There is little and con icting evidence on the prevalence of alcohol misuse and treatment available for people with Intellectual Disabilities (also referred as Learning Disabilities). As is similar to other vulnerable populations, adults with ID have increasingly lived more independently in the community following the closure of long-stay hospitals. This has increased their exposure to environmental stressors and substance and alcohol misuse, negatively impacting on their functioning, relationships, physical and mental health, and safety. Traumatic Brain Injury (TBI) is the most common cause of disability in younger adults. Yet the community care for patients with TBI varies hugely in the UK. There is a well-established link between TBI and alcohol misuse, with both TBI leading to increased levels of alcohol misuse and alcohol misuse contributing to risk of TBIs. The effects of neuronal damage have been shown to increase after TBI accompanied by alcohol intoxication.This presentation is based on the experience gained from the rst in the UK feasibility study on this topic, and draws from the experience of setting up and running the first ever pilot of a combined TBI and alcohol brief intervention service in London.

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ALCOHOL MISUSE IN SPECIAL POPULATIONS;
People with Intellectual Disabilities and people
with Traumatic Brain Injury
Christos Kouimtsidis, FRCPsych, MSc, PhD
Consultant Psychiatrist in Addictions, Surrey & Borders Partnership NHS Foundation Trust
Chair of Mental Health Clinical Academic Group, Surrey Health Partners
Honorary Clinical Senior Lecturer Imperial College London

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Conflict
 Executive Director of
 Private Practice at
The London Psychiatry Centre

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Why special populations
 Magnitude of the problem
 Special risks
 Special barriers to access treatment
 People
 Services
 Treatment might require modifications
 Treatment content
 Staff skills

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People with Intellectual Disabilities
IQ<70

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Why People with Intellectual Disabilities?
 Now live in the community
 Are more likely to be exposed to substances and to consume them
 Are more vulnerable to adverse effect

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Special barriers to access treatment
 History of Paternalism & Restricted Choice
 Extent of problem drinking among people with ID poorly understood and not
addressed
Before when I was in supported care,
the carer said “no, that’s not allowed,
we’re not allowed to come with you, if
you’re having an alcoholic drink”. And
that stopped me, stopped my freedom
of going out.

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Magnitude of the problem
 Any substance misuse: 0.5% to 2.5% (McGillicuddy & Blane, 1999).
 Alcohol misuse by 50% of adults with ID who are
drinkers (Westermeyer et al, 1996)
 Alcohol 17.8% (men), 15.2% (women) (Adult Psychiatric Morbidity
Survey: England, 2014)
 Alcohol in ID NHS service: 22.5% (Pezzoni, Kouimtsidis, 2015).
 Approximately 5% of youths in D&A services have a
degree of ID (Barrett & Paschos, 2006)

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Why such diversity?

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Special risks
 Screening tools used
 People with ID
may have reduced verbal communication skills (Burnip, 2002),
may be more suggestible (Everington & Fuller, 1999).
may try to mask their difficulties in understanding and
communication (Hassiotis at al, 2012).
 Barriers associated with care providers

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Screening tools need to be modified
Need to be administered by trained personnel
Carers support is crucial

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Treatment modifications

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Clinical trials

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ID psychosocial interventions
People with LD have cognitive deficits that impair
their ability to learn or generalise new learning and
therefore may require interventions to last longer,
to include maintenance sessions and to be
supported to seek help and attend appointments.

14. A feasibility study of a psychological intervention to address alcohol misuse for people
with mild to moderate learning disabilities living in the community (EBI-LD)
This presentation presents independent research funded by the National Institute for Health Research (NIHR)
under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-1111-26022).
The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the
Department of Health.
Team:
Chief Investigator: Dr Christos Kouimtsidis
Prof Angela Hassiotis, University College London
Dr Katrina Scior, Reader in Psychology, UCL
Dr Gianluca Baio, Reader in Medical Statistics, UCL
Ms Rachael Hunter, Senior Research Associate, Health Economics, UCL
Dr Vittoria Pezzoni, Consultant Psychiatrist HPFT
Dr Eileen McNamara, Consultant Psychiatrist HPFT

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EBI-LD
 A feasibility study (RCT, economic evaluation & qualitative
study)
 Funded by NIHR (RfPB)
 30 months
 Collaboration between 2 NHS trusts & UCL

