Working across boundaries: clinical outcomes for an integrated mental health service for people with intellectual disabilities

Mental healthcare for adults with mild intellectual disabilities: population-based database study in Dutch mental health services

BACKGROUND

Adults with mild intellectual disability (MID) experience more mental health disorders than the general population. However, mental healthcare may be insufficiently tailored to match their needs. Detailed information is lacking regarding care provided to people with MID in mental health services.

AIMS

To compare mental health disorders and care provided to patients with and without MID in Dutch mental health services, including patients with missing MID status in the service files.

METHOD

In this population-based database study, we used a Statistics Netherlands mental health service database, containing health insurance claims of patients who utilised advanced mental health services in 2015-2017. Patients with MID were identified by linking this database with Statistic Netherlands' social services and long-term care databases.

RESULTS

We identified 7596 patients with MID, of whom 60.6% had no intellectual disability registration in the service files. Compared with patients without intellectual disability (n = 329 864), they had different profiles of mental health disorders. They received fewer diagnostic (odds ratio 0.71, 95% CI 0.67-0.75) and treatment activities (odds ratio 0.56, 95% CI 0.53-0.59), and required more interprofessional consultations outside of the service (odds ratio 2.06, 95% CI 1.97-2.16), crisis interventions (odds ratio 2.00, 95% CI 1.90-2.10) and mental health-related hospital admissions (odds ratio 1.72, 95% CI 1.63-1.82).

CONCLUSIONS

Patients with MID in mental health services have different profiles of mental health disorders and care than patients without intellectual disability. In particular, fewer diagnostics and treatments are provided, especially in those with MID with no intellectual disability registration, putting patients with MID at risk of undertreatment and poorer mental health outcomes.

Crisis stabilisation services for people with intellectual disabilities: A systematic review

People with intellectual and developmental disabilities sometimes engage in challenging behaviours. When behaviours escalate to the point where they pose imminent risk to the safety of people and environments, a crisis occurs that jeopardises community living and participation. In these situations, timely access to crisis stabilisation services is required. We conducted a systematic review of the literature to synthesise evidence on effective crisis stabilisation service models for challenging behaviours. A total of 46 publications met the inclusion criteria. The literature describes a spectrum of crisis stabilisation services of varying intensities including: outreach, outpatient, inpatient, respite, and capacity building through education and training. However, there is limited guidance on how to best structure service models. This review highlights the need for comprehensive and person-centred programme evaluations.

A systematic review of in-patient psychiatric care for people with intellectual disabilities and/or autism: effectiveness, patient safety and experience

BACKGROUND

An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists.

AIMS

The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care.

METHOD

A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services).

RESULTS

A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates.

CONCLUSIONS

There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.

An evaluation of outcomes for service users with an intellectual disability admitted to an assessment and treatment unit

This service evaluation comprised pre- and post measures with service users and their carers on admission to and discharge from an assessment and treatment (A&T) unit. The Behaviour Problems Inventory (BPI), Psychiatric Assessment Scale for Adults with Developmental Disabilities Checklist-Revised (PASSAD) and World Health Organisations Quality of Life Scale (WHO-QOL 8; adapted for people with intellectual disabilities) were used to evaluate outcomes of their admission to the unit. Significant improvements were found after admission in relation to behaviour that challenges (measured by the BPI), mental health symptoms (measured by the PASSAD) and quality of life (measured by the WHO-QOL). The importance of completing outcome measures as feedback for the service user, team and wider service managers are discussed, but also in this political context when the role of A&T units are being questioned, the importance of showing good practice and clinical outcomes for individuals.

Risk factors for in-patient admission among adults with intellectual disability and autism: investigation of electronic clinical records

Adults with intellectual disability or autism are at risk of psychiatric admission which carries personal, social and economic costs. We identified 654 adults with intellectual disability or autism in the electronic clinical records of one mental health trust. We investigated the demographic and clinical factors associated with admission and readmission after discharge. Young male patients with intellectual disability, schizophrenia and previous admissions are most at risk of the former, whereas affective and personality disorders predict the latter. Both community intellectual disability services and mental health crisis care must focus on providing effective support for those patients.

