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

Fetal alcohol syndrome and population level health care usage in British Columbia, Canada

BACKGROUND

The literature indicates that youth with Fetal Alcohol Syndrome (FAS) may experience high rates of both physical and mental health issues compared to youth without FAS. However, there is little population level health data available for youth with FAS, particularly for youth transitioning from pediatric to adult healthcare services.

OBJECTIVE

The objective of this study was to compare health care usage of youth with Fetal Alcohol Syndrome to youth without any intellectual/developmental disabilities (IDD).

METHODS

This study used a retrospective cohort design and population-level administrative health data to examine five aspects of health care usage by youth with FAS and compare them to youth with no intellectual/developmental disability. The variables were medically required dental care, visits to emergency departments and visits for mental health issues. In addition, the study stratified data by age groups and examined the difference between youth aged 15-19 and youth aged 20-24.

RESULTS

Youth with FAS had higher adjusted odds of medically required dental care, visits to the emergency department and visits for anxiety/depression, psychotic illnesses and substance use disorders compared to youth with no IDD. The odds of a medically required dental visit, emergency department visit and visit for psychotic illness or substance use disorder were also higher for youth aged 20-24 years compared to youth aged 15-19 years.

CONCLUSIONS

These findings indicate that youth with FAS require urgent attention for each of the medically-related variables included in this study. The need for attention to their health care needs may increase as these youth transition from pediatric to adult health care services.

Population Level Mental Health Diagnoses for Youth with Intellectual/Developmental Disabilities Compared to Youth without Intellectual/Developmental Disabilities

There is evidence in the literature that youth with intellectual/developmental disabilities (IDD) experience mental health issues to a greater extent compared to youth without IDD. In addition, transition from pediatric to adult services may be a period of increased anxiety and mental health problems for these youth. This study used a retrospective cohort design using population level administrative health data to compare mental health diagnoses between youth with IDD and youth without IDD; particularly examining the period when youth transition from pediatric health services to adult health services. In addition, this study compared the mental health of youth with various types of IDD (Down syndrome, autism, fetal alcohol syndrome and other rarer diagnoses). Results showed that at the population level youth with IDD have greater odds of anxiety/depression or psychotic illness than youth without IDD. Adjusted odds of anxiety/depression or psychotic illness also varied with age, income level, sex, and type of IDD. Youth with fetal alcohol syndrome had the greatest odds of both anxiety/depression and a psychotic illness. Odds of anxiety/depression increased from age 15-19 years old. Odds of a psychotic illness increased from age 15 to age 24 years old.

Young adults with intellectual and developmental disabilities who participate in Special Olympics are less likely to be diagnosed with depression

PURPOSE

People with intellectual and developmental disabilities (IDD) experience high rates of depression. Evidence indicates that physical activity, or participation in a sports club, in a supportive social environment has mental and physical health benefits. Adults with IDD, on average, engage in low levels of physical activity. The purpose of this study was to compare the rates of depression among young adult Special Olympics participants with IDD compared to non-participants with IDD.

METHODS

This was a 20-year retrospective cohort study of young adults (19-29 years) with IDD in the province of Ontario, Canada that compared rates of depression among Special Olympics participants (n = 8710) to non-participants (n = 42,393) using administrative health databases housed at ICES (formerly the Institute for Clinical Evaluative Sciences). Using cox proportional hazard models, the crude hazard ratios were calculated for the association between each independent variable and the dependent variable.

RESULTS

After controlling for other variables, the hazard rate for depression among Special Olympics participants compared to the hazard rate for depression among non-participants generated an adjusted hazard ratio of 0.51. Over the 20-year follow-up, the participants were 0.51 times as likely to develop depression as non-participants; this represents a 49% reduction in risk among Special Olympics participants. This result was statistically significant and represents a medium effect size.

CONCLUSION

Future research is needed on how much of this risk reduction is related to a physiological response to physical activity/exercise, and how much is related to the social connectedness of being part of a group participating in Special Olympics.

