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The Nilgiri tahr Nilgiritragus hylocrius is an Endangered species of mountain ungulate endemic to the Western Ghats of India, a biodiversity hotspot. Habitat fragmentation, hunting and a restricted range are the major threats to this species. Although several surveys have assessed the species' status, a population estimate based on a scientifically robust method is needed. We used the double-observer method to estimate the population of the Nilgiri tahr in the Anamalai Tiger Reserve, a protected area in the Western Ghats. We walked 257 km of transects across the Reserve, covering 36 grassland blocks (i.e. clusters of montane grasslands that were relatively separate from each other). We counted a minimum of 422 individuals in 28 groups, and estimated the tahr population in the study area to be 510 individuals (95% CI 300–858) in 35 groups. The male:female ratio was 0.71 and the young:female ratio was 0.56. Comparing our estimate with previous surveys suggests that the Nilgiri tahr population in Anamalai Tiger Reserve is stable. We found the double-observer survey method to be appropriate for population estimation and long-term monitoring of this species, and make recommendations for improved field protocols to facilitate the implementation of the method in the tropical mountains of the Western Ghats. Our findings suggest that the Reserve harbours 20–25% of the global population of the Nilgiri tahr, highlighting the area's importance for the conservation of this species. [ABSTRACT FROM AUTHOR]

The effects of fragmentation and overstorey tree diversity on tree regeneration were assessed in tropical rain forests of the Western Ghats, India. Ninety plots were sampled for saplings (1–5 cm diameter at breast height (dbh); 5×5-m plots) and overstorey trees (>9.55 cm dbh; 20×20-m plots) within two fragments (32 ha and 18 ha) and two continuous forests. We tested the hypotheses that fragmentation and expected seed-dispersal declines (1) reduce sapling densities and species richness of all species and old-growth species, and increase recruitment of early-successional species, (2) reduce the prevalence of dispersed recruits and (3) increase influence of local overstorey on sapling densities and richness. Continuous forests and fragments had similar sapling densities and species richness overall, but density and richness of old-growth species declined by 62% and 48%, respectively, in fragments. Fragments had 39% lower densities and 24% lower richness of immigrant saplings (presumed dispersed into sites as conspecific adults were absent nearby), and immigrant densities of old-growth bird-dispersed species declined by 79%. Sapling species richness (overall and old-growth) increased with overstorey species richness in fragments, but was unrelated to overstorey richness in continuous forests. Our results show that while forest fragments retain significant sapling diversity, losses of immigrant recruits and increased overstorey influence strengthen barriers to natural regeneration of old-growth tropical rain forests. [ABSTRACT FROM PUBLISHER]

Himalayan glaciers have been shrinking and losing mass rapidly since 1970s with an enhanced rate after 2000. The shrinkage is, however, quite heterogeneous and it is important to document individual glacier characteristics and their changes at the basin scale. We present an updated glacier inventory of the Upper Alaknanda Basin (UAB), Central Himalaya for the year 2020 and report area, debris cover and length changes for the periods 1994–2006 and 2006–2020 based on remote-sensing data. We identified 198 glaciers, comprising an area of 354.6 ± 8.5 km2, and classified them according to their size and morphology. The glaciers of the basin lost 4.2 ± 2.9% (0.16 ± 0.11% a−1) of their frontal area (from 368.6 ± 9.2 to 353.0 ± 5.3 km2) from 1994 to 2020. The average retreat rate was higher in the period 2006–2020 (13.3 ± 1.8 m a−1) in comparison to 1994–2006 (9.3 ± 1.9 m a−1). However, the area change rate was similar for the two periods (0.14 ± 0.27% a−1 for 1994–2006 and 0.16 ± 0.19% a−1 for 2006–2020). The debris-covered area has increased by 13.4 ± 4.4% from 1994 to 2020. A comparison with previous studies in UAB indicates consistent area loss of ~0.15% a−1 since the 1960s.

A supraglacial debris layer controls energy transfer to the ice surface and moderates ice ablation on debris-covered glaciers. Measurements of vertical temperature profiles within the debris enables the estimation of thermal diffusivities and sub-debris ablation rates. We have measured the debris-layer temperature profiles at 16 locations on Satopanth Glacier (central Himalaya) during the ablation seasons of 2016 and 2017. Debris temperature profile data are typically analysed using a finite-difference method, assuming that the debris layer is a homogeneous one-dimensional thermal conductor. We introduce three more methods for analysing such data that approximate the debris layer as either a single or a two-layered conductor. We analyse the performance of all four methods using synthetic experiments and by comparing the estimated ablation rates with in situ glaciological observations. Our analysis shows that the temperature measurements obtained at equispaced sensors and analysed with a two-layered model improve the accuracy of the estimated thermal diffusivity and sub-debris ablation rate. The accuracy of the ablation rate estimates is comparable to that of the in situ observations. We argue that measuring the temperature profile is a convenient and reliable method to estimate seasonal to sub-seasonal variations of ablation rates in the thickly debris-covered parts of glaciers.

