Models of Mental Health Care for Adults with Intellectual Disabilities

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Models of Mental Health Care for Adults with
Intellectual Disabilities Nick Bouras
www.estiacentre.org
Models F/25.09.06/VA D06
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Outline

• Concepts and Definitions
• Broad International Mapping
• Delivery of Services
• Evidence based Practice

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Concepts

• Mental health problems indicate the presence of
  psychopathology symptoms, signs or abnormal
  traits
• This approach encompass both significant
  behaviours and clusters of symptoms occurring as
  part of a mental illness
• Challenging behaviour is determined by a
  combination of what the person does, the setting
  in which they do it and how their behaviour is
  interpreted.

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Operational Definitions

• Psychiatric Disorders in people with ID include a
  spectrum of problems ranging from depression,
  anxiety, psychosis, personality disorders and any
  psychiatric diagnosis as described in the
  international classification systems ICD-10 and
  DSM IV.
• Some also include serious behavioural
  problems/challenging behaviours requiring
  psychiatric intervention because of their
  intensity and or risks related the person with ID
  or others.

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MH Problems by Level of ID
Severe ID
Mild ID
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Implications of Dual Diagnosis

• Research has identifies 3 consistent findings
• Co-occurrence is common
• Associated with a variety of negative outcomes
  e.g. hospitalisation, exclusion from habilitation
  programmes etc.
• Ineffective and fragmented service systems and
  delivery of care

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Broad International Mapping

• USA
• Very few centres
• Complex insurance cover systems
• Ohio
• The Rochester Crisis Intervention Model (UAP)
• The Ulster County Comprehensive Mental Health
  Model
• N.Y. University
• The Greater Boston START Model
• Massachusetts specialised out in patients
• The Minnesota Model Crisis Intervention
• California

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Canada Rapid de-institutionalisationSmall
centres individually ledLack of trained
psychiatristsMoving towards specialist MH
services

• The Toronto MATCH Project
• Vancouver
• Montreal

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Australia

• Melbourne
• GP Child Psychiatry led
• The Victorian Dual Disability
  Service MMH led specialist consultative-adviso
  ry service
• Queensland Specialist MH - GP led
• Sidney Child Psychiatry

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Asia Institutional care Hong Kong
Specialist MH service linked to MMH

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• Europe
• MEROPY study Holt et al 2001
• Institutional care
• De-institutionalisation programmes
• Dutch Regional Advisory and Consultative Service
• Emerging services in some European countries
  without clear trends yet

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MEROPE EUROPEAN PROJECT

• Implications of current policy not fully
  considered for PWID MH
• Policy separates ID MH
• Lack of clear policy guidance
• Lack of specialist training
• Lack of good quality data at clinical
  epidemiological level

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SERVICE SYSTEMS ISSUES

• Mainstream Vs. specialist mental health services
• Admissions for assessment treatment
• Support services for people with DD

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CURRENT STATE OF AFFAIRS

• Indecision
• Ambiguity
• Confusion
• Demands have increased
• Additional clinical services and resources are
  not forthcoming
• Several thousand people with ID and psychiatric
  disorders have been placed in dispersed
  facilities out of the place of origin

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Patterns of services

• Diverse
• Mix in expertise, staffing levels and funding
  options
• Predictions of service use and need vary
  according local circumstances and population
  profile

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DELIVERY OF CARE ISSUES FOR PWID MH PROBLEMS

• Provided within ID services
• Delivered from mainstream mental health services
• Specialist MH services either within ID or
  mainstream MH services

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COMMON ID SERVICE DELIVERY
ID
MMH
CIDT
CMHTS INPATIENTS REHAB CAMHS MH OLDER
ADULTS FORENSIC SUBSTANCE MISUSE
Communication Functional skills Challenging
behaviour Social care

MHiID (psychiatrist)

Social Services Lead
Health Services Lead
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COMMON ID SERVICE DELIVERY
ID

• Pros
• Commissioning from ID
• Cons
• Multi purpose multi function
• service for a people with highly
• complex needs
• Except psychiatrist others have little knowledge
  and skills for MH care
• Isolation - cut off from MMH/ difficult access
• Try to provide MH care outside the current MH
  framework
• Confused as a type of CMHT/
• frequent disputes

