Primary mental healthcare for adults with mild intellectual disabilities: Patients' perspectives

BACKGROUND

People with mild intellectual disabilities (MID) experience more mental health (MH) problems than the general population but often do not receive appropriate primary MH care. Primary MH care is essential in integrative MH care and, therefore, demands high quality. To improve primary MH care for this patient group, account must be taken of the experiences of people with MID. So far, their perspectives have been largely absent from primary MH care research.

OBJECTIVES

To explore patients' experiences, needs, and suggestions for improvement regarding primary MH care for people with MID.

METHODS

Qualitative study among adults with MID who visited their GP with MH problems in the previous 12 months. Semi-structured interviews were conducted using a guide based on Person-Centred Primary Care Measures. Transcripts were analysed thematically.

RESULTS

The 11 interviews that we conducted revealed four themes. The first theme, cumulative vulnerability, describes the vulnerability - instigated by the MID and reinforced by MH problems - experienced on a GP visit. The other themes (needs regarding the GP, needs regarding the network, self-determination) arise from this vulnerability.

CONCLUSION

People with both MID and MH problems are extra vulnerable in primary care but desire self-determination regarding their MH care trajectory. This requires investment in a good GP-patient relationship and the organisation of additional support to meet these patients' needs, for which collaborative care with the patient, the patient's network, and other (care) professionals is of utmost importance.

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.

Out-of-hours primary care for people with intellectual disabilities: interviews in general practice

BACKGROUND

Out-of-hours primary care for people with intellectual disabilities (ID) involves different groups of health care professionals, who are often not familiar to one another nor to the specific health care needs of this vulnerable population. It is not known to what extend these specific health care needs or organizational factors influence the delivery of out-of-hours primary care for people with ID.

OBJECTIVE

The objective of this study is to explore the experiences of health care professionals regarding the medical content and the organizational context of out-of-hours primary care for people with ID.

METHODS

Semi-structured interviews were conducted with daily care professionals, triage nurses and general practitioners (GPs) involved in out-of-hours primary care for people with ID in the Netherlands. Interviews were thematically analysed for medical content and organizational context.

RESULTS

The analysis resulted in four interconnected themes: (i) uncertainties in the triage assessment of ID patients; (ii) confusion about inter-professional responsibilities; (iii) impact on routines and workflow concerning ID patients and (iv) constraints in the decision-making process. All issues raised were related to the organizational context.

CONCLUSIONS

Health care professionals involved in out-of-hours primary care for people with ID indicate that the quality of this care is more influenced by the organizational context than by the medical content. We recommend out-of-hours GP services and care provider services for people with ID to set standards for roles and responsibilities in order to facilitate health care professionals in delivering accessible and high-quality care to this vulnerable population.

Mental health care for adults with mild intellectual disabilities: A retrospective database study

People with mild ID suffer more mental health disorders (MHD) than people without ID. Practitioners working in mental health services (MHS) indicate limited knowledge and experience to provide the care needed. Besides diagnosing MHD, identification of the ID itself is a challenge and not all people with a ID are recorded in the MHS as such. These factors contribute to insufficient care and can result in chronic, more difficult to treat MHD. For this study, all adult users of Dutch MHS between 2015 and 2017 were enrolled in MHS databases of Statistics Netherlands. Presence of mild ID was established by linking MHS data with social services and chronic care databases. Characteristics of new cases of MHC were analyzed and compared between patients with and without mild ID. Linking databases identified 11,374 MHC patients with mild ID, and 525,162 patients without ID. A substantial proportion of patients with mild ID did not have this characteristic noted in their MHS records (60.6%). Preliminary results showed people with mild ID were younger, were more often man, had different diagnostic profiles, required more crisis interventions, and more psychiatric hospital admissions compared to people without ID. In addition, people with a mild ID and no ID record in MHS received less treatment compared to both people with mild ID and a ID record, and people with no ID. According to these findings, the prevalence of MHD and provided care between people with and without a mild ID, in MHS deviated. The Mild ID is potentially under recognized among MHS patients. The findings are a first step towards improving mental healthcare for patients with ID.