Training and service provision for people with intellectual disability and mental illness: the views of psychiatrists

  Objectives: The objectives of this mixed methods study are to 1) investigate the knowledge and skills of mainstream psychiatrists in managing patients with Intellectual Disability (ID) and comorbid mental health disorders, 2) assess their perception of the quality and accessibility of services for this population, and 3) establish the local implementation of the Green Light Toolkit. Method: We surveyed mainstream psychiatrists in the Thames Valley region working in general adult, forensic, and older adult services, to ascertain their opinions about their knowledge and skills in managing patients with ID and comorbid mental disorder, as well as quality and accessibility of services. We compared our findings with previous UK and international research. Results: Respondents mirrored views expressed in earlier studies that inpatient care should be provided in dedicated units for people with ID, rather than general adult inpatient wards. Limited resources, training and competence, and lack of collaborative working were highlighted as key barriers to provision of effective care. Conclusion: Psychiatrists broadly support a specialist service model for people with ID. In the UK, specialist psychiatric services for people with ID have been delivered through inpatient and community services, but there is a current shift towards integrating ID with mainstream service models. Participants expressed concern that mainstream services fail to meet the mental health needs of this patient group, and lead to increased patient vulnerability. The Green Light Toolkit was not well known or used within services. A number of ways of improving collaborative care between services are suggested.

In-patient services for people with intellectual disability and mental health or behavioural difficulties

Over the past few decades, care for people with intellectual disability in the UK has moved from long-stay hospitals to the community. As in the general population, a number of these people have mental health and behavioural difficulties for which they may require in-patient services. Consequently, psychiatrists need to be aware of the in-patient mental healthcare provision for these individuals. This article describes the different categories of in-patient bed for patients with intellectual disability and ways to monitor the quality and outcomes of in-patient care.

Training therapists to work with people with intellectual disability in Improving Access to Psychological Therapies (IAPT) services

BACKGROUND

Current policy in the England suggests that people with intellectual disabilities should, where possible, access mainstream mental health services; this should include access to mainstream therapy services. It is likely that mainstream therapists will need training and support to work with people with intellectual disabilities.

METHOD

Sixty-eight therapists working in an English Improving Access to Psychological Therapies (IAPT) service received one- or 2-day training on working with people with intellectual disabilities. Measures of confidence, general therapeutic self-efficacy and attitudes to people with intellectual disabilities' use of mainstream mental health services were completed pre-training, post-training and at 3-month follow-up; at which time, 12 participants were interviewed about the impact of the training on their practice.

RESULTS

There was a significant positive change in all measures immediately post-training which was maintained at 3-month follow-up.

CONCLUSIONS

Training considerations for mainstream therapists who may work with people with intellectual disabilities are discussed.

Integration as a scientific paradigm

Purpose

Integration is policy, practice as well as object of systematic investigation. What we do not know is whether or not integration can be understood as a science. In his book The Structure of Scientific Revolutions, Thomas Kuhn formulated a notion of (natural) sciences based on the emergence of commitments amongst a community of scientists to a set of logics, model and exemplars. He called this a paradigm. The purpose of this paper is to assess the scientific nature of integration by perceiving it as a paradigm in Kuhn’s sense.

Design/methodology/approach

The paper proceeds by conceptual reflection through matching existing components, theories and exemplifications of integration to Kuhn’s model of a scientific paradigm. Integration is understood broadly, either vertical or horizontal, and located within the practical domains of policy formulation, policy implementation and evaluation research. The nature, scope and depth of group commitments amongst students and practitioners of integration receive particular attention in line with Kuhn’s social interactionist approach.

Findings

Employing Kuhn’s notion of paradigm in the context of integration highlights the fundamental tension between integration efforts and integration outcomes. Whilst integration defines itself in contradistinction to professional boundaries and fragmentation, the paper argues that it fails to develop a strong theoretical and empirical foundation for a robust and stable group commitment. The reason is that the key motivational force that may create a stable group commitment amongst those engaged in integration, the patient perspective, remains outside the integration paradigm. This leaves integration as a practice and policy model underdeveloped, mainly paradigmatically illustrated by singular exemplars and rooted in aspirational policy vocabulary, while clustered around a near dogmatic belief that working together between services must lead to improved quality of care. To become a scientific paradigm the group commitment in integration would have to coalesce around a clear ontology (symbolic generalisations), epistemology (models of knowledge) and manifestations in practice (exemplars).