Co-Occurring Mental Illness and Behavioral Support Needs in Adults with Intellectual and Developmental Disabilities

People with intellectual and developmental disabilities (IDD) have higher incidences of mental health conditions and behavioral support needs than people without IDD but may not receive needed care from community providers. We examined rates of co-occurring conditions in a representative sample of adults with IDD who use state funded services in Virginia. Using data from two datasets, we identified four categories of mental health and behavioral conditions. We used these categories to examine differences in individual- and system-level factors in people with and without co-occurring conditions. We found high rates of co-occurring conditions in our sample. We found important disability factors and system-level characteristics that were associated with having a diagnosed mental health condition or behavioral support needs. Differing patterns of diagnosis and treatment for co-occurring conditions suggests more work needs to be done to support people with IDD and co-occurring mental health conditions living in the community.

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.

Psychiatric Presentations and Medication Use in Older Adults With Intellectual and Developmental Disabilities

OBJECTIVE

Adults with intellectual and developmental disabilities (IDD) are living longer, yet research about the medical and psychiatric needs of older adults still lags behind that of younger individuals with IDD. The aim of this study was to assess age-related differences in the mental health presentations of adults with IDD.

METHODS

Fully deidentified data for adults 30 years and older were extracted from the START (Systemic, Therapeutic, Assessment, Resources, and Treatment) Information Reporting System, a deidentified database housed at the Center for START Services. Caregivers and START team documents reported psychiatric diagnoses, service use, recent stressors, and challenging behaviors. t Tests, Mann Whitney U tests, χ² tests, and multinominal logistic regression models were used to compare the two age groups, 30-49 years (n = 1,188) versus 50 years and older (n = 464).

RESULTS

Older adults had more medical conditions, fewer reported psychiatric conditions, and were more likely to be taking more psychiatric medications compared to younger adults, after adjusting for demographic variables, disability level, and number of recent stressors.

CONCLUSION

Although older individuals reported fewer psychiatric diagnoses, they were more likely to take higher numbers of psychiatric medications and have more medical conditions. Clinicians and researchers ought to devote more attention to the healthcare needs of older adults with IDD, a vulnerable group exposed to polypharmacy and at risk of adverse events.

Healthcare utilisation patterns among older people with intellectual disability and with affective and anxiety diagnoses in comparison with the general population

OBJECTIVES

This study investigates specialist healthcare visits of older people with intellectual disability ID having affective and anxiety diagnoses in comparison with the general population, as well as across different levels of ID, behavioural impairment, and living in special housing in Sweden.

METHOD

The study is a retrospective national-register-based study from 2002-2012 of people with ID 55 years and older (n = 7936) and a control group the same size matched by birth year and sex from the general population at the end of study. The study groups comprised those with affective (n = 918) and anxiety (n = 825) diagnoses who visited specialist healthcare, including data about living in special housing at the end of study in 2012.

RESULTS

Older people with ID and with affective and anxiety diagnoses have a higher risk of inpatient and unplanned visits to psychiatric and somatic healthcare than the general population. The average length of stay in inpatient psychiatric healthcare was higher in older people with ID and anxiety diagnoses than in the general population. Within the ID group, more inpatient and unplanned visits were made by those with moderate and severe levels of ID, behavioural impairment, and living in special housing.

CONCLUSION

Older people with ID and affective and anxiety diagnoses are more likely to have inpatient and unplanned visits for specialist healthcare than the general population. Future research should explore the quality of healthcare services delivered by healthcare providers to older people with ID and with affective and anxiety diagnoses.

Tool development to improve medication information transfer to patients during transitions of care: A participatory action research and design thinking methodology approach

BACKGROUND

Medication changes during transitions of care is a recognized challenge that has been linked to adverse events. The delivery of medication instructions during transition from hospital to home is a priority area for improvement.

OBJECTIVE

The goals of this work were to 1) understand the current experiences of patients and families; and 2) co-design tools to improve medication information transfer during transitions of care together with patients, families, and providers.

