Health, healthcare utilization and psychiatric disorder in people with intellectual disability in Taiwan

Objectives The aims of the present study were to examine health characteristics and healthcare utilization in relation to people with intellectual disability (ID) having psychiatric disorders in Taiwan. Methods A cross-sectional study was employed; study subjects were recruited from the National Disability Registration Database. Taiwan, stratified by administrative geographical area for the study. Statistical analysis of 1026 carers for people with ID was made to examine the health status and healthcare utilization of individuals with ID having psychiatric disorders. Results Approximately 12.1% of people with ID had psychiatric disorders. These individuals were more likely to be poorer in health condition and consuming more medical services (in the outpatient, inpatient and emergency care areas), than those individuals without psychiatric disorders. These individuals with psychiatric disorders were also taking medicines regularly at a far greater percentage than did those without psychiatric disorders. Conclusions Given the high prevalence of psychiatric disorders among individuals with ID, the healthcare system should take further steps to develop an appropriate health status monitoring system and community-based and easily accessible mental health services for them.     

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.     

The trajectory of psychiatric disorders in young people with intellectual disabilities

OBJECTIVE: This study addresses the question of how prevalence and patterns of psychiatric disorder change from childhood to adolescence in young people with intellectual disability (ID). METHOD: A representative epidemiological sample of 582 young people with ID aged 4-19 years was surveyed in 1991-1992 and again in 1995-1996. The main measure of psychiatric disturbance was the developmental behaviour checklist (DBC), a 96 item parent/carer completed questionnaire with robust psychometric properties which provided an overall score, 6 subscale or syndrome measures of psychiatric disturbance and determined caseness. RESULTS: The findings confirmed that about 40% of young people with ID had psychiatric disorders which persisted over 4 years. Clinically significant change in symptoms with either deterioration or improvement occurred in around 14% of the sample. CONCLUSION: Psychiatric disorder is 3-4 times more prevalent in young people with ID than in the general population. Less than 10% of these young people receive specialist services for a problem which is numerically as large as schizophrenia.     

Use of psychiatric services by the elderly in Canada

There is increasing emphasis on identifying mental disorders in the elderly and developing appropriate mental health services. However, there are few quantitative studies on service use by the elderly. This paper gives a national perspective on the use of psychiatric services by the aged in Canada, and details two of the health care studies used to assess their mental health needs in southern New Brunswick. The elderly now make up a higher proportion of the long-term mental hospital population than they did 20 years ago. Despite the increase in number of short-stay general hospital psychiatric units, there are still marked differences in their use by the elderly. There is a marked decrease in short-term psychiatric in-patient care after the sixth decade. As well there are marked regional variations. The results of a Level of Care Survey in a New Brunswick mental hospital shows the discrepancies between the needs for care and the level of care actually received. In comparison with other patient sub-groups, elderly long-stay mental hospital patients had the highest proportion (79%) deemed suitable for care in alternative settings outside the hospital. The anonymized merged statistical file revealed that the elderly mentally ill were more likely to be identified and cared for within non-specialized wards of general hospitals, and least likely to have contact with mental health clinics. Instead of adding new services to the existing system, reallocation and redirection of existing resources are crucial strategies in improving the mental health services for the elderly. The general hospital is an important area for psychiatric consultation and back-up to primary care services.     

General psychiatric services for adults with intellectual disability and mental illness

BACKGROUND: Adults with intellectual disability (ID) and mental illness may use general or specialist psychiatric services. This review aims to assess if there is evidence for a difference in outcome between them. METHODS: A literature review was conducted using a variety of electronic databases and hand-search strategies to identify all studies evaluating the outcome of people with ID and mental illness using general psychiatric services. RESULTS: There is no conclusive evidence to favour the use of general or specialist psychiatric services. People with ID stay less time on general psychiatric than specialist inpatient units. People with severe ID appear not to be well served in general services. Older studies of inpatient samples suggest a worse outcome for people with ID. Novel specialist services generally improve upon pre-existing general services. Assertive outreach in general services may preferentially benefit those with ID. Recent studies suggest similar lengths of stay in general psychiatric beds for people with and without ID. CONCLUSIONS: Although 27 studies were located, only two were randomized controlled trials. The evidence is poor quality therefore further evaluation of services employing a variety of designs need to be employed to give more robust evidence as to which services are preferred.     

