Risperidone, haloperidol, and placebo in the treatment of aggressive challenging behaviour in patients with intellectual disability: a randomised controlled trial.

BACKGROUND: Aggressive challenging behaviour is frequently reported in adults with intellectual disability and it is often treated with antipsychotic drugs. However, no adequate evidence base for this practice exists. We compared flexible doses of haloperidol (a typical, first-generation antipsychotic drug), risperidone (an atypical, second-generation antipsychotic), and placebo, in the treatment of this behaviour. METHODS: 86 non-psychotic patients presenting with aggressive challenging behaviour from ten centres in England and Wales, and one in Queensland, Australia, were randomly assigned to haloperidol (n=28), risperidone (n=29), or placebo (n=29). Clinical assessments of aggression, aberrant behaviour, quality of life, adverse drug effects, and carer uplift (positive feelings about the care of the disabled person) and burden, together with total costs, were recorded at 4, 12, and 26 weeks. The primary outcome was change in aggression after 4 weeks' treatment, which was recorded with the modified overt aggression scale (MOAS). Analysis was by intention to treat. This study is registered as ISRCTN 11736448. FINDINGS: 80 patients had adherence of 80% or more to prescribed drug. Aggression decreased substantially with all three treatments by 4 weeks, with the placebo group showing the greatest change (median decrease in MOAS score after 4 weeks=9 [95% CI 5-14] for placebo, 79% from baseline; 7 [4-14] for risperidone, 58% from baseline; 6.5 [5-14] for haloperidol, 65% from baseline; p=0.06). Furthermore, although no important differences between the treatments were recorded, including adverse effects, patients given placebo showed no evidence at any time points of worse response than did patients assigned to either of the antipsychotic drugs. INTERPRETATION: Antipsychotic drugs should no longer be regarded as an acceptable routine treatment for aggressive challenging behaviour in people with intellectual disability.

Critical developments in the assessment of personality disorder.

BACKGROUND: The assessment of personality disorder is currently inaccurate, largely unreliable, frequently wrong and in need of improvement. AIMS: To describe the errors inherent in the current systems and to indicate recent ways of improving personality assessment. METHOD: Historical review, description of recent developments, including temporal stability, and of studies using document-derived assessment. RESULTS: Studies of interrater agreement and accuracy of diagnosis in complex patients with independently established personality status using document-derived assessment (PAS-DOC) with a four personality cluster classification, showed very good agreement between raters for the flamboyant cluster B group of personalities, generally good agreement for the anxious/dependent cluster C group and inhibited (obsessional) cluster D group, but only fair agreement for the withdrawn cluster A group. Overall diagnostic accuracy was 71%. CONCLUSIONS: Personality function or diathesis, a fluctuating state, is a better description than personality disorder. The best form of assessment is one that uses longitudinal repeated measures using a four-dimensional system.

The Quantification of Violence Scale: a simple method of recording significant violence.

BACKGROUND: Although there are many rating scales recording the incidence and intensity of violence there are none that are specifically concerned with the measurement and assessment of severe violence. AIMS: To develop a scale sensitive to variation centred on severe violence, establish its normative values, test its feasibility, and assess its reliability and validity in different populations. METHOD: The Quantification of Violence Scale (QOVS) was developed in two stages. First, a list of 30 commonly experienced violent episodes in clinical psychiatric practice were evaluated and tested by weighting each episode by severity. Second, a numerical scale used to record the severity of the episode according to its degree of planning, intent and consequences. Violent episodes in two clinical populations were compared using the Modified Overt Aggression Scale (MOAS) and the preliminary version of the QOVS over periods up to 18 months, following which the numerical scale was developed. RESULTS: Good (0.60-0.74) to Excellent (> 0.75) test-retest and inter-rater reliability agreement was obtained with both forms of the scale (intra-class correlations of 0.75 and 0.69 respectively), and similar agreement with MOAS scores was reached (0.67) in clinical populations. The scale was quick and easy to use in practice, and a score defining severe violence (9 on the numerical scale and 16 on the matched scale) was determined. CONCLUSIONS: The QOVS, in its two forms, is a useful measure of recording significant violence in clinical and forensic practice.

The bed requirement inventory: a simple measure to estimate the need for a psychiatric bed.

