Inpatient Children and Adolescent Mental Health Services (CAMHS): outcomes of young people with and without intellectual disability.

BACKGROUND: Little is known about the effectiveness of inpatient care for young people with co-morbid mental illness and intellectual disability (ID). This study aims to compare the demographics and outcome of young people with mental illness with or without ID admitted to psychiatric hospital. A secondary aim is to look into the outcome of those with ID admitted to general mental health young people's units. METHOD: Data were collected on the outcome of young people's admissions to specialist ID and general adolescent mental health units as part of a larger quality improvement project run by the College Centre for Quality Improvement. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scores were completed by local clinical staff at admission and discharge on 38 young people with and 113 people without ID from 14 units. RESULTS: Young people with mental disorders significantly improved clinically over the admission whether or not they had ID. There were no differences between the groups in age or use of the Mental Health Act but people admitted with ID were more likely to be male and had longer lengths of stay. Admission to a general adolescent unit was associated with clinical improvement for people with ID. CONCLUSIONS: This study needs replication because of the small sample and incomplete data but it suggests that young people with ID and mental disorders significantly improve clinically when admitted to hospital as do their non-disabled peers.

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness.

BACKGROUND: There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services. METHOD: A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies. RESULTS: People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services. CONCLUSIONS: Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.

The effectiveness of mood stabilizers and antiepileptic medication for the management of behaviour problems in adults with intellectual disability: a systematic review.

BACKGROUND: Psychotropic medications are used to manage behaviour problems in adults with intellectual disability (ID). One group of psychotropic medication are mood stabilizers such as lithium and some antiepileptic drugs. METHOD: A comprehensive systematic review was performed to determine the evidence base for the effectiveness of mood stabilizers in the management of behaviour problems among adults with ID. Electronic searches of PsycInfo, Medline, Embase and Cinahl databases were conducted, as well as a thorough hand search for relevant literature. We reviewed primary trials relating to adults only that satisfied strict inclusion criteria. RESULTS: One randomized controlled trial (RCT) relating to lithium use and two non-RCTs, one on lithium and the other on carbamazepine, were revealed. In addition, one prospective non-controlled trial on sodium valproate and three retrospective case series studies were discovered, of which one considered the efficacy of lithium, one valproate and one topiramate. CONCLUSIONS: The current evidence lends some support for the use of lithium and some antiepileptic mood stabilizer medication for the management of behaviour problems in adults with ID. However, because most studies reviewed here are riddled with obvious methodological constrains, the findings have to be interpreted with caution.

The mechanical properties of recovered PMMA bone cement: a preliminary study.

Samples of polymethylmethacrylate (PMMA) bone cement, used in the fixation of hip prostheses, have been recovered from 11 patients after in service life spans of between 15 and 24 years. Eighteen samples in total have been recovered from the acetabular and/or femoral cement. Samples were subjected to three point bending tests, their density, porosity and microhardness determined and all specimens were examined using EDX and X-ray techniques. Since the porosity of many of the samples is very high, the continuous matrix properties are inferred from the performance of individual specimens. No evidence has been found to suggest that the PMMA has deteriorated whilst in-vivo and the mechanical properties of the cement matrices appear to be comparable to freshly made PMMA.

The impact of intellectual functioning on symptoms and service use in schizophrenia.

BACKGROUND: This study aims to evaluate differences in the clinical profiles and use of psychiatric services by people with schizophrenia with and without borderline intellectual functioning. Both groups in this study were receiving standard community psychiatric care. METHODS: A naturalistic sample of 372 people with schizophrenia completed the National Adult Reading Test. Data were collected prospectively over 18 months on psychiatric symptoms and service use. Three hundred and thirteen had normal intellectual functioning (mean age 43, range 20-76 years) and 59 had borderline or lower intellectual functioning (mean age 45, range 21-81 years). This was defined by a National Adult Reading Test error score of more than 40. RESULTS: People with borderline or lower intellectual functioning had a lower quality of life, more severe psychotic symptoms, reduced functioning and fewer antidepressant prescriptions. There were no significant differences in service use including hospital admission. CONCLUSIONS: People with schizophrenia and borderline or lower intellectual functioning are a more disabled group within general adult psychiatric services who should be the focus of initiatives for improved service delivery.

