Referral trends of people with intellectual disabilities and psychiatric disorders

Prevalence of co-occurring psychiatric disorders in adults and adolescents with intellectual disability: A systematic review and meta-analysis

BACKGROUND

Subjects with intellectual disability (ID) are vulnerable to experience psychiatric disorders. The present authors performed a systematic review and meta-analysis to estimate the prevalence of co-occurring psychiatric disorders, excluding co-occurring autism spectrum disorders, in subjects with intellectual disability.

METHOD

The present authors performed a random-effects meta-analysis of the prevalence of psychiatric disorders in adults and adolescents with intellectual disability.

RESULTS

Twenty-two studies were included. The pooled prevalence of any co-occurring psychiatric disorders in intellectual disability was 33.6% (95% CI: 25.2%-43.1%) with high heterogeneity but no publication bias. Prevalence was lower in population-based studies, in studies that used ICD criteria for the psychopathology and in studies with low risk of bias. The prevalence was higher in mild, moderate and severe intellectual disability than in profound intellectual disability.

CONCLUSIONS

Psychiatric disorders are common in subjects with intellectual disability, and the present authors found that clinical and methodological moderators affect the pooled prevalence.

Referral trends in mental health services for adults with intellectual disability and autism spectrum disorders

Researchers have paid increasing attention to mental health issues in adults with autism spectrum disorders (ASDs) over the last decades. However, little is known about how rates of clinical referrals, types of mental health diagnoses and treatment in adults with ASDs and intellectual disability have changed. We examined patterns of change in referral trends to specialist mental health services in south London from 1983 to 2000 ( N = 137). The majority of the cases (58.4%) did not have a diagnosable psychiatric disorder. Schizophrenia was the most frequent psychiatric diagnosis followed by depression, adjustment reaction and anxiety. There was a significant change in the rate of referrals, an increase in the diagnosable psychiatric disorders over time and a significant reduction of medication at time of referral. There were no significant changes in the use of other therapeutic interventions. The proportion of participants living independently increased. Implications for services and future research are discussed.

Disparities in Substance Abuse Treatment Utilization Among Women with Intellectual Disability

Despite concerns about health disparities among women with intellectual disabilities, little is known about substance abuse treatment access in this population. Using standardized performance measures, treatment initiation and engagement were examined retrospectively for women aged 18 to 64 (N = 3,752), men with (N = 5,732) and women without intellectual disability (N = 493,446). Logistic regression models of utilization were conducted. Women in the sample were less likely than men in the sample or women without intellectual disability to utilize treatment, suggesting both gender-related and disability-related barriers. Policy and practice implications for improving the health and welfare of women with intellectual disabilities are discussed.

Psychiatric disorders in adolescents and young adults with Down syndrome and other intellectual disabilities

BACKGROUND

Relative to other aspects of Down syndrome, remarkably little is known about the psychiatric problems experienced by youth and young adults with this syndrome and if these problems differ from others with intellectual disabilities. Yet adolescence and young adulthood are particularly vulnerable time periods, as they involve multiple life transitions in educational, medical, and other service systems.

METHODS

This study compared the psychiatric diagnoses of 49 adolescent and young adult patients with Down syndrome to 70 patients with other intellectual disabilities (IDs). The groups were similar in age, gender, and level of intellectual impairment. The 119 participants, aged 13 to 29 years (M = 21) were evaluated in one of two specialized psychiatric clinics.

RESULTS

In contrast to previous literature, those with Down syndrome versus other IDs had significantly higher rates of psychosis NOS or depression with psychotic features (43% versus 13%). Unlike the ID group, psychosis was predominantly seen in females with Down syndrome. Marked motoric slowing in performing routine daily activities or in expressive language was manifested in 17% of patients with Down syndrome. No group differences were found in anxiety or depressive disorders, and the ID group had significantly higher rates of bipolar and impulse control disorders.

CONCLUSIONS

These preliminary observations warrant further studies on genetic, neurological, and psychosocial factors that place some young people with Down syndrome or other IDs at high risk for severe psychiatric illness.

Experiences of mental health services by people with intellectual disabilities from different ethnic groups: a Delphi consultation

BACKGROUND

Patient experience of those accessing mental health services has been found to be different between ethnic groups. Although the needs of people with intellectual disabilities (ID) from different ethnic communities are being increasingly recognised, little has been published about their experiences of mental health services. The aim of this study was to establish whether there are any differences in the experiences of people with ID and mental health problems from two ethnic communities in South London.