Glaciological ablation is computed from point-scale data at a few ablation stakes that are usually regressed as a function of elevation and averaged over the area-elevation distribution of a glacier. This method is contingent on a tight control of elevation on local ablation. However, in debris-covered glaciers, systematic and random spatial variations of debris thickness modify the ablation rates. We propose and test a method to compute sub-debris ablation where stake data are interpolated as a function of debris-thickness alone and averaged over the debris-thickness distribution at different parts of the glacier. We apply this method on Satopanth Glacier located in Central Himalaya utilising ~1000 ablation measurements obtained from a network of up to 56 stakes during 2015–2017. The estimated mean sub-debris ablation ranges between 1.5±0.2 to 1.7±0.3 cm d−1. We show that the debris-thickness-dependent regression describes the spatial variability of the sub-debris ablation better than the elevation dependent regression. The uncertainties in ablation estimates due to the corresponding uncertainties in the measurement of ablation and debris-thickness distribution, and those due to interpolation procedures are estimated using Monte Carlo methods. Possible biases due to a finite number of stakes used are also investigated.

Avalanching is a prominent source of accumulation on glaciers that have high and steep valley-walls surrounding their accumulation zones. These glaciers are typically characterised by an extensive supraglacial debris cover and a low accumulation area ratio. Despite an abundance of such glaciers in the rugged landscapes of the High Himalaya, attempts to quantify the net avalanche contribution to mass balance and its long-term variation are almost missing. We first discuss diagnostic criteria to identify strongly avalanche-fed glaciers. Second, we develop an approximate method to quantify the magnitude of the avalanche accumulation exploiting its expected control on the dynamics of these glaciers. The procedure is based on a simplified flowline model description of the glacier concerned and utilises the known glaciological mass-balance, velocity and surface-elevation profiles of the glacier. We apply the method to three Himalayan glaciers and show that the data on the recent dynamics of these glaciers are consistent with a dominant contribution of avalanches to the total accumulation. As a control experiment, we also simulate another Himalayan glacier where no significant avalanche contribution is expected, and reproduce the recent changes in that glacier without any additional avalanche contribution.

We have compiled and analysed available records and data on the shrinkage of Satopanth (SPG) and Bhagirath Kharak (BKG) Glaciers, Uttarakhand, India, during the period 1936–2013. We estimate the mean retreat rates of the snouts of SPG and BKG for this period at 9.7±0.8m a–1 and 7.0±0.6m a–1 respectively. We have also revised the estimates of the area vacated during the period 1956–2013 to be 0.27 ± 0.05 km2 and 0.17 ± 0.04 km2 for SPG and BKG respectively, corresponding to front-averaged retreat rates of 5.7±0.6m a–1 and 6.0±0.9m a–1. The study revealed an average thinning of glacial ice in the lower ablation zone of SPG of 9 ± 11 m in the past 51 years. We observed that while the fronts of SPG and BKG depicted in the Survey of India topographic map published in 1962 are inconsistent with other available records, the elevation contours are consistent with them.

In November 2023, the Department of Health and Social Care published guidance, entitled 'Baroness Hollins' Final Report: My Heart Breaks - Solitary Confinement in Hospital Has no Therapeutic Benefit for People with a Learning Disability and Autistic People'. The report's commendable analysis of the problems and identification of the areas where practice should be improved is unfortunately not matched by many of its recommendations, which appear to be contrary to evidence-based approaches. The concerns are wide-ranging, from the use of the term 'solitary confinement' for current long-term segregation (LTS) and seclusion, to presumption that all LTS and seclusion is bad, to holding clinicians (mainly psychiatrists) responsible for events beyond their locus of control. Importantly, there is a no guidance on how to practically deliver the recommendations in an evidence-based manner. This Feature critically appraises the report, to provide a comprehensive summary outlining potential positive impacts, identifying specific concerns and reflecting on best practice going forward.

Background: Nearly 25% of people with intellectual disability (PwID) have epilepsy compared to 1% of the UK general population. PwID are commonly excluded from research, eventually affecting their care. Understanding seizures in PwID is particularly challenging because of reliance on subjective external observation and poor objective validation. Remote electroencephalography (EEG) monitoring could capture objective data, but particular challenges and implementation strategies for this population need to be understood., Aim: This co-production aimed to explore the accessibility and potential impact of a remote, long-term EEG tool (UnEEG 24/7 SubQ) for PwID and epilepsy., Method: We conducted six, 2-hour long workshops; three with people with mild intellectual disability and three with families/carers of people with moderate-profound intellectual disability. Brief presentations, easy read information and model demonstrations were used to explain the problem and device. A semi-structured guide developed by a communication specialist and art-based techniques facilitated discussion with PwID. For family/carers, active listening was employed. All conversations were recorded and transcribed. Artificial intelligence-based coding and thematic analysis (ATLAS.ti and ChatGPT) were synthesised with manual theming to generate insights., Results: Co-production included four PwID, five family members and seven care professionals. Three main themes were identified: (1) perceived benefits for improving seizure understanding, informing care and reducing family and carer responsibility to accurately identify seizures; (2) the device was feasible for some PwID but not all; and (3) appropriate person-centred communication is essential for all stakeholders to reduce concerns., Conclusions: The workshops identified key benefits and implementing barriers to SubQ in PwID.

