Mental Health Learning Disabilities Strategy Event Dr Asim Naeem Consultant Psychiatrist Sutton CMHL

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Mental Health Learning DisabilitiesStrategy
EventDr Asim NaeemConsultant Psychiatrist
(Sutton CMHLD team) Honorary Senior
Lecturer(St Georges University of London).

• Antoinette Hotel, Kingston (3 October 2007)

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• Our service model for the delivery of mental
  healthcare for
• people with learning disabilities.

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Content

• Salient background information.
• What are the drivers to change?
• Current models of care.
• Future possibilities for models of care?
• Key challenges in service delivery for PLD.
• Conclusion.
• Key references.

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Salient background information

• total prevalence rate of mental health problems
  in PLD is considerably higher than in the general
  population.
• 30 50 (Smiley, 2005).
• more children with complex health needs LD
  living into adulthood.
• ageing LD population links with dementia /
  anxiety mood disorders (Cooper, 1997).

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Drivers to change?

• Deinstitutionalisation CHAI reports (Cornwall
  Sutton Merton).
• Valuing people PCP / HAPs / health
  facilitation.
• CPA effective care co-ordination for people
  with complex mental health needs.
• Joint health-social care models of working.
• LD partnership boards / users carers /
  advocacy.
• New ways of working with PLD for
  Psychiatrists.
• Changes to commissioning (local needs
  practice-based).

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Drivers to change?

• CTPLD model deficiencies.
• NHS Plan (2000) assertive outreach models of
  care.
• NHS Modernisation Agency (2004) high impact
  changes (reviewed by NIMHE, 2005)
• co-ordinated care (CPA)
• better crisis Mx / relapse prevention
• home care services
• user - / needs led.

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Complex interactions in PLD
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Complex interactions in PLD
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Complex interactions in PLD

• environment (incl. institutionalisation).
• life events abuse (Sequeira Hollins, 2003).
• staff / carer factors.
• service user perceptions.
• 10 15 prevalence of problem behaviours
• multi-factorial causation (Xeniditis et
  al, 2001).

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Mental Healthcare for PLD current models
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Mental Healthcare for PLD current models
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Principles of Assertive outreach

• risk assessment.
• crisis / contingency plans.
• management of medications.
• psychological support.
• physical health monitoring.
• relapse prevention.
• skills training access to activities /
  education / employment.
• (Hassiotis et al, 2003 Burns Guest, 1999)

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Strengths

• good data from USA on efficacy esp. mild
  borderline LD (Kent Burns, 2005 Tyrer et al,
  1999).
• Valuing People PCP / HAP / health facilitation.
• improved levels of engagement with services
• (Prakash et al, 2007).
• needs - user led service, helping to
  facilitate greater independence.
• enhancing skills in natural community
  environment
• (c.f. day hospitals / sheltered workshops).
• joint working.

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Weaknesses

• USA data not always replicated in UK studies?
• may not be translated into reduced in-patient bed
  occupancy in short-term (Prakash et al, 2007).
• institutionalisation can occur in community
  settings.
• lack of structured day activities / appropriate
  housing.
• lack of user / carer involvement in service
  planning.
• small no. service users fail to engage with any
  service.

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Mental Healthcare for PLD future models?

• 1. No change (CTPLD MHLD teams).
• Standard CPA CTPLD.
• Enhanced CPA MHLD team.
• 2. MHLD teams.
• Standard CPA.
• Enhanced CPA.
• 3. CMHTs with MHLD team input /inreach.
• 4. GPs / Primary care split with MHLD team.
• Standard CPA Primary care.
• Enhanced CPA MHLD team.

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Mental Healthcare for PLD future models?

• 5. CMHT / MHLD team split for standard CPA.
• Standard CPA mild LD (CMHT) moderate-severe LD
  (MHLD team).
• 6. Joint models of care with other mental health
  services with similar needs.
• Rehabilitation psychiatry.
• Old Age psychiatry.
• Neuropsychiatry.
• (Role of a behavioural intervention / support
  team for pts with severe challenging behaviour
  ? PCT vs. MHTrust)

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Challenges to service delivery for PLD

• Remit of current CMHTs (cover secondary mental
  health care CTPLDs cover primary secondary
  mental health care).
• Knowledge
• Skills
• Attitudes
• Diagnostic overshadowing / psychosocial masking /
  baseline exaggeration)
• Autistic spectrum disorders.
• Significant challenging behaviour (incl. SIB).
• Epilepsy (neurobehavioural aspects).

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Challenges to service delivery for PLD

• Younger old age PLD group.
• Alzheimers dementia.
• Physical illnesses / frailty.
• Mild LD group with significant receptive vs.
  expressive language difficulties.
• PLD with low frequency / high intensity
  behaviours.
• Mixing up of LD / mainstream pts.
• differing levels of needs different levels of
  intellectual functioning.

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Challenges to service delivery for PLD

• Access to mainstream services.
• Environmental barriers.
• Longer appointments.
• Complex needs.
• Specialist services eg, psychology.

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Conclusion

• New developments in providing specialist mental
  healthcare for PLD complex needs living in the
  community are driven by a range of changes to
  healthcare provision (eg, deinstitutionalisation
  VP NHS Plan).
• They offer significant advantages over
  traditional models of care, which should improve
  the lives of PLD their families/carers, whilst
  also providing CPD opportunities for staff.
• All models of care provision have weaknesses,
  too.

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Complex interactions in PLD
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Key References

• Burns T Guest L (1999). Running an assertive
  community treatment team. Advances in
  Psychiatric Treatment, 5, 348 356.
• Cooper SA (1997). Epidemiology of psychiatric
  disorders in elderly compared with younger adults
  with learning disability. British Journal of
  Psychiatry, 170, 375 380.
• Department of Health (2001). Valuing People A
  New Strategy for Learning Disability for the 21st
  Century. London DoH.
• Hassiotis A, Tyrer P Oliver P (2003).
  Psychiatric assertive outreach learning
  disability services. Advances in Psychiatric
  Treatment, 9, 368 373.
• Kent A Burns T (2005). Assertive community
  treatment in UK practice. Advances in
  Psychiatric Treatment, 11, 388 397.
• Prakash J, Andrews T Porter I (2007). Service
  innovation assertive outreach teams for adults
  with learning disability. Psychiatric Bulletin,
  31, 138 141.

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Key References

• Sequeira H Hollins S (2003). Clinical effects
  of sexual abuse on people with learning
  disability critical literature review. British
  Journal of Psychiatry, 182, 13 19.
• Smiley E (2005). Epidemiology of mental health
  problems in adults with learning disability an
  update. Advances in Psychiatric Treatment, 11,
  214 - 222.
• Tyrer P, Hassiotis A Ukoumume O, et al (1999).
  Intensive case management for psychotic patients
  with borderline intelligence. Lancet, 354, 999
  1000.
• Xenitidis K, Russell A Murphy D (2001).
  Management of people with challenging behaviour.
  Advances in Psychiatric Treatment, 7, 109 116.

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