A couple of months ago, we posted about a trial of group based cognitive therapy to help with anger management in people with learning disabilities. The study was interesting in that it showed the approach was effective in improving anger control and in decreasing supporter rated challenging behaviour.
What was also interesting about the trial however, was its design and approach. The authors designed the study in a way that enabled support staff in the day service to deliver the intervention as part of the ongoing service support that the participants received.
This is an approach described as ‘close to market’ by Richard Hastings in an editorial in the British Journal of Psychiatry last month.
State of the Evidence
As you know, the National Elf service is committed to identifying and sharing high quality evidence across its subject areas, which throws up challenges for all the elves, but there are particular ones in the field of learning disabilities, where there is a scarcity of what Hastings calls ‘knock-out trials’, the kind of evidence that enables changes in practice.
Interestingly, an analysis of the posts by the Learning Disabilities Elf in a twelve month period showed that only 13% of posts related to systematic reviews, compared to 48% of posts on the mental Elf site. Only 6% related to meta-analyses compared to 28% of Mental Elf posts.
This means that the vast majority of posts relate to non-systematic literature reviews, individual qualitative studies or posts about projects or information for people with disabilities and their families.
This suggests that there is a good deal of ‘catch-up’ to be done in the field of learning disabilities if practice is to be based on high quality evidence. Hastings points out that there is much general mental health evidence that can be adopted, although some trials use learning disability as a specific exclusion criterion. This approach also overlooks the clear differences that might need to be taken into account when considering the potential of certain therapies, for example in psychological therapies.
Hastings suggests that there is sufficient weight to the argument that there is a special case for the generation of learning disability specific evidence. However, he states that “Slow, incremental progress in the development of evidence is probably not a luxury that can be afforded in the field of intellectual disability. Rather, evidence is needed now.” He suggests an approach that is ‘closer to market’, as evidenced in the trial of Wilner et al above.
Such studies will address questions of immediate relevance to the mental health of people with learning disabilities and focus on working in real life settings in real time.
Close to Market
He points to two further trials that have taken this approach, one by Hassiotis et al which looked at the effectiveness and costs of specialist behaviour therapy teams which found this to be effective with the potential for cost savings, and the trial by Tyrer et al which looked at haloperidol, risperidone and placebo in the treatment challenging behaviour and found no important differences between the treatments so concluded that antipsychotic drugs should no longer be regarded as an acceptable routine treatment for aggressive challenging behaviour.
Hastings calls for more high-quality studies of this ‘close-to-market’ type, using typical service settings, and typical clinical staff and suggests that this may be the answer for the rapid generation of evidence in the field of learning disabilities to inform mental health interventions.
Running to catch up: rapid generation of evidence for interventions in learning disability services, Hastings R in British Journal of Psychiatry, 203, 4, 245-246