Assessment of wear on the cones of modular stainless steel Exeter hip stems.

The wear on the stem cones of retrieved Exeter Universal hip stems has been assessed using scanning electron microscopy (SEM), energy-dispersive X-ray analysis (EDX) and surface profilometry. The in-service life of these prosthetic stems varied, up to a maximum of 7 years. A combination of SEM, EDX and visual assessment indicates that the stem cones have not suffered from any corrosion. SEM scans indicate that damage to stem cones (excluding extraction and post-removal damage) can be categorised into insertion marks and fretting marks. In some cases there are signs of material being deposited on the cone surface. Surface profilometry suggests that the levels of debris generation at the cone/internal head interface are very low relative to those that are likely to be associated with head articulation against the acetabular cup. A total of 20 stem cones underwent SEM scans. From these, 10 subsequently have undergone surface profilometry along with the corresponding internal head surfaces. There is a good correlation between surface roughness measured by surface profilometry and the topography observed in the SEM images. The surface roughness of each stem cone is similar to that of the corresponding internal head surface.

General psychiatric services for adults with intellectual disability and mental illness.

BACKGROUND: Adults with intellectual disability (ID) and mental illness may use general or specialist psychiatric services. This review aims to assess if there is evidence for a difference in outcome between them. METHODS: A literature review was conducted using a variety of electronic databases and hand-search strategies to identify all studies evaluating the outcome of people with ID and mental illness using general psychiatric services. RESULTS: There is no conclusive evidence to favour the use of general or specialist psychiatric services. People with ID stay less time on general psychiatric than specialist inpatient units. People with severe ID appear not to be well served in general services. Older studies of inpatient samples suggest a worse outcome for people with ID. Novel specialist services generally improve upon pre-existing general services. Assertive outreach in general services may preferentially benefit those with ID. Recent studies suggest similar lengths of stay in general psychiatric beds for people with and without ID. CONCLUSIONS: Although 27 studies were located, only two were randomized controlled trials. The evidence is poor quality therefore further evaluation of services employing a variety of designs need to be employed to give more robust evidence as to which services are preferred.

Household spending on health care.

OBJECTIVES: This article examines changes in household spending on health care between 1978 and 1998. It also provides a detailed look at household spending on health care in 1998. DATA SOURCES: Data on household spending are from Statistics Canada's Family Expenditure Survey for survey years between 1978 and 1996, and from the annual Survey of Household Spending for 1997 and 1998. ANALYTICAL TECHNIQUES: Proportion of after-tax spending was calculated by subtracting average personal income taxes from average total expenditures and then dividing health care expenditures by this figure. Per capita spending was calculated by dividing average household spending by average household size. Constant dollar figures and adjustments for inflation were calculated using the Consumer Price Index (1998 = 100) to control for the effect of inflation over time. MAIN RESULTS: Almost every Canadian household (98.2%) reported health care expenditures in 1998, spending an average of close to $1,200, up from around $900 in 1978. In 1998, households dedicated a larger share of their average after-tax spending (2.9%) to health care than they did 20 years earlier (2.3%). Health insurance premiums claimed the largest share (29.8%) of average health care expenditures, followed by dental care, then prescription medications and pharmaceutical products.

Informing patients about tardive dyskinesia. Controlled trial of patient education.

BACKGROUND: This paper evaluates the effects on knowledge and clinical stability of an educational intervention about tardive dyskinesia. METHOD: Fifty-six patients receiving antipsychotic maintenance completed a questionnaire assessing their knowledge about tardive dyskinesia. After random allocation to either an educational intervention or a control group, their knowledge was reassessed at six months. RESULTS: Ninety-five per cent of patients completed the study. The study patients gained significantly more knowledge than the controls, who made modest gains. There were no significant differences in clinical outcome between the groups. CONCLUSION: Patients can learn about serious toxic effects of antipsychotic treatment with a low risk of non-compliance. Discussion about tardive dyskinesia is necessary in the process of obtaining informed consent to treatment.

