Mental Health Services for Individuals with Intellectual Disabilities in Canada: Findings from a National Survey

Psychiatry training in autism spectrum disorder and intellectual disability: Ongoing gaps and emerging opportunities

LAY ABSTRACT

Children, adolescents, and adults with autism spectrum disorder and intellectual disability experience high rates of co-occurring psychiatric conditions throughout their lifetime. However, there is a shortage of psychiatrists to treat these populations. We evaluated how much education psychiatrists-in-training receive on how to care for individuals with autism spectrum disorder/intellectual disability. We found that in many psychiatry programs, residents receive limited training experiences in autism spectrum disorder/intellectual disability involving lectures and patient contact and that psychiatry program directors would benefit from more resources to strengthen education in autism spectrum disorder/intellectual disability.

Cost Effects of a Health Coaching in Children and Adolescents With Mental Health and Developmental Disorders

OBJECTIVE

Health coaching (HC) aims to strengthen the role of primary care pediatricians in the treatment of children and adolescents with mental health and developmental disorders by extending consultation time and using disease-specific manuals. We evaluated the effect of HC on costs of specialized, pediatrician, and overall care.

METHODS

In a retrospective cohort study based on German health insurance claims data, we identified children aged up to 17 years with a newly diagnosed mental health and/or developmental disorder between 2013 and 2015. Patients getting HC were matched to patients receiving usual care. Costs were calculated for 1 year following the start of the treatment and compared by 2-part and gamma models. Absolute costs and cost differences were calculated with bootstrapped 95% confidence intervals (CI).

RESULTS

We compared 5597 patients receiving HC with 5597 control patients. The probability of incurring specialized care costs was similar between the groups (0.96, 95% CI: 0.88; 1.05). However, for those who did incur costs, specialized care costs were significantly lower for HC-treated patients (0.77, 95% CI: 0.63; 0.93). Accordingly, specialized care costs were lower by €-94 (95% CI: €-175; €-18), while pediatrician care costs were higher for HC-treated patients by €57 (95% CI: €49; €64). Hence, overall costs did not differ between the groups (€-59, 95% CI: €-191; €71).

CONCLUSION

Provision of HC has the potential to lower the costs of specialized care, while increasing the costs of pediatrician care. Overall costs did not differ, suggesting that the additional costs incurred by the HC were offset.

Looking across health and healthcare outcomes for people with intellectual and developmental disabilities and psychiatric disorders: population-based longitudinal study

BACKGROUND

Intellectual and developmental disabilities (IDDs) and psychiatric disorders frequently co-occur. Although each has been associated with negative outcomes, their combined effect has rarely been studied.

AIMS

To examine the likelihood of five negative health and healthcare outcomes for adults with IDD and mental health/addiction disorders (MHAs), both separately and together. For each outcome, demographic, clinical and system-level factors were also examined.

METHOD

Linked administrative data-sets were used to identify adults in Ontario, Canada, with IDD and MHA (n = 29 476), IDD-only (n = 35 223) and MHA-only (n = 727 591). Five outcomes (30-day readmission, 30-day repeat ED visit, delayed discharge, long-term care admission and premature mortality) were examined by logistic regression models with generalised estimating equation or survival analyses. For each outcome, crude (disorder groups only) and complete (adding biosocial covariates) models were run using a general population reference group.

RESULTS

The IDD and MHA group had the highest proportions across outcomes for both crude and complete models. They had the highest adjusted ratios for readmissions (aOR 1.93, 95%CI 1.88-1.99), repeat ED visit (aOR 2.00, 95%CI 1.98-2.02) and long-term care admission (aHR 12.19, 95%CI 10.84-13.71). For delayed discharge, the IDD and MHA and IDD-only groups had similar results (aOR 2.00 (95%CI 1.90-2.11) and 2.21 (95%CI 2.07-2.36). For premature mortality, the adjusted ratios were similar for all groups.

CONCLUSIONS

Poorer outcomes for adults with IDD, particularly those with MHA, suggest a need for a comprehensive, system-wide approach spanning health, disability and social support.

Pharmacotherapy for mood and anxiety disorders in older people with intellectual disability in comparison with the general population

BACKGROUND

People with intellectual disability (ID) have high prevalence of psychiatric disorders, but even higher rates of prescription of psychotropic drugs.