METHOD

A two-round Delphi process was utilised. White British and Black or Black British service users from a specialist community-based mental health service for adults with ID completed a specially compiled questionnaire. Statements on participants' experiences, including satisfaction with care, staff members' attitudes, cultural awareness and level of support, were rated using a Likert scale.

RESULTS

Twenty-four out of 32 participants (75%) completed both rounds of the Delphi consultation. Consensus (≥80% agreement with the group median) was reached for 20 items in the White group and five items in the Black group. All responses that reached consensus were positive about the services that were being received. The Black group were less positive about a range of their experiences, including the use of medication.

CONCLUSIONS

People with ID from two ethnic groups were able to successfully complete a Delphi consultation regarding their experiences of mental health services. Broad consensus on positive experiences of services was reached in the White group but not for the Black participants.

Ethnic factors in mental health service utilisation among people with intellectual disability in high-income countries: systematic review

BACKGROUND

An emerging literature suggests that ethnic and cultural factors influence service utilisation among people with intellectual disability (ID), but this has not previously been reviewed.

AIMS

To investigate possible ethnic variation in uptake of mental health services in children, adolescents and adults with ID in high-income countries.

METHOD

A systematic review using main databases of studies that consider ethnic influences on mental health utilisation of people with ID. Methodological quality of studies was assessed.

RESULTS

Nine studies that reached selection criteria were identified. Six studies that compared two or more ethnic groups found a variation in levels of mental health service utilisation. The most consistent finding was that South Asian children, adolescents and adults with ID in the UK had lower use of mental health services than White British comparison groups.

CONCLUSION

Ethnic influences on mental health service utilisation were identified. Understanding their significance and potential negative consequences requires further investigation.

Nurses' role in caring for people with a comorbidity of mental illness and intellectual disability: a literature review

This article examines literature on the role of the nurse caring for people with a dual disability (DD) of intellectual disability and mental illness. A search of the literature between 2000 and 2010 resulted in a total of 21 articles that met the inclusion criteria. Seven key categories of the role of the nurse were identified: (i) advocacy/health promotion (including working with family); (ii) assessment/case management; (iii) behavioural interventions; (iv) communication; (v) leadership and the nurse's role within the multidisciplinary team; (vi) functions regarding medication administration; and (vii) safety/risk management. There is a paucity of research about the role of nurses working with people with DD, although a number of opinion-based articles exist. This article identifies a need for the role of the nurse working in DD to be more clearly articulated and for the development of evidence to guide best practice.

Demographic and clinical characteristics of people with intellectual disabilities with and without substance abuse disorders in a Medicaid population

Little is known about the demographic and clinical characteristics of people with intellectual disabilities and substance abuse problems. Drawing on health care billing claims for people with Medicaid coverage aged 12-99 years, the characteristics of people with intellectual disability and a history of substance abuse (N=9,484) were explored and compared with people with intellectual disability but without substance abuse. Age- and/or gender-adjusted odds ratios were derived from logistic regression analyses to consider differences in demographic and clinical diagnoses. People with intellectual disability and substance abuse constituted 2.6% of all people with intellectual disability, most of whom had a diagnosis of mild or moderate intellectual disability. People with intellectual disability and substance abuse problems were, on average, 2 years older than the comparison group and less likely to be White. The sample was more likely than the comparison group to have serious mental illness or depression and substance abuse-related disorders were not prevalent. These data provide a comparison point for existing studies of mental health diagnoses as well as new information about substance abuse disorders. Implications relate to the identification of substance abuse among people with intellectual disabilities as well as the establishment of demographic and clinical correlates.

Medicaid-covered alcohol and drug treatment use among people with intellectual disabilities: evidence of disparities

For some, community inclusion facilitates access to alcohol and drugs and, therefore, the potential for developing substance abuse disorders. However, little is known about substance abuse treatment use among people with intellectual disabilities. Using standardized performance measures, substance abuse treatment utilization was examined for Medicaid-covered people with intellectual disabilities and substance abuse (N=9,484) versus people without intellectual disabilities (N=915,070). The sociobehavioral model of healthcare use guides multivariate logistic regression analyses of substance abuse treatment utilization patterns, revealing disability-related disparities. Factors associated with utilization included being non-White, living in a nonurban area, having a serious mental illness, and living in a state with a generous Medicaid plan for substance abuse treatment. Implications relate to health policy, service delivery patterns, and the need for cross-system collaboration in the use of integrated treatment approaches.