Research limitations/implications

At present both the ontology and epistemological foundations of integration practice and research are insufficiently clear. This hampers the development of integration practice as well as a better understanding of how to evaluate integration outcomes. Future studies should focus on the depth, nature and subject of group commitments to assess whether integration is a viable candidate for scientific paradigm or an assorted construct of policy aspirations.

Originality/value

The paper questions the rigour and trajectory of integration practice, policy and research. It identifies a tension at the centre of the field between group commitments to scientific exemplars (case studies) and symbolic generalisations, encapsulated in the desire to improve patient care. The notion of a scientific paradigm thus helps to re-frame the discussion about research and practice in integration.

Clinical needs and outcomes of adults with intellectual disabilities accessing an inpatient assessment and treatment service and the implication for development of community services

The role and future of assessment and treatment units for people with intellectual disabilities is once again the focus of debate and government policy. Reviewing the admissions to inpatient services can provide useful information about the characteristics, needs and clinical outcomes of clients. Data were collected retrospectively for all 36 referrals accepted to an inpatient assessment and treatment unit for people with intellectual disability, between January 2013 and April 2014. Clinical and demographic characteristics of service users were identified through descriptive analysis. Male service users, mild intellectual disability and diagnosis of autistic spectrum disorder were frequent, and a high proportion of admissions had complex and multiple needs. The Health of the Nation Outcome Scale-Intellectual Disabilities was used as a clinical outcome measure. We conclude with recommendations for service development following closure of our inpatient service.

'What vision?': experiences of Team members in a community service for adults with intellectual disabilities

BACKGROUND

In the UK, the closure of 'long-stay' hospitals was accompanied by the development of community teams (CTs) to support people with intellectual disabilities (IDs) to live in community settings. The self-reported experiences of staff working in such teams have been neglected.

METHODS

Focusing on a single county-wide service, comprising five multi-disciplinary and inter-agency CTs, we measured perceptions among the health care and care management Team members of (1) their personal well-being; (2) the functioning of their team; and (3) the organisation's commitment to quality, and culture.

RESULTS

Almost three-quarters of the questionnaires were returned (73/101; 72%). The scores of health care practitioners and care managers were very similar: (1) the MBI scores of more than half the respondents were 'of concern'; (2) similarly, almost four in ten respondents' scores on the Vision scale of the TCI were 'of concern'; (3) the perceived commitment to quality (QIIS-II Part 2) was uncertain; and (4) the organisational culture (QIIS-II, Part 1) was viewed as primarily hierarchical.

DISCUSSION

The perceived absence of a vision for the service, combined with a dominant culture viewed by its members as strongly focussed on bureaucracy and process, potentially compromises the ability of these CTs to respond proactively to the needs of people with IDs. Given the changes in legislation, policy and practice that have taken place since CTs were established, it would be timely to revisit their role and purpose.

Translation and validation of the Spanish version of the Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD)

INTRODUCTION

The Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD) is a brief instrument that assesses functioning in people with intellectual development disorder and mental health problems/behaviour disorders. The aim of the present study was to examine the evidence on the validity of the scores based on the Spanish version of the HoNOS-LD.

MATERIAL AND METHODS

The study included 111 participants that were assessed by the Spanish version of the HoNOS-LD and other questionnaires that measured different variables related to the scale. Thirty-three participants were assessed by 2 examiners, and retested 7 days later, in order to study inter-examiner reliability and test-retest reliabilities.

RESULTS

Based on clinical and conceptual criteria, and on the results of the parallel analysis, a factorial solution with one factor was selected. Internal consistency was good (Omega coefficient of 0.87). Inter-examiner and test-retest reliabilities were excellent (intraclass correlation coefficients of 0.95 and 0.98, respectively). Correlations between sections of the HoNOS-LD and the related instruments showed the expected direction, and were highly significant (P<.001), and the HoNOS-LD score increased with the intensity of the support required by the participants. These results showed evidence of the validity of association with other external variables.

