Models of care in secure services for people with intellectual and developmental disability: Implementing the Walkway to Wellness.

BACKGROUND: Changes to policy around inpatient services for people with intellectual and developmental disability (IDD) who offend, have led to a need for services to reconsider their models of care. This has led to calls for more tailored, patient-centred care models, with less reliance solely on offence-related treatment programmes which can be unsuitable for a growing proportion of patients with more complex cognitive and behavioural difficulties. In response, the Walkway to Wellness (W2W) was developed at one National Health Service Trust providing secure services to people with IDD, with the intention of delivering a more collaborative, co-produced and goal-oriented care model that was better understood by staff and patient stakeholders. AIMS: To evaluate the implementation of the W2W using Normalisation Process Theory (NPT), an evidence-based theoretical approach is used across a number of health settings. METHODS: Staff were invited to complete a short questionnaire, using the NPT informed Normalisation Measure Development questionnaire, at two time points along the implementation process. Patients were invited to complete a simplified questionnaire. Both groups were asked for their views on the W2W and the process of its implementation. RESULTS: Although the W2W was more familiar to staff at the second time point, scores on the four NPT constructs showed a trend for it being less embedded in practice, with significant results concerning the ongoing appraisal of the new model. Patient views were mixed; some saw the benefit of more goal-oriented processes, but others considered it an additional chore hindering their own perceived goals. CONCLUSION: Early involvement of all stakeholders is required to enhance the understanding of changes to models of care. Live feedback should be used to refine and revise the model to meet the needs of patients, carers and staff members.

The Effects of Noninvasive Vagus Nerve Stimulation on Fatigue in Participants With Primary Sjögren's Syndrome.

OBJECTIVES: Fatigue is one of the most important symptoms needing improvement in Primary Sjögren's syndrome (PSS). Previous data from our group suggest that noninvasive stimulation of the vagus nerve (nVNS) may improve symptoms of fatigue. This experimental medicine study uses the gammaCore device (electroCore) and a sham device to investigate the relationship between nVNS and fatigue in PSS, and to explore potential mechanisms involved. MATERIALS AND METHODS: Forty participants with PSS were randomly assigned to use active (n = 20) or sham (n = 20) nVNS devices twice daily for 54 days in a double-blind manner. Patient-reported measures of fatigue were collected at baseline and day 56: Profile of Fatigue (PRO-F)-Physical, PRO-F-Mental and Visual Analogue Scale of abnormal fatigue (fVAS). Neurocognitive tests, immunologic responses, electroencephalography alpha reactivity, muscle acidosis, and heart rate variability were compared between devices from baseline to day 56 using analysis of covariance. RESULTS: PRO-F-Physical, PRO-F-Mental, and fVAS scores were significantly reduced at day 56 in the active group only (p = 0.02, 0.02, and 0.04, respectively). Muscle bioenergetics and heart rate variability showed no change between arms. There were significant improvements in digit span and a neurocognitive test (p = 0.03), and upon acute nVNS stimulation, frontal region alpha reactivity showed a significant negative relationship with fatigue scores in the active group (p < 0.01). CONCLUSIONS: We observed significant improvements in three measures of fatigue at day 56 with the active device but not the sham device. Directly after device use, fatigue levels correlate with measures of alpha reactivity, suggesting modulation of cholinergic system integrity as a mechanism of action for nVNS.

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.

The Penrose hypothesis in the second half of the 20th century: investigating the relationship between psychiatric bed numbers and the prison population in England between 1960 and 2018-2019.