Background: A quarter of People with Intellectual Disabilities (PwID) have epilepsy compared with 1% of the general population. Epilepsy in PwID is a bellwether for premature mortality, multimorbidity and polypharmacy. This group depends on their care provider to give relevant information for management, especially epilepsy. There is no research on care status relationship and clinical characteristics of PwID and epilepsy., Aim: Explore and compare the clinical characteristics of PwID with epilepsy across different care settings., Method: A retrospective multicentre cohort study across England and Wales collected information on seizure characteristics, intellectual disability severity, neurodevelopmental/biological/psychiatric comorbidities, medication including psychotropics/anti-seizure medication, and care status. Clinical characteristics were compared across different care settings, and those aged over and younger than 40 years., Results: Of 618 adult PwID across six centres (male:female = 61%:39%), 338 (55%) received professional care whereas 258 (42%) lived with family. Significant differences between the care groups existed in intellectual disability severity ( P = 0.01), autism presence ( P < 0.001), challenging behaviour ( P < 0.001) and comorbid physical conditions ( P = 0.008). The two groups did not vary in intellectual disability severity/genetic conditions/seizure type and frequency/psychiatric disorders. The professional care cohort experienced increased polypharmacy ( P < 0.001) and antipsychotic/psychotropic use ( P < 0.001/ P = 0.008).The over-40s cohort had lower autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) comorbidity ( P < 0.001/ P = 0.007), increased psychiatric comorbidity and challenging behaviour ( P < 0.05), physical multimorbidity ( P < 0.001), polypharmacy ( P < 0.001) and antipsychotic use ( P < 0.001) but reduced numbers of seizures ( P = 0.007)., Conclusion: PwID and epilepsy over 40 years in professional care have more complex clinical characteristics, increased polypharmacy and antipsychotic prescribing but fewer seizures.

Background: After the rapid implementation of digital health services during the COVID-19 pandemic, a paucity of research exists about the suitability of remote consulting in people with intellectual disabilities and their carers, particularly for neuropsychiatric reviews., Aim: This study examines when remote neuropsychiatric routine consulting is suitable for this population., Method: A survey was conducted of people with intellectual disabilities and their carers, examining their preference between face-to-face and video consultations for ongoing neuropsychiatric reviews within a rural countywide intellectual disability service in Cornwall, England (population: 538 000). The survey was sent to all adults with intellectual disabilities open to the service on 30 July 2022, closing on 30 September 2022. Participants were asked to provide responses on 11 items predesigned and co-produced between clinicians and experts by experience. The entire service caseload of people had White ethnicity, reflecting the ethnic demographics of Cornwall. Responses received without consent were excluded from the study dataset., Results: Of 271 eligible participants, 119 responses were received, 104 of whom consented to having their anonymised data used for research analysis. There were no significant differences between preferences and age and gender variables. There was no statistically significant difference regarding preference for the reintroduction of face-to-face appointments (52.0%) compared with video consultations (48.0%). Travel distance (>10 miles) to the clinical setting was important but did not outweigh benefits for those preferring a face-to-face appointment., Conclusions: This study offers insights into the factors that influence preferences about what type of neuropsychiatric appointment is most suitable for people with intellectual disabilities.

Background: Recovery colleges provide personalised educational mental health support for people who self-refer. The research evidence supporting them is growing, with key components and the positive experiences of attendees reported. However, the quantitative outcome evidence and impact on economic outcomes is limited., Aims: To evaluate the impact of attending a UK recovery college for students who receive a full educational intervention., Method: This is a pre- and post-intervention study, with predominantly quantitative methods. Participants recruited over an 18-month period (01.2020-07.2021) completed self-reported well-being (Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS)) and recovery (Process of Recovery (QPR)) surveys, and provided details and evidence of employment and educational status. Descriptive statistics for baseline data and Shapiro-Wilk, Wilcoxon signed-rank and paired t -tests were used to compare pre- and post-intervention scores, with Hedges' g -statistic as a measure of effect size. Medical records were reviewed and a brief qualitative assessment of changes reported by students was conducted., Results: Of 101 student research participants, 84 completed the intervention. Well-being (mean SWEMWBS scores 17.3 and 21.9; n = 80) and recovery (mean QPR scores 27.2 and 38.8; n = 75) improved significantly ( P < 0.001; Hedges' g of 1.08 and 1.03). The number of economically inactive students reduced from 53 (69%) to 19 (24.4%). No research participants were referred for specialist mental health support while students. 'Within-self' and 'practical' changes were described by students following the intervention., Conclusions: Findings detail the largest self-reported pre-post data-set for students attending a recovery college, and the first data detailing outcomes of remote delivery of a recovery college.