What difficulties do people with mild intellectual disabilities experience when seeking medical help from their GP? A qualitative study

BACKGROUND

People with intellectual disabilities often have low health literacy as a result of their limited language comprehension. The aim of this study was to explore the difficulties Dutch people with intellectual disabilities experience during the process of considering and seeking medical help from their GP. The study was intended as input for an online intervention supporting health literacy.

METHODS

A qualitative study, in which 12 semi-structured interviews were conducted with people with mild intellectual disabilities and 4 with relatives of people with mild intellectual disabilities. The interviews were analysed following the principles of thematic analysis.

RESULTS

Difficulties were experienced in the following activities: assessing and proactively reacting to health complaints, processing health information, communicating with a GP and retaining information from the consultation. Support workers and relatives play an important role in all these activities.

CONCLUSIONS

To increase the capacity of people with intellectual disabilities to manage their health and seek care from their GP, it is important to support them in the activities they find difficult. Recommendations resulting from the study have been incorporated in an online intervention.

Priority-setting and feasibility of health information exchange for primary care patients with intellectual disabilities: A modified Delphi study

OBJECTIVE

Accurate health information exchange (HIE) is fragile in healthcare for patients with intellectual disabilities (ID), threatening the health outcomes for this patient group. In conjunction with a group of experts, we aimed to identify the principal actions and organisational factors facilitating HIE for primary care patients with ID and to assess their perceived feasibility in daily practice.

METHODS

We conducted a two-round modified Delphi study with Dutch GPs (n=22), support workers (n=18) and ID physicians (n=20). In an extensive set of 61 items covering actions and organisational factors, experts ranked items in order of importance and rated their feasibility.

RESULTS

Agreement was reached on the importance of 22 actions and eight organisational factors, of which 82% were deemed (very) feasible in daily practice. Experts stressed the importance of listed actions and factors being implemented simultaneously and remarked that further priority should be based on contextual demands.

CONCLUSION AND PRACTICE IMPLICATIONS

This study indicates the principal actions and organisational factors for HIE regarding primary care patients with ID. The set can be used as a practical guide to optimise inter-professional cooperation and arrange the distribution of HIE roles and responsibilities in relation to this patient group.

Experiences of patients with intellectual disabilities and carers in GP health information exchanges: a qualitative study

BACKGROUND

Accurate health information exchange (HIE) is pivotal for good quality of care. However, patients with intellectual disabilities (ID) face challenges in processing and exchanging health information around GP consultations. Knowledge of HIE barriers and facilitators, including the roles of carers, may help to improve GP care for people with ID.

OBJECTIVE

To gain more insight into HIE barriers and facilitators for ID patients in GP care.

METHODS

A qualitative study exploring GP consultation experiences of people with ID (n = 35), professional carers (n = 20) and relatives (n = 15). Transcripts from interviews and focus groups were analyzed using a framework analysis approach.

RESULTS

Analyses resulted in four themes: (i) Recognizing patient health needs; (ii) Impaired doctor-patient communication; (iii) Carers' mediating roles during consultations; and (iv) Patients' autonomy and self-determination. Barriers related to communication skills, lack of time, continuity of carers and physicians, information alignment between relative or professional carer and the GP, and information transfer and recording within the patient network. Facilitating factors related mainly to carer interventions, personal connections with patients and GP communication with patients and carers outside the consultation.

CONCLUSION

There is considerable HIE potential in patients themselves, as well as in their network, although many barriers have to be overcome to profit from this. GP practices are recommended to adjust consultations and communication practices and to facilitate deployment of the patient's network, while still considering patient autonomy.

