Publications
333 results found
Deb S, Limbu B, Unwin G, 2022, Comprehensive Assessment of Triggers for Behaviours of Concern Scale (CATS)., Royal College of Psychiatrists Conference, London.
BackgroundBehaviours of concern (BoC) may be displayed by many people with neurodevelopmental disorders such as intellectual disabilities or autism spectrum disorder (20-60%). BoC can be difficult to manage if caregivers do not understand the reasons for the behaviour. Identifying the contextual variables/triggers for the behaviour is likely to help undertake a functional analysis leading to a person-centred positive behaviour support plan.AimsWe have developed a comprehensive triggers/contextual variables scale called Comprehensive Assessment of Triggers for behaviours of concern Scale (CATS).MethodsCATS was developed in two stages. In stage 1, we used a ‘bottom-up’ approach, in which caregivers of adults with intellectual disabilities who show aggressive behaviour were interviewed to identify the triggers for aggression. In stage two, using a ‘top-down’ approach, a comprehensive literature review was conducted to gather items from existing trigger checklists. Trigger items from both stages were combined and the duplicates were removed.ResultsIn stage 1, 168 contextual variables were identified which were categorised under five main themes (internal environment (within the person), external environment (outside of the person), expression of volition, characteristics of intellectual disabilities, and specific activities/events) and 12 subthemes. The highest number of items mentioned by the caregivers fell in the categories of external environment (n = 92) and internal environment (n = 76). In stage 2, 20 articles were selected for inclusion. Six published scales were found related to contextual variables and another five related to functional assessment. The final list in CATS consists of 333 contextual triggers categorised under five main domains and 12 subdomains (https://spectrom.wixsite.com/project). CATS can be used by caregivers to identify triggers or antecedents of BoC. ConclusionsCATS is easy to use by the caregivers and does not req
Deb S, Akrout Brizard B, Limbu B, 2022, Is epilepsy a risk factor for behaviours that challenge in adults with intellectual disabilities? A systematic review and meta-analysis., Royal College of Psychiatrists conference, London, UK.
BackgroundBoth epilepsy (c.24%) and behaviours that challenge (BtC) (24-60%) are common in adults with intellectual disabilities (ID). However, the relationship between epilepsy and BtC, particularly in the inter-ictal phase in adults with ID is not clear. AimsWe have carried out a systematic review and meta-analysis of the published data using a random effects model to identify whether there is an association between epilepsy and BtC among adults with ID as pervious systematic reviews failed to show any such association.MethodsEmbase, PubMed/MEDLINE, PsycINFO, DARE and ASSIA (ProQuest) databases were searched. We also hand searched six relevant journals in the fields of ID and epilepsy. All selected titles, abstracts and full articles were screened independently by two authors using standardised eligibility criteria for selection derived from Cochrane handbook. Several meta-analyses were carried out.ResultsThe narrative analysis of data from 34 included articles involving overall 14,168 adults with ID of whom 4781 had epilepsy showed overall no significant association between epilepsy and BtC. Only 19 studies used a control group (only nine were matched). Data from only 16 controlled studies could be pooled for meta-analysis. This showed no significant intergroup difference but after sensitivity analysis meta-analysis of 10 studies showed a significantly higher rate of overall BtC in the epilepsy group (effect size: 0.16) when compared with the non-epilepsy group. Aggression and self-injurious behaviour both showed a statistically significant higher rate in the epilepsy group with very small effect sizes (0.16 and 0.28 respectively). No significant intergroup difference was observed in the rate of stereotypy.ConclusionsThe findings are contradictory and have to be interpreted with caution because of the difficulty in pooling data from a vary varied studies which is likely to introduce confounding, and where significant the effect sizes are small and may not be clin
Deb S, Limbu B, Retzer A, et al., 2022, The effectiveness of parent training for children with autism spectrum disorder: a systematic review and meta-analyses., Royal College of Psychiatrists conference, London, UK.
Background Various parent training interventions are shown to have some effect on the symptoms of children with autism spectrum disorder, but the interventions used are heterogeneous. Methods A systematic review and several meta-analyses using random effects method were carried out to assess effectiveness of parental training for children with autism spectrum disorder on their core autism symptoms and associated behaviours such as agitation and irritability, and also parental stress. We searched four electronic databases, namely CINAHL, EMBASE, MEDLINE and PsycINFO for relevant literature. Two reviewers independently and blindly screened titles, abstracts and full articles using an eligibility checklist designed following Cochrane handbook guide and extracted data using a structured proforma adapted from Cochrane handbook. Several meta-analyses were carried out where it was possible to pool data from different studies that used the same outcome measures.Results Seventeen papers from 15 studies were included for data analysis. Fifteen papers showed a positive treatment effect when compared with the control group, although not always significant. Meta-analysis based on pooled data from only two studies in each respective intervention, showed small to moderate treatment effects for three interventions, DIR/Floortime, Pivotal Response and Parent focused training. Conclusions As in previous systematic reviews there was a mild to moderate treatment effects of three specific types of interventions respectively. However, it was difficult to draw any definitive conclusion about the effectiveness and generalisability of any intervention because of the wide variation in the interventions, control groups, outcome measures, small sample size, small number of studies in meta-analysis, overlap between the intervention and control procedures used in the included studies. There is an urgent need for experts in various international centres to jointly standardise a parent training in
Deb S, Limbu B, Roy M, et al., 2022, Randomised controlled trials of mood stabilisers for people with autism spectrum disorder: A systematic review and meta-analysis., Royal College of Psychiatrists conference, London, UK.