The relationship among dietary undetermined anion, acid-base balance, and nutrient metabolism in swine.

Dietary undetermined anion (dUA) reflects, in part, the net acid load contributed by the diet. Although dUA is known to influence performance and nutrient metabolism of swine, a lack of knowledge impairs its application to diet formulation. This study was undertaken to separate the effects of dUA from the individual electrolytes that constitute its calculation. Eighteen 35-kg pigs were fitted with indwelling venous catheters and fed one of three barley and soybean meal-based diets: a control diet (C), an acidogenic diet containing calcium chloride (A), or a compensated acidogenic diet containing alkaline salts of sodium and potassium, as well as calcium chloride (CA). Compared with diet C, diet A lowered (P < .05) blood pH, bicarbonate, and base excess and increased (P < .05) urinary ammonium, titratable acid (TA), and net acid excretion (NAE). Diet CA returned blood acid-base values to normal and reduced urinary ammonium, TA, and NAE relative to diet A. Total nitrogen balance was unaffected by diet. Diet CA increased (P < .05) water intake and urine output. Diet A, but not CA, increased (P < .05) serum ionized Ca and C1. Apparent Ca and S digestibility and retention were reduced by diet A, but not by CA. Sodium retention was enhanced (P < .05) by diets A and CA; potassium retention was impaired (P < .05) by CA. Dietary UA altered systemic and renal acid-base balance in pigs. Mineral, but not nitrogen, metabolism was affected by both dUA and specific ion effects.

The psychiatric care of people with intellectual disabilities: the perceptions of consultant psychiatrists in Victoria.

OBJECTIVE: This study was undertaken to establish the perceptions of psychiatrists regarding the care of people of intellectual disabilities. METHOD: A 28-item self-administered questionnaire was developed, piloted and sent on two occasions to 467 psychiatrists who receive the newsletter of the Victorian branch of the Royal Australian and New Zealand College of Psychiatrists. The questionnaire incorporated a Likert scale to document the opinions of the respondents. RESULTS: A response rate of 51.1% was achieved. The respondents indicated that, in their opinion, people with intellectual disabilities receive a poor standard of care in the inpatient and community setting. To improve this situation, the following strategies were recommended: the development of improved liaison between services; improved training for all personnel who provide services to people with intellectual disabilities; the development of greater resources; and support for professionals working in the area. The study also indicates that there is a core group of very interested psychiatrists who are currently practising and that people with intellectual disabilities are accessing private psychiatric services. In addition, the results suggest that diagnostic overshadowing is not a major barrier to psychiatric assessment, and that disorders which were presumed to be commonly overlooked by doctors (such as depression) are in fact frequently being diagnosed. CONCLUSIONS: Despite some positive findings, the majority of psychiatrists who responded held major concerns about the situation of people with intellectual disabilities. To improve the care provided to these people, it is recommended that these concerns are addressed by the psychiatric profession and responsible government departments in conjunction with university departments of psychiatry.

Psychiatric disorder in Asian adults with learning disabilities: patterns of service use.

Asian and white Caucasian adults with learning disabilities seen by the Department of the Psychiatry of Learning Disabilities, Frith Hospital, Leicester, England, in 1991 were studied. Asian adults with learning disabilities were under-represented with respect to the local population (as measured by learning disability register), but not the population of individuals with learning disabilities known to the psychiatric services. Asians were significantly more likely to receive a psychiatric diagnosis, in particular that of psychosis, but there were striking similarities in the routes of referral, the number of contacts with the service and the range of defined disabilities.

The psychiatric care of people with intellectual disabilities: the perceptions of trainee psychiatrists and psychiatric medical officers.