Background: Constipation is overrepresented in people with intellectual disabilities. Around 40% of people with intellectual disabilities who died prematurely were prescribed laxatives. A quarter of people with intellectual disabilities are said to be on laxatives. There are concerns that prescribing is not always effective and appropriate. There are currently no prescribing guidelines specific to this population., Aims: To develop guidelines to support clinicians with their decision-making when prescribing laxatives to people with intellectual disabilities., Method: A modified Delphi methodology, the RAND/UCLA Appropriateness Method, was used. Step 1 comprised development of a bespoke six-item, open-ended questionnaire from background literature and its external validation. Relevant stakeholders, including a range of clinical experts and experts by experience covering the full range of intellectual disability and constipation, were invited to participate in an expert panel. Panel members completed the questionnaire. Responses were divided into 'negative consensus' and 'positive consensus'. Members were then invited to two panel meetings, 2 weeks apart, held virtually over Microsoft Teams, to build consensus. The expert-by-experience group were included in a separate face-to-face meeting., Results: A total of 20 people (ten professional experts and ten experts by experience, of whom seven had intellectual disability) took part. There were five main areas of discussion to reach a consensus i.e. importance of diagnosis, the role of prescribing, practicalities of medication administration, importance of reviewing and monitoring, and communication., Conclusions: Laxative prescribing guidelines were developed by synthesising the knowledge of an expert panel including people with intellectual disabilities with the existing evidence base, to improve patient care.

Background: One-third to half of people with intellectual disabilities suffer from chronic constipation (defined as two or fewer bowel movements weekly or taking regular laxatives three or more times weekly), a cause of significant morbidity and premature mortality. Research on risk factors associated with constipation is limited., Aims: To enumerate risk factors associated with constipation in this population., Method: A questionnaire was developed on possible risk factors for constipation. The questionnaire was sent to carers of people with intellectual disabilities on the case-loads of four specialist intellectual disability services in England. Data analysis focused on descriptively summarising responses and comparing those reported with and without constipation., Results: Of the 181 people with intellectual disabilities whose carers returned the questionnaire, 42% reported chronic constipation. Constipation was significantly associated with more severe intellectual disability, dysphagia, cerebral palsy, poor mobility, polypharmacy including antipsychotics and antiseizure medication, and the need for greater toileting support. There were no associations with age or gender., Conclusions: People with intellectual disabilities may be more vulnerable to chronic constipation if they are more severely intellectually disabled. The associations of constipation with dysphagia, cerebral palsy, poor mobility and the need for greater toileting support suggests people with intellectual disabilities with significant physical disabilities are more at risk. People with the above disabilities need closer monitoring of their bowel health. Reducing medication to the minimum necessary may reduce the risk of constipation and is a modifiable risk factor that it is important to monitor. By screening patients using the constipation questionnaire, individualised bowel care plans could be implemented.

Background: The frequent prescribing of psychotropics and high prevalence of polypharmacy among older adults with intellectual disabilities require close monitoring., Aims: To describe change in prevalence, predictors and health outcomes of psychotropic use during the four waves (2009/2010, 2013/2014, 2016/2017, 2019/2020) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA)., Method: Eligible participants were adults (≥40 years) with intellectual disabilities who participated in all four waves of IDS-TILDA and who reported medication use for the entire period. Differences between groups were tested using Cochran's Q test for binary variables and the McNemar-Bowker test for variables with more than two categories. Generalised estimating equation models were used to assess associations between psychotropic use, participants' characteristics and health outcomes., Results: Across waves (433 participants) there were no significant differences in prevalence of psychotropic use (61.2-64.2%) and psychotropic polypharmacy (42.7-38.3%). Antipsychotics were the most used subgroup, without significant change in prevalence between waves (47.6-44.6%). A significant decrease was observed for anxiolytics (26.8-17.6%; P < 0.001) and hypnotics/sedatives (14.1-9.0%; P < 0.05). A significant increase was recorded for antidepressants (28.6-35.8%; P < 0.001) and mood-stabilising agents (11.5-14.6%; P < 0.05). Psychotropic polypharmacy (≥2 psychotropics) was significantly associated with moderate to total dependence in performing activities of daily living over the 10-year period (OR = 1.80, 95% CI 1.21-2.69; P < 0.05)., Conclusions: The study indicates an increase in usage of some classes of psychotropic, a reduction in others and no change in the relatively high rate of antipsychotic use over 10 years in a cohort of older adults with intellectual disabilities and consequent risk of psychotropic polypharmacy and medication-related harm.