Background Around 9% of people with autism spectrum disorder (ASD) receive mood stabilisers/antiepileptic medications such as sodium valproate despite lack of evidence to suggest psychotropic medications including mood stabilisers are effective in individuals with ASD.Aims A systematic review and meta-analysis were carried out on the RCTs that assessed the effectiveness of mood stabilisers including lithium in people with ASD.Method The following databases were searched: Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, DARE, and ClinicalTrials.gov. Additionally, we hand-searched 12 relevant journals in the fields of intellectual disabilities, ASD and psychopharmacology. The Cochrane Risk of Bias tool and Jadad score were used to assess the quality of included RCTs. A meta-analysis was also carried out using a random-effects model.Results Eight RCTs were included in this systematic review (three on divalproex sodium, two on levetiracetam, and one each on sodium valproate, lamotrigine and topiramate) that included a total of 310 people with ASD, primarily children. No RCT on lithium was found. Outcomes were based on ASD core symptoms such as restrictive and repetitive behaviour, language and communication impairment, and associated symptoms such as irritability and agitation but not bipolar disorder or any other psychiatric disorders. Only two small studies (25%) from the same group showed definite superiority over placebo and one over psychoeducation alone. Meta-analysis of pooled data on Aberrant Behavior Checklist-Irritability subdomain score (ABC-I), Clinical Global Impression-Improvement (CGI-I), and Overt Aggression Scale (OAS)/OAS-Modified (OAS-M) did not show any significant intergroup difference. The rates of adverse effects did not show any significant intergroup difference.Conclusions It is difficult to draw any definitive conclusion about the effectiveness of mood stabilisers including lithium and antiepileptic medications to treat either ASD cor
Deb S, Limbu B, Roy M, et al., 2022, Randomised controlled trials of antidepressant and anti-anxiety medications for people with autism spectrum disorder: A systematic review and meta-analysis., Royal College of Psychiatrists conference, London, UK
Background Around 17% of people with ASD are prescribed antidepressants and 7% antianxiety medications despite limited evidence of their efficacy.Aims We have carried out a systematic review and meta-analysis of the RCTs that assessed the effectiveness of antidepressants and antianxiety medications in people with ASD of all ages.Method We have searched the following databases: Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, DARE, and ClinicalTrials.gov. Additionally, we have hand-searched 11 relevant journals in the field of intellectual disabilities, ASD and psychopharmacology. The quality of the included papers was assessed using the Cochrane Risk of Bias tool and Jadad score. We have also carried out a meta-analysis using a random-effects model.Results We have found 15 RCTs (13 on antidepressants and two on antianxiety medication buspirone) that included a total of 958 people with ASD primarily children and adolescents. There were four RCTs on fluoxetine, two each on clomipramine, venlafaxine, fluvoxamine, and one each on citalopram, sertraline and agomelatine. RCTs assessed efficacy of these medications on ASD core symptoms and associated behaviours such as agitation, irritability, and aggression rather than psychiatric disorders like anxiety or depression. Data showed contradictory findings among the studies with larger studies mostly showing a non-significant difference in outcomes between the treatment and the placebo group. Meta-analysis of pooled Yale-Brown Obsessive Compulsive Scale and Clinical Global Impression Scale data from nine studies (60%) did not show any statistically significant intergroup difference on either of the outcome measures. The adverse effects reported were mild and, in most studies, their rates did not show any significant intergroup difference.Conclusions It is difficult to draw any definitive conclusion about the effectiveness of either antidepressants or antianxiety medications to treat either ASD core symptoms or assoc
Deb S, Nancarrow T, Limbu B, et al., 2022, UK psychiatrists’ experience of withdrawal of antipsychotics prescribed for behaviours that challenge in adults with intellectual disabilities and/or autism., Royal College of Psychiatrists conference, London, UK.