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Participants
Adults
Mild to moderate ID
Known to ID professionals as possibly having an alcohol problem
Screening
 Full Scale IQ <70 (based on WASI or previous results)
 Alcohol Use Disorder Identification Test (AUDIT) 8-20
 Participant and carer recruited in pairs

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Feasibility study in England
RCT: EBI versus TAU
30 participants (15 each arm)
5 weekly, 40 mins sessions
+ 60 mins at week 8
Assessments: Baseline, 2/12 and 3/12

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Intervention
 Delivered by trained therapist within ID services
 Combination of Motivational Enhancement Therapy (MET-UKATT) & coping
skills training (UK-CBT)
Motivational assessment
Link amount & problems
Coping skills
Healthy life style

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Qualitative study
 7 participants from intervention arm (6 M), aged 39-70 years; 5 completed all
sessions, 1 declined treatment and 1 attended four sessions.
 Identified themes: being part of the research project, having therapy
sessions, impact of therapy on drinking, reasons of dropping out from therapy.
 6 carers (4 paid carers, and 2 family carers) and 1 health professional.

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Lessons learned for future RCT
 Involvement of service users, family and paid carers in the design, and
execution of the research may increase understanding of the problem.
 Induction of researchers to aid recall in the participants
 A carer rated primary/secondary measure of the outcome of interest could
provide an additional perspective.
 Health and social care professionals’ buy-in of the study could augment their
support in identifying potential participants.

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EBI-LD publications
 Kouimtsidis C, Hassiotis A, Scior K, Hunter R, Baio G, Pezzoni V. 2015. A feasibility study of a
psychological intervention to address alcohol misuse for people with mild to moderate learning
disabilities living in the community (EBI-LD); study protocol for a randomized controlled trial.
Trials DOI: 10.1186/s13063-015-0629-x
 Kouimtsidis C, Bosco A, Scior K, Baio G, Hunter R, Pezzoni V, Mcnamara E, Hassiotis A. 2017. A
feasibility randomised controlled trial of extended brief intervention for alcohol misuse in
adults with mild to moderate intellectual disabilities living in the community. TRIALS,
12;18(1):216. DOI: 10.1186/s13063-017-1953-0
 Kouimtsidis C, Scior K, Baio G, Hunter R, Pezzoni V, Hassiotis A. 2017. Development of a manual
for Extended Brief Intervention for alcohol misuse for adults with mild to moderate intellectual
disabilities living in the community. Journal of Applied Research in Intellectual Disabilities. (DOI:
10.1111/jar.12409

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Kouimtsidis C, Scior K, Hassiotis A. A Manual for Extended Brief Intervention for Alcohol Misuse by People
with Learning Disabilities; http://www.sabp.nhs.uk/research/news-and-events/alcohol-misuse-pld

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People with Traumatic Brain Injury

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Magnitude of the problem

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Special risks for people with TBI
 43-68% of mild TBI have normal MRI
 Primary BI not adequate to explain subsequent deterioration
 Frontal lobe damage is the most common problem
1/3 of people with post-concussion syndrome (headaches, dizziness,
concentration difficulties, low mood) difficulties persist:
memory loss occurs in up to 80%
impaired attention, judgment, reduced processing speed
depression, anxiety disorders; 2-3x ↑ suicide rate
‘organic personality disorder’; disinhibition, aggression, impulsiveness, lack of
initiative, inappropriateness, poor social judgment

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Special barriers to access treatment

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Link between AUD and TBI

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AUD pre TBI
43-66% of TBI have prior alcohol abuse/dependence
38-53% of alcohol dependents have TBI history
Consequences
People with AUD ↑ risk of TBI 60% in any year & ↑risk multiple TBIs
TBI compromises the AUD treatment; ↑ risk of disengagement

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Intoxication at the time of TBI
35-50% TBI incidents involve alcohol intoxication
From those
75% intoxicated when TBI have preinjury AUD
Consequences
more severe TBI, medical complications, ↑ neuronal damage
•3x ↑ ITU days
•2.5x ↑ benzodiazepines
•2x ↑ opioids

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AUD post TBI

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Treatment challenges
 No evidence-based algorithm for treatment
 Cognitive barriers
↓ Attention, judgment, insight, language
↓ Sort term memory, behavioural control
 Interpersonal barriers
 System barriers
 Inpatient AUD programs may exclude TBI
 Physical disabilities, antidepressants, analgesics

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Summary
 Magnitude of the problem
 Special risks
 Special barriers to access treatment
 Treatment might require modifications

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