Background: Brain in Hand (BIH) is a UK-based digital self-support system for managing anxiety and social functioning., Aims: To identify the impact of BIH on the psychological and social functioning of adults with autism., Method: Adults with diagnosed or suspected DSM-5 (level 1) autism, identified by seven NHS autism services in England and Wales, were recruited for a 12-week prospective mixed-methods cohort study. The primary quantitative outcome measures were the Health of the Nation Outcome Scales for People with Learning Disabilities (HONOS-LD) and the Hospital Anxiety and Depression Scale (HADS). Fisher's exact test explored sociodemographic associations. Paired t -test was utilised for pre-post analysis of overall effectiveness of BIH. Multivariable linear regression models, univariable pre-post analysis, Wilcoxon signed-rank test, logistic regression analysis, Bonferroni correction and normative analysis were used to give confidence in changes identified. A thematic analysis of semi-structured exist interviews following Braun and Clarke's six-step process of 10% of participants who completed the study was undertaken., Results: Sixty-six of 99 participants completed the study. There was significant reduction in mean HONOS-LD scores, with 0.65 s.d. decrease in those who used BIH for 12 weeks. Significant positive changes were identified in HONOS-LD subdomains of 'self-injurious behaviours', 'memory and orientation', 'communication problems in understanding', 'occupation and activities' and 'problems with relationship'. A significant reduction in the anxiety, but not depression, component of the HADS scores was identified. Thematic analysis showed high confidence in BIH., Conclusions: BIH improved anxiety and other clinical, social and functioning outcomes of adults with autism.

The draft Mental Health Bill, which amends the Mental Health Act 1983 for England and Wales, proposes protections for people with intellectual disability and/or autism (ID/A) to prevent detention in hospital in the absence of mental illness. This editorial critically appraises the positive impact and unintended consequences of the proposed reforms for people with ID/A.

Antiseizure medications (ASMs) are the second most widely prescribed psychotropic for people with intellectual disabilities in England. Multiple psychotropic prescribing is prevalent in almost half of people with intellectual disabilities on ASMs. This analysis identifies limited evidence of ASM benefit in challenging behaviour management and suggests improvements needed to inform clinical practice.

An area of interest presently is the lingering symptoms after COVID-19, i.e. post-COVID-19 syndrome (PCS). Specifics of diagnosis and management of PCS are emerging. However, vulnerable populations such as those with intellectual disabilities, who were disproportionately affected by the pandemic, risk being 'left behind' from these considerations.

Background: Psychological stress has an established bi-directional relationship with obesity. Mindfulness techniques reduce stress and improve eating behaviours, but their long-term impact remains untested. CALMPOD (Compassionate Approach to Living Mindfully for Prevention of Disease) is a psychoeducational mindfulness-based course evidenced to improve eating patterns across a 6-month period, possibly by reducing stress. However, no long-term evaluation of impact exists., Aims: This study retrospectively evaluates 2-year outcomes of CALMPOD on patient engagement, weight and metabolic markers., Method: All adults with a body mass index >35 kg/m 2 attending an UK obesity service during 2016-2020 were offered CALMPOD. Those who refused CALMPOD were offered standard lifestyle advice. Routine clinic data over 2 years, including age, gender, 6-monthly appointment attendance, weight, haemoglobin A1C and total cholesterol, were pooled and analysed to evaluate CALMPOD., Results: Of 289 patients, 163 participated in the CALMPOD course and 126 did not. No baseline demographic differences existed between the participating and non-participating groups. The CALMPOD group had improved attendance across all 6-monthly appointments compared with the non-CALMPOD group ( P < 0.05). Mean body weight reduction at 2 years was 5.6 kg (s.d. 11.2, P < 0.001) for the CALMPOD group compared with 3.9 kg (s.d. 10.5, P < 0.001) for the non-CALMPOD group. No differences in haemoglobin A1C and fasting serum total cholesterol were identified between the groups., Conclusions: The retrospective evaluation of CALMPOD suggests potential for mindfulness and compassion-based group educational techniques to improve longer-term patient and clinical outcomes. Prospective large-scale studies are needed to evaluate the impact of stress on obesity and the true impact of CALMPOD.

There is growing evidence for the use of pharmacogenomics in psychotropic prescribing. People with intellectual disabilities are disproportionately prescribed psychotropics and are at risk of polypharmacy. There is an urgent need for safeguards to prevent psychotropic overprescribing but it is equally crucial that this population is not left behind in such exciting initiatives. Understanding how genetic variations affect medications is a step towards personalised medicine. This may improve personalised prescribing for people with intellectual disabilities, especially given the high rate of psychiatric and behavioural problems in this population. Our editorial explores opportunities and challenges that pharmacogenomics offers for the challenges of polypharmacy and overprescribing of psychotropics in people with intellectual disabilities.

The prescribing of psychotropic medications for people with an intellectual disability has changed. In many locations across England, antidepressants have become the most widely prescribed psychotropic. In the context of the current NHS England STOMP programme to reduce inappropriate psychotropic prescribing for people with intellectual disability, there is an urgent need to understand whether this change reflects evidence-based use of the medications involved. There has been little analysis into the benefits or problems associated with the change and whether it is of concern. This paper offers a variety of possible explanations and opportunities to improve clinical practice and policy.