Background A high proportion of adults with intellectual disabilities (ID) are prescribed off-licence antipsychotics in the absence of a psychiatric illness primarily for behaviours that challenge (Batch). NHS England launched an initiative, ‘Stopping over-medication of people with a learning (intellectual) disability, autism or both’ (STOMP), to address this major public health concern to which STAMP was also added recentlyAims To gain understanding of the prescribing practice of the UK psychiatrists who work with adults with ID on the successes and challenges of withdrawing antipsychotics for batch. Methods An online questionnaire was sent to all UK psychiatrists working with adults with ID (estimated n = 225). Among other things, the questionnaire covered psychiatrists’ prescribing habits, the structures in place to support the withdrawal process, the barriers to achieving withdrawal.Results Eighty-eight psychiatrists (39%) responded. About 52% of the respondents stated that they are less likely to initiate an antipsychotic to treat BtC in adults with ID since the launch of STOMP. However, since then, 47% are prescribing other classes of psychotropic medication instead of antipsychotics for BtC, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11% reported deterioration in BtC in over 50% of patients upon withdrawal and the same proportion (11%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid caregivers’ concern, lack of multiagency and multidisciplinary input, unavailability of nonmedical psychosocial intervention, and a nationally agreed structure for antipsychotic withdrawal backed up by appropriate training for local adaptation are key reported factors hampering the withdrawal attempt. Conclusions There is an urgent
Limbu B, Deb S, Roy M, et al., 2022, Randomised controlled trials of mood stabilisers for people with autism spectrum disorder: systematic review and meta-analysis, BJPSYCH OPEN, Vol: 8, ISSN: 2056-4724
Deb SS, Strydom A, Hithersay R, et al., 2022, Dementia in People with Intellectual Disabilities, Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder, Pages: 719-756, ISBN: 9783319957197
With the increasing life expectancy in the last five decades, people with intellectual disabilities (ID) are exposed to the risk of age-related neurodegenerative disorders including dementia. The prevalence of dementia is increased in people with ID compared with that in the general population. People with Down syndrome (DS) are at even a higher risk of developing Alzheimer’s dementia (AD) compared with non-DS people with ID. However, there are difficulties in making an early and accurate diagnosis of dementia in individuals with ID and the screening instruments such as the Mini Mental Status Examination that are used in the general population often show floor effects when used for individuals with ID because of their pre-existing cognitive impairment, the level of which varies depending on the severity of ID. Both informant-rated and direct neuropsychological tests have been used for the case detection of dementia for individuals with ID. However, direct neuropsychological tests cannot be used for those who have severe ID and their validity could still be questionable in a number of cases of mild to moderate ID. There are many similarities and some differences in the clinical manifestation of dementia in individuals with ID and the non-ID general population. Impaired recent memory and confusion in the context of relatively intact distant memory are likely to be the early symptoms in individuals with ID who have a mild ID, whereas loss of skills and change in behaviour are likely to be the early features for those with more severe ID. Many symptoms, including features of ‘frontal lobe dysfunction’ that tend to appear late in dementia in the general population, may appear early in individuals with ID and DS. Ideally, individuals with ID should be screened for signs of dementia from before the age of 30/35. A multi-disciplinary approach should be taken for diagnosis of dementia in individuals with ID using a combination of informant-rated scales and
Deb SS, Roy M, 2022, Behavioural and Emotional Disorders with Onset Usually Occurring in Childhood and Adolescence, Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder, Pages: 513-535, ISBN: 9783319957197
Disruptive, impulse-control, and conduct disorders is a new category under DSM-5 classification system. These disorders originate in childhood and often continue into adulthood. There is a strong association between these disorders and intellectual disabilities (ID). They include conduct disorder, oppositional defiant disorder which is a less severe form of conduct disorder, and intermittent explosive disorder, which was part of impulse control disorder in previous DSM classifications. However, by definition many of these disorders have to show an intention behind the behaviour, which is not easy to determine, particularly among those who have severe and profound ID. Other impulse control disorders include pyromania, kleptomania, gambling disorder, compulsive sexual behaviour disorder, trichotillomania, and excoriation disorder. Body-focussed repetitive behaviour, on the other hand, includes stereotyped movement disorder and self-injurious behaviour. The aetiology of these disorders is complex and often is the outcome of an interaction between internal factors within the person and external factors such as the environment. Management of these behaviours is often difficult, therefore, requires input from a multitude of professionals with relevant and specific skills to provide a person-centred assessment and management. The ultimate aim should be to improve the quality of life of the person with ID and their family members.