METHODS

A participatory action approach, using mixed methods within a design thinking framework was used. Participants were chosen from patient groups at higher risk of adverse events, guided by extreme user design, which posits that needs of extreme users can also fit the majority. Providers, patients and family (users) were interviewed to understand current experiences with medication information transfer during transitions of care and to solicit input on potential elements to inform tool design. Users were engaged in iterative creation of prototypes.

RESULTS

A total of 116 patients, family caregivers, and providers were engaged throughout this project. Findings highlighted challenges currently experienced, strengthening the case for tools that engage the patient and family in medication information transfer. Important information included why medications were prescribed, how to take them, side effects, and an explanation of the role of community pharmacists. Displaying information in a grid format was preferred. Two tools were prototyped: (1) A Medication Whiteboard for engaging patients and families in creating their medication routine, and (2) A Patient Oriented Medication List for providing medication instructions and as a reference once patients are home.

CONCLUSIONS

Through the use of mixed methods within a design thinking framework, the team was able to understand the challenges and design prototypes of tools that both engage patients and families in developing their medication routine and improve medication information transfer during transitions of care.

Predictors of Mental Health Crises Among Individuals With Intellectual and Developmental Disabilities Enrolled in the START Program

OBJECTIVE

Individuals with intellectual and developmental disabilities disproportionately use emergency psychiatric services compared with their neurotypical peers, suggesting that such individuals and their supports are at increased risk for crisis events. This prospective study examined the timing, outcomes, and predictors of mental health crises for this population.

METHODS

The data came from Systemic, Therapeutic, Assessment, Resources, and Treatment (START), a national model that provides mental health crisis services for those with intellectual and developmental disabilities in the United States. The study included 1,188 individuals from four U.S. regions enrolled between 2018 and 2019. The outcome was urgent crisis contacts with the START program. Baseline and clinical predictors were examined with multivariate regression analyses.

RESULTS

More than a quarter had at least one crisis contact, and 9% had three or more. Contacts increased within the initial 3 months of START enrollment, followed by a steep drop-off thereafter; few contacts happened after 1 year. Almost 45% of the contacts occurred after hours, and 30% involved police. Clinical factors predicted crisis contact most robustly, followed by lack of occupational supports. After START crisis intervention, 73% of individuals remained in their primary setting.

CONCLUSIONS

For individuals with intellectual and developmental disabilities and mental health needs, crisis stabilization resources are needed, including after hours. Results clearly identify times and risk factors for mental health crisis contacts, including frequent involvement with emergency responders. Importantly, gainful employment conveyed benefits for community stabilization. Findings may be leveraged to develop effective mental health crisis intervention services and supports for this underserved group.

Stakeholder-driven approach to developing a peer-mentoring intervention for young adults with intellectual/developmental disabilities and co-occurring mental health conditions

BACKGROUND

Young adults with intellectual/developmental disabilities and co-occurring mental health conditions (IDD-MH) experience significant mental health disparities. Barriers to services include transportation and stigma associated with services. Peer mentoring (PM) may be one solution to these barriers.

METHODS

We conducted exploratory research to develop a PM intervention for young adults with IDD-MH by partnering with 3 young adults with IDD-MH and a seven-member advisory board. In addition, we conducted focus groups with mental health clinicians (n = 10), peer providers (n = 9), and transition specialists (n = 20) to identify the desired PM outcomes and features and content that may facilitate these outcomes.

RESULTS

Prioritized outcome: identifying and utilizing leisure activities as coping strategies. PM features: mentors should use relationship- and outcome-driven actions to operationalize a mentee-centred approach. Features and content considerations: safety, mentor matching, degree of structure, mentor training and support, and collaboration with mentees' support teams.

DISCUSSION

Findings are aligned with previous research on PM.