METHODS

Using Swedish national registers, we identified a group of older people with ID and diagnosis of mood disorders (ICD-10 codes F32-F39) and/or anxiety (ICD-10 code F4) during 2006-2012 (n = 587) and a referent group of people from the general population with the same diagnoses during the same time period (n = 434). For both groups, we collected information on prescription of anxiolytics, hypnotics and sedatives, antidepressants, and GABA-agonists.

RESULTS

Among those with a diagnosis of anxiety, people with ID were more likely than those in the general population to be prescribed anxiolytics (Relative Risk 1.32 [95% Confidence Interval 1.19-1.46]) and GABA-agonists (1.10 [1.08-1.31]). Moreover, among those with anxiety but without mood disorders, ID was associated with increased prescription of antidepressants (1.20 [1.03-1.39]). Within the ID cohort, behaviour impairment and MSP (i.e. moderate, severe, or profound) ID was associated with increased prescription of anxiolytics, both among those with anxiety (1.15 [1.03-1.30] for behaviour impairment and 1.23 [1.10-1.38] for MSP ID) and among those with mood disorders (1.14 [0.97-1.35] for behaviour impairment and 1.26 [1.04-1.52] for MSP ID). Moreover, MSP ID was associated with increased prescription of GABA-agonists among those with anxiety (1.23 [1.10-1.38]).

CONCLUSIONS

The excess prescription of anxiolytics but not antidepressants may suggest shortages in the psychiatric health care of older people with intellectual disability and mood and anxiety disorders.

Prevalence of intellectual and developmental disabilities among first generation adult newcomers, and the health and health service use of this group: A retrospective cohort study

BACKGROUND

Attention to research and planning are increasingly being devoted to newcomer health, but the needs of newcomers with disabilities remain largely unknown. This information is difficult to determine since population-level data are rarely available on newcomers or on people with intellectual and developmental disabilities (IDD), although in Ontario, Canada these databases are accessible. This study compared the prevalence of IDD among first generation adult newcomers to adult non-newcomers in Ontario, and assessed how having IDD affected the health profile and health service use of newcomers.

METHODS

This population-based retrospective cohort study of adults aged 19-65 in 2010 used linked health and social services administrative data. Prevalence of IDD among newcomers (n = 1,649,633) and non-newcomers (n = 6,880,196) was compared. Among newcomers, those with IDD (n = 2,830) and without IDD (n = 1,646,803) were compared in terms of health conditions, and community and hospital service use.

RESULTS

Prevalence of IDD was lower in newcomers than non-newcomers (171.6 versus 898.3 per 100,000 adults, p<0.0001). Among newcomers, those with IDD were more likely than those without IDD to have comorbid physical health disorders, non-psychotic, psychotic and substance use disorders. Newcomers with IDD were also more likely to have psychiatry visits, and frequent emergency department visits and hospitalizations.

CONCLUSION

First generation adult newcomers have lower rates of IDD than non-newcomers. How much of this difference is attributable to admission policies that exclude people expected to be high health service users versus how much is attributable to our methodological approach is unknown. Finding more medical and psychiatric comorbidity, and more health service use among newcomers with IDD compared to newcomers without IDD is consistent with patterns observed in adults with IDD more generally. To inform polices that support newcomers with IDD future research should investigate reasons for the prevalence finding, barriers and facilitators to timely health care access, and pathways to care.

Pass the parcel: Service provider views on bridging gaps for youth with dual diagnosis of intellectual disability and mental health disorders in regional areas

AIM

Youth with both intellectual disability (ID) and mental health (MH) disorders (dual diagnosis) have complex physical and MH needs that can make providing integrated care for this complex group challenging. We conducted a mixed methods needs assessment to identify gaps and challenges in care delivery, identify bridges for these and identify what works well in existing services.

METHODS

Our research team recruited service providers (n = 126) caring for youth aged 14-24 years with a dual diagnosis in the Illawarra Shoalhaven region of New South Wales, Australia, to participate in focus group interviews. Data were transcribed and analysed thematically.

RESULTS

We identified six themes related to caring for youth with dual diagnosis in regional areas: access to services and information about services, communication between service providers and with clients and carers, the divide between MH and ID, early intervention and health promotion, capacity building of service providers and capacity building of clients and carers. Across these themes, service providers highlighted the transition from child to adult services as a particularly challenging time for clients, families and carers.