Personality disorders in offenders with intellectual disability: a comparison of clinical, forensic and outcome variables and implications for service provision

AIM

To establish any differences between patients with and without a diagnosis of personality disorders, being treated in a secure inpatient service for offenders with intellectual disability (ID) in the UK.

METHOD

A cohort study involving a selected population of people with ID and offending behaviours. Results The study included a total of 138 patients, treated over a 6 year period - 77 with a dissocial or emotionally unstable personality disorder and 61 without. Women were more likely to be in the personality disorder group. Both groups had high prevalence of abuse with no significant differences. Depressive disorders and substance abuse were more common in the personality disorder group, while epilepsy and autistic spectrum disorders were more common in the non-personality disorder group. Rather than differences, what was more striking was the rate and range of these comorbidities across both groups. Although past histories of violence and institutional aggression were no different, compulsory detention under criminal sections and restriction orders were more common in the personality disorder group. There were no differences in treatment outcomes.

CONCLUSIONS

Although about half of patients detained in secure units for offenders with ID have a personality disorder, there were more similarities than differences between this group and the rest. While good treatment outcomes supported the case for specialised secure treatment units for people with ID, the case for establishing a more specialised ID-personality disorder unit was less convincing. There is also a need to explore whether there are alternative diagnostic models that can delineate better the group with personality difficulties in this population.

Not Immune: Access to Substance Abuse Treatment Among Medicaid-Covered Youth With Mental Retardation

Youth with mental retardation* (MR) have experienced increasing levels of participation in community life over the last 30 years. This freedom has facilitated access to community life beyond school settings; it has also created the potential for alcohol and drug use and for the development of substance abuse (SA). Little is known about access to SA treatment for youth with MR—an especially vulnerable population. Through the application of a set of standardized performance measures, this study examines SA treatment access among youth aged 12 to 21 with and without MR ( N = 150,009). Guided by Andersen’s sociobehavioral model of health care utilization, multivariate logistic regression analyses modeled SA treatment initiation and engagement. Youth with MR and SA were less likely to initiate or engage in treatment. Engagement among youth with MR and SA was associated with being male and/or non-White. Implications relate to a need for improved treatment access for youth with MR and SA through cross-system collaboration.

Clinical predictors of severe behavioural problems in people with intellectual disabilities referred to a specialist mental health service

Associations between demographic and clinical variables and severe behavioural problems in people with intellectual disabilities were examined in a cross-sectional survey of 408 adults consecutively referred to a specialist mental health service. Severe behavioural problems were present in 136 (33.3%) of the sample. The demographic and clinical predictors of severe behavioural problems in this sample were identified by logistic regression. Age and gender were not associated with severe behavioural problems. The presence of severe ID independently predicted the presence of severe behavioural problems. Schizophrenia spectrum disorders and personality disorders independently predicted the presence of severe behavioural problems, whereas the presence of an anxiety disorder independently predicted their absence. There is an increasing evidence base of relationships between mental disorders and behavioural problems in people with ID although the pattern of these relationships remains unclear.

Diagnosis and treatment of mood disorders in adults with developmental disabilities

While the idea that individuals with developmental disabilities (DD) can suffer from mental illness has been largely accepted since the late 1980's, this is still an underserved and poorly studied population. In particular, mood disorders have traditionally been misdiagnosed, under-recognized and poorly treated. Through the years, reported rates of mood disorders in adults with DD have varied widely. Recent epidemiological studies have focused on community samples and find rates of mood disorders from 3 to 8.1%. Mood disorders are found to be more prevalent than psychotic disorders or anxiety disorders. The empirical literature on assessment of mood symptoms in adults with DD is limited, particularly in individuals with severe and profound DD. Several tools have been developed to assist in identification and diagnosis. However, the work on their psychometric properties and validity studies is still quite limited. The treatment literature is sparse and focused primarily on pharmacotherapy. This review considers the epidemiology and diagnosis of mood disorders in individuals with DD. Recent developments in assessment are reviewed. The literature regarding pharmacological treatment with antidepressants, mood stabilizers, electroconvulsive therapy and antipsychotics is summarized and the current state of psychological treatments for mood disorders in persons with DD is presented. Implications for clinical care and future research are considered.