Specialist psychiatric health care utilization among older people with intellectual disability - predictors and comparisons with the general population: a national register study

BACKGROUND

People with intellectual disability (ID) face considerable barriers to accessing psychiatric health care, thus there is a risk for health disparity. The aims of the present study were 1) to compare specialist psychiatric health care utilization among older people with ID to that with their age peers in the general population, taking into account demographic factors and co-morbidities associated with specialist psychiatric health care utilization and 2) to determine a model for prediction of specialist psychiatric health care utilization among older people with ID.

MATERIAL AND METHODS

We identified a national cohort of people with ID (ID cohort), aged 55+ years and alive at the end of 2012 (n = 7936), and a referent cohort from the general population (gPop cohort) one-to-one matched by year of birth and sex. Data on utilization of inpatient and outpatient specialist psychiatric health care, as well as on co-morbidities identified in either psychiatric or somatic specialist health care, were collected from the National Patient Register for the time period 2002-2012.

RESULTS

After adjusting for sex, age, specialist psychiatric health care utilization the previous year, and co-morbidities, people in the ID cohort still had an increased risk of visits to unplanned inpatient (relative risk [RR] 1.95), unplanned outpatient (RR 1.59), planned inpatient (RR 2.02), and planned outpatient (RR 1.93) specialist psychiatric health care compared with the general population. Within the ID cohort, increasing age was a predictor for less health care, whereas psychiatric health care the previous year predicted increased risk of health care utilization the current year. As expected, mental and behavioral disorders predicted increased risk for psychiatric health care. Furthermore, episodic and paroxysmal disorders increased the risk of planned psychiatric health care.

CONCLUSIONS

Older people with ID have a high need for psychiatric specialist health care due to a complex pattern of diagnoses. Further research needs to investigate the conditions that can explain the lesser psychiatric care in higher age groups. There is also a need of research on health care utilization among people with ID in the primary health care context. This knowledge is critical for policymakers' plans of resources to meet the needs of these people.

The occurrence of comorbidities with affective and anxiety disorders among older people with intellectual disability compared with the general population: a register study

BACKGROUND

Little is known regarding the burden of comorbidities among older people with intellectual disability (ID) who have affective and anxiety disorders. Therefore, we aimed to investigate the occurrence and risk of psychiatric and somatic comorbidities with affective and/or anxiety disorders in older people with ID compared to the general population.

METHODS

This population study was based on three Swedish national registers over 11 years (2002-2012). The ID group was identified in the LSS register, which comprises of data on measures in accordance with the Act Concerning Support and Service for Persons with Certain Functional Impairments (n = 7936), and a same-sized reference cohort from the Total Population Register was matched by sex and year of birth. The study groups consisted of those with affective (n = 918) and anxiety (n = 825) disorder diagnoses. The information about diagnoses were collected from the National Patient Register based on ICD-10 codes.

RESULTS

The rate of psychiatric comorbidities with affective and anxiety disorders was approximately 11 times higher for people with ID compared to the general reference group. The two most common psychiatric comorbidities occurred with affective and anxiety disorders were Unspecified non-organic psychosis and Other mental disorders due to brain damage and dysfunction and to physical disease (8% for each with affective disorders and 7 and 6% with anxiety disorders, respectively). In contrast, somatic comorbidity comparisons showed that the general reference group was 20% less likely than the ID cohort to have comorbid somatic diagnoses. The most commonly occurring somatic comorbidities were Injury, poisoning and certain other consequences of external causes (49 and 47% with affective and anxiety disorders, respectively) and Signs and symptoms and abnormal clinical and laboratory findings not elsewhere classified (44 and 50% with affective and anxiety disorders, respectively).

CONCLUSION

Older people with ID and with affective and anxiety diagnoses are more likely to be diagnosed with psychiatric comorbidities that are unspecified, which reflects the difficulty of diagnosis, and there is a need for further research to understand this vulnerable group. The low occurrence rate of somatic diagnoses may be a result of those conditions being overshadowed by the high degree of psychiatric comorbidities.

