Angela Hassiotis UCL and Camden & Islington Foundation Trust Symposium 190: Mental health and borderline intellectual functioning: how should services respond? Findings from the UK Adult Psychiatric Morbidity Surveys Angela Hassiotis UCL and Camden & Islington Foundation Trust

Will cover Background Methods Results Conclusions

What is Borderline intellectual functioning (BIF)? IQ based definition (70-85) Included in DSM-IV but has since been omitted from recent revisions Not included in ICD 10 Not coded in International Classification of Functioning Likely to include 13% of population

Impact of BIF Persons with BIF may not be recognised as a special group for services but included in studies Overshadowed by other mental disorders, particularly psychosis or intellectual disability (ID) Neurodevelopmental deficits and increased psychiatric morbidity

Development and education “slow learners” impaired information processing (Vaney et al 2015) motor and executive function abnormalities (Baglio et al, 2014) Motor abnormalities, e.g. manual dexterity, balance (Vuijk et al, 2010) Impulse control problems (van der Meere et al, 2012) IQ range 77-81

Health comorbidities in children with BIF Psychological distress/low self-esteem (Karande et al, 2008) Inattention and impulsivity Lower engagement between parents and children with BIF Parents of BIF children see them as behaviourally disturbed (Valliant and Davis, 2000; Fenning et al, 2007) The Longitudinal Study of Australia Children showed over a fifth of all children with obesity also had BIF and a threefold rise in any mental condition (Emerson and Robertson, 2010) High rates of exposure to socioeconomic disadvantage (Emerson et al, 2010)

interventions Parent training programmes for challenging behaviour (7 out of 11 studies) Social competence training CBT 1 RCT of risperidone vs placebo (n=13)

Adults with BIF

APMS Programme of national surveys started in 1993 Carried out by the Office of National Statistics and commissioned by the DH or devolved governments in the UK Most recently the National Centre for Social Research has taken over (2007-2014) Examine a wide range of populations and disorders Adults living in private households; Residents of institutions providing care and support to people with mental health problems; Homeless adults; Adults with a psychotic disorder; Prisoners and young offenders; Young people in local authority care; Children and adolescents; Carers.

General design Standardised questionnaires Two-phase approach Domains examined reflect policy priorities and are added at each new survey Ethical review Inclusion of the National Adult Reading Test (prediction of verbal IQ)

What we know of adults with BIF (APMS 2000 & 2007) 20% have a common mental disorder 9.5% have severe alcohol dependence Appear to receive more psychiatric/other medications Majority of GP consultations are for physical problems More admissions for mental ill-health (Hassiotis et al 2008) Twice as likely report non-fatal self harm (Hassiotis et al, 2011) Less happy (Hassiotis et al, 2012) 2.7% have Autism Spectrum Disorder (vs 0.4% in vIQ>100) (Brugha et al, 2009) Lower IQ is associated with problem gambling (Rai et al, 2014)

IQ and psychosis reduced IQ may serve both as an outcome, or a causal factor in relation to psychotic disorders

BIF and Psychosis: analysis of associations using the Adult Psychiatric Morbidity Surveys Using the combined 2000 and 2007 surveys we investigated whether individuals with BIF have a higher prevalence of psychotic disorders are more likely to report specific types of psychotic symptoms (paranoia, mania, thought insertion, strange experiences and hallucinations) And To investigate whether anxiety and depression mediate or moderate the relationship between BIF and psychotic disorder.

Instruments Phase 1 of surveys Psychosis Screening Questionnaire (PSQ) Clinical Interview Schedule-Revised (CIS-R) Diagnostic Interview Schedule Existing survey methodology

Relationship between BIF, psychosis, sociodemographic and clinical variables   Odds Ratio (OR) P 95% Conf. Interval (CI) Lower Upper Unadjusted 1.89 0.03 1.08, 3.31 Adjusted for each moderator Age 2.23 0.01 1.25, 3.99 Sex 1.90 1.08, 3.33 Social Class (L) 1.48 0.20 0.81, 2.69 Ethnicity 1.71 0.07 0.96, 3.05 Cannabis Use 1.95 0.02 1.12, 3.41 Stimulant Use 1.91 1.09, 3.37 Psychedelic Use 1.11, 3.44 Adjusted for All Confounders 1.59 0.15 0.84, 2.99

Relationship between BIF and individual PSQ items   n % Odds Ratio (OR) P 95% Conf. Interval (CI) Hypomania 985 52.5 0.94 0.28 0.83, 1.05 Thought Insertion 156 8.3 1.00 0.99 0.81, 1.24 Persecution 408 21.8 1.17 0.03 1.01, 1.34 Strange experiences 188 10.0 1.31 0.01 1.08, 1.60 Hallucinations 131 7.0 1.93 0.00 1.53, 2.44

Mediators of the relationship between BIF and psychosis   Odds Ratio (OR) P 95% Conf. Interval (CI) Unadjusted 1.89 0.03 1.08, 3.31 Adjusted for Depression 1.15 0.73 0.52, 2.57 Adjusted for Anxiety 1.81 0.04 1.02, 3.20 Adjusted for both Depression and Anxiety 1.19 0.68 0.53, 2.65

Summary of findings Further confirmation of significant morbidity associated with BIF Findings on ethnicity defer from those of a similar investigation Potentially treatable common disorders such as depression appear to explain the relationship Social adversity appears to be an important factor in onset of psychosis and is further underlined by lower social class Common mental disorders and building resilience may need to be the focus of interventions in this group It is questionable whether this patient group is managed effectively within current mental health services

Future? Literature consistently suggests increased mental illhealth in adults with BIF Is the lack of inclusion in classification systems likely to increase psychological distress by underascertainment? Are patients with BIF managed effectively within existing mental health care models? How to achieve balance between preserving autonomy and protecting against exploitation?