CIDT

Communication Functional skills Challenging
behaviour Social care

MHiID (psychiatrist)

Social Services Lead
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ID INTERFACE WITH MMH SERVICES
ID
MMH
CMHTS INPATIENTS REHAB CAMHS MH OLDER ADULTS
FORENSIC SUBSTANCE MISUSE
CIDT

Communication Functional Skills Challenging
behaviour Social care


MHiID (Psychiatrist)
Social Services Lead
Health Services Lead
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ID INTERFACE WITH MMH SERVICES
ID
MMH

• Pros
• Commissioning from ID
• Some access to MMH
• Cons
• Multi purpose multi function
• service for a people with highly
• complex needs
• Except psychiatrist others
• have little knowledge and
• skills for MH care
• Try to provide MH care outside
• the current MH framework
• Confused as a type of CMHT/
• frequent disputes

CIDT

Communication Functional Skills Challenging
behaviour Social care


MHiID (Psychiatrist)
Social Services Lead
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SPECIALIST INTEGRATED MHiID SERVICE
DELIVERED FROM MMH ID
MMH

• Communication
• Functional Skills
• Challenging Behaviour
• Person Centred Planning
• Health Facilitators
• Social care

CMHTs
AMH
CAMHS

OLDER ADULTS

• MH-ID
• Outreach
• Admissions

FORENSIC

SUBSTANCE MISUSE
REHAB
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SPECIALIST INTEGRATED MHiID SERVICE
DELIVERED FROM MMH
MMH

• Pros
• Specialist MH service
• compatible with other
• MH services
• Delivered from MMH
• within the current
• framework
• Natural hub
• Interfaces with ID and
• MMH
• Easier access to MMH
• Secondary and Tertiary
• Cons
• Commissioning?
• Might become a
• Parallel service

CMHTs
AMH
CAMHS

OLDER ADULTS

FORENSIC

• MH-ID
• Outreach
• Admissions

SUBSTANCE MISUSE


REHAB
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WHAT IS THE EVIDENCE BASED PRACTICE ?

• Age of Enlightenment
• Inconclusive
• Retrospective reports
• Uncontrolled studies
• Small numbers of participants
• Few examples of systematic descriptive studies
• Service users and carers views
• Emerging in the last years

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RANDOMISED CONTROLLED TRIALS ID

• A Dutch study showed reduction in hospitalisation
  from a service provided by a Community ID Service
  (Van Minnen et al. 1997)
• Intensive case management has shown to improved
  adaptive functioning in people with ID and
  mental disorders (Coalhole et al. 1993)
• UK 700 study found that people with borderline ID
  spent less time in hospital if they received
  intensive community care (Tyrer et al. 1999)

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Recent RCTs

• Randomised controlled trial comparing the
  effectiveness of Assertive and Standard Community
  Treatment in adults with ID in terms of unmet
  needs, quality of life, symptomatology and cost
  no substantial statistical differences were found
  between the two treatments (Martin et al 2005)
• However, the results might suggest that the two
  treatments models we not that different i.e
  problems with model fidelity. Also small sample
• Similar results were reported by another parallel
  study in west London (Oliver et al. 2005)

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Matrix Model MHiID
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Matrix Model MHiID
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Matrix Model MHiLD
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The Right to Quality MH Care

• Every person with ID should have
• Access to expert assessment leading to
• Accurate and comprehensive diagnosis
• Individualised treatment plan
• Delivered at the right time and place and in the
  right amount
• Appropriate support for housing, day time
  activities, case management etc.

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Coordinated and Comprehensive MH Care

• A MH service system for People with ID should
  provide
• Full access to assessment, treatment and support
  services
• Coordinated, comprehensive and culturally
  competent delivery of service
• Continuity of care
• Therapeutic intervention supported by evidence
  based practices
• Pharmacological treatment based on efficacy
• Support services for housing, employment when
  ever possible and leisure activities
• Assist in improving independence and quality of
  life