SummaryBackgroundPsychological therapies are first-line interventions for depression, but existing provision is not accessible for many adults with intellectual disabilities. We investigated the clinical and cost-effectiveness of a behavioural activation intervention (BeatIt) for people with intellectual disabilities and depression. BeatIt was compared with a guided self-help intervention (StepUp).MethodsWe did a multicentre, single-blind, randomised, controlled trial with follow-up at 4 months and 12 months after randomisation. Participants aged 18 years or older, with mild to moderate intellectual disabilities and clinically significant depression were recruited from health and social care services in the UK. The primary outcome was the Glasgow Depression Scale for people with a Learning Disability (GDS-LD) score at 12 months. Analyses were done on an intention-to-treat basis. This trial is registered with ISCRTN, number ISRCTN09753005.FindingsBetween Aug 8, 2013, and Sept 1, 2015, 161 participants were randomly assigned (84 to BeatIt; 77 to StepUp); 141 (88%) participants completed the trial. No group differences were found in the effects of BeatIt and StepUp based on GDS-LD scores at 12 months (12·03 [SD 7·99] GDS-LD points for BeatIt vs 12·43 [SD 7·64] GDS-LD points for StepUp; mean difference 0·26 GDS-LD points [95% CI −2·18 to 2·70]; p=0·833). Within-group improvements in GDS-LD scores occurred in both groups at 12 months (BeatIt, mean change −4·2 GDS-LD points [95% CI −6·0 to −2·4], p<0·0001; StepUp, mean change −4·5 GDS-LD points [–6·2 to −2·7], p<0·0001), with large effect sizes (BeatIt, 0·590 [95% CI 0·337–0·844]; StepUp, 0·627 [0·380–0·873]). BeatIt was not cost-effective when compared with StepUp, although the economic analyses indicated substantial uncertainty. Treatment costs were only approximately 3·6–6·8% of participants' total support costs. No treatment-related or trial-related adverse events were reported.InterpretationThis study is, to our knowledge, the first large randomised controlled trial assessing individual psychological interventions for people with intellectual disabilities and mental health problems. These findings show that there is no evidence that BeatIt is more effective than StepUp; both are active and potentially effective interventions.FundingNational Institute for Health Research.

Violence and aggression in the ED can often be an overwhelming yet inevitable experience for staff. A strong organisational commitment to reducing violence and aggression is imperative.

Physical Restraint and the Therapeutic Relationship Medium secure psychiatric services in the UK are designed to fulfil a therapeutic function in addition to those of security and custodianship (Mason et al., 2009). The development of strong nurse-patient therapeutic relationships is seen as essential in developing an effective therapeutic milieu in such environments (Thomas, Shattell, & Martin, 2002). However, in addition to such a therapeutic role, nurses who work in secure settings also have to deal with security issues such as compulsory detention, forced treatment, and risk to others (Mason, Lovell, & Coyle, 2008). It has been questioned whether staff who work in such services can fulfill both security and therapeutic roles, or whether these roles are incompatible. Physical restraint activities may be used in a forensic environment as part of routine care, but concerns have been raised about how restraint fits with ethical practice (Mohr, 2010). In addition to being the one who employs the restraint techniques, it is also usually nursing staff who make the decision of whether the patient is restrained. The emotional effect of being involved in restraint or nurses being seen as being part of the system of detention may damage any staff / patient therapeutic alliance (Steele, 1993;. Conacher, 1993). The literature on the impact of physical restraint on the therapeutic relationship is limited. Research has mainly focused on nursing staff views of physical restraint. For example, Lee, Gray, Gournay, Wright, Parr and Sayer (2003) found that nurses reported that physical restraint was useful in regaining control after an incident, but expressed feelings of ambivalence and concern regarding the after-effects of the restraint. Bigwood and Crowe (2008 found that nurses felt a conflict between their therapeutic role and the milieu of control in the service. They expressed feeling better about physically restraining a patient if they were able to undertake the restraint in a therapeutic way and if they thought that all other options had been explored. Perkins, Prosser, Riley and Whittington (2012) found that nurses

The participants' accounts identify a number of practical points which services could implement to improve the experiences of service users.