Background: People living with intellectual and developmental disabilities (IDD) have suffered disproportionately in health outcomes and general well-being during the COVID-19 pandemic. There is emerging evidence of increased psychological distress. Increased strain has also fallen on clinicians managing the psychological needs of people with IDD, in the context of learning new technologies, staff shortages, reduced services and paused training opportunities., Aims: To examine clinicians' experiences of patient care, clinical management and the impact of care delivery., Method: A mixed fixed-response and free-text survey comprising 28 questions covering four areas (responder demographics, clinical practice, changes to local services and clinician experiences) was developed, using the STROBE guidance. It was disseminated through an exponential snowballing technique to clinicians in seven high-income countries. Quantitative data were analysed and presented with Microsoft Excel. Qualitative data were coded and thematically analysed, and presented with in-text quotations., Results: There were 139 respondents, mostly senior physicians (71%). Two-thirds reported over 10 years working in the field. Quantitative findings include increased clinician stress (77%), referrals (53%), patient distress presentations (>70%), patient isolation (73%) and carer burden (89%), and reduced patient participation in daily activities (86%). A third reported increased psychotropic prescribing. Qualitative analysis outlined changes to clinical practice, particularly the emergence and impact of telehealth., Conclusions: In the countries surveyed, the pandemic has not only had a significant impact on people with IDD, but also their carers and clinicians. A proactive, holistic international response is needed in preparedness for future public health emergencies.

There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.

Background: There has been an increase in the development and application of serious games to support management of mental ill health, but their full impact is unclear., Aims: Evaluation of the current evidence of acceptability and effectiveness of serious games in improving mental health disorders., Method: A PRISMA-guided scoping review was conducted, using a predefined criteria and a relevant word combination on three databases: EMBASE, Medline and PsycINFO. Each included study was examined for game format, study type, number of participants, basic demographics, disorder targeted, recruitment, setting, control conditions, duration and follow-up, study attrition, primary outcomes and their results. Each study was given a Grading of Recommendations, Assessment, Development and Evaluations rating for quality., Results: Fourteen out of 513 studies met the inclusion criteria. The serious games focused on symptoms of anxiety (n = 4), attention-deficit hyperactivity disorder (n = 3), depression (n = 2), schizophrenia (n = 2), alcohol use disorder (n = 2) and bipolar disorder (n = 1). There were multiple significant outcomes favouring serious games across conditions covered in the review. Study quality varied, with studies rated high (n = 3), moderate (n = 6), low (n = 3) and very low (n = 2)., Conclusions: The available evidence suggests that serious games could be an effective format for an intervention to reduce mental health symptoms and improve outcomes of individuals. Better designed studies would further develop confidence in this area. This is a potential vehicle of change to deliver some of the much-needed psychiatric support to both economically developed and developing regions in a resource-utilitarian manner. Partnerships between the gaming industry, researchers and health services may benefit patients.

Background: Coronavirus disease 2019 (COVID-19) has had a disproportionate impact on people with intellectual disability (PwID). PwID are at higher risk of mental illness and receive psychotropic prescribing 'off licence' also, to manage distress behaviour. The lockdown and reduction of multidisciplinary face-to-face appointments had an impact on care delivery, the recourse possibly being psychotropic prescribing. It is imperative to comprehend the influence the pandemic had on psychotropic prescribing patterns to enable future planning., Aims: The aim was to understand the impact of the pandemic by comparing psychotropic prescribing patterns during the England lockdown with the prescribing patterns before lockdown in specialist urban and rural psychiatric services for PwID., Method: Data was collected from Cornwall (rural) and London (urban) intellectual disability services in England as a service evaluation project to rationalise psychotropic prescribing. PwID in both services open across January 2020 to January 2021 were included. Baseline patient demographics including age, gender, ethnicity, intellectual disability level and neurodevelopmental and psychological comorbidities were collected. Baseline psychotropic prescribing and subsequent % change for each psychotropic group for the two services was compared using Pearson's chi-square and z-statistic (two tailed) with significance taken at P < 0.05., Results: The two centres London (n = 113) and Cornwall (n = 97) were largely comparable but for baseline differences in terms of presence of severe mental illness (37 v. 86, P < 0.001), challenging behaviour (44 v. 57, P < 0.05) and attention-deficit hyperactivity disorder (37 v. 3, P < 0.001). There was an overall increase in psychotropic prescribing during lockdown in urban as compared with rural settings (11% v. 2%)., Conclusions: The pandemic caused an increase in psychotropic prescribing associated with lockdown severity and urban settings. Team structures could have played a role.