OBJECTIVE: To develop an assessment of bed need that was as little affected by personal bias as possible. METHOD: The Bed Requirement Inventory (BRI) is an eight-point scale designed to identify the appropriate use of an acute psychiatric bed. This is completed by a member of the ward staff, usually a nurse, and takes 5 minutes to fill in. The reliability, validity and feasibility of using the scale in normal practice were tested in a one-year study, and variations in inappropriate bed use described. RESULTS: The inter-rater reliability of the scale was good (intra-class correlation coefficient = 0.63) and a comparison of the need for a psychiatric bed (comparing the BRI score with the judgement of an independent multidisciplinary group of professionals) also showed good agreement (k = 0.69), suggesting reasonable validity (although when the assessment was made by the named nurse agreement was less good). Results from a year-long survey in two West London hospitals showed that 17% of admissions were inappropriate and 32% had delayed discharge, black Caribbean patients had a significantly higher proportion (25%) of inappropriate admission than others (11%) and those referred from housing charities and hostels had a higher proportion (50%) of inappropriate bed use at some time than other groups (33%). CONCLUSIONS: The Bed Requirement Inventory is a quick and reliable method of determining the appropriate use of a psychiatric bed and could be of use in estimating local bed needs. Delayed discharge remains a serious reason for inappropriate bed use in London.

The Social Functioning Questionnaire: a rapid and robust measure of perceived functioning.

BACKGROUND: The Social Functioning Questionnaire (SFQ), an eight-item self-report scale (score range 0-24), was developed from the Social Functioning Schedule (SFS), a semi-structured interview which has been used primarily with non-psychotic patients and has good test-retest and inter-rater reliability as well as construct validity. The SFQ was developed following the need for a quick assessment of perceived social function. AIMS: To give further details of old and new data sets from studies involving over 4000 subjects assessed with the SFQ illustrating its epidemiological and clinical associations. METHOD: New data were analysed from a national epidemiological study, a comparison of key-worker and subject versions of the SFQ, and reanalysis of data from three earlier clinical studies, of psychiatric emergencies, general practice psychiatric patients and those with recurrent psychotic illnesses. These data were examined further to determine their range, their relationship to other clinical measures, and change over time in clinical trials. RESULTS: The population mean score in 4164 subjects was 4.6 and the data from all studies suggested that a score of 10 or more indicated poor social functioning. Those presenting as psychiatric emergencies had the poorest social function (mean 11.4) and psychiatric patients from general practice the best function (mean 7.7) of the clinical populations. The eight item scores had a normal distribution in psychiatric populations and a skewed one in a normal population; scores were relatively stable over the short (weeks) and long-term (months), and were high in the presence of acute mental health disturbance and personality disorder, giving support to the validity of the scale. The results from a UK sample of a randomly selected population specifically weighted for ethnic minorities showed similar social function across groups.

The Social Functioning Questionnaire: A Rapid and Robust Measure of Perceived Functioning.

BACKGROUND: The Social Functioning Questionnaire (SFQ), an eight-item selfreport scale (score range 0-24), was developed from the Social Functioning Schedule (SFS), a semi-structured interview which has been used primarily with non-psychotic patients and has good test-retest and inter-rater reliability as well as construct validity. The SFQ was developed following the need for a quick assessment of perceived social function. AIMS: To give further details of old and new data sets from studies involving over 4000 subjects assessed with the SFQ illustrating its epidemiological and clinical associations. METHOD: New data were analysed from a national epidemiological study, a comparison of key-worker and subject versions of the SFQ, and reanalysis of data from three earlier clinical studies, of psychiatric emergencies, general practice psychiatric patients and those with recurrent psychotic illnesses. These data were examined further to determine their range, their relationship to other clinical measures, and change over time in clinical trials. RESULTS: The population mean score in 4164 subjects was 4.6 and the data from all studies suggested that a score of 10 or more indicated poor social functioning. Those presenting as psychiatric emergencies had the poorest social function (mean 11.4) and psychiatric patients from general practice the best function (mean 7.7) of the clinical populations. The eight item scores had a normal distribution in psychiatric populations and a skewed one in a normal population; scores were relatively stable over the short (weeks) and long-term (months), and were high in the presence of acute mental health disturbance and personality disorder, giving support to the validity of the scale. The results from a UK sample of a randomly selected population specifically weighted for ethnic minorities showed similar social function across groups.