CONCLUSIONS

The Spanish version of the HoNOS-LD is a brief, valid and reliable instrument, which will enable a routine assessment of functioning for different uses, including diagnosis and intervention.

Problem behaviours and symptom dimensions of psychiatric disorders in adults with intellectual disabilities: An exploratory and confirmatory factor analysis

BACKGROUND

The limited evidence on the relationship between problem behaviours and symptoms of psychiatric disorders experienced by adults with intellectual disabilities leads to conflict about diagnostic criteria and confused treatment. This study examined the relationship between problem behaviours and other psychopathology, and compared the predictive validity of dimensional and categorical models experienced by adults with intellectual disabilities.

METHODS

Exploratory and confirmatory factor analyses appropriate for non-continuous data were used to derive, and validate, symptom dimensions using two clinical datasets (n=457; n=274). Categorical diagnoses were derived using DC-LD. Severity and 5-year longitudinal outcome was measured using a battery of instruments.

RESULTS

Five factors/dimensions were identified and confirmed. Problem behaviours were included in an emotion dysregulation-problem behaviour dimension that was distinct from the depressive, anxiety, organic and psychosis dimensions. The dimensional model had better predictive validity than categorical diagnosis.

CONCLUSIONS

International classification systems should not include problem behaviours as behavioural equivalents in diagnostic criteria for depression or other psychiatric disorders. Investigating the relevance of emotional regulation to psychopathology may provide an important pathway for development of improved interventions.

WHAT THIS PAPER ADDS

There is uncertainty whether new onset problem behaviours or a change in longstanding problem behaviours should be considered as symptoms of depression or other types of psychiatric disorders in adults with intellectual disabilities. The validity of previous studies was limited by the use of pre-defined, categorical diagnoses or unreliable statistical methods. This study used robust statistical modelling to examine problem behaviours within a dimensional model of symptoms. We found that problem behaviours were included in an emotional dysregulation dimension and not in the dimension that included symptoms that are typical of depression. The dimensional model of symptoms had greater predictive validity than categorical diagnoses of psychiatric disorders. Our findings suggest that problem behaviours are a final common pathway for emotional distress in adults with intellectual disabilities so clinicians should not use a change in problem behaviours as a diagnostic criterion for depression, or other psychiatric disorders.

Mental Health Nursing of Adults With Intellectual Disabilities and Mental Illness: A Review of Empirical Studies 1994-2013

Mental health nursing for adults with intellectual disabilities and mental illness is underresearched. The aim of this review is to summarize empirical mental health nursing studies including adults with intellectual disabilities and additional mental illness. Out of 137 hits, 16 articles were reviewed in full text. Thirteen of the articles presented modified nursing interventions. Three articles discussed training and education. The main finding is that mental health nursing interventions in patients with intellectual disabilities and additional mental illness are in line with mental health nursing for the general population. There are still not many publications on empirical studies concerning mental health nursing for adults with intellectual disabilities. Clinical implications are primarily related to the need for facilitated nurse-patient communication adjusted to the patients' cognitive levels. Insights drawn from this review illuminate the importance of mental health nursing interventions adjusting to the particular patients' symptoms, instead of targeting behavior change. The findings underpin factors found to have a positive impact on patients with mental illness in the general population as relevant topics for future research.

The Development of a Measure of Confidence in Delivering Therapy to People with Intellectual Disabilities

Current policy in UK health services emphasizes that, where possible, people with intellectual disabilities should access the same services as people without intellectual disabilities. One of the barriers to this is the confidence of clinicians and therapists. In this paper, we report on the development of a scale to describe the confidence of therapists in working with people with intellectual disabilities (the Therapy Confidence Scale-Intellectual Disabilities [TCS-ID]). One-hundred and eighty-one therapists who provided talking therapies but who did not work primarily with people with intellectual disabilities completed the scale; 43 people completed the scale twice for test-retest reliability purposes. One-hundred and seven people also completed a scale of general therapy self-efficacy. The TCS-ID has a single factor structure accounting for 62% of the variance, Cronbach's alpha for the scale is 0.93 and test-retest reliability is 0.83. There are significant differences in confidence based upon participants experience in working with people with intellectual disabilities and their therapeutic orientation, and there is a significant association between the TCS-ID and the General Therapy Self-efficacy Scale. Sixty clinicians working in mainstream mental health services received training on adapting their therapeutic approaches to meet the needs of people with intellectual disabilities. The TCS-ID was used pre-training and post-training and demonstrated a significant increase in confidence for all group. We suggest that the scale has good psychometric properties and can be used to develop an understanding of the impact of training for mainstream therapist in working with people with intellectual disabilities.

