An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues.

BACKGROUND: Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach. METHOD: A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID. RESULTS: There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

BIOMED-MEROPE project: service provision for adults with intellectual disability: a European comparison.

The aim of the present paper is to describe and compare services for adults with intellectual disability (ID) and mental health needs in five European countries: Austria, England, Greece, Ireland and Spain. A framework and structure for collecting information about service provision was designed. This information was collected through a mixture of interviews with service providers, questionnaires and a review of the research literature within each country. Information was collected on historical context, policy, legislation, assessment, treatment and the structure of services for people with ID and mental health problems. Overall, the needs of those with additional mental health needs have not been specifically addressed at a national level with perhaps the exception of England and Ireland, although there are still gaps in services in these nations. Normalization has been adopted in each of the five countries, and there are moves toward deinstitutionalization, integration and inclusion. Families and self-advocacy groups have grown. The pace of this change varies between and even within countries. The main findings of the study include: unclear policy, trends for legislative changes, increased prevalence of mental health problems, inadequate generic service provision, a need for specialist mental health services, a need for improved interconnections of services, and a need for training developments. Policy and legislation in the five European countries under consideration tend to separate the disability aspects of people with ID from their mental health needs. Consequently, the service needs of this group remain largely invisible. This might be a direct reflection of policy clarity and legislation, or could be the result of a failure to implement existing guidelines. This has a detrimental effect on the lives of people with ID, and their families and carers.

Reliability and validity of the Mini PAS-ADD for assessing psychiatric disorders in adults with intellectual disability.

The Mini PAS-ADD is an assessment schedule for psychiatric disorders in people with an intellectual disability. It is designed to provide a link between the mental health expertise of psychiatrists and psychologists, and the detailed knowledge of individual service users possessed by support staff. In broad terms, the aim of the Mini PAS-ADD is to enable non-psychiatrists accurately to recognize clinically significant psychiatric disorders in the people who they care for, so that they can make informed referral decisions. The instrument comprises 86 psychiatric symptoms and generates a series of subscores on: depression, anxiety and phobias, mania, obsessive-compulsive disorder, psychosis, unspecified disorder (including dementia), and pervasive developmental disorder (autism). The present paper reports the results of a study investigating internal consistency, inter-rater agreement and validity in relation to clinical opinion, using a sample of 68 people with intellectual disability who were in contact with psychiatric services. In terms of the instrument fulfilling its main intended function, i.e. accurate case recognition, the crucial question was whether the support workers, with their lesser knowledge of psychopathology, were also able to correctly identify cases identified by expert clinicians. The validity results in this respect (81% agreement on case recognition) were sufficiently good that it is to be anticipated that the Mini PAS-ADD should have a significant impact on the identification of psychiatric disorders in the community of people with intellectual disability.

Reliability and validity of the PAS-ADD Checklist for detecting psychiatric disorders in adults with intellectual disability.

The PAS-ADD Checklist is a screening instrument specifically designed to help staff recognize mental health problems in the people with intellectual disability for whom they care, and to make informed referral decisions. The instrument consists of a life-events checklist and 29 symptom items scored on a four-point scale. Scores are combined to provide three threshold scores. The crossing of any of these thresholds indicates the need for a fuller assessment. The items are worded in everyday language, making the Checklist suitable for use by individuals who do not have a background in psychopathology. The present paper presents the results of a number of studies evaluating the reliability and validity of the Checklist. Factor analysis of Checklists completed on a community sample of 201 individuals yielded eight factors, of which seven were readily interpretable in diagnostic terms. Internal consistency of the scales was generally acceptable. Inter-rater reliability in respect to individual items gave a fairly low average Kappa of 0.42. However, agreement on case identification, the main purpose of the Checklist, was quite good, with 83% of the decision being in agreement. Validity in relation to clinical opinion was also satisfactory, case detection rising appropriately with the clinically judged severity of disorder. The PAS-ADD Checklist is published and distributed by the Hester Adrian Research Centre, Manchester, England, from where further information and order forms are available on request.

Reliability of the ICD 10 version of the Psychiatric Assessment Schedule for Adults with Developmental Disability (PAS-ADD).

The Psychiatric Assessment Schedule for Adults with Developmental Disability (PAS-ADD) is a semi-structured clinical interview designed for use with respondents who have learning disability. The first version was based on the Present State Examination. The revised version was derived from the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), and makes ICD 10 diagnoses using the SCAN diagnostic program. This current version has a 4-point scale of severity, compared with the 3-point scale of the first version. It also has a new module relating to psychotic disorders. The sample consisted of 40 individuals representing a spectrum of neurotic, depressive and psychotic disorders. Videotapes of 40 PAS-ADD interviews were re-rated by trained interviewers who had not been involved in the original study in which the videotapes were produced. The mean Kappa across all individual item codes was 0.65, ranging from 0.94 to 0.35. The mean Kappa agreement on item groups was 0.66. Correlation between total symptom scores was 0.74. Agreement on index of definition was Kappa 0.70. We concluded that, agreement was generally lower than for the ICD 9 version. This was probably due mainly to the increase in the severity categories from three to four. However, the new items (most of which related to psychosis) were of comparable reliability to other items.

Dietary selenium intake of preschool children.

The results of this investigation indicate that the range of selenium intakes of the preschool children who were studied was in the acceptable range of adequate and safe as suggested by the Food and Nutrition Board. The majority of the selenium in the diets of the subjects came from grains. Although the amount of selenium consumed was within normal limits, the concentration in the diet was estimated to be 70% of the expected value for mixed diets, i.e., 0.1 microgram/gm.

Drug resistance among previously treated tuberculosis patients, a brief report.

The choice of an appropriate chemotherapeutic regimen for the treatment of tuberculosis is more difficult if the patient has been treated for tuberculosis in the past. This study was undertaken to determine drug-resistance rates among patients previously treated with isoniazid (INH), streptomycin (SM), and/or paraaminosalicylic acid (PAS). The study population consisted of 4,017 patients for whom the length and type of previous therapy was known. Forty-one per cent of these patients were found to be excreting organisms resistant to 1 or more of the following 3 drugs: INH, SM, and PAS. Resistance to INH was encountered most (36.8%), followed by resistance to SM (19.2%), and resistance to PAS (17.2%). Resistance rates were considerably higher among the 1,168 patients who had previously received monotherapy (60%) than among those who had never received single-drug therapy (33%). In general, the percentage of patients excreting resistant organisms increased with increasing duration of the previous therapy. The implications of these findings for the design of retreatment regimens are discussed.

The incidence of cancer among participants in controlled, randomized isoniazid preventive therapy trial.

Cancer morbidity and mortality were examined among 11,894 Puerto Rican participants in a US Public Health Service preventive therapy trial begun in 1957. The mean duration of follow-up was 18 years (range 16-19 years). No statistically significant difference in overall cancer rates was observed between the participants in the trial assigned isoniazid and those assigned placebo. There were also no significant differences between the groups when rates for specific types of cancer and age-specific cancer rates were compared. No trend toward an increasing cancer rate in the isoniazid group was observed with the passage of time. The mortality rate due to cancer was similar in the two groups. These data coupled with other information reported in the literature provide substantial evidence that isoniazid, when given in the usual therapeutic doses, is not carcinogenic in humans.