Psychometric properties of Psychopathology checklists for Adults with Intellectual Disability (P-AID) on a community sample of adults with intellectual disability

The DC-LD is a new classification system providing operationalized diagnostic criteria in recognition of lacking applicability of standard psychiatric criteria for adults with intellectual disability. This study attempts to evaluate internal consistency, inter-rater reliability and factor structure of the Psychopathology Checklists for Adults with Intellectual Disability (P-AID), a set of checklists developed from the DC-LD. The P-AID checklists comprising 10 psychiatric diagnoses and 8 types of problem behaviors were filled in by staff at community based homes for adults with intellectual disability in Western Norway. A total of 593 were returned (66%) of which 83 had two sets of checklists. Intellectual disability was administratively defined. Alpha (alpha) values for the total P-AID checklists indicating high internal consistency. The inter-rater reliability measured by ICC showed values between 0.63 and 0.88 in 8 of 10 psychopathology Checklists. Factor analysis indicated four orthogonal units measured by the P-AID. Issues regarding sensitivity and specificity are discussed. This study is the first attempt to develop and evaluate Psychopathology Checklists based on the DC-LD. The results from this study indicate the P-AID can be used in identifying mental health needs at a detailed diagnostic level.

Psychiatric co-morbidity and gender differences in intellectual disability

BACKGROUND

Although gender differences in psychopathology among the general psychiatric population appear to be well documented, such differences have been either ignored or inconsistently investigated among people with intellectual disability (ID).

METHODS

The study examined psychiatric co- morbidity in 295 men and 295 women with ID and significant social impairments living in community settings. The sample was drawn from consecutive clinical referrals to a specialist mental heath service of South-East London. Psychiatric diagnoses were based on ICD-10 criteria.

RESULTS

Personality disorder was more common among men, although dementia and adjustment reaction were more common among women. There were also gender differences in marital status, with a larger percentage of women being either married or in a stable relationship. Gender differences in the source of referral were also observed, with more women being referred through primary care and more men being referred through generic mental health services.

CONCLUSIONS

Female patients seem to have at some extent different mental health needs from male patients. Such differences should be taken into account in the design and delivery of clinical service for people with ID.

Psychopathology in Adults with Autism and Intellectual Disability

There have been few studies of psychopathology in adult with autism. This study examined psychiatric co-morbidity in 147 adults with intellectual disability (ID) and autism and 605 adults with ID but without autism. After controlling for the effects of gender, age, psychotropic medication and level of ID, people with autism and ID were no more likely to receive a psychiatric diagnosis than people with ID only. People with autism were less likely to receive a diagnosis of personality disorder. These findings cast doubts on the hypothesis that adults with ID and autism are more vulnerable to certain psychiatric disorders than non-autistic adults with ID.

An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues

BACKGROUND

Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach.

METHOD

A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID.

RESULTS

There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

Health, healthcare utilization and psychiatric disorder in people with intellectual disability in Taiwan

OBJECTIVES

The aims of the present study were to examine health characteristics and healthcare utilization in relation to people with intellectual disability (ID) having psychiatric disorders in Taiwan.

METHODS

A cross-sectional study was employed; study subjects were recruited from the National Disability Registration Database. Taiwan, stratified by administrative geographical area for the study. Statistical analysis of 1026 carers for people with ID was made to examine the health status and healthcare utilization of individuals with ID having psychiatric disorders.

RESULTS

Approximately 12.1% of people with ID had psychiatric disorders. These individuals were more likely to be poorer in health condition and consuming more medical services (in the outpatient, inpatient and emergency care areas), than those individuals without psychiatric disorders. These individuals with psychiatric disorders were also taking medicines regularly at a far greater percentage than did those without psychiatric disorders.

CONCLUSIONS

Given the high prevalence of psychiatric disorders among individuals with ID, the healthcare system should take further steps to develop an appropriate health status monitoring system and community-based and easily accessible mental health services for them.