KEY PRACTITIONER MESSAGE

There is increasing emphasis on people with intellectual disabilities receiving services from mainstream mental health services. There is no research describing the experiences and outcomes of people with intellectual disabilities receiving mainstream talking therapy services. The confidence that clinicians have in working with people with intellectual disabilities may be a barrier to them receiving mainstream services. The Therapy Confidence Scale-Intellectual Disabilities is a psychometrically sound scale for measuring the confidence of therapists in working with people with intellectual disabilities and is a useful outcome measure for training clinicians to work with people with intellectual disabilities.

Health professionals' attitudes and emotions towards working with adults with intellectual disability (ID) and mental ill health

OBJECTIVES

Mainstream mental health services are providing more care for individuals with an intellectual disability (ID); this has implications for staff and service users. Attitudes of staff towards people with ID in mental health services may be negative and negative staff attitudes may have a detrimental impact on service provision.

DESIGN

A cross-sectional design was used.

METHODS

A questionnaire designed to investigate the attitudes and emotions of staff towards delivering mental health care to adults with ID was completed by 84 staff from mainstream and specialist ID services.

RESULTS

Staff in both services experienced more positive emotions when working with clients whom they are currently employed to work with. When the frequency of contact with adults with ID, the number of individuals worked with and the amount of formal ID training received were considered, there was no significant difference between the attitudes of staff in both services. Positive correlations were found between attitude scores and positive emotional experiences in both services.

CONCLUSIONS

The research suggests that numerous factors, including the role of emotional experience and a number of environmental aspects, need to be considered in the context of providing mental health services to adults with ID to ensure the highest quality. Research limitations and clinical implications of the study are also considered.

Mental health services for people with intellectual disabilities

PURPOSE OF REVIEW

This review summarizes recent research into psychiatric services for adults with intellectual disabilities, with a particular focus on inpatient care.

RECENT FINDINGS

People with intellectual disability appear to be admitted with more severe problems and receive more interventions than those without intellectual disability when admitted to general psychiatric units. Qualitative research has shown poor standards of care on some general psychiatric inpatient units. Studies of supported generic inpatient units have reported successful outcomes, supported by qualitative studies of satisfaction. Length of stay for people with intellectual disability is not consistently longer on specialist than general psychiatric units. Delayed discharge and restrictive practices, however, still need addressing. The important components of community mental health services have been evaluated from the points of view of psychiatrists, patients and carers. Emergency provision of psychiatric assessment and care remains a problem in some centres.

SUMMARY

There have been few randomized controlled trials in this field; however, uncontrolled comparisons and service evaluations suggest positive outcomes in specialist services. Qualitative work has made important contributions to understanding the patients' and carers' experiences. Further work should focus on the measurements of outcome and satisfaction.

[Psychiatric disorders and neurological comorbidity in children with intellectual disability]

INTRODUCTION

This article gives an overview of the consultant child and adolescent psychiatric services in the region of Upper Bavaria (Germany).

METHOD

The data of 257 children and adolescents with intellectual disability and psychiatric disorders were evaluated.

RESULTS

About 14% of the children with ID in special schools or day care centers, and 40% of the children with ID in residential care showed a definite psychiatric disorder. The most frequently diagnosed disorders were adjustment disorders, hyperkinetic disorders and conduct disorders, as well as emotional problems and pervasive developmental disorders. Children with severe intellectual disability had more additional somatic disorders and were more impaired in their psychosocial functions.

CONCLUSIONS

The results show the need for psychiatric services for children and adolescents with intellectual disability and psychiatric disorders. The development and implementation of integrative and interdisciplinary models is necessary to allow for adequate medical care for these patients.