Healthcare needs of people with intellectual disability in institutions in Taiwan: outpatient care utilization and implications

Background The present study assessed the outpatient care use of people with intellectual disability (ID) in order to identify patterns of healthcare needs and the factors affecting this utilization. Methods The primary method used in this study was a cross‐sectional survey of 1390 subjects with ID in Taiwan. Data were obtained from questionnaires completed at 30 registered institutions caring for people with ID. Results The findings show that people with ID in Taiwan are likely to make more outpatient visits per year than members of the general population. The prevalence of illness in people with ID was 41%, with epilepsy being the most frequently reported disease. A total of 39.5% of individuals with ID took medicine regularly, and 38.9% had used alternative forms of medication besides Western medicine. In terms of the use of outpatient facilities by people with ID, paediatric clinics were the most frequently utilized. The average monthly number of outpatient visits per person with ID was 2.18 (around 26 visits per year). This study found that the need for outpatient care is determined by a variety of factors relating to: the age of people with ID, the type of handicap, the place of medical treatment, having a family physician, the accessibility of medical care, the time‐consuming nature of the medical visits, having an illness, ID accompanied with other disabilities, and finally, a need for rehabilitative care. Conclusions From the examination of the expressed needs of people with ID, it was found that these individuals have a heightened need for healthcare and the treatment of special diseases/disorders in comparison to members of the general population in Taiwan. Within the context of ordinary services, it is particularly important to have a precise view of the ways in which the health needs of people with ID are different from the general population as a whole. This will enable healthcare services to respond to these needs, either through support systems within generic care or, in some cases, through the delivery of specific healthcare through specialized services which are kept separate from generic care.     

Occurrence of mental health problems in Swedish samples of adults with intellectual disabilities

Abstract. Objective: The aim of this study was to investigate the occurrence of mental health problems in adults with intellectual disabilities (ID) and the number of adults with ID receiving care at general mental health clinics. Method: The Reiss Screen for Maladaptive Behaviour and the Psychopathology Inventory for Mentally Retarded Adults were used to investigate mental health problems in samples from two Swedish counties. Adults with ID receiving psychiatric care at general mental health clinics were investigated via the mental health services register in one county. Results: The overall occurrence of mental health problems in adults with ID ranged from 34 % to 64%. The most common mental health problems were aggressive, self-injurious behaviours, signs of depression, anxiety or adjustment problems. The occurrence of adults with ID among patients receiving out- or in-patient psychiatric care was approximately 1%. Between 70 % and 90% of these persons had a mild level of ID. Conclusion: The overall occurrence of mental health problems was similar to reported overall figures in comparable studies conducted in the US, UK and Denmark. The number of adults with ID registered for out- or in-patient psychiatric care was low compared with the occurrence of mental health problems based on the screening results.     

A prospective case control study of psychiatric disorders in adults with epilepsy and intellectual disability

Purpose: No study to date has prospectively investigated the impact of epilepsy on psychiatric disorders among adults with an intellectual disability (ID). This study aimed to determine prospectively the influence of epilepsy on the development of psychiatric disorders in adults with ID. Method: Psychiatric symptoms were measured prospectively over a 1‐year period among 45 adults with ID and active epilepsy and 45 adults with ID without epilepsy, matched on level of ID. The 1‐year incidence rate (IR) of commonly occurring Axis 1 psychiatric disorders was compared with and without controlling for possible confounding factors. Total psychiatric symptom scores over the period were compared between the two groups using repeated‐measures analysis of covariance. Key Findings: Adults with epilepsy and ID had a more than seven times increased risk for developing psychiatric disorders, particularly depression and unspecified disorders of presumed organic origin, including dementia, over a 1‐year period compared to those with ID only. Comparison of the psychiatric scores showed the epilepsy group to have significantly higher unspecified disorder and depression symptom scores. Significance: The findings point to an increased risk of depression and unspecified disorders, including dementia, among adults with ID and epilepsy. Further exploration of the nature and treatment of these unspecified disorders may help the care of people with epilepsy and ID.     