CONCLUSIONS

Our data suggest several approaches to break down silos and to facilitate collaboration between current services for youth with a dual diagnosis, including increasing specialised ID/MH services and building the capacity of current disability and MH service providers. Our results provide important information to provide quality and integrated care for youth with complex health needs.

Antipsychotic Use With and Without Comorbid Psychiatric Diagnosis Among Adults with Intellectual and Developmental Disabilities

OBJECTIVE

Antipsychotic use is controversial in the management of adults with intellectual and developmental disabilities (IDD) because of inconclusive evidence for efficacy in the absence of a comorbid psychiatric condition, and substantial concerns about adverse effects. We aimed to characterize antipsychotic use among Ontario adults with IDD and compare profiles of those with and without a documented psychiatric diagnosis.

METHOD

This population-based study included 51,881 adults with IDD under 65 y as of April 2010 receiving provincial drug benefits in Ontario who were followed until March 2016 to identify those dispensed at least one antipsychotic medication. Profiles of those with and without a psychiatric diagnosis were compared.

RESULTS

Overall, 39.2% of adults ( n = 20,316) were dispensed an antipsychotic medication, which increased to 56.4% in a subcohort residing in group homes. Almost one-third (28.91%) of people prescribed an antipsychotic medication did not have a documented psychiatric diagnosis. Those without a psychiatric diagnosis differed considerably from those with a diagnosis. In particular, those without a psychiatric diagnosis were older, less likely to have used antidepressants or benzodiazepines in the year before, and less likely to have used ambulatory and acute care.

CONCLUSIONS

Antipsychotic use in IDD is common, and occurs frequently without a psychiatric diagnosis. Attention toward how antipsychotics are prescribed and monitored for people with IDD in Canada is warranted to ensure appropriate prescribing.

A qualitative study of the service experiences of women with autism spectrum disorder

It is recognized that the experiences of women with autism spectrum disorder are often underrepresented in the literature. In this study, 20 women with autism spectrum disorder participated in five focus groups with discussions centered on their service use, unmet service needs, and barriers to care. Overall, women emphasized high unmet service needs, particularly with respect to mental health concerns, residential supports, and vocational and employment services. Participants also perceived many service providers as disregarding or misunderstanding women’s service needs. Findings of the current exploratory study are discussed in relation to areas of future research required to ensure effective care for this understudied population.

Impaired or Not Impaired, That Is the Question: Navigating the Challenges Associated with Using Canadian Normative Data in a Comprehensive Test Battery That Contains American Tests

It has been well documented that IQ scores calculated using Canadian norms are generally 2-5 points lower than those calculated using American norms on the Wechsler IQ scales. However, recent findings have demonstrated that the difference may be significantly larger for individuals with certain demographic characteristics, and this has prompted discussion about the appropriateness of using the Canadian normative system with a clinical population in Canada. This study compared the interpretive effects of applying the American and Canadian normative systems in a clinical sample. We used a multivariate analysis of variance (ANOVA) to calculate differences between IQ and Index scores in a clinical sample, and mixed model ANOVAs to assess the pattern of differences across age and ability level. As expected, Full Scale IQ scores calculated using Canadian norms were systematically lower than those calculated using American norms, but differences were significantly larger for individuals classified as having extremely low or borderline intellectual functioning when compared with those who scored in the average range. Implications of clinically different conclusions for up to 52.8% of patients based on these discrepancies highlight a unique dilemma facing Canadian clinicians, and underscore the need for caution when choosing a normative system with which to interpret WAIS-IV results in the context of a neuropsychological test battery in Canada. Based on these findings, we offer guidelines for best practice for Canadian clinicians when interpreting data from neuropsychological test batteries that include different normative systems, and suggestions to assist with future test development.

Mental health needs and availability of mental health care for children and adolescents with intellectual disability in Berlin

BACKGROUND

The increased risk of mental health problems in children and adolescents with intellectual disability (ID) has been reported in several studies. However, almost no research has been conducted on parents' experiences with the general mental health system. We have investigated the prevalence of emotional and behavioural problems in children with ID as well as the availability and quality of mental health care from the parents' point of view.

METHODS

Teachers of specialised schools for ID in Berlin were asked to complete the Teacher's Report Form (TRF) of the Child Behavior Checklist. Information was collected for 1226 children and adolescents aged 6-18 years with mild to profound ID (response 70.5%). The availability and quality of mental health care was assessed by a questionnaire given to parents who had already been seeking help for their children. A total of 330 parents completed the questionnaires (response 62.0%). In addition to univariate analysis, we conducted multiple logistic regressions regarding the psychopathology reported by teachers (TRF-syndrome scales) and difficulties concerning mental health care reported by parents for a paired sample of 308 children.