Rate and characteristics of urgent hospitalisation in persons with profound intellectual disabilities compared with general population

BACKGROUND

Little is known about the hospitalisation rate of adults with severe/profound intellectual disability (PID) presenting at emergency services or about the appropriateness of hospital admissions in this population. Examining the possible differences in the patterns of hospitalisation between people with PID and those without intellectual disability (ID) may shed light on aspects of health and illness in these patients and may in turn make it possible to differentiate more clearly between mild-moderate ID and PID.

METHODS

After an evaluation of the emergency visits made by adults with PID and by people without ID, patients in both groups requiring one or more hospitalisations were subsequently followed up for 18 months. The appropriateness of the decision to hospitalise was assessed using the ambulatory care-sensitive conditions index.

RESULTS

There were no differences in the proportion of people with PID and controls admitted to hospital after their emergency visit. The median hospital stay was higher for PIDs: 7.5 vs. 4 days for controls. People with PID were admitted more than controls for respiratory reasons and somewhat less for other somatic causes unrelated to the nervous system. There were no admissions for psychiatric causes in the group with PID other than unspecified conduct disorders. There were no differences in other diagnostic groups. The rate of inappropriate admissions was similar in the two study groups.

CONCLUSIONS

In contrast to previous results reported for the group with ID as a whole, patients with PID consulting the emergency service were not admitted to hospital more frequently than the general population nor did they present a higher rate of inappropriate admissions. These results support the utility of maintaining two distinct groups of people with ID: mild-moderate and severe-profound.

Implementation and evaluation of health passport communication tools in emergency departments

BACKGROUND

People with IDD (intellectual or developmental disabilities) and their families consistently report dissatisfaction with their emergency department experience. Clear care plans and communication tools may not only improve the quality of patient care, but also can prevent unnecessary visits and reduce the likelihood of return visits.

AIMS

To evaluate communication tools to be used by people with IDD in psychiatric and general emergency departments in three different regions of Ontario.

METHODS AND PROCEDURES

Health passport communication tools were locally tailored and implemented in each of the three regions. A total of 28 questionnaires and 18 interviews with stakeholders (e.g., hospital staff, community agency representatives, families) were completed across the regions to obtain feedback on the implementation of health passports with people with IDD.

OUTCOMES AND RESULTS

Participants felt that the health passport tools provided helpful information, improved communication between patients with IDD and hospital staff, and were user friendly. Continued efforts are needed to work with communities on maintenance of this tool, ensuring all hospital staff are utilizing the information.

CONCLUSIONS AND IMPLICATIONS

These findings emphasize the merits of health passport tools being implemented in the health system to support communication between patients with IDD and health care practitioners and the importance of tailoring tools to local settings.

Utilizing health records to characterize obesity, comorbidities, and health-care services in one human service agency in the United States

US surveys report higher prevalence of obesity in adults with intellectual disability. Health records of 40 adults with intellectual disability were retrospectively reviewed for data on health status, problem lists with International Classification of Diseases, Ninth Revision codes, medication lists, and health encounters over 18 months. Mean age was 49.5 years, 53% were males. Prevalence of overweight, obese, and morbidly obese was 28%, 58%, and 23%, respectively. Primary diagnosis was intellectual disability (50% mild, 33% moderate, 10% severe, and 8% profound), 85% had mental health disorders (67.5% with affective or mood and 42.5% had anxiety disorders). On average, residents consumed 2.63 psychotropic medications daily with additional 5.75 medications for axis 3 diagnoses and made 39.2 health visits over past 18 months. Our analysis supports increased prevalence of overweight/obesity, higher comorbidities, dual psychiatric diagnosis, substantial medication consumption, and higher utilization of health-care services in adults with intellectual disabilities. Targeted health interventions are therefore essential to improve their health and quality of life.

Pain underreporting associated with profound intellectual disability in emergency departments

BACKGROUND

Little information is available regarding the visits made by persons with profound intellectual disability (PID) to general hospital emergency departments (ED). This study aims to know whether persons with PID who attend ED are given the same type of diagnoses as people with no such disability.