Reliability and validity of the SPAID-G checklist for detecting psychiatric disorders in adults with intellectual disability

SPAID (Psychiatric Instrument for the Intellectually Disabled Adult) is the first Italian tool-package for carrying out psychiatric diagnosis in adults with Intellectual Disabilities (ID). It includes the “G” form, for general diagnostic orientation, and specific checklists for all groups of syndromes stated by the available classification systems. SPAID was established to provide an easy and quick tool for daily practice of the personnel working with ID. The present study was aimed at evaluating psychometric and psychodiagnostic characteristics of the SPAID-G and at supplying new data on the prevalence rate of psychiatric disorders in a multicentric Italian sample of people with ID living in different settings. The SPAID-G was randomly applied to 304 participants with ID attending residential facilities or assessment services across Italy. A part of the sample was also consecutively assessed through the use of DASH, PDD-MRS and by the clinical application of the DSM-IV TR criteria. The correlation between SPAID-G scores and those provided by other evaluation tools was over 60%. Additionally, the internal consistency and inter-rater reliability resulted to be good. Psychopathological symptoms were detected in approximately 40% of the sample. Respectively, autistic spectrum disorders, impulse control disorders, mood disorders, and dramatic personality disorders were the diagnostic orientations providing the most prevalent over-threshold scores. SPAID-G seems to be a valid diagnostic tool, quick and easy to use in psychiatric disorders assessment within the Italian population with ID.     

Utilization of psychiatric in-patient care among new patients in a comprehensive community-care system: a 3-year follow-up study

Utilization of psychiatric in-patient care among 537 new patients was studied in the Department of Psychiatry in Oulu, Finland, during a 3-year follow-up period. Hospitalization during the second and third years of the follow-up was predicted by hospitalization and number of emergency out-patient contacts during the first year of the study, diagnosis of functional psychosis or personality disorder, and previous in-patient care. In total, 5% of the cohort fulfilled our criteria for ‘revolving-door’ patients. The ‘revolving-door’ phenomenon was associated with in-patient care at the first contact with the psychiatric services and diagnosis of psychosis or personality disorder. In total, 2% of the cohort became long-stay hospital patients, and this was predicted by psychosis diagnosis. The clinical implications of these findings are that increased attention should be paid to the first assessment of new patients and to the interaction between psychiatric services and patients during the first year of care.     

Psychometric evaluation of a Dutch version of the Mini PAS‐ADD for assessing psychiatric disorders in adults with different levels of intellectual disability

Background People with intellectual disabilities (ID) have an increased vulnerability to develop psychiatric problems. Moreover, the early recognition and the accurate diagnosis of psychiatric disorders in the population of persons with ID are challenging. Method A Dutch version of the Mini PAS‐ADD, which is a screening instrument for identification of mental health problems in people with ID, was evaluated in terms of internal consistency, interinformant reliability, item grouping and criterion validity based on a large‐scale random sample (n = 377) and a clinical sample (n = 99) of adults with ID. Results The Dutch version of the Mini PAS‐ADD showed moderate internal consistency, and moderate concordance among informants. Both aspects of the reliability were comparable for different levels of ID. A factor analysis largely confirmed the scale structure. Concurrent validity with the Reiss Screen for Maladaptive Behavior was high for the Depression, Psychosis and Autism scale. The outcome of the criterion‐validity analysis indicated high specificity. The sensitivity for specific psychiatric disorders by the corresponding scales was moderate, but the general sensitivity for the presence of psychopathology on the basis of any of the scales was satisfying. Conclusions The present research reconfirmed the use of the Mini PAS‐ADD as a primary screening device for the identification of mental health problems among people with ID.     

Utility of the Brief Symptom Inventory (BSI) in psychiatric outpatients with intellectual disabilities

Background Diagnostics and care for people with intellectual disabilities (ID) and psychiatric disorders need to be improved. This can be done by using assessment instruments to routinely measure the nature and severity of psychiatric symptoms. Up until now, in the Netherlands, assessment measures are seldom used in the psychiatric care for this population. The objective of the present paper is to evaluate the use of the Brief Symptom Inventory (BSI), a widely used standardised questionnaire in general psychiatry, in a well‐defined sample of people with borderline intellectual functioning or mild ID diagnosed with one or more psychiatric disorders. Methods A total of 224 psychiatric outpatients with either borderline intellectual functioning or mild ID participated in this study. All participants were new patients of Kristal, Centre for Psychiatry and Intellectual Disability in the Netherlands, in the period between 1 April 2008 and 1 October 2009. All participants were assessed by a multidisciplinary team, including a certified psychiatrist. Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV‐TR) criteria were applied. The mean total intelligence quotient was measured with the Wechsler Adult Intelligence Scale (WAIS‐III). The BSI was administered in an assisted fashion. Utility and psychometric properties of the BSI were investigated. Internal consistency coefficients (Cronbach's alphas) were computed. Bivariate correlations between the sub‐scales were computed to assess differentiation between the scales. Mean sub‐scale scores were compared between different DSM‐IV‐TR subgroups to investigate the discriminant abilities of the scales. A confirmatory factor analysis was conducted. Results The results suggest that the BSI is practically useful. Internal consistencies ranged from 0.70 to 0.96 and thus are considered good to adequate. Sub‐scale inter‐correlations showed there is a degree of differentiation between the sub‐scales. Discriminant validity was shown for the sub‐scales depression, anxiety and phobic anxiety. Confirmatory factor analysis showed that the underlying structure of the BSI could be described by the same nine‐factor model as reported in previous studies. Conclusions As a result of the psychometric properties illustrated, this study supports the use of the BSI as a screener for psychopathology and a general outcome measure in people with ID.     