BACKGROUND: NHS Psychiatric beds comprise mental illness and intellectual disability beds. Penrose hypothesised that the number of psychiatric in-patients was inversely related to prison population size. AIMS: To ascertain whether the Penrose hypothesis held true in England between 1960 and 2018-2019. METHOD: A time-series analysis explored the association between total prison population and NHS psychiatric beds; this was also tested for the male and female prison populations, using non-psychiatric beds as a comparator. Associations were explored with time lags of up to 20 years. Linear regression was conducted to estimate the size of the effect of bed closures. RESULTS: NHS psychiatric beds decreased 93% and the prison population increased 208%. A strong (r =-0.96) and highly significant negative correlation between these changes was found. Annual reduction in psychiatric bed numbers was associated with an increase in prison population, strongest at a lag of 10 years. The closure of mental illness and intellectual disability beds was associated with increases in female prisoners 10 years later. The only significant explanatory variable for the increase in male prison population was intellectual disability bed reduction. CONCLUSIONS: The Penrose hypothesis held true between 1960 and 2018-2019 in England: psychiatric bed closures were associated with increases in prison population up to 10 years later. For every 100 psychiatric beds closed, there were 36 more prisoners 10 years later: 3 more female prisoners and 33 more male prisoners. Our results suggest that the dramatic increase in the female prison population may relate to the closure of NHS beds.

The prevalence of mental illness and unmet needs of police custody detainees.

BACKGROUND: Internationally, there is evidence of high rates of mental disorders amongst police custody detainees but this literature is limited, and there has been little research into the unmet needs of police detainees in the UK, or elsewhere. Such research could support better focussed interventions for improving health and recidivism outcomes. AIM: To examine psychiatric and developmental morbidity amongst police detainees, and ascertain differences in need between morbidity categories. METHOD: We used a cross-sectional study design and interviewed a 40% sample of people entering police custody in one South London police station over a 2-week period. A series of standardised measures was administered to screen for the presence of mental illness, general health and social care needs. RESULTS: A cohort of 134 people was generated, of whom nearly one-third (39, 29%) had current mental illness (major depression and/or psychosis); more had a lifetime diagnosis (54, 40%). Just under a fifth met the threshold for post-traumatic stress disorder (11, 8%). Clinically relevant alcohol or daily cannabis use affected about one quarter of the sample. Twenty-one percent (or 28) screened positive for personality disorder, 11% (or 15) for attention deficit hyperactivity disorder and 4% (6) for intellectual disability. Nearly one-fifth (24, 18%) were at risk for suicide. Those with psychosis, and those deemed at risk for suicide, had the highest levels of unmet need and, indeed, overall need. The most frequent unmet need was for accommodation. CONCLUSION: Our findings not only confirm high rates of mental health problems amongst police detainees but also demonstrate their high risk of suicide and high levels of unmet need, especially as regards accommodation. This underscores the need to provide mental health services in police stations, to help identify and resolve these issues at this early stage in the criminal justice system. Extending accommodation capacity to help some arrestees may help to save lives and interrupt cycling through the criminal justice system.

Changes in the use of the Mental Health Act 1983 in England 1984/85 to 2015/16.

BACKGROUND: Concerns have been raised about the increase in the use of involuntary detentions under the Mental Health Act in England over a number of years, and whether this merits consideration of legislative change.AimsTo investigate changes in the rate of detentions under Part II (civil) and Part III (forensic) sections of the Mental Health Act in England between 1984 and 2016. METHOD: Retrospective analysis of data on involuntary detentions from the National Archives and NHS Digital. Rates per 100 000 population were calculated with percentage changes. The odds of being formally admitted to a National Health Service hospital compared with a private hospital were calculated for each year. RESULTS: Rates of detention have at least trebled since the 1980s and doubled since the 1990s. This has been because of a rise in Part II (civil) sections. Although the overall rate of detentions under Part III (forensic) sections did not rise, transfers from prison increased and detentions by the courts reduced. The odds of being detained in a private hospital increased fivefold. CONCLUSIONS: The move to community-based mental health services in England has paradoxically led to an increase in the number of people being detained in hospital each year, and in particular an inexorable rise in involuntary admissions. This is likely to be partly because of improved case finding with an increased focus on treatment and risk management, and partly because of changes in legislation. An increasing proportion of this government-funded care is being provided by private hospitals.Declaration of interestNone.

Contextualising health screening risk assessments in police custody suites - qualitative evaluation from the HELP-PC study in London, UK.