METHODS

Over a period of 18 months, we gathered data from all non-scheduled visits to an ED by persons with PID to identify the reason for consultation (according to the classification used by the Spanish Society for Emergency Nursing) and the final diagnosis upon discharge. The results were compared with data obtained from a control group of people with no ID who attended an ED for any reason during the same period.

RESULTS

Somatic complaints were the main reason for ED attendance among persons with PID (90% of consultations). These complaints were more often related to the central nervous system than was the case among non-ID patients (16 vs. 4.7%), whereas other kinds of non-central nervous system somatic complaint were less common among persons with PID (74 vs. 91%). A diagnosis implying physical pain was given less often to people with PID than to controls (3 vs. 20%).

CONCLUSIONS

The results suggest that persons with PID are less able to conceptualise and communicate information about their symptoms, especially as regards pain, and that this influences the diagnosis they are given when attending an ED. Professionals working in this environment need to be aware of this possibility so as not to underestimate or overlook such symptoms and the illnesses related to them.

Needs among persons with human immunodeficiency virus and intellectual and developmental disabilities in community mental health care: a cross-sectional study

BACKGROUND

The experience of having human immunodeficiency virus (HIV) is often associated with co-occurring mental health issues. Community mental health services are an important source of support for persons with HIV living in the community. Persons with intellectual disability (ID) are vulnerable to HIV and may have unique support needs beyond those without ID receiving community care. This study compared support needs of men with HIV in community mental health programmes, with and without ID.

METHODS

The sample was composed of 138 HIV-positive men with and without ID receiving mental health case management from one community organisation in Ontario, Canada, on 31 March 2013. Staff-rated needs across 16 domains grouped into four clusters were measured using the Camberwell Assessment of Need: Basic needs (accommodation, food, public transportation, money and benefits); self-care/functional needs (looking after the home, self-care and daytime activities); health/safety needs (physical health, psychological distress, psychotic symptoms, safety to self and safety to others); and social needs (company, intimate relationships and sexual expression). Adjusted logistic regression models examined the association between ID and each need domain.

RESULTS

One-quarter of the sample (n = 34/138, 24.6%) had co-occurring ID. Those with ID were more likely to have needs in the basic cluster [odds ratios: food 4.05 (1.14, 14.44), P:0.031; benefits 2.58 (1.05, 6.32), P:0.038)] and self-care/functional cluster [looking after the home (2.75 (1.17, 6.49), P:0.021); self-care (2.72 (1.18, 6.27), P:0.019)], but were less likely to have need for sexual expression: 0.35 (0.14,0.90), P:0.030) (social cluster). There were no differences in the domains in the health/safety cluster.

CONCLUSION

Despite elevated cognitive needs in the basic and self-care/functional clusters for the ID group, limited other differences suggest that with moderate additional targeting, community mental health programmes for persons with HIV may be appropriate for men with ID.

Unmet Needs of Adults in Community Mental Health Care With and Without Intellectual and Developmental Disabilities: A Cross-Sectional Study

The cross-sectional study compared the clinical and need profiles for clients with and without intellectual and developmental disabilities (IDD) in seven mental health case management programs in Toronto, Canada on March 31, 2013. Unmet needs in domains within four broad clusters were measured by staff using an internationally utilized tool, the Camberwell Assessment of Need. Among the 2560 clients, 8.3 % had a co-occurring IDD. For most assessed domains rates of unmet need were not different for persons with and without IDD. However, the IDD group had greater unmet needs for adaptive functioning/skills and cognitive needs [self-care (p = 0.023), education (p < 0.001), transportation (p < 0.001), and information on condition (p = 0.038)]. While clients with IDD and psychiatric diagnoses often receive poor quality care, in the case management programs examined their rates of unmet need were similar to individuals without IDD across most assessed domains, including in the areas of addictions and physical health care.

