Models of Mental Health Care for Adults with Intellectual

Disabilities

Nick Bouras www.estiacentre.org

estia centre

Models F/25.09.06/VA D06

Concepts and Definitions

Broad International Mapping

Delivery of Services

Evidence based Practice

Outline

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.

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.

IntellectualDisabilities Mental Health

DualDiagnos

is

MH Problems by Level of ID

Severe ID Mild ID

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

Broad International Mapping

USA:Very few centres Complex insurance cover systems

OhioThe Rochester Crisis Intervention Model

(UAP)The Ulster County Comprehensive

Mental Health Model N.Y. UniversityThe Greater Boston START ModelMassachusetts specialised out & in

patientsThe Minnesota Model Crisis Intervention California

Canada:

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

The Toronto MATCH Project Vancouver Montreal

Australia:

Melbourne GP – Child Psychiatry led The Victorian Dual Disability Service

MMH led: specialist consultative-advisory service

Queensland: Specialist MH - GP led

Sidney: Child Psychiatry

Asia:

Institutional care

Hong Kong: Specialist MH service linked to MMH

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

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

Mainstream Vs. specialist mental health services

Admissions for assessment & treatment

Support services for people with DD

SERVICE SYSTEMS ISSUES

IndecisionAmbiguity Confusion Demands have increased Additional clinical services and resources

are not forthcomingSeveral thousand people with ID and

psychiatric disorders have been placed in

dispersed facilities out of the place of

origin

CURRENT STATE OF AFFAIRS

Diverse

Mix in expertise, staffing levels and

funding options

Predictions of service use and need vary

according local circumstances and

population profile

Patterns of services

Provided within ID services

Delivered from mainstream mental health services

Specialist MH services either within ID or mainstream MH services

DELIVERY OF CARE ISSUES FOR PWID & MH PROBLEMS

ID MMH

CIDT CMHTS

INPATIENTS

REHAB

CAMHS

MH OLDER ADULTS

FORENSIC

SUBSTANCE

MISUSE

COMMON ID SERVICE DELIVERY

CommunicationFunctional skillsChallenging behaviourSocial care

Social Services Lead Health Services Lead

MHiID (psychiatrist)

ID

CIDT

COMMON ID SERVICE DELIVERY

CommunicationFunctional skillsChallenging behaviourSocial care

Social Services Lead

MHiID (psychiatrist)

ProsProsCommissioning from ID

ConsConsMulti purpose –multi function service for a people with highly complex needsExcept psychiatrist others have little knowledge and skills for MH careIsolation - cut off from MMH/ difficult accessTry to provide MH care outside the current MH frameworkConfused as a type of CMHT/frequent disputes

CMHTS

INPATIENTS

REHAB

CAMHS

MH OLDER ADULTS

FORENSIC

SUBSTANCE MISUSE

ID MMH

ID INTERFACE WITH MMH SERVICES

CommunicationFunctional SkillsChallenging behaviourSocial care

Social Services Lead Health Services Lead

MHiID(Psychiatrist)

CIDT

ID MMH

ID INTERFACE WITH MMH SERVICES

CommunicationFunctional SkillsChallenging behaviourSocial care

Social Services Lead

MHiID(Psychiatrist)

CIDT ProsProsCommissioning from IDSome access to MMH

ConsConsMulti purpose –multi function service for a people with highly complex needsExcept psychiatrist others have little knowledge and skills for MH careTry to provide MH care outside the current MH frameworkConfused as a type of CMHT/frequent disputes

MH-ID•Outreach•Admissions

CMHTs

OLDERADULTS

CAMHS

FORENSIC

REHAB

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

AMH

SUBSTANCEMISUSE

SPECIALIST INTEGRATED MHiID SERVICE DELIVERED FROM MMH ID MMH

CMHTs

OLDERADULTS

CAMHS

FORENSIC

REHAB

AMH

SUBSTANCEMISUSE

SPECIALIST INTEGRATED MHiID SERVICE DELIVERED FROM MMH MMH

ProsSpecialist MH servicecompatible with otherMH servicesDelivered from MMH within the current frameworkNatural hubInterfaces with ID and MMHEasier access to MMHSecondary and Tertiary

ConsCommissioning?Might become a Parallel service

MH-ID•Outreach•Admissions

“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

WHAT IS THE EVIDENCE BASED PRACTICE ?

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)

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)

LEVEL OF FOCUS

TIME DIMENSION

Inputs Processes Outcomes

National

Local

ServiceUser

Resources available

‘Visible’ resourcese.g. Finances and staff

‘Invisible’e.g. staff skills, good working relationships

Policies

The activities which take place to deliver health services

AssessmentandTreatment models

Changes in morbidity and quality of life, both in the population and in individual users

TOWARDS A CONCEPTUAL FRAMEWORK: MATRIX MODEL

TOWARDS A CONCEPTUAL FRAMEWORK: MATRIX MODEL

Moss, Bouras and Holt (2000)

NATIONAL LEVEL I NPUTS

PROCESSES OUTCOMES

NFS -MH Valuing People RCPsych Laws

MH Act

Mental Capacity

Act Expenditure

Green Light

Toolkit Typology of

MHiLD

services Test new

models Apply research

to new policies

I dentif y

unrecognised

needs,at-risk,

under-served e.g

borderline,

Asperger’s Cost-

eff ectiveness I mprove quality

of lif e

Matrix Model MHiID

LOCAL LEVEL INPUTS PROCESSES OUTCOMES

Protocols f or

collaboration

between specialist

I D, residential.

day services and

GMH services,

social services &

primary care Protocols of care

co-ordination Workforce skills Budget

Review interfaces

on collaboration,

access to GMH

services and care

co-ordination Eligibility criteria

- Transition

- Forensic Case identification CPA

implementation

Appropriateness

of referrals Clinical

eff ectiveness Cost-

eff ectiveness

Matrix Model MHiID

Matrix Model MHiLDSERVICE USER LEVEL

INPUTS PROCESSES OUTCOMES

Assessment and

treatment

methods Promotion and

information

materials to

service users,

f amilies, carers

and agencies

Application of

assessment and

treatment

methods Test new

assessment

techniques Test

eff ectiveness of

treatments Advocacy groups

Fewer symptoms

and MH problems Better QoL Less carer burden Higher

satisf action with

services

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.

Coordinated and Comprehensive MH Care

A MH service system for People with ID should provide:

Full access to assessment, treatment and support servicesCoordinated, comprehensive and culturally competent delivery of serviceContinuity of careTherapeutic intervention supported by evidence based practicesPharmacological treatment based on efficacySupport services for housing, employment when ever possible and leisure activitiesAssist in improving independence and quality of life