The relationship between psychiatric and physical health in elderly people with intellectual disability

Elderly people with intellectual disability have high rates of both psychiatric and physical disorders. In the elderly general population, these disorders are known to be associated. Whether such an association exists amongst elderly people with intellectual disability is unclear, but the resolution of this question is of clinical as well as academic importance. Psychiatric and physical assessments were completed on 134 people with intellectual disability aged 65 years and over (93.7% of the ascertained population living in Leicestershire, UK). The relationship between the two disorders was statistically examined. The number of physical disorders, age, level of intellectual disability and smoking status were retained in the logistic regression equation which predicted caseness for dementia in 79.9%. Similar statistical modelling for psychiatric disorders (other than dementia) retained the level of intellectual disability as the only explanatory variable in the equation. These results differ from the elderly general population, but are in keeping with the one previous intellectual disability study. In view of the poor use of general medical services by elderly people with intellectual disability, knowledge of such comorbidity should alert psychiatrists to the need for physical assessments in order to optimize health.     

Duration of inpatient treatment of various psychiatric disease categories. A follow-up study]

The frequency and duration of in-patient treatment in psychiatric and general hospitals was observed over an average 14-year period for 328 patients with different psychiatric diseases. Schizophrenics were more frequently admitted and spent longer in psychiatric institutions than all other diagnostic groups, but were admitted less frequently and for shorter periods to general hospitals. Patients suffering from organic mental illness and those with neurotic disorders had more frequent and longer periods of general hospital care. Drug dependent and neurotic patients were hospitalised more frequently and longer for psychiatric rather than for medical reasons in general hospitals. The total frequency and duration of psychiatric in-patient treatment was distinctly less frequent and of shorter duration for neurotic disorders as compared with schizophrenic or affective psychoses.     

Epidemiology of psychiatric disorders in Finland A five-year follow-up

Summary This study reports a five-year follow-up of a random population sample consisting of 1000 persons, who initially underwent a fairly thorough psychiatric examination. The method used at the follow-up consisted of a mail inquiry, the collection of recorded information and, for a certain proportion of the subjects, a psychiatric interview. The factors studied were the prevalence and incidence of psychiatric disorders, recovery and improvement, need for treatment and utilization of treatment services in the population. The total prevalence of psychiatric disorders was 294 per 1000, and the annual incidence 15.2 per 1000. The incidence was found to be associated with certain socio-demographic variables. A need for psychiatric treatment was found in a total of 11.4% of the subjects; in addition, 18.6% were assessed as needing supportive measures. Over the five-year period psychiatric treatment had been received by a total of 18% of the subjects. The most common provider of treatment had been the general practitioner. Psychiatric hospital care during the follow-up period had been received by 3.9% of the subjects.     

The relationship between autism and psychiatric disorders in Intellectually Disabled Adults

Intellectual Disability (ID) shows a high comorbidity with psychiatric disorders with a great variability in the prevalence rates. An important subgroup is represented by subjects with ID and autism or other autistic spectrum disorders (PDD). The purpose of the present study was to assess PDD with specific screening tools in a population of people with ID and compare the groups with or without PDD through the administration of a psychopathological scale in order to verify the differences of psychiatric disorders’ rates. The study was conducted on 90 subjects attending daily centres or residential centres in Florence, Italy. In order to assess the presence of PDD, the PDD-MRS was administrated, while for the assessment of the psychopathological aspects we have used the DASH-II. The presence of a psychiatric disorder has a significant effect on anxiety, depression and organic syndromes and statistically significant differences have been registered in many DASH-II subscales. The statistical comparison between the two groups shows that PDD was clearly correlated with an increased presence of psychiatric disorders. The variable PDD could be considered as a vulnerability factor for psychiatric disorders. However there was still the need to focus on categorical diagnoses, in order to increase our knowledge about the concept of vulnerability in people with ID.     

