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.     

The overweight: obesity and plasma lipids in adults with intellectual disability and mental illness

Background Previous studies in adults with intellectual disabilities (ID) have reported a higher prevalence of obesity than in the general population, and a trend to an increase in the prevalence of excess weight. However, little information is available on body weight status and lipids levels of adults with ID and co‐existing mental illness. The aim of this study was to address this information gap, by conducting a stepwise multiple regression analysis to predict BMI, thereby allowing the investigation of (semi‐)partial correlations, which assess the extent to which a particular predictor variable is associated with BMI over and above the other predictors. Methods A study of the patients with ID and psychiatric illness registered in the service. Collected data included body mass index (BMI), age, gender, the presence of additional physical conditions, residential status, mental illness and use the psychotropic medication. We analysed the lipid profile including serum cholesterol together with low‐density lipoprotein, high‐density lipoprotein (HDL), triglycerides and the serum cholesterol/HDL ratio. Data for these variables were entered into a stepwise multiple linear regression to predict BMI. Results 28% of the participants were overweight and 41% obese. Most of the obese patients were men with mild ID (P = 0.039). Level of ID (P = 0.003), gender (P = 0.001) and serum triglycerides (P = 0.026) had significant predictive value in the regression model. There were no significant differences in either the mean serum cholesterol levels or the mean triglyceride levels between those taking and those not taking first‐generation antipsychotics, second‐generation antipsychotics or anti‐epileptic medication. Conclusions The rate of obesity in our sample was higher than in previous studies. The most predictive combination of predictors to predict BMI was ID level, gender and serum triglyceride levels. Serum triglyceride and cholesterol levels did not appear to be unduly affected by first‐ or second‐generation antipsychotic medication or by antiepileptic medication.     

Differences in coping effectiveness and well-being among aging mothers and fathers of adults with mental retardation

In this longitudinal study, we examined stress and coping processes among 133 married mothers (age 59 to 83) and fathers (age 56 to 84) of adults with mental retardation (age 19 to 53). There were no differences between mothers and fathers with respect to their frequency of use of emotion-focused coping, but mothers used significantly more problem-focused coping strategies than did their husbands. For mothers, greater use of problem-focused coping strategies and lower use of emotion-focused coping buffered the impacts of caregiving stress on their psychological well-being. However, for fathers, no buffering effects of coping were detected. The implications of gender differences in coping effects were examined in the context of the impact of lifelong caregiving.     

Health status of mothers of adults with intellectual disability

A cross‐sectional survey was conducted to describe the health of mothers of adults with intellectual disability (ID), and the influence of the mother's and her adult child's characteristics on her health. The sample consisted of 108 mothers divided into mid‐life and later‐life groups. Four service agencies mailed SF‐36 forms and demographic questionnaires to their clients. The return rate from primary caregivers was 70%. The physical and the mental components of health of both groups of mothers were found to be similar to or better than those of their counterparts in the US national norms. Arthritis was found to influence the physical health of both groups of mothers. Employment was found to influence physical health of the mid‐life mothers, while family income was found to influence mental health of the later‐life mothers. The characteristics of adults with ID did not influence the mothers' health significantly. Mothers' caregiving for their adult children with ID might not be as detrimental to the mid‐life mothers' physical component of health as it might be to the later‐life mothers. Further studies are needed.     

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.     

Clinical outcomes of a specialised inpatient unit for adults with mild to severe intellectual disability and mental illness

Background   Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service.
Method   Thirty-three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re-admission to hospital were explored.
Results   Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning.
Conclusions   This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.     