Deb SS, Unwin G, Cooper SA, et al., 2022, Problem Behaviour, Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder, Pages: 145-185, ISBN: 9783319957197
Individuals with intellectual disabilities (ID) are at a higher risk of developing problem behaviour (PB). The prevalence varies from study to study depending on the definition of PB used and the population recruited. Although prevalence rates vary widely between 2% and 60%, the majority of studies quoted a prevalence rate of overall PB somewhere around in 60% of people but the more severe challenging behaviour is reported in a smaller proportion of people (around 10-15%). Outwardly directed aggression (about 10%) to other individuals and objects and self-injurious behaviour are the commonest forms of PB. PB, in general, and aggression, in particular, poses a major management problem and is a major barrier to social integration, leads to caregiver stress, community placement breakdown and use of the restrictive practice. Various factors such as age, gender, level of ID, level of communication, co-morbidities such as psychiatric disorder, other neurodevelopmental disorders such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) may influence the rate and the severity of PB. A thorough person-centred assessment is vital for a successful management. The assessment should take a bio-psycho-social approach by incorporating assessments of the behaviour; the person showing the behaviour, medical, psychiatric/psychological and social/environmental issues. A number of instruments are available to rate different types of PB and assess their impact. Some of these are generic and some are specific to PB. Some functional assessment scales that assess the environmental effect are also available. The aetiology of PB is complex and often is the outcome of an interaction between internal factors within the person and external factors such as the environment. Therefore, the management of PB requires input from a multitude of professionals with relevant and specific skills. The ultimate aim should be to improve the quality of life of the person with
Weber G, Bertelli MO, Deb SS, et al., 2022, Educational and Training Opportunities, Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder, Pages: 869-886, ISBN: 9783319957197
This chapter reviews the educational and training opportunities on mental health and intellectual disabilities (ID). The lack of well-trained professionals in ID mental health, such as psychiatrists and clinical psychologists, is highlighted in the background of recent service development and advancement in knowledge in the field. This chapter reveals major disparities in training of professionals in mental health issues in ID, both within and among countries, particularly in Europe. Formal accredited training schemes, where available, as well as online resources for self-learning have been described in this chapter. We point out the role and responsibility of national governments in strengthening effective leadership and governance for mental health policy and take the necessary steps to assure a high-quality mental health system, including ID mental health. Stakeholders from the ID mental health field are encouraged to set up a pan-European or international collaboration to coordinate the development of a shared generic framework for curriculum for education and training for professionals and carers in the ID mental health field.
Deb SS, Bertelli MO, Rossi M, 2022, Psychopharmacology, Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder, Pages: 247-279, ISBN: 9783319957197
Psychotropic medications are used regularly off-label for the management of problem behaviour in individuals with intellectual disabilities (ID) in the absence of a diagnosed psychiatric disorder. This practice is controversial. Evidence for the efficacy of psychotropic medication in this context is poor. Three RCTs involving risperidone among adults with ID showed equivocal results. Six RCTs involving children with ID +/- autism showed risperidone being significantly more effective compared with the placebo. In two pharmaceutical company-run studies, aripiprazole was shown to be significantly effective compared with placebo in children with ASD, some of whom also had ID. Equivocal results are found based on primarily cross-over RCTs on the opioid antagonists. Old small studies of lithium showed equivocal results. It is, therefore, suggested that the use of psychotropic medication in this context should be monitored carefully and regularly using national and international guides.
Deb SS, Perera B, Bertelli MO, 2022, Attention Deficit Hyperactivity Disorder, Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder, Pages: 457-482, ISBN: 9783319957197
Attention deficit hyperactivity disorder (ADHD) is characterised by inattention or hyperactivity/ impulsivity or both. The onset of ADHD is in childhood, but in a proportion of cases some symptoms continue into adulthood. There is a strong association among ADHD, intellectual disability (ID), problem behaviour, and autism spectrum disorder (ASD). The prevalence of ADHD in persons with ID and ASD is significantly higher than the general population, ranging between 10% and 28%. It might be difficult to diagnose ADHD in persons with ID and low-functioning ASD. The stringent use of categorical diagnostic criteria might limit the identification of the disorder since some criteria may not be applicable, particularly for those with more severe cognitive and communication impairments. Observation of a person’s distractibility that is not consistent with their developmental level may help when considering the symptom of inattention in an individual with ID, while hyperactivity and impulsivity are better indicated by fidgeting most of the time, appearing ‘on the go’, and being unable to remain seated for a long time and to wait for one’s turn, which can often lead to verbal or physical aggression, irritability, mood fluctuations, or self-harming behaviour. Although ADHD in the non-ID population is a widely researched area, the lack of high-quality research in ADHD in ID has been a barrier to the advancement of treatment in this patient group, with most studies having named ID as an exclusion criterion. Drug treatment such as psychostimulants like methylphenidate along with psychosocial interventions is effective in a high proportion of cases to improve ADHD symptoms. In people with ID, the overall effect size of psychostimulants is smaller than that reported in the general population, while the adverse effect profile is similar in both populations.