BACKGROUND: In the UK, police custody officers have a responsibility to screen for health morbidity and vulnerability among detainees. This study aimed to develop an understanding of the barriers to performing effective health screening in police custody suites, understand the impact of screening tools on practice within the custody suite, and to identify factors that could hinder or facilitate the future implementation of a new screening intervention in this environment. METHODS: A qualitative study was conducted alongside a quantitative evaluation of a novel screening tool. Qualitative methods included observation of the custody environment, semi-structured interviews with police staff, and elicitation of comments from detainees about their experiences of screening. Data were analysed inductively using thematic analysis. Normalization Process Theory (NPT) was used to inform data collection and as a framework for higher level analysis of findings. RESULTS: Five overall constructs were identified that develop understanding of the integration of health screening within custody: the workability of risk assessment screening tools; the effect of the custody environment and the people therein; shifts in professional roles and interrelationships amongst staff; cultural responses to risk and liability in police work; how infrastructure, knowledge and skills can impact on detainee safety. CONCLUSIONS: Health and risk assessment screening in police custody is a complex and demanding activity which extends beyond the delivery of a screening tool. Professional roles, the demanding environment and police culture impact on the overall process. Recommendations for improved integration of health and risk assessment screening in wider police custody practice are proposed.

A UK-wide survey of community forensic services for adults with intellectual disability and/or autism.

BACKGROUND: Specialist forensic community teams for people with intellectual disability and/or autism have been developed, but little is known about their extent and delivery. AIMS: To describe specialist forensic community teams for people with intellectual disability and/or autism across the UK. METHOD: An online survey was sent to representatives of each UK Trust/Health Board providing adult mental health and/or intellectual disability services. Questions covered the availability, structure and activities of specialist community forensic services. Quantitative data were summarised and associations between access to specialist forensic teams and care were tested with Chi-squared tests. Thematic analysis of free-text survey responses was used to understand the challenges of providing community forensic mental health services for this group. RESULTS: A total of 49 out of 78 (63%) eligible Trusts/Health Boards responded, of which 25 (51%) had access to a specialist forensic community team. Teams operated either as part of a single Trust/Board (n = 13) or over a larger regional footprint (n = 12). The availability of specialist forensic community teams was associated with better access to offence-related interventions (χ2 = 15.1002, P < 0.005) and co-production of patient care plans (χ2 = 7.8726, P = 0.005). Respondents reported a wide variation in availability, expertise and perceived quality of community services. The availability of secure and generic in-patient beds, commissioning and legal barriers were also significant challenges in providing appropriate care. CONCLUSIONS: Coverage of specialist community forensic teams is not universal. There are indications that such teams are associated with improved care processes, but further work is needed to establish longer-term outcomes and the optimal model of care.

What are the key influences and challenges around weight management faced by patients in UK adult secure mental health settings? A focused ethnographic approach.

OBJECTIVES: Excess weight is highly prevalent in secure (forensic) mental health services and impacts negatively on patients' physical and mental health. This study sought to identify the key influences and challenges around weight management in UK adult secure mental health settings. DESIGN: Qualitative focused ethnography. Analysis of written fieldnotes was undertaken through a combined inductive and deductive approach, informed by thematic analysis. SETTING: Low secure male mental health ward and associated patient activities and events, in a National Health Service Trust delivering mental health, intellectual disability and neurorehabilitation services in the UK. PARTICIPANTS: 12 males (primarily white British) on the low secure ward; additional male participants from low and medium secure services, who took part in group events and activities; and multidisciplinary low and medium secure services staff. Approximately 23 hours of observation were undertaken over a 6-month period from April 2022. RESULTS: Secure mental healthcare delivered an environment predisposing patients to excessive weight gain and sedentary behaviour, which was often perceived as inevitable. Key themes highlighted the heightened salience of food in secure settings; inadequacy of catered hospital food and shortcomings of alternative food options; limited physical activity opportunities; and a ward culture that was not conducive to healthy behaviours. Perceptions and behaviour towards the ethnographer were primarily positive and accepting. CONCLUSIONS: Weight management in secure services is a complex challenge. In future, whole setting-based interventions to promote healthy weight are likely to be required. These should integrate physical and mental health, incorporate underpinning determinants such as adequate staffing and a culture promoting weight management, and involve both patients and staff.