Elevated rates of schizophrenia in a familial sample with mental illness and intellectual disability

Background It is unknown whether intellectual disability (ID) is more familially related to psychotic mood disorders or schizophrenia. L. S. Penrose's large sample of families with two or more members admitted to psychiatric hospitals provided a unique opportunity to investigate the familial relationship between mild ID, schizophrenia and psychotic affective disorders. Method There were 183 affected relative pairs comprising probands with mild ID (95 male, 88 female) and their first or second degree relatives with schizophrenia or psychotic affective disorder. Results There were nearly twice as many relatives with a diagnosis of schizophrenia (n = 121) as relatives with affective disorders (n = 62) among the intellectually impaired probands. This excess of schizophrenia was statistically significant, even after accounting for the increased risk of hospitalization for schizophrenia (P = 0.005), and was fairly constant across the different relative types. First‐degree relatives with either mental illness were more likely to be parents (n = 77) than siblings (n = 51) or children (n = 3), but there was no excess of mother–son pairs. Conclusions These results suggest a stronger familial relationship of ID with schizophrenia than psychotic affective disorder, and lend some support to the neurodevelopmental hypothesis of schizophrenia.     

Mothers of young adults with intellectual disability: multiple roles, ethnicity and well-being

Background Two opposing perspectives – role strain and role enhancement – were considered as predictive of women’s psychological and physical health. The authors examined the relation between multiple role occupancy (parenting, employment, marriage) and well‐being (depression and health) among mothers of young adults with intellectual disability (ID). Methods Participants were 226 mothers aged 35–70 years old caring for a young adult aged 16–26 years old with moderate to severe/profound ID. Mothers were of either Latino ethnicity (n = 117) or Anglo (n = 109). Mothers’ ethnicity and degree of acculturation and young adults’ adaptive behaviour and behaviour problems were examined as potential moderators. Results Mothers who were employed, married, or both reported better well‐being than mothers who were both unemployed and unmarried, especially when their offspring had relatively higher adaptive functioning. This relationship between role occupancy and well‐being was fully mediated by socio‐economic status (SES) factors. Results did not suggest a role enhancement effect, but instead indicated a role shortage effect; unemployed, unmarried mothers experienced markedly poor well‐being, while all other mothers experienced comparable well‐being. Well‐being scores were higher for Anglo than for Latino mothers; this relationship was entirely accounted for by SES. In Latina mothers, the relation between role occupancy and well‐being was moderated by degree of acculturation. Conclusions Findings suggest that multiple roles benefit mothers of young adults with ID primarily through their impact on socio‐economic resources. For more acculturated Latina mothers, occupying more roles predicted better well‐being even after controlling for SES. Latina mothers who were unemployed and unmarried had lower SES, and this group emerged as at particular risk. The latter group may benefit most from respite assistance and other interventions aimed at addressing their physical and mental health.     

The feasibility of psychomotor therapy in acute mental health services for adults with intellectual disability

Background Psychomotor therapy enables people to reflect on the relationship between experiences and feelings by starting from awareness of bodily responses rather than from awareness of emotion. In this study we examine PsyMot (ID), an assessment that directs this psychological therapy.

Method Twelve suitable consecutive admissions were recruited from a specialist intellectual disability (ID) assessment and treatment unit for adults. Video-recordings of PsyMot (ID) allowed assessment of interrater reliability (IRR). Treatment goals indicated by PsyMot (ID) were addressed using psychomotor therapy as part of a comprehensive program of interventions.

Results Psychomotor therapy was both feasible and popular with patients who participated without any adverse effects. Nine patients completed PsyMot (ID). IRR of the treatment goals identified by all 3 raters was good to excellent in 81% cases, but there were discrepancies for individual items.

Conclusions PsyMot (ID) and psychomotor therapy is feasible within this context, and enriched the clinical team's formulation. Further studies of reliability and efficacy should be undertaken.     