Deb SS, Roy M, Bachmann C, et al., 2022, Specific Learning Disorders, Motor Disorders, and Communication Disorders, Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder, Pages: 483-511, ISBN: 9783319957197
This chapter includes developmental learning, communication, and motor disorders, which affect persons with intellectual disability (ID), autism spectrum disorders (ASD), and/or other neurodevelopmental disorders more often than neurotypical persons, and have a significant influence on the emotional and adaptive development as well as on overall functioning and personality throughout the whole lifespan of the person. Specific learning disorders (SLDs) occur early during the first years of formal schooling, with difficulty in learning, reading, writing, and arithmetic. They occur in the absence of a global impairment of intelligence and intellectual capability, although these disorders are prevalent among children and adults with cognitive impairments within the range of ID. These disorders originate in childhood and often continue into adulthood among many. Various treatments are available showing a varied rate of success for SLDs. Motor disorders such as motor coordination difficulties, tic, and Tourette’s syndrome are common in children and adults with ID. Children and adults with ID also manifest various types of communication disorders including speech sound disorder, speech fluency disorder (stuttering), and social (pragmatic) communication disorder. Social communication disorder is common among children and adults with ASD. There are significant gaps in current knowledge of phenomenology, categorization, aetiology, and natural history of communication, and motor disorders in persons with ID and/or ASD. It is also difficult to decipher the many causal links between these conditions and the frequently associated psychiatric disorders. Although the outcomes of many therapeutic programmes are still ambiguous and underdocumented, treatment of communication and motor disorders, as well as prevention of associated psychiatric problems, seems to be more effective when based on a coordinated multidisciplinary approach.
Deb S, Perera B, Krysta K, et al., 2022, The European guideline on the assessment and diagnosis of psychiatric disorders in adults with intellectual disabilities, The European Journal of Psychiatry, Vol: 36, Pages: 11-25, ISSN: 0213-6163
Background and objectivesIn most countries worldwide, general adult psychiatrists look after the mental health of adults with intellectual disabilities (ID) without appropriate specialist training in the field. It is, therefore, necessary to develop a practice guideline to help these clinicians to assess and diagnose psychiatric disorders in adults with ID.MethodsWe have developed an evidence and consensus-based practice guideline for the assessment and diagnosis of major functional psychiatric disorders in adults with ID. Several senior psychiatrists from different European countries formed a guideline development group who assessed the evidence gathered from a systematic literature search to produce the guideline.ResultsAdults with ID develop the same psychiatric disorders as their non-ID counterparts. The overall rate of major functional psychiatric disorders such as schizophrenia, depressive disorder, bipolar disorder, and anxiety disorders seems to be somewhere between 14.4-22.4%. However, if a wider definition of psychopathology and mental ill-health is considered including depressive and anxiety symptoms, behaviours of concern, and other neurodevelopmental disorders such as autism spectrum disorder the rate becomes much higher than that in the general population. The risk factors for psychiatric disorders seem similar in both the ID and the non-ID populations. However certain risk factors such as genetic burden, certain comorbidities, psychosocial adversities, and reduced coping capacity are more prevalent among adults with ID.ConclusionThis guideline describes how the main symptoms of major psychiatric disorders may manifest differently in adults with ID and provides recommendations as to how to address these issues in day-to-day clinical practice.
Bertelli MO, Deb SS, Munir K, et al., 2022, Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder, ISBN: 9783319957197
This textbook provides a state of the art of the knowledge on the prevalence, risk and etiological factors, clinical features, assessment procedures and tools, diagnostic criteria, treatment, and prognosis of the psychiatric disorders encountered in people with intellectual disability (ID) and low-functioning autism spectrum disorder (ASD). ID and ASD represent two meta-syndromic groups of several different conditions, each with particular cognitive and communication features. People with ID/ASD display an increased prevalence of a variety of psychiatric disorders, including psychotic disorders, mood disorders, anxiety and stress-related disorders, somatoform disorders, and obsessive-compulsive disorder, as well behavioral syndromes, personality disorders, and disorders due to psychoactive substance use. This book will enable readers to understand the specificities of psychiatric disorders in the context of ID/ASD. It explains clearly how diagnostic criteria and assessment procedures for psychiatric disorders that were created for the general population have to be modified for use with ID/ASD. Above all, it will enable clinicians to overcome difficulties in diagnosis and to deliver more effective care that meets the particular needs of patients with ID/ASD.