RESULTS

Overall, 52.4% of the children and adolescents with ID had a total problem score on the TRF in the deviant range (47.1% when eliminating four items reflecting cognitive deficits). Compared with the general population normative sample of children, this is a three-time higher prevalence. The most striking problems were thought problems (schizoid and obsessive-compulsive), aggressive behaviour, attention problems and social problems. Parents whose children had more severe behavioural or emotional dysfunction reported more difficulties with the mental health system. From the parents' point of view, mental health professionals frequently did not feel responsible or were not sufficiently skilled for the treatment of children with ID. As a consequence, 96% of all parents were longing for specialised in- and outpatient services.

CONCLUSIONS

This study confirms the findings from other studies regarding the high rate of co-occurrence of ID and mental health problems in youths. Results indicate that both are strongly requested by parents: specialised in- and outpatient services, as well as more professional general services and equitable treatment for all children, with and without ID.

Predictors of specialized inpatient admissions for adults with intellectual disability

Individuals with intellectual disability (ID) have complex mental health needs and may seek specialized ID psychiatric services. This study reports on predictors of specialized inpatient admissions for 234 individuals with ID who received outpatient services at a psychiatric hospital. Overall, from 2007-2012, 55 of the 234 outpatients were triaged into the specialized inpatient unit. Aggression towards others and psychotropic polypharmacy significantly predicted these admissions. Unlike previous research, schizophrenia and level of ID did not predict admissions, suggesting that these factors may have a differential impact in specialized versus mainstream inpatient services. Findings are discussed in relation to how specialized inpatient units can be most responsive to these vulnerable patients and the factors that may impact clinical decision making.

Contemporary issues in the training of UK health and social care professionals--Looking after people with a learning disability

The health and social care of people labelled with 'learning disability' has historically been a disputed territory for those individuals working within the nursing and allied health professions. In recent times this situation has seen public debate as instances of poor care and avoidable deaths have received a high profile in the popular and professional presses. Here we report on a local initiative where students can study for a joint honours award which allows them to practise as a generic social worker and a learning disability nurse. We believe that the inter-professional perspective improves their ability to manage the increasingly complex aspects of health and social care that this client group demands. Furthermore, we suggest that if a similar model were to be applied at a foundation module level to the training of ALL health and social care professionals, then the results would be a win/win situation for all parties. This would also go some way to meeting the recommendations of Sir Jonathan Michael's report, Health Care for All (DH, 2008).

Emergency department visits and use of outpatient physician services by adults with developmental disability and psychiatric disorder

OBJECTIVE

To compare the emergency department (ED), primary, and psychiatric care visit rates associated with the presence and absence of a developmental disability (DD) and a mental illness.

METHOD

This is a population-based study comparing Ontario adults, with and without DDs and mental illnesses, in terms of rates of primary, psychiatric, and ED care, from April 2007 to March 2009.

RESULTS

In Ontario, 45% of adults with a DD received a psychiatric diagnosis during a 2-year period, and 26% of those with a psychiatric diagnosis were classified as having a serious mental illness (SMI), compared with 8% of those with a psychiatric diagnosis but no DD. People with DDs had an increased likelihood of psychiatric and ED visits. Patients with SMIs and DDs had the highest rates of such visits.

CONCLUSIONS

People with more severe impairments had the greatest likelihood of ED visits, despite access to outpatient services, suggesting that outpatient care (primary and psychiatric), as currently delivered, may not be adequate to meet their complex needs.

Mental health: knowledge, attitudes and training of professionals on dual diagnosis of intellectual disability and psychiatric disorder

BACKGROUND

Dual diagnosis (DD) refers to the coexistence of intellectual disability and psychiatric disorder. In order to provide individuals with DD with adequate care, it is essential for mental health workers to have adequate knowledge and positive attitudes. These may be achieved through proper training.

AIMS

To summarise the available literature examining the knowledge, attitudes and training of psychiatrists and other professional caregivers in regard to serving people with DD.

METHODS

A search strategy was developed to find manuscripts published in English since 1995.

RESULTS

Twenty-seven studies on knowledge, attitudes and training in the field of DD were identified and reviewed in this paper.

CONCLUSION

The findings of this review stress the need to improve the knowledge, competence and attitudes of practitioners within the DD field via training and practice opportunities. In light of this review, recommendations for improving training opportunities and for conducting future research are made.

Prevalence of Depression and Dementia among Adults with Developmental Disabilities in Manitoba, Canada

Study Objective. To estimate and compare the prevalence of dementia and depression among adults with and without developmental disabilities (DDs). Methods. We linked data from several provincial administrative databases to identify persons with DDs. We matched cases with DD with persons without DD as to sex, age, and place of residence. We estimated the prevalence of dementia and depression and compared the two groups using the Generalized Estimating Equations (GEEs) technique. Results. The estimated prevalence of depression and dementia among younger adults (20-54) and older adults (50+) with DD was significantly higher than the estimated rates for the matched non-DD group (Depression: younger adults: RR = 2.96 (95% CI 2.59-3.39); older adults: RR = 2.65 (95% CI 1.84-3.81)), (Dementia: younger adults: RR = 4.01 (95% CI 2.72-5.92); older adults: RR = 4.80 (95% CI 2.48-9.31)). Conclusion. Significant disparities exist in mental health between persons with and without DDs.

Dual diagnosis: A national study of psychiatric hospitalization patterns of people with developmental disability

OBJECTIVE

To report national demographics and diagnostic profiles of people with developmental disability hospitalized for psychiatric reasons, and to contrast results to psychiatric hospitalizations among patients with no comorbid developmental disability.

METHOD

People with developmental disability across Canada were identified using data administered by the Canadian Institute for Health Information. Among this cohort of people with developmental disability, records of hospitalization for psychiatric reasons were aggregated for the 2005/06 fiscal year (April 2005 to March 2006). Descriptive statistics on province of residence, age, sex, specific diagnoses, length of stay, and hospitalization frequency were calculated and compared with people without developmental disability.

RESULTS

In Canada, people with developmental disability were hospitalized a total of 8378 times in 2005/06; among these, 3478 (42%) were for psychiatric conditions. The number of people with developmental disability hospitalized for a psychiatric condition represents about 2% of the general population hospitalized for such conditions. Among people with developmental disability hospitalized for a psychiatric condition most were men and people aged between 15 and 34 years. For almost all psychiatric disorder categories, people with developmental disability were hospitalized at rates significantly different than their counterparts without developmental disability. Lengths of hospital stays for psychiatric conditions were very similar when comparing the study groups; however, people with developmental disability were more likely to have 2 or more hospitalizations during the year.

CONCLUSIONS

People with developmental disability display unique hospitalization patterns, compared with the general population.

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.

Gender differences in psychiatric diagnoses among inpatients with and without intellectual disabilities

There are few published studies on the relationship between gender and psychiatric disorders in individuals with intellectual disabilities. Adults (N = 1,971) with and without intellectual disabilities who received inpatient services for psychiatric diagnosis and clinical issues were examined. Among individuals with intellectual disabilities, women were more likely to have a diagnosis of mood disorder and sexual abuse history; men were more likely to have a substance abuse diagnosis, legal issues, and past destructive behavior. Gender difference patterns found for individuals with intellectual disabilities were similar to those of persons without intellectual disabilities, with the exception of eating disorder and psychotic disorder diagnoses. Gender issues should receive greater attention in intellectual disabilities inpatient care.

Emergency psychiatric services for individuals with intellectual disabilities: perspectives of hospital staff

Strains on the mainstream mental health system can result in inaccessible services that force individuals with intellectual disabilities into the emergency room (ER) when in psychiatric crisis. The purpose of this study was to identify clinical and systemic issues surrounding emergency psychiatry services for people with intellectual disabilities, from the perspective of hospital staff. Focus groups were conducted with emergency psychiatry staff from 6 hospitals in Toronto, Canada. Hospital staff reported a lack of knowledge regarding intellectual disabilities and a shortage of available community resources. Hospital staff argued that caregivers need more community and respite support to feel better equipped to deal with the crisis before it escalates to the ER and that hospital staff feel ill prepared to provide the necessary care when the ER is the last resort. Input from hospital staff pointed to deficiencies in the system that lead caregivers to use the ER when other options have been exhausted. Both staff and caregivers need support and access to appropriate services if the system is to become more effective at serving the psychiatric needs of this complex population.