Health information exchange in general practice care for people with intellectual disabilities--a qualitative review of the literature

Many barriers to the provision of general practice (GP) care for people with intellectual disabilities (ID) relate to problems in exchanging health information. Deficits in the exchange of health information may have an adverse impact on healthcare access and health outcomes in individuals with ID. The aim of this paper is to report how health information exchange (HIE) in GP care for people with ID is being described in the ID healthcare literature. Thematic analysis of 19 included articles resulted in six major themes: (1) communication skills; (2) organisational factors; (3) record keeping and sharing; (4) health literacy and self-advocacy; (5) carers and health professionals' knowledge; and (6) third parties. The results indicate that HIE takes place in a chain of events happening before, during, and after a medical consultation, depending on specific contextual care factors. The included papers lack a broad focus on the entire HIE process, and causes and effects of gaps in health information are described only marginally or on a very general level. However, a study of the HIE process in its entirety is imperative in order to identify weak links and gaps in information pathways. The themes presented here provide a starting point for an in-depth study on the HIE process in GP care for individuals with ID that may facilitate future research on health interventions in this setting.

Update on Kleefstra Syndrome

Kleefstra syndrome is characterized by the core phenotype of developmental delay/intellectual disability, (childhood) hypotonia and distinct facial features. The syndrome can be either caused by a microdeletion in chromosomal region 9q34.3 or by a mutation in the euchromatin histone methyltransferase 1 (EHMT1) gene. Since the early 1990s, 85 patients have been described, of which the majority had a 9q34.3 microdeletion (>85%). So far, no clear genotype-phenotype correlation could be observed by studying the clinical and molecular features of both 9q34.3 microdeletion patients and patients with an intragenic EHMT1 mutation. Thus, to further expand the genotypic and phenotypic knowledge about the syndrome, we here report 29 newly diagnosed patients, including 16 patients with a 9q34.3 microdeletion and 13 patients with an EHMT1 mutation, and review previous literature. The present findings are comparable to previous reports. In addition to our former findings and recommendations, we suggest cardiac screening during follow-up, because of the possible occurrence of cardiac arrhythmias. In addition, clinicians and caretakers should be aware of the regressive behavioral phenotype that might develop at adolescent/adult age and seems to have no clear neurological substrate, but is rather a so far unexplained neuropsychiatric feature.

Chromosome 1p21.3 microdeletions comprising DPYD and MIR137 are associated with intellectual disability

BACKGROUND

MicroRNAs (miRNAs) are non-coding gene transcripts involved in post-transcriptional regulation of genes. Recent studies identified miRNAs as important regulators of learning and memory in model organisms. So far, no mutations in specific miRNA genes have been associated with impaired cognitive functions.

METHODS AND RESULTS

In three sibs and two unrelated patients with intellectual disability (ID), overlapping 1p21.3 deletions were detected by genome-wide array analysis. The shortest region of overlap included dihydropyrimidine dehydrogenase (DPYD) and microRNA 137 (MIR137). DPYD is involved in autosomal recessive dihydropyrimidine dehydrogenase deficiency. Hemizygous DPYD deletions were previously suggested to contribute to a phenotype with autism spectrum disorder and speech delay. Interestingly, the mature microRNA transcript microRNA-137 (miR-137) was recently shown to be involved in modulating neurogenesis in adult murine neuronal stem cells. Therefore, this study investigated the possible involvement of MIR137 in the 1p21.3-deletion phenotype. The patients displayed a significantly decreased expression of both precursor and mature miR-137 levels, as well as significantly increased expression of the validated downstream targets microphthalmia-associated transcription factor (MITF) and Enhancer of Zeste, Drosophila, Homologue 2 (EZH2), and the newly identified target Kruppel-like factor 4 (KLF4). The study also demonstrated significant enrichment of miR-137 at the synapses of cortical and hippocampal neurons, suggesting a role of miR-137 in regulating local synaptic protein synthesis machinery.

CONCLUSIONS

This study showed that dosage effects of MIR137 are associated with 1p21.3 microdeletions and may therefore contribute to the ID phenotype in patients with deletions harbouring this miRNA. A local effect at the synapse might be responsible.