Deb S, Limbu B, Unwin G, et al., 2021, Short-term Psycho-Education for Caregivers To Reduce Over Medication of people with intellectual disabilities (SPECTROM): development and field testing, International Journal of Environmental Research and Public Health, Vol: 18, ISSN: 1660-4601
People with intellectual disabilities (PwID) are at a higher risk of developing challenging behaviours (CB). Despite the poor evidence for the effectiveness of medications in managing CB, they are used widely among PwID (50–63%). The aims of our study were to develop a training programme, SPECTROM for support staff to help reduce overmedication in PwID and carry out field testing of SPECTROM including a process evaluation. We developed SPECTROM using the Experience-based co-design method that included four focus groups and a one-day co-design event. Twenty trainees received SPECTROM training. We used the Management of Aggression and Violence Attitudes Scale-Revised-Intellectual Disabilities (MAVAS-R-ID) and the Psychotropic knowledge questionnaire. A semi-structured interview and a feasibility questionnaire were used for process evaluation. SPECTROM website contains 14 modules, resources, and face-to-face training. MAVAS-R-ID scores showed change in staff attitude to ‘medication management’ domain was statistically significant (p < 0.05). Psychotropic knowledge questionnaire showed statistically significant post-training improvement in correct responses (p < 0.05). Process evaluation data showed that SPECTROM was acceptable, applicable, practical, and relevant to staff practice, and helped to improve self-reflection, knowledge, and support to PwID. SPECTROM is a useful training that helps to change the support staff’s attitude toward CB and improve their knowledge of psychotropic medications.
Deb S, Limbu B, 2021, Randomised controlled trials of antidepressant and anti-anxiety medications for people with autism spectrum disorder: a systematic review and meta-analysis., British Journal of Psychiatry, Vol: 7, Pages: 1-15, ISSN: 0007-1250
Background Although used widely the current evidence for the efficacy of antidepressant and antianxiety medications for people with autism spectrum disorder (ASD) is limited and conflicting.Aims We have carried out a systematic review and meta-analysis of the RCTs that assessed the effectiveness of these medications in people with ASD.Method We have searched the following databases: Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, DARE, and ClinicalTrials.gov. Additionally, we have hand-searched 11 relevant journals. We used the Cochrane Risk of Bias and Jadad score to assess the quality of each included RCT. We have carried out a meta-analysis using a random-effects model.Results We have included 15 RCTs (13 on antidepressants and two on antianxiety medications) that included a total of 958 people with ASD. Data showed contradictory findings among the studies with larger studies mostly showing a non-significant difference in outcomes between the treatment and the placebo group. Meta-analysis of pooled Yale-Brown Obsessive Compulsive Scale and Clinical Global Impression Scale data from nine studies (60%) did not show any statistically significant intergroup difference on either of the outcome measures. The adverse effects reported were mild and, in most studies, their rates did not show any significant intergroup difference.Conclusions Given the methodological flaws in the most included studies and contradictory findings it is difficult to draw any definitive conclusion about the effectiveness of either antidepressant or antianxiety medications to treat either ASD core symptoms or associated behaviors. Robust large-scale RCTs are needed in the future to address this issue.
Limbu B, Unwin G, Deb SS, 2021, Comprehensive assessment of triggers for behaviours of concern scale (CATS): initial development, International Journal of Environmental Research and Public Health, Vol: 18, Pages: 1-33, ISSN: 1660-4601
Challenging behaviour displayed by people with intellectual disabilities (ID) can be difficult to manage if caregivers do not understand the reasons for the behaviour. Identifying the contextual variables/triggers for the behaviour is likely to help undertake a functional analysis leading to a person-centred positive behaviour support plan. Currently, a limited number of checklists are available for trigger assessment and none were developed using an interview with the family caregivers. This article describes the development and contents of the comprehensive assessment of triggers for behaviours of concern scale (CATS). CATS was developed in two stages. Stage 1 used a ‘bottom-up’ approach, in which caregivers of adults with ID who show aggressive behaviour were interviewed to identify the triggers for aggression. In stage two, using a ‘top-down’ approach, a comprehensive literature review was conducted to gather items from existing trigger checklists. Trigger items from both stages were combined and the duplicates were removed. The final list in CATS consists of 333 contextual triggers categorised under five main domains and 12 subdomains. CATS can be used by caregivers to identify triggers or antecedents of challenging behaviour. Further work is needed to test its psychometric properties, utility, and acceptability.
Deb S, Shankar R, 2021, Challenges to deprescribe psychotropics in people with intellectual disability: The medical view, Journal of Applied Research in Intellectual Disabilities, ISSN: 1360-2322
Deb SS, 2021, 16. Deb S., & Limbu B. (2021) SPECTROM-An online training programme to reduce the overmedication of people with intellectual disabilities. Journal of Intellectual Disability Research, 65(8), 691-692., Journal of Intellectual Disability Research
Deb S, 2021, Limbu B., Deb S. Unwin G., Rose J., Weaver T., Cooper V. and Fullerton M. (2021) The development and field testing of a support staff training programme, SPECTROM, to help reduce the overmedication of adults with intellectual disabilities. Royal College of Psychiatrists, Faculty of Psychiatry of Intellectual Disabilities, Spring Conference. London, UK., Royal College of Psychiatrists, Faculty of Psychiatry of Intellectual Disabilities, Spring Conference. London, UK.