OBJECTIVE: The main aim of this study was to document the perceptions of trainee psychiatrists and psychiatric medical officers regarding the psychiatric care of people with intellectual disabilities. METHOD: A 28-item self-administered questionnaire was developed by the investigators and pretested on eight psychiatrists and psychiatric trainees. A revised version of the questionnaire was then sent to 128 psychiatric trainees and 27 medical officers working in the public psychiatric services in Victoria. 116 questionnaires were returned, and the responses analysed. RESULTS: The results indicate a high degree of interest in the psychiatry of intellectual disability, however this was tempered by a feeling that the respondents and their senior colleagues are inadequately trained. The respondents expressed major concerns regarding the care of people with dual disabilities in the hospital and community setting, and significant support for the development of specialised units and subspecialisation within psychiatry. The major concerns which were identified would in part explain why 30% of the respondents felt that they would prefer not to treat people with an intellectual disability and a psychiatric disorder. CONCLUSION: We can only support the assertion made by the Burdekin Report [12] that "there is an urgent need for academic research, increased clinical expertise and substantial increased resources in the much neglected area of dual disability.

Effects of chronic corticosterone treatment on electrophysiological and behavioral measures in the rat.

The electrophysiological and behavioral effects of daily oral exposure to a corticosterone or vehicle solution was evaluated in 20 male Wistar rats over a 10-wk period. Evaluation of the rats' behavior in an open field apparatus, as well as in automated locomotor cages, revealed no significant differences between steroid-treated and control animals following 5-6 wk of exposure. No differences in mean EEG power, as estimated by spectral analysis of cortical and dorsal hippocampal recordings, were observed between the two groups following 8 wk of exposure. However, some increases in EEG "stability" were noted in the corticosterone-treated rats. At 9 wk, responses to auditory stimuli, as assessed by evoked responses, in cortex and dorsal hippocampus were also found to be unaltered by corticosterone exposure. These studies suggest that exposure to daily oral corticosterone, in the doses used, over a period of 2-3 mo is not associated with gross electrophysiological or spontaneous behavioral effects in the brain areas assessed.

Effects of dizocilpine (MK-801) and ethanol on the EEG and event-related potentials (ERPS) in rats.

Recent neurophysiological data have suggested an interaction of ethanol (EtOH) with the glutamate-NMDA receptor complex. For instance, low levels of alcohol have been found to inhibit the ion current, activated by NMDA in in vitro preparations. The present study extends these paradigms in order to evaluate the electrophysiological effects of ethanol and the nonspecific NMDA receptor antagonist, dizocilpine (MK-801) in awake, conscious rats. Twenty Wistar rats were stereotaxically implanted with electrodes, aimed at dorsal hippocampus, amygdala, thalamus and frontal cortex. Rats received the following drugs: saline (s.c.), 0.01 and 0.1 mg/kg MK-801 (s.c.); EtOH, 0.75 g/kg (i.p.); 0.75 kg EtOH plus 0.01 mg/kg MK-801; 0.75 g/kg EtOH plus 0.10 mg/kg MK-801. Five minutes of EEG was collected and event-related potentials (ERPs) recorded in response to an auditory "oddball" paradigm. Spectral analysis revealed that MK-801 (0.1 m/kg) produced significant increases in low frequency EEG components, at all sites (1-6 Hz) and decreases in higher frequencies (16-32 Hz). Whereas ethanol (0.75 g/kg) produced decreases in power in all frequency bands. The combined administration of EtOH and MK-801 produced some antagonistic effects on the EEG in the low frequency range. Evaluation of ERPs revealed that MK-801 (0.1 mg/kg) produced significant decreases in amplitude of the N1 and P2 components in the cortex, decreases in the P1 and N2 in the thalamus and a profound decrease in the P3 components in hippocampus and amygdala. Ethanol was also found to produce decreases in the N1 component in cortex. The administration of MK-801 and ethanol together did not produce significant interactions on ERPs. These studies suggest that antagonism of the NMDA receptor by MK-801 may produce some effects similar to those of ethanol, however, their combined administration did not produce synergistic effects within these dose ranges.