Background: Attention-deficit hyperactivity disorder (ADHD) is common among people with intellectual disability. Diagnosing ADHD in this clinically and cognitively complex and diverse group is difficult, given the overlapping psychiatric and behavioural presentations. Underdiagnoses and misdiagnoses leading to irrational polypharmacy and worse health and social outcomes are common. Diagnostic interviews exist, but are cumbersome and not in regular clinical use., Aims: We aimed to develop a screening tool to help identify people with intellectual disability and ADHD., Method: A prospective cross-sectional study, using STROBE guidance, invited all carers of people with intellectual disability aged 18-50 years open to the review of the psychiatric team in a single UK intellectual disability service (catchment population: 150 000). A ten-item questionnaire based on the DSM-V ADHD criteria was circulated. All respondents' baseline clinical characteristics were recorded, and the DIVA-5-ID was administered blinded to the individual questionnaire result. Fisher exact and multiple logistic regressions were conducted to identify relevant questionnaire items and the combinations that afforded best sensitivity and specificity for predicting ADHD., Results: Of 78 people invited, 39 responded (26 men, 13 women), of whom 30 had moderate-to-profound intellectual disability and 38 had associated comorbidities and on were medication, including 22 on psychotropics. Thirty-six screened positive for ADHD, and 24 were diagnosed (16 men, eight women). Analysis showed two positive responses on three specific questions to have 88% sensitivity and 87% specificity, and be the best predictor of ADHD., Conclusions: The three-question screening is an important development for identifying ADHD in people with intellectual disability. It needs larger-scale replication to generate generalisable results.

Background: A significant number of people with autism require in-patient psychiatric care. Although the requirement to adequately meet the needs of people with autism in these settings is enshrined in UK law and supported by national guidelines, little information is available on current practice., Aims: To describe characteristics of UK in-patient psychiatric settings admitting people with autism. Also to examine psychiatric units for their suitability, and the resultant impact on admission length and restrictive interventions., Method: Multiple-choice questions about in-patient settings and their ability to meet the needs of people with autism and the impact on their outcomes were developed as a cross-sectional study co-designed with a national autism charity. The survey was distributed nationally, using an exponential and non-discriminatory snowballing technique, to in-patient unit clinicians to provide a current practice snapshot., Results: Eighty responses were analysed after excluding duplications, from across the UK. Significant variation between units across all enquired parameters exist. Lack of autism-related training and skills across staff groups was identified, this becoming disproportionate when comparing intellectual disability units with general mental health units particularly regarding psychiatrists working in these units (psychiatrists: 94% specialist skills in intellectual disability units versus 6% specialist skills in general mental health units). In total, 28% of survey respondents felt people with autism are more likely to be subject to seclusion and 40% believed in-patients with autism are likely to end in segregation., Conclusions: There is no systematic approach to supporting people with autism who are admitted to in-patient psychiatric units. Significant concerns are highlighted of lack of professional training and skill sets resulting in variable clinical practice and care delivery underpinned by policy deficiency. This could account for the reported in-patient outcomes of longer stay and segregation experienced by people with autism.

Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations.

People with neurodevelopmental disorders often present with challenging behaviours and psychiatric illnesses. Diagnosis and treatment require patients, families and healthcare professionals to work closely together in partnership, acknowledging their respective areas of expertise. Good treatment outcomes should also be underpinned by robust research evidence. Key research priorities are highlighted.

Background: The approach taken to support individuals during the coronavirus disease 2019 (COVID-19) pandemic needs to take into account the requirements of people with intellectual disabilities and/or autism, who represent a major vulnerable group, with higher rates of co-occurring health conditions and a greater risk of dying prematurely. To date, little evidence on COVID-related concerns have been produced and no report has provided structured feedback from the point of view of people with intellectual disabilities and/or autism or of their family/carers., Aims: To provide systemised evidence-based information of the priority concerns for people with intellectual disabilities and/or autism regarding the COVID-19 pandemic., Method: Senior representatives of major UK-based professional and service-user representative organisations with a stake in the care of people with intellectual disabilities and/or autism were contacted to provide a list of concerns across three domains: 'mental health and challenging behaviour', 'physical health and epilepsy' and 'social circumstances and support'. The feedback was developed into statements on frequently reported priorities. These statements were then rated independently by expert clinicians. A video-conference meeting to reconcile outliers and to generate a consensus statement list was held., Results: Thirty-two organisations were contacted, of which 26 (81%) replied. From the respondent's data, 30 draft consensus statements were generated. Following expert clinician review, there was initially strong consensus for seven statements (23%), increasing to 27 statements (90%) following video conferencing., Conclusions: These recommendations highlight the expectations of people with intellectual disabilities and/or autism in the current pandemic. This could support policymakers and professionals' deliver and evidence person-centred care.