Deb S, 2021, Limbu B., Deb S. Unwin G., Rose J., Weaver T., Cooper V. and Fullerton M. (2021) Short-term Psycho-Education for Carers To Reduce the Over Medication of people with intellectual disabilities (SPECTROM): development and field testing. 38th National Conference of The National Association for the Dually Diagnosed (NADD), Ohio, USA., 38th National Conference of The National Association for the Dually Diagnosed (NADD), Ohio, USA.
Deb S, 2021, Perera B., Korb L., Courtenay K., Shankar R., Collins G., Knight C., O’Regan D., Deb S., et al. (2021) Attention Deficit Hyperactivity Disorder in adults with intellectual disability. Royal College of Psychiatrists College Report CR230. RCPsych Publication, London, UK.
Deb S, Biswas A, Lovell M, et al., 2021, Stopping the over medication of people with intellectual disability, autism or both (STOMP) and supporting treatment and appropriate medication in paediatrics (STAMP), Stopping the overmedication of people with intellectual disability, autism or both (STOMP) and supporting treatment and appropriate medication in paediatrics (STAMP), Publisher: Royal College of Psychiatrists, PS 05/21
Brizard BA, Limbu B, Baeza-Velasco C, et al., 2021, Association between epilepsy and psychiatric disorders in adults with intellectual disabilities: systematic review and meta-analysis, BJPsych Open, Vol: 7, Pages: 1-21, ISSN: 2056-4724
BackgroundPsychiatric disorders, such as depression and anxiety, are commonly associated with epilepsy in the general population, but the relationship between psychiatric disorders and epilepsy among adults with intellectual disabilities is unclear.AimsTo conduct a systematic review and meta-analysis to assess whether epilepsy is associated with an increased rate of psychiatric disorders in adults with intellectual disabilities.MethodWe included literature published between 1985 and 2020 from four databases, and hand-searched six relevant journals. We assessed risk of bias by using SIGN 50 and the Cochrane risk of bias tool. Several meta-analyses were carried out.ResultsWe included 29 papers involving data on 9594 adults with intellectual disabilities, 3180 of whom had epilepsy and 6414 did not. Of the 11 controlled studies that compared the overall rate of psychiatric disorders between the epilepsy and non-epilepsy groups, seven did not show any significant inter-group difference. Meta-analysis was possible on pooled data from seven controlled studies, which did not show any significant inter-group difference in the overall rate of psychiatric disorders. The rates of psychotic disorders, depressive disorders and anxiety disorders were significantly higher in the non-epilepsy control groups compared with the epilepsy group, with effect sizes of 0.29, 0.47 and 0.58, respectively. Epilepsy-related factors did not show any definite association with psychiatric disorders.ConclusionsIt is difficult to pool data from such heterogeneous studies and draw any definitive conclusion because most studies lacked an appropriately matched control group, which will be required for future studies.
Deb S, Limbu B, Acharya R, et al., 2020, The effectiveness of parent training for children with autism spectrum disorders: a systematic review and meta-analyses, BMC Psychiatry, Vol: 20, ISSN: 1471-244X
BackgroundVarious parent training interventions have been shown to have some effect on the symptoms of children with autism. We carried out a systematic review and meta-analyses to assess effectiveness of parental training for children with autism on their symptoms and parental stress.MethodsFour electronic databases, CINAHL, EMBASE, MEDLINE and PsycINFO were searched until March 2020 for relevant literature. Two reviewers independently screened bibliographies using an eligibility checklist and extracted data using a structured proforma. We have also carried out meta-analyses when data were available for pooling.ResultsSeventeen papers from 15 studies were included for data analysis. Fifteen papers showed a positive treatment effect when compared with the control group, although not always significant. Meta-analysis based on pooled data from only two studies in each respective intervention, showed small to moderate treatment effects for three interventions, DIR/Floortime, Pivotal Response and Parent focused training respectively.ConclusionsAs in previous systematic reviews there was a mild to moderate treatment effects of three specific types of interventions respectively. However, it was difficult to draw any definitive conclusion about the effectiveness and generalisability of any intervention because of the wide variation in the interventions, control groups, outcome measures, small sample size, small number of studies in meta-analysis, overlap between the intervention and control procedures used in the included studies. There is an urgent need for experts in various international centres to jointly standardise a parent training intervention for children with autism and carry out a large scale RCT to assess its clinical and economic effectiveness.
