Proposed model for the delivery of a mental health service to people with intellectual disability

There have been great improvements in the quality of life of people with intellectual disabilities in Ireland over the past 20 years: education, housing, work and recreational opportunities have all been significantly developed. Although this progress must be acknowledged, many educational, work and health-related services for those with intellectual disabilities are still not good enough. In particular, mental health/psychiatric services for people with intellectual disabilities have not kept pace with these developments - they remain underresourced and grossly underdeveloped in many Health Board areas in Ireland. Some counties have no psychiatric service at all for people with intellectual disabilities.

Medicine and psychiatry have progressed over the years by specialisation, ensuring that the best care possible is delivered to patients. Psychiatry has developed specialties by age (child and adolescent psychiatry, old age psychiatry) and by need of special groups (intellectual disability psychiatry and forensic psychiatry). To meet the mental health needs of people with intellectual disabilities, a specialist mental health service is required by virtue of the following factors:

1. • Special expertise and experience is required for accurate diagnosis, because of the atypical presentation of mental disorders, communication difficulties and the absence of subjective complaints.

2. • Special expertise, experience and treatment is required in the management of chronic and persistent problem behaviours.

3. • Special expertise is needed in diagnosing autistic spectrum disorder and treating comorbid mental health problems in this group.

4. • Drug therapy may be complicated by a high frequency of side-effects and atypical responses.

5. • Co-existing epilepsy and other medical conditions need to be taken into consideration.

6. • Ethical issues arise in relation to capacity and consent.

A number of countries allocate specific and significant resources to mental health services for people with intellectual disabilities, and promote training and research in this area. The National Association for Dually Diagnosed (NADD) in the USA and the European Association for Mental Health in Mental Retardation (MHMR) have been influential in promoting research and specialist psychiatric service development for this group. There is a lack of such research and development in Ireland.

We hope that this Occasional Paper will unