Objectives: To examine the process and outcome of use of clozapine in patients with mental handicap, with particular reference to selection of patients, response to treatment, adverse effects and withdrawal from treatment.Methods: The case notes and medication charts of all patients commenced on clozapine between January 1991 and December 1994 were examined.Results: Seventeen patients had been commenced on clozapine, the majority in the mild and moderate range of handicap. Fifteen had ICD-9 diagnosis of schizophrenia and all were refractory to conventional neuroleptics. Improvement was marked in 47% and substantial in 76%, with a mean daily dose of 453.8(sd = 238.5)mg and a range of 200mg-900mg. Reduction of aggressive behaviour was an important indicator of improvement. Five patients were withdrawn but only one related to side effects. Four patients had a past history of epilepsy and six others either developed seizures or EEG changes on treatment.Conclusion: Clozapine use has been associated with considerable benefit in patients with mild and moderate handicap wh o have schizophrenia. In this population aggression responded well but a high prevalence of drug-induced epilepsy was evident.

In Ireland today it is considered that approximately 6.7% of the population have learning disabilities.' According to the National Intellectual Disability Database Report, 2 26,760 people are registered as being in receipt of, or in need of, a learning disability service (prevalence rate of 7.38/1000 total population). Many of these people have coexisting physical disabilities and psychiatric disorder, both of which increase in prevalence in proportion to the severity of the learning disability. Actual estimates of co-morbidity of learning disability and psychiatric illness have ranged across studies from 10% to 39%, 3 but all are significantly higher than the general population and the prevalence of behaviour disorders (which often reflect psychiatric disorder in this group) has been found to be even higher at 60.4%. 4 The World Health Organisation, 5 in its definition of learning disability, points to the importance of holistic approaches to understanding individual needs; however there is still a tendency to attribute much emotional distress experienced by an individual to the disability rather than to particular emotional needs or psychiatric disorder.Over the last 20 years many changes have taken place in the development of care and services for people with learning disabilities. The philosophies of normalisation 6 and inclusion have brought about a change in focus for these services, with more emphasis on individual characteristics and needs than disabilities, so that even people with severe problems are seen as having a right to be supported in community settings.Increasingly, people with mild and moderate learning disabilities now find themselves working and living within the community, where they benefit from the advantages of choice in many aspects of life but also have to endure the many stresses and disadvantages, including difficulties with access to mainstream services. It is within this changing context that the whole issue of psychotherapy provision for people with learning disabilities is beginning to be addressed. Psychological difficultiesThe development of a child with learning disabilities will be Therapeutic difficultiesTraditionally, people with learning disabilities were excluded from the 'talking therapies'.' 3 In the first instance, many emotional and mental health problems were not recognised as such, and when they were, low IQ was commonly used as an exclusion criterion for suitability for therapy. In practice, there are significant problems in adapting psychotherapeutic approaches to working with this patient group. These include a high frequency of sensory disabilities, communication problems, dependence on others to access therapy, and related to this, consent to engage. However, regarding the dynamic based treatments, an acknowledgement of the importance of the therapeutic relationship between therapist and patient has allowed a rethink of the capacity of people with learning disabilities to participate and benefit.' 4 ' 5 Similarly the cognitive based therapies require some adap...

Objectives: Much has been written about the costs and cost-effectiveness of community care for people with learning disabilities resettled from long stay hospital care. However, comparatively little has been published about the cost of hospital services relating to the preparatory process before eventual resettlement and the disengagement of formal, sustained input from hospital staff. This study describes and costs the input provided by a hospital based multi-disciplinary team into the resettlement of adults with learning disabilities from long stay wards in Muckamore Abbey Hospital in Northern Ireland between 1996 and 1999 (n = 71).Method: The study employs a retrospective survey design. Information about the nature and frequency of the input of each member of hospital multi-disciplinary team was collected for each former client. According to the level of professional resources expended during the resettlement process, each former client was then categorised into one of three categories. One case was then selected at random to represent each category. A summary of clinical information, a description of the resettlement process and an estimate of the cost of the process was provided for each case.Results: Approximately 55% of people resettled in the community during the study period did so with a modest degree of input from hospital staff. For 18% resettlement proved to be a demanding and prolonged process, requiring intensive input from hospital staff. Financial costs of the resettlement process ranged from approximately stg£1,500 to stg£8,000, with an average of stg£3,400 for each person.Conclusion: This study provides evidence of the input by hospital staff into the process of community resettlement of long stay hospital clients and the associated costs. These costs must be included in service budgets if quality care and appropriate service provision is to be maintained in resettlement practice.

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Nine offender patients, who are mentally handicapped and detained in a secure environment were included in a psychotherapy group, which met weekly for sixteen weeks. The patients demonstrated an ability t o interact within a group setting and to use the milieu in a therapeutic way. The therapists gained an insight into the dynamics of patient relationships and the subculture of life in a hospital.There was no evidence that running such a group in a secure unit undermined staff authority or caused any deterioration in other staff patient relationships. We would recommend group therapy be included in the range of treatments offered t o patients with a mental handicap, including those living in a secure setting.