Deb S, Limbu B, 2020, Association between epilepsy and problem (challenging) behaviour in adults with intellectual disabilities: a systematic review and meta-analysis, BJPsych Open, Vol: 6, Pages: 1-17, ISSN: 2056-4724
BackgroundThe exact relationship between aggression and epilepsy is a matter of ongoing debate. AimsIdentify whether there is an association between epilepsy and problem behaviour among adults with intellectual disabilities by carrying out a systematic review of published data.MethodWe searched for relevant articles using five relevant databases and hand searched six relevant journals, reviews and papers for cross referencing. Two authors have independently screened titles, abstracts and full articles using a standardised eligibility checklist. The data were extracted by two authors who also completed Cochrane risk of bias tool and SIGN-50 checklist. Several meta-analyses were carried out.ResultsThirty-four articles from 32 studies provided data on 14,168 adults with intellectual disabilities. Of the 19 controlled studies, 13 did not show any statistically significant intergroup difference in the rate of problem behaviour. A meta-analysis showed no statistically significant intergroup difference when data from 16 studies were amalgamated, but when data from nine studies were pooled after a sensitivity analysis, epilepsy group showed a significantly higher rate of overall problem behaviour (effect size: 0.16). Aggression and self-injurious behaviour both showed a statistically significant higher rate in the epilepsy group with a very small effect size (0.16 and 0.28 respectively). No significant intergroup difference was observed in the rate of stereotypy.ConclusionsThe included studies assessed only inter-ictal behaviour. However, problem behaviour may be manifested during pre-ictal, ictal and post-ictal phase which needs to be addressed by exploring factors leading to problem behaviours in adults with intellectual disabilities.
Deb S, Crawford M, Sharp D, et al., 2020, Risperidone versus placebo for aggression following traumatic brain injury: a feasibility randomised controlled trial, BMJ Open, Vol: 10, ISSN: 2044-6055
Objectives: To conduct a feasibility randomised controlled trial of risperidone for the treatment of aggression in adults with traumatic brain injury (TBI).Design: Multi-centre, parallel design, placebo controlled (1:1 ratio) double-blind feasibility trial with an embedded process evaluation. No statistical comparison was performed between the two study groups.Setting Four neuropsychiatric and neurology outpatient clinics in London and Kent, UK. Participants Our aim was to recruit 50 TBI patients over 18 months. Follow up participants at 12 weeks using a battery of assessment scales to measure changes in aggressive behaviour (MOAS-primary outcome, IRQ) as well as global functioning (GOS-E, CGI) and quality of life (EQ-5D-5L, SF-12), mental health (HADS) and medication adverse effects (UKU).Results: Six participants were randomised to the active arm of the trial and eight to the placebo arm over a 10-month period (28% of our target). Two participants withdrew because of adverse events. Twelve out of 14 (85.7%) patients completed a follow up assessment at 12 weeks. At follow up, the scores of all outcome measures improved in both groups. Placebo group showed numerically better score change according to the primary outcome MOAS. No severe adverse events were reported. The overall rate of adverse events remained low. Data from the process evaluation suggest that existence of specialised TBI Follow-up clinics, availability of a dedicated database of TBI patients’ clinical details, simple study procedures and regular support to participants would enhance recruitment and retention in the trial. Feedback from participants showed that once in the study, they did not find the trial procedure onerous.Conclusions: It was not feasible to conduct a successful randomised trial of risperidone versus placebo for post-TBI aggression using the methods we deployed in this study. It is not possible to draw any definitive conclusion about risperidone’s efficacy from such a s
Deb S, Nancarrow T, Limbu B, et al., 2020, UK psychiatrists' experience of withdrawal of antipsychotics prescribed for challenging behaviours in adults with intellectual disabilities and/or autism, BJPsych Open, Vol: 6, Pages: 1-7, ISSN: 2056-4724
BackgroundA high proportion of adults with intellectual disabilities are prescribed off-licence antipsychotics in the absence of a psychiatric illness. The National Health Service in England launched an initiative in 2016, ‘Stopping over-medication of people with a learning disability [intellectual disability], autism or both’ (STOMP), to address this major public health concern.AimsTo gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours.MethodAn online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225).ResultsHalf of the 88 respondents stated that they started withdrawing antipsychotics over 5 years ago and 52.3% stated that they are less likely to initiate an antipsychotic since the launch of STOMP. However, since then, 46.6% are prescribing other classes of psychotropic medication instead of antipsychotics for challenging behaviours, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11.4% reported deterioration in challenging behaviours in over 50% of patients on withdrawal and the same proportion (11.4%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid carers’ concern, lack of multi-agency and multidisciplinary input and unavailability of non-medical psychosocial intervention are key reported factors hampering the withdrawal attempt.ConclusionsThere is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.
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