Background: Rapid spread of coronavirus disease 2019 (COVID-19) has affected people with intellectual disability disproportionately. Existing data does not provide enough information to understand factors associated with increased deaths in those with intellectual disability. Establishing who is at high risk is important in developing prevention strategies, given risk factors or comorbidities in people with intellectual disability may be different to those in the general population., Aims: To identify comorbidities, demographic and clinical factors of those individuals with intellectual disability who have died from COVID-19., Method: An observational descriptive case series looking at deaths because of COVID-19 in people with intellectual disability was conducted. Along with established risk factors observed in the general population, possible specific risk factors and comorbidities in people with intellectual disability for deaths related to COVID-19 were examined. Comparisons between mild and moderate-to-profound intellectual disability subcohorts were undertaken., Results: Data on 66 deaths in individuals with intellectual disability were analysed. This group was younger (mean age 64 years) compared with the age of death in the general population because of COVID-19. High rates of moderate-to-profound intellectual disability (n = 43), epilepsy (n = 29), mental illness (n = 29), dysphagia (n = 23), Down syndrome (n = 20) and dementia (n = 15) were observed., Conclusions: This is the first study exploring associations between possible risk factors and comorbidities found in COVID-19 deaths in people with intellectual disability. Our data provides insight into possible factors for deaths in people with intellectual disability. Some of the factors varied between the mild and moderate-to-profound intellectual disability groups. This highlights an urgent need for further systemic inquiry and study of the possible cumulative impact of these factors and comorbidities given the possibility of COVID-19 resurgence.

Background: A 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., Aims: To gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours., Method: An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225)., Results: Half 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., Conclusions: There is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.

Background: There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects., Aims: To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms., Method: Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert., Results: Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned., Conclusions: Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines.

Background: Public health strategies have focused largely on physical health. However, there is increasing recognition that raising mental health awareness and tackling stigma is crucial to reduce disease burden. National campaigns have had some success but tackling issues locally is particularly important., Aims: To assess the public's awareness and perception of the monthly BBC Cornwall mental health phone-in programmes that have run for 8.5 years in Cornwall, UK (population 530 000)., Method: A consultation, review and feedback process involving a multiagency forum of mental and public health professionals, people with lived experience and local National Health Service trust's media team was used to develop a brief questionnaire. This was offered to all attendees at two local pharmacies covering populations of 27 000 over a 2-week period., Results: In total, 14% (95% CI 11.9-16.5) were aware of the radio show, 11% (95% CI 9.0-13.1) have listened and the majority (76%) of those who listened did so more than once. The estimated reach is 70 000 people in the local population, of whom approximately 60 000 listen regularly. The show is highly valued among respondents with modal and median scores of 4 out of 5., Conclusions: Local radio is a successful, cost-effective and impactful way to reach a significant proportion of the population and likely to raise awareness, reduce stigma and be well received. The format has been adopted in other regions thus demonstrating easy transferability. It could form an essential part of a public health strategy to improve a population's mental well-being., Declaration of Interest: W.H. received support from the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula UK. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. L.R. and D.S. were involved in delivering the programmes but had no role in their evaluation.

Mental health services in the UK National Health Service have evolved to include primary-care generalist, secondary-care generalist and secondary-care specialist services. We argue that there continues to be an important role for the secondary-care generalists as they minimise interfaces, can live with diagnostic uncertainty and support continuity of care. The lack of commissioning and clinical boundaries in secondary-care generalist services can undermine their feasibility, leading to difficulties recruiting and retaining staff. There is a risk of a polo-mint service, where the specialist services on the edge are well resourced, but the secondary-care generalist services taking the greatest burden struggle to recruit and retain clinicians. We need to establish equity in resources and expectations between generalist and specialist mental health services.Declaration of interestNone.

Background: Community mental health services in the UK have struggled to measure the clinical effectiveness of their services.AimsTo measure clinical outcomes for different diagnostic clusters., Method: Clinicians measure the clinical status of patients by the Health of the Nation Outcome Scales (HoNOS), and HoNOS scores should be recorded annually after treatment. Clinical outcomes were measured by changes in HoNOS for diagnostic clusters., Results: In two time periods (2014 and 2016), the health of patients with mild to moderate common mental disorders deteriorated after intervention. Patients with severe common mental disorders and psychoses improved in their clinical status., Conclusions: British community mental health teams may be effective in improving the clinical status of people with severe mental illness, but may have a negative effect on people with mild to moderate illnesses. These teams need to focus on the severely mentally ill and build on this demonstrable effectiveness.Declaration of interestNone.

Objective: This study aimed to compare the success rate of type I tympanoplasty in active (wet) and inactive (dry) mucosal chronic otitis media., Methods: A prospective study was performed of 35 patients each with dry ear and wet ear undergoing type I tympanoplasty in the Otolaryngology Department, Postgraduate Institute of Medical Education and Research, India. All patients underwent type I tympanoplasty between January 2010 and June 2011 by the post-auricular approach. Samples of the remnant tympanic membrane were sent for histopathological examination., Results: After a minimum follow up of one year, the success rate was 88.6 per cent for dry ears and 80 per cent for wet ears. Neither the type (p = 0.526) nor the presence (p = 0.324) of discharge influenced the success rate. Histopathological examination of the tympanic membrane margins was performed for 46 patients: of these, 19 showed evidence of vascularity and 27 did not. There was no significant difference in success rate between groups (p = 0.115)., Conclusion: The success rate was not influenced by the presence of ear discharge at the time of surgery, and tympanic membrane vascularity did not influence graft uptake.