A survey of off-label prescribing for inpatients with mild intellectual disability and mental illness

Background The term ‘off-label prescribing’ refers to the use of a drug outside the terms of its Marketing Authorisation, including prescribing for an unlicensed indication. There have been few reports about off-label prescribing in psychiatry. The aims of the study were to determine the frequency of off-label prescribing of psychotropics for inpatients with mild intellectual disability (ID) and mental illness resident in a large psychiatric hospital, the nature of the off-label clinical indications and details about patient consent and case note documentation of the off-label usage. Methods Cross-sectional survey of inpatients of the ID division of a charitable hospital was carried out. Interviews with consultant psychiatrists about off-label use of psychotropics were also made. Results Of the 56 patients studied, 38 (67.9%) were receiving one or more psychotropic drugs and 26 (46.4%) were receiving at least one off-label psychotropic. The most frequently cited off-label indications were: reduction of aggression, arousal and behavioural disturbance (14 cases) and mood stabilization of affective disturbance (13). The principle psychotropics involved were atypical antipsychotics (17 cases) and mood stabilizers (13). Although in most instances the psychiatrist was aware the drug was being used off-label and had consulted other professionals, in only two (6%) instances had the patient been informed of the off-label usage, largely because the psychiatrist felt they lacked the capacity to understand the off-label concept. In most cases the off-label usage had not been documented in the case notes. Conclusions Off-label prescribing is common in patients with comorbid ID and mental disorder. When prescribing off-label, psychiatrists need to consider the evidence that the drug is likely to be effective for the unlicensed indication and any risks involved. Where there is limited evidence of benefit a trial of the drug, with clinical monitoring may be indicated. Patients should be fully informed about their medication. However, many patients with ID cannot understand the off-label concept. In some circumstances psychiatrists may find it helpful to consult other professionals before prescribing off-label. Good case note documentation of the process is important and supports the prescriber.     

Prevalence of intellectual disability and comorbid mental illness in an Australian community sample

OBJECTIVE: The aim of this study was to bring to light the high prevalence of Australians affected by intellectual disability and comorbid serious mental illnesses. Results from a broad scale study are used to explore the reasons for this regularly overlooked phenomenon. METHODS: This study was based on secondary analysis of data collected in the national 'Disability, Ageing and Carers Survey, 1998'. The analysed data consisted of an Australian wide sample of 42 664 individuals living at home or in cared accommodation. Classification of intellectual disability and comorbid psychosis, anxiety and depressive disorder was based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). RESULTS: The prevalence of intellectual disability in the sampled population was 1.25%. Of these people 1.3% had a psychotic disorder, 8% had a depressive disorder and 14% had an anxiety disorder that had been present for at least 6 months and was of such severity that it too was disabling. CONCLUSIONS: Findings indicate that people with intellectual disability are at high risk of developing comorbid serious mental illness. Dual diagnosis is however, often overlooked due to difficulties associated with establishing a diagnosis of a mental disorder in people with an intellectual disability, a problem which is heightened when the individual's capacity to participate in a clinical assessment is limited.     

The use of clozapine in adults with intellectual disability

Background There are not many studies on the use of clozapine in patients with intellectual disability (ID). The authors describe a case series of patients treated with clozapine, drawn from a medium secure unit, a low secure assessment and treatment service and a community team in the London region. Method A retrospective file‐review of patients treated in these three settings during the time period March–June 2002 was performed (n = 24). Information was collected using a semistructured proforma. Results Of the 24 patients, 67% had schizophrenia, 17% had schizoaffective disorder and 8% had bipolar disorder. Patients had been unwell for a mean of 6 years and had been tried on a mean of four antipsychotics. The mean maximum dose of clozapine was 488 mg. The outcomes on the clinical global impression (CGI) scale showed 29% very much improved, 42% much improved, 21% minimally improved and 8% no change. 54% of the whole sample and 53% of those from the medium secure unit were discharged to homes in the community. The drug had to be stopped in four patients, of which three were because of neutropaenia. Conclusion Clozapine appears to be safe and efficacious in many people with ID. Careful monitoring of side‐effects is needed during therapy.     

