients. Bivariate and multivariate analyses showed that patients with epilepsy were more likely to live in residential housing and have severe ID in line with previous evidence. However, the presence of epilepsy was not associated with an increased likelihood of co-morbid psychopathology. On the contrary, rates of mental health problems, including schizophrenia spectrum, personality and anxiety disorders, were significantly lower among patients with epilepsy. The results are discussed in the context of mood-stabilizing and other psychotropic effects of anti-epileptic drugs in adults with ID and epilepsy, as well as possible diagnostic overshadowing.

Challenging behavior and co-morbid psychopathology in adults with intellectual disability and autism spectrum disorders.

We investigated the relationship between challenging behavior and co-morbid psychopathology in adults with intellectual disability (ID) and autism spectrum disorders (ASDs) (N=124) as compared to adults with ID only (N=562). All participants were first time referrals to specialist mental health services and were living in community settings. Clinical diagnoses were based on ICD-10 criteria and presence of challenging behavior was assessed with the Disability Assessment Schedule (DAS-B). The analyses showed that ASD diagnosis was significantly associated with male gender, younger age and lower level of ID. Challenging behavior was about four times more likely in adults with ASD as compared to non-ASD adults. In those with challenging behavior, there were significant differences in co-morbid psychopathology between ASD and non-ASD adults. However, after controlling for level of ID, gender and age, there was no association between co-morbid psychopathology and presence of challenging behavior. Overall, the results suggest that presence of challenging behavior is independent from co-morbid psychopathology in adults with ID and ASD.

Mental ill-health and care pathways in adults with intellectual disability across different residential types.

The aim of this study was to investigate co-morbid psychopathology and clinical characteristics of adults with ID living across different types of residential settings. All participants were first time referrals to specialist services in South-East London who lived either with their family (N=375) or in supported residence (N=280) or independently (N=95). Psychiatric diagnoses were based on ICD 10 criteria following clinical interviews with key informants and patients. Logistic regression analyses showed that personality disorders were more likely to be diagnosed in people who lived independently or in supported residence, while anxiety disorders were more likely in those living with their family. Overall, those who lived in independent residence had higher rates of co-morbid psychopathology. These effects were independent of ID level and age differences. Younger adults were more likely to live with their families while those with higher ID level were about 17 times more likely to live independently. The largest proportion of referrals to outpatients lived in independent residence although there were no significant differences in other care pathways. The findings are discussed in terms of implications for service planning and development.

The role of ethnicity in clinical psychopathology and care pathways of adults with intellectual disabilities.

The objective of this study was to explore whether people with intellectual disability from ethnic minority groups have higher rates of mental health problems and access different care pathways than their White counterparts. Clinical and socio-demographic data were collected for 806 consecutive new referrals to a specialist mental health service for people with intellectual disabilities in South London. Referrals were grouped according to their ethnic origin. The analyses showed that there was an over-representation of referrals from ethnic minority groups with diagnoses of schizophrenia spectrum disorder. In addition, Black participants were more likely to have an autistic spectrum disorder. Referrals of ethnic minority groups were considerably younger than White referrals, and less likely to be in supported residences. The results are discussed in the context of cultural and familial factors in particular ethnic groups that may play an important role in accessing and using mental health services.

Mental health in adults with mild and moderate intellectual disabilities: the role of recent life events and traumatic experiences across the life span.

The aim of the present study is to investigate the association between recent life events and traumatic experiences across the life span and psychiatric disorders in people with ID. One hundred seventy-seven individuals with mild and moderate intellectual disability and their principal carers were assessed. Psychiatric disorders were evaluated with a semistructured psychiatric interview, the Psychiatric Assessment for Adults with Developmental Disabilities. This interview also includes a checklist of life events experienced over the previous 12 months, which was assessed through key informants. Presence of traumas was assessed through Allen's trauma history screen, also administered to key informants. After a descriptive analysis, binary logistic regression was used to see whether traumatic events and life events predicted the presence of ICD-10 disorders. A 75% of the participants had experienced at least 1 traumatic event during their life span, and 50% of the participants had experienced at least 1 life event in the 12 months previous to the study. Binary logistic regression showed that exposure to 1 or more traumatic experiences significantly increased the odds of a mental disorder (OR = 1.8), as did exposure to life events (OR = 1.4). However, when both life events and traumatic experiences were entered together in the model, calculation of odds ratios revealed that traumatic experiences significantly increased the odds of ICD-10 disorders (OR = 1.7) although life events were no longer significant. Though they have been less studied by the literature regarding predictors of mental illness in people with intellectual disability, traumatic experiences seem to play a more important role in psychopathology than life events.