A systematic study of mental health services utilization by homeless men and women

Summary Psychiatric illness is overrepresented among the homeless, but mental health services are underutilized in this population in proportion to their needs. The current study was concerned with 900 homeless men and women randomly sampled and systematically interviewed with the Diagnostic Interview Schedule; it focuses on psychiatric and substance abuse rehabilitation service patterns and stated needs of this population in relation to specific psychiatric disorders. Although rates of lifetime treatment utilization were fairly high in comparison with general population utilization patterns, rates of treatment in the current year were low. In particular, outpatient services have been neglected for reliance upon inpatient services. Although the major reason cited for not obtaining treatment by homeless persons with mental illness was lack of insurance and inability to pay for it, having health insurance was not associated with mental health services utilization, nor were other important predictors apparent. Mental health professionals serving mentally ill homeless populations would best serve them by focusing on creative and innovative ways to improve the availability and attractiveness of ambulatory care services.     

The Nordic Comparative Study on Sectorized Psychiatry: patients who use only psychiatric in-patient care in comprehensive community-based services — a 1-year follow-up study

In the present paper a sample of patients using psychiatric in-patient care only is characterized and analysed with regard to characteristics of the psychiatric services. This paper forms part of the Nordic Comparative Study on Sectorized Psychiatry, designed to investigate contact rates and use of psychiatric care by new patients in 7 catchment areas in 4 Nordic countries during a 1-year follow-up. One-year treated incidence cohorts were used. The logistic regression analysis revealed that the variable ‘psychiatric service’ was one of the statistically significant determinants of using only in-patient care during the follow-up. The diagnostic groups with the highest probability of using only in-patient care were dependencies and functional psychoses. The following factors were associated with a high risk of using only in-patient care: older age, being referred by another psychiatrist, having received previous psychiatric in-patient care, male sex, being retired, and not living with one's parents or a partner. Patients who used only inpatient care had fewer admissions and days in in-patient care than others during the 1-year follow-up period. Lack of 24-hour emergency services in out-patient care correlated positively with the use of only in-patient care.     

Use of health care services and costs of psychiatric disorders among National Health Insurance enrollees in Taiwan

The National Health Insurance (NHI) database in Taiwan was used to detect the use of health care services and the costs of psychiatric disorders among NHI enrollees. Data were analyzed for 126,146 enrollees. Four categories were used for enrollees: no psychiatric disorder, a minor psychiatric disorder, a major psychiatric disorder without catastrophic illness registration, and a major psychiatric disorder with catastrophic illness registration (which eliminates copayments). Compared with enrollees with a minor psychiatric disorder, those with a major psychiatric disorder, either with or without catastrophic illness registration, had higher use and costs of mental health care services. Compared with enrollees without a psychiatric disorder, those with a minor psychiatric disorder or a major psychiatric disorder without catastrophic illness registration had higher use and costs of non-mental health care services. Both the mental and general health care of persons with psychiatric disorders are important.     

Prevalence of psychiatric disorders in children and adolescents with and without intellectual disability

Background There have been very few population‐based studies of the prevalence of psychiatric disorders among children and adolescents with and without intellectual disability (ID). Methods Secondary analysis of the 1999 Office for National Statistics survey of the Mental Health of Children and Adolescents in Great Britain was performed. This survey collected information on a multistage, stratified, random sample of 10 438 children between 5 and 15 years of age across 475 postcode sectors in England, Scotland and Wales. Results The prevalence of any diagnosed ICD‐10 disorder, conduct disorder, anxiety disorder, hyperkinesis and pervasive developmental disorders were significantly greater among children with ID than among their non‐ID peers. There were no statistically significant differences between children with and without ID with regard to the prevalence of depressive disorders, eating disorders or psychosis. Factors associated with an increased risk of psychopathology among children and adolescents with ID included age, gender, social deprivation, family composition, number of potentially stressful life events, the mental health of the child's primary carer, family functioning and child management practices. Conclusions Children and adolescents with ID are at significantly increased risk of certain forms of psychiatric disorder. Careful consideration of the social and economic adversity facing such families will be necessary to ensure that support services are responsive to both the needs of child as well as the needs of the family in which they are living.