Health screening of people in police custody--evaluation of current police screening procedures in London, UK.

BACKGROUND: Previous research has highlighted excess health morbidity in offender populations. A small number of studies have described health problems within police custody settings. The efficacy of police screening procedures has not been evaluated. METHODS: Prospective clinical interviews with custody detainees in London were conducted. Clinical findings were compared with those recorded in police health screening documentation. RESULTS: High levels of health morbidity were observed. The sensitivity and specificity of the current screen with respect to its ability to trigger a call for a health-care professional (HCP), regardless of the reason, was 70 and 66%, respectively. Fifty-one percent of the detainees with asthma, 36% with diabetes mellitus and 40% with epilepsy were not picked up by the screen. Fewer than one-half of the detainees at risk of alcohol withdrawal syndrome had 'alcohol' documented on their screen, although 81% saw the HCP. The police screen missed heroin use in 28% and crack cocaine use in 68% of users. A HCP was called in 84 and 64% of the cases, respectively, for any reason. Two of the 12 detainees (17%) who described a head injury with serious-associated symptoms were detected; 9 had a HCP called for any reason. Whereas mental disturbance was detected in 79% of the detainees with serious mental illness, one-third of the detainees with a risk history of suicide and one-half of the detainees with suicidal ideation were not documented as such on the police screen. CONCLUSION: Given the amounts of morbidity and the need for reliable triage, improvement in the health screening procedures used by the police is needed.

Factors that influence psychiatric trainees' choice of higher training specialty: mixed-methods study.

AIMS AND METHOD: Factors influencing trainees' decisions about choosing and remaining in higher training subspecialties have not been widely researched. We administered telephone questionnaires to higher specialist trainees in the north-east of England to ascertain what influences these decisions. Thematic analysis was employed to develop overall constructs. RESULTS: Twenty-seven trainees were interviewed, resulting in six overall constructs. These were: supervisory experiences; perceived work-life balance; career prospects; training and working environments; interest in the chosen subspecialty; and previous experience within the chosen subspecialty. Most trainees interviewed felt they had made the right specialty choice. CLINICAL IMPLICATIONS: This study demonstrates the particular importance of exposure to a specialty and perceptions of the supervisory experience in determining trainees' choices of, and decisions to remain in, a particular psychiatric specialty. Factors highlighted in this study must inform training, recruitment and workforce planning in order to bolster the recruitment and retention of trainees into higher specialty training.

Revisiting vitamin D status and supplementation for in-patients with intellectual and developmental disability in the North of England, UK.

AIMS AND METHOD: To re-evaluate vitamin D testing and supplementation among in-patients with intellectual and developmental disability (IDD) and examine any correlates with physical health conditions, including COVID-19. Records of all in-patients between January 2019 and July 2020 (n = 78) were examined for 25-hydroxyvitamin D (25(OH)D) level, ward area, supplementation status, test seasonality, medication and health status. RESULTS: The mean 25(OH)D level for supplemented (800 IU/day) patients was 75 nmol/L (s.d. = 20), compared with 40 nmol/L (s.d. = 19) in the non-supplemented group (P < 0.001). Thirty-eight percent of those who were in-patients during the first wave of the COVID-19 pandemic developed symptoms, but the small sample size could not establish vitamin D levels as a predictor of outcome. CLINICAL IMPLICATIONS: Vitamin D (800 IU/day) supplementation is effective but the adequacy of the nationally recommended dose of 400 IU/day is unclear. Links to COVID-19 merit further research.

Questionnaires used in complex trauma intervention evaluations and consideration of their utility for autistic adults with mild intellectual disability: A systematic review.