The experience of sexuality in adults with intellectual disability

Background

People with intellectual disability have the same sexual needs as those without any disability, yet their sexuality is often restricted by reluctant attitudes and/or fears based on irrational beliefs. The aim of this study is to describe and analyse different areas of sexuality in adults with mild or moderate intellectual disability.

Method

The sample consisted of 180 men and 180 women attending occupational centres. All the participants were administered a questionnaire about sexuality adapted to their characteristics.

Results

Results show that 84.2% have had sexual relationships with another person, this percentage being higher in females and in people aged between 38 and 55 years old. Condoms are used by 41.4%. The most frequently used contraceptive methods are the pill (39.6%), transdermal patch (30.2%) and intrauterine device (6.7%). 9.4% of the women and 2.8% of the men has experienced sexual abuse.

Conclusion

In conclusion, there is a need to draw up educational programmes, differentiated according to gender and adapted to their reality, which include contents related with sexual health, sexual abuse and condom use.     

Gender, coping, and psychological well-being in spouses of older adults with chronic dementia

Relationships among gender, types of coping strategies, and psychological well-being were examined in 61 spousal caregivers of older adults with chronic dementia. Gender emerged as a significant correlate of well-being (with women reporting higher levels of distress), although not of related coping strategies. Implications for research into interactions among biological, psychological, and social factors contributing to women's psychological distress are discussed.     

Environmental characteristics of nursing homes and community-based settings, and the well-being of adults with intellectual disability

The present study examined whether characteristics of the environment of nursing homes and community-based residential settings are associated with the adaptive behaviour, health and community integration of adults with intellectual disability living in those settings. The specific characteristics of the environment were type of facility, size, level of residential involvement in policy-making, and the degree of variety and stimulation of the physical environment. The study assessed 249 residents with intellectual disability over a 3-year period who lived in nursing homes at baseline. At follow-up, 50 of the residents had moved to community-based facilities while 199 of the residents remained in nursing homes. The results indicated that type, size and characteristics of the environment were related to the level of adaptive behaviour and community integration at follow-up. Residents living in community-based settings had better health and greater levels of community integration than residents living in nursing homes. Residents living in smaller facilities had greater adaptive behaviour at follow-up than residents living in larger facilities. More variety and stimulation in the residential physical environment was associated with greater adaptive behaviour among residents at follow-up. Residential facilities that permitted greater resident involvement in policy-making, and had greater variety and stimulation in their physical environment were associated with greater levels of community integration among their residents at follow-up.     

An examination of stress and coping among adults diagnosed with severe mental illness

The present study explored the types of major life and chronic stressors that people with severe mental illness experience, and the coping strategies that are used in response to them. Twenty-eight adults with severe mental illness completed qualitative interviews focused on stress and coping in the prior six months. Participants reported experiencing disruptive major life events including the sudden death of a loved one, loss of housing, and criminal victimization, as well as chronic stressors such as psychiatric symptoms and substance abuse issues, substandard living conditions, legal problems, and health concerns. Results suggested that persons with severe mental illness frequently use problem-centered coping strategies in response to most types of stressors, including major life events, although this occurred after the initial application of avoidant coping strategies. Future research should explore whether or not the identified stressors and the coping strategies used in response to them are unique to this population.     

Depression in mothers and fathers of children with intellectual disability

Parental depression was assessed using the Beck Depression Inventory (BDI) in 216 families with children with autism and/or intellectual disability (ID), and in 214 control families. Mothers with children with autism had higher depression scores (mean = 11.8) than mothers of children with ID without autism (mean = 9.2), who in turn, had higher depression scores than fathers of children with autism (mean = 6.2), fathers of children with ID without autism (mean = 5.0), and control mothers (mean = 5.0) and fathers (mean = 4.1). Forty‐five per cent of mothers with children with ID without autism and 50% of mothers with children with autism had elevated depression scores (BDI > 9), compared to 15–21% in the other groups. Single mothers of children with disabilities were found to be more vulnerable to severe depression than mothers living with a partner.