Clinical outcomes of a specialised inpatient unit for adults with mild to severe intellectual disability and mental illness

BACKGROUND

Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service.

METHOD

Thirty-three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re-admission to hospital were explored.

RESULTS

Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning.

CONCLUSIONS

This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

BACKGROUND

There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services.

METHOD

A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies.

RESULTS

People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services.

CONCLUSIONS

Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.

A comparison of patients with intellectual disability receiving specialised and general services in Ontario's psychiatric hospitals

BACKGROUND

Over the years, the closure of institutions has meant that individuals with intellectual disabilities (IDs) must access mainstream (i.e. general) mental health services. However, concern that general services may not adequately meet the needs of patients with ID and mental illness has led to the development and implementation of more specialised programmes. This study compares patients with ID receiving specialised services to patients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources and clinical service needs.

METHOD

A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for all 371 inpatients with ID, from both specialised and general programmes.

RESULTS

Inpatients in specialised programmes were more likely to have a diagnosis of mood disorder and were less likely to have a substance abuse or psychotic disorder. Individuals receiving specialised services had higher ratings of challenging behaviour than those in more general programmes. The two groups did not differ significantly in terms of recommended level of care, although more inpatients from specialised programmes were rated as requiring Level 4 care than inpatients from general programmes.

CONCLUSIONS

In Ontario, inpatients in specialised and general programmes have similar overall levels of need but unique clinical profiles that should be taken into consideration when designing interventions for them.

Community services for people with intellectual disabilities and mental health problems

PURPOSE OF REVIEW

This review will examine the most recently published studies of community services for people with intellectual disabilities and mental health problems.

RECENT FINDINGS

There is a continuing lack of evidence regarding these community-based services. Few studies have been published at all whilst even fewer still have reported outcomes in any detail. Recent studies have attempted to evaluate assertive community treatment for this service user group; however, they have been unsuccessful owing to inconsistency about what an assertive community treatment service should be for people with intellectual disabilities.

SUMMARY

An evidence base is urgently needed for these community-based services. Research should utilize the opinions of service users and their carers as well as professionals and focus on those people with intellectual disabilities and more severe mental health problems. It may be more fruitful to examine the components of community-based services rather than use the terminology of specific models such as assertive community treatment. The service components considered to be essential need first to be identified using a systematic methodology and then evaluated using a broad range of outcomes.

Deinstitutionalization in intellectual disabilities

PURPOSE OF REVIEW

The process of deinstitutionalization for intellectual disability services is at different stages across the world, varying from complete closure in Sweden to a vague hope in Taiwan. This review explores recent literature on deinstitutionalization and intellectual disabilities and focuses on papers published in academic journals mainly during 2006.

RECENT FINDINGS

Work on deinstitutionalization continues to show that outcomes are better in the community than in institutional care but recent papers highlight that there is more to deinstitutionalization than just hospital closure. Just moving people out of institutions into community settings does not bring about automatic improvement in quality of life in terms of choice and inclusion as well as self-identity and access to effective healthcare and treatment. This is especially true for people with more severe intellectual disabilities as well as complex needs such as challenging behaviour. Some of the current research illustrates that even offenders with intellectual disability can be successfully supported in the community.

SUMMARY

Recent research provides further examples and lessons on how community care can and should work, which it would be hoped will help those countries just starting the process of institutional closure to move more quickly to full deinstitutionalization.

Psychosocial interventions for people with intellectual disabilities and mental ill-health

PURPOSE OF REVIEW

To summarize recent research on psychosocial interventions for people with intellectual disabilities and mental ill-health.

RECENT FINDINGS

Psychosocial interventions for people with intellectual disabilities and mental ill-health are poorly developed. Recent research has focused upon individual therapeutic interventions and the evaluation of structures for the delivery of services to people with intellectual disabilities and mental ill-health. There is little research that has examined psychosocial interventions with carers or families, and the impact of housing, leisure and employment for this group of people.

SUMMARY

As people with intellectual disabilities are increasingly recognized as having severe and enduring mental ill-health, the development of an evidence base for psychosocial intervention is of considerable importance.