INTRODUCTION: Research suggests some trauma symptoms e.g. avoidance are difficult to recognise in autistic people with intellectual disability while arousal/emotional and interpersonal difficulties may be useful signals. This review aims to (i) identify questionnaires used in general population complex trauma interventions to measure emotional and interpersonal difficulty and (ii) evaluate their psychometric properties to inform selection of a potential measure/s for use and/or adaptation for autistic people with mild intellectual disability and trauma related mental health conditions. METHODS: Stage 1: we searched Medline, Cinahl, Embase and PsycInfo for general population and clinical complex trauma intervention studies. Stage 2: we used a search filter in Embase to identify psychometric evaluations of relevant questionnaires used in Stage 1 studies and assessed these with the COnsensus based Standards for the selection of health based Measurement Instruments (COSMIN) checklist. RESULTS: five studies were identified in Stage 1 utilising three measures of emotion dysregulation and interpersonal difficulties. Thirty-three articles on their psychometric properties were identified in Stage 2. Strongest psychometric evidence was found for the Emotion Regulation Questionnaire (ERQ) and Difficulties in Emotion Regulation Scale (DERS). CONCLUSIONS: Evaluating content validity/acceptability of the ERQ and DERS for autistic people with mild intellectual disability and trauma-related mental health conditions are useful next steps.

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.

Offenders with mental disorders in prison and the courts: links to rates of civil detentions and the number of psychiatric beds in England - longitudinal data from 1984 to 2016.

BACKGROUND: The Mental Health Act in England and Wales allows for two types of detention in hospital: civil and forensic detentions. An association between the closure of mental illness beds and a rise in civil detentions has been reported. AIMS: To examine changes in the rate of court orders and transfer from prison to hospital for treatment, and explore associations with civil involuntary detentions, psychiatric bed numbers and the prison population. METHOD: Secondary analysis of routinely collected data with lagged time series analysis. We focused on two main types of forensic detentions in National Health Service (NHS) hospitals and private units: prison transfers and court treatment orders in England from 1984 to 2016. NHS bed numbers only were available. RESULTS: There was an association between the number of psychiatric beds and the number of prison transfers. This was strongest at a time lag of 2 years with the change in psychiatric beds occurring first. There was an association between the rate of civil detentions and the rate of court orders. This was strongest at a time lag of 3 years. Linear regression indicated that 135 fewer psychiatric beds were associated with one additional transfer from prison to hospital; and as the rate of civil detentions increased by 72, the rate of court treatment orders fell by one. CONCLUSIONS: The closure of psychiatric beds was associated with an increase in transfers from prison to hospital for treatment. The increase in civil detentions was associated with a reduction in the rate of courts detaining to hospital individuals who had offended. DECLARATION OF INTEREST: None.

Vitamin D in patients with intellectual and developmental disability in secure in-patient services in the North of England, UK.

Aims and method To assess the benefits of the introduction of routine vitamin D serum sampling for all patients admitted to a secure in-patient hospital in the North of England providing medium security, low security and rehabilitation services for offenders with intellectual and developmental disability. The vitamin D levels of 100 patients were analysed at baseline. Those with insufficient or deficient levels were offered treatment and retested after 1 year. Vitamin D levels were analysed in the context of level of security, seasonality of test and co-prescription of psychotropic medications. RESULTS: Eighty-three per cent of patients had suboptimal vitamin D levels at initial test (41% deficient and 42% insufficient). This was seen among established patients and new admissions. Regression analysis of baseline vitamin D levels revealed no differences for levels of security, seasonality, whether patients were taking antipsychotic or anticonvulsant medication, or length of stay. Patients with deficiency or insufficiency were all offered supplementation. Those who opted in had significantly higher vitamin D levels at follow-up, compared with those who declined treatment. Clinical implications Established and newly admitted patients in our secure mental health services had substantial levels of vitamin D insufficiency. In the light of the morbidities that are associated with deficient vitamin D levels, routine screening and the offer of supplementation is advisable. Declaration of interest None.

The impact of transforming care on the care and safety of patients with intellectual disabilities and forensic needs.

NHS England recently published a national plan to develop community services for people with intellectual disabilities and autism who display challenging behaviour by using resources from the closure of a large number of hospital beds. An ambitious timescale has been set to implement this plan. The bed closure programme is moving ahead rapidly, but there has been little progress in developing community services to support it. This paper discusses the impact of the gap between policy and practice on the care and safety of patients with intellectual disabilities and forensic needs who form a distinct subgroup of the target population and are being disproportionately affected by this government policy.