Caregiving for youth with co-occurring developmental disabilities and behavioral health issues when caregivers face additional health-related stressors: Analysis of risk and protective factors from a national sample

BACKGROUND

Family caregivers of youth with DD and behavioral health issues experience the highest level of caregiving strain. Many must also deal with their own or another family member's chronic health condition, which may place them at additional risk for poor outcomes.

AIMS

(1) Provide a "snapshot" of DD family caregivers based on a national sample; (2) identify risk and protective factors among groups of DD caregivers with graduated levels of health-related stressors; (3) examine the impact of risk and protective factors on strain for DD caregivers.

METHODS AND PROCEDURES

We conducted a secondary analysis of data from N=600 DD caregivers recruited through sites across the United States. Risk and protective factors were compared among three groups of caregivers at study enrollment: (1) those focused on providing care for the target youth with DD, without additional health-related stressors with which to contend; (2) those contending with minor additional health-related stressors; and, (3) those contending with major additional health-related stressors. Predictors of caregiving strain at six months post-enrollment were identified.

RESULTS

52% of the overall sample was unemployed and 71% were living at or below poverty. Differences were found among groups on a variety of risk and protective factors. With some exceptions, predictors of caregiving strain were similar to non-DD populations.

CONCLUSIONS AND IMPLICATIONS

This study provides valuable information about a population of caregivers who are highly vulnerable to poor outcomes. Findings highlight the importance of considering the needs, strengths, and outcomes of family caregivers.

Psychiatric hospitalisation among individuals with intellectual disability referred to the START crisis intervention and prevention program

BACKGROUND

Little is known about inpatient psychiatric hospitalisation among adults with intellectual disability (ID) in the United States. Greater research is, therefore, required to inform efforts aimed at preventing this costly and restrictive form of care.

METHODS

Data were from 3299 individuals with ID (mean age = 31 years; SD = 14 years) who were referred to START (Systemic, Therapeutic, Assessment, Resources, and Treatment), a community-based crisis intervention and prevention programme. A random effects logistic regression model was used to examine the association between 11 factors and caregiver report of psychiatric hospitalisation in the past 12 months.

RESULTS

Twenty eight percent of the sample had at least one psychiatric inpatient stay in the prior year. Factors associated with an increased likelihood of prior hospitalisation included: younger age, diagnosis of a psychotic disorder, a score of >30 on the irritability subscale of the Aberrant Behavior Checklist, increasing number of psychiatric diagnoses, less severe ID, Black/AA race and not having a home and community waiver.

CONCLUSIONS

Among this high-risk referred group, more than 1 in 4 individuals were hospitalised in the year prior to referral. While results from the analyses will help profile those at risk for hospitalisation, the findings suggest that interventions at the policy level may play an important role in reducing psychiatric hospitalisation.

Psychiatric care utilization among older people with intellectual disability in comparison with the general population: a register study

BACKGROUND

People with intellectual disability have been found to have higher prevalence of psychiatric disorders than the general population. However, they do not seem to have a corresponding increase in psychiatric care utilization. The aim of the present study was to investigate psychiatric care utilization among older people with intellectual disability.

METHODS

We used a cohort of people with intellectual disability, 55+ years in 2012 (n = 7936), and an equally sized age and sex matched reference cohort from the general population. Psychiatric care utilization was measured using registrations in the Swedish National Patient register during 2002-2012, where each registration corresponds to a psychiatric care occasion.

RESULTS

About 20 % of those with intellectual disability had at least one registration during the study period, compared to some 6 % in the general population sample. In the whole cohort as well as stratified by sex, people with intellectual disability were 3-4 times more likely than those in the general population sample to have had at least one registration during the study period. The effect was, however, only consistent in age groups comprising people younger than 65 years. Among people with intellectual disability, men were more likely than women to have had at least one registration, and people living in special housing (group home or service home) during the entire study period were less likely than those who only lived in special housing for parts of the study or not at all. People with intellectual disability had longer stays per inpatient registration compared with the general population sample. When stratifying on sex, the effect was found only among men, although there were no sex differences within the cohort of people with intellectual disability. Among people with intellectual disability, living in special housing during the entire study period was associated with shorter stays per inpatient registration.

CONCLUSIONS

Although people with intellectual disability had higher psychiatric care utilization than the general population during the 11 year study period, it does not correspond to the high prevalence of psychiatric disorders in this population. Future research is required to establish if the level of care utilization is appropriate among older people with intellectual disability.

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.

Acute inpatient treatment, hospitalization course and direct costs in bipolar patients with intellectual disability

To explore the impacts of intellectual disability (ID) on psychotropic medication use, length of hospital stay (LOS) and direct hospitalization costs during inpatient treatment for acute bipolar episodes, all 17,899 index hospitalizations due to acute bipolar episodes between 1998 and 2007 in Taiwan were identified from a total population health insurance claims database, amongst which 544 subjects had a concomitant diagnosis of ID. Pattern of psychotropic medication use, LOS, discharge outcome and direct costs during hospitalization were compared between bipolar patients with ID and without ID and multivariate models controlling for major cost confounders were used to explore the impacts of ID on LOS, discharge outcome and inpatient costs. The results indicated that, compared to bipolar patients without ID, bipolar patients with ID were younger, had longer LOS and received significantly lower daily equivalent dosages of antipsychotics, mood stabilizers, lithium and benzodiazepines. Significantly more bipolar patients with ID could not be discharged successfully. The longer LOS possibly reflected slower clinical stabilization, conservative use of medications and difficulty in community placement. The lower average daily reimbursements indicated that treatment of bipolar patients with ID were under-funded, whereas the higher total direct costs resulting from prolonged LOS placed greater economic straint on healthcare system. The findings support that bipolar patients with ID are clinically unique but relatively under-supported during acute hospitalization. Modifying current pharmacological intervention, health care resources allocation and community supporting structure is paramount to reducing LOS and improving hospitalization outcome.

Using administrative health data to identify individuals with intellectual and developmental disabilities: a comparison of algorithms

BACKGROUND

Individuals with intellectual and developmental disabilities (IDD) experience high rates of physical and mental health problems; yet their health care is often inadequate. Information about their characteristics and health services needs is critical for planning efficient and equitable services. A logical source of such information is administrative health data; however, it can be difficult to identify cases with IDD in these data. The purpose of this study is to evaluate three algorithms for case finding of IDD in health administrative data.

METHODS

The three algorithms were created following existing approaches in the literature which ranged between maximising sensitivity versus balancing sensitivity and specificity. The broad algorithm required only one IDD service contact across all available data and time periods, the intermediate algorithm added the restriction of a minimum of two physician visits while the narrow algorithm added a further restriction that the time period be limited to 2006 onward. The resulting three cohorts were compared according to socio-demographic and clinical characteristics. Comparisons on different subgroups for a hypothetical population of 50,000 individuals with IDD were also carried out: this information may be relevant for planning specialised treatment or support programmes.

RESULTS

The prevalence rates of IDD per 100 were 0.80, 0.52 and 0.18 for the broad, intermediate and narrow algorithms, respectively. Except for 'percentage with psychiatric co-morbidity', the three cohorts had similar characteristics (standardised differences < 0.1). More stringent thresholds increased the percentage of psychiatric co-morbidity and decreased the percentages of women and urban residents in the identified cohorts (standardised differences = 0.12 to 0.46). More concretely, using the narrow algorithm to indirectly estimate the number of individuals with IDD, a practice not uncommon in planning and policy development, classified nearly 7000 more individuals with psychiatric co-morbidities than using the intermediate algorithm.

CONCLUSIONS

The prevalence rate produced by the intermediate algorithm most closely approximated the reported literature rate suggesting the value of imposing a two-physician visit minimum but not restricting the time period covered. While the statistical differences among the algorithms were generally minor, differences in the numbers of individuals in specific population subgroups may be important particularly if they have specific service needs. Health administrative data can be useful for broad-based service planning for individuals with IDD and for population level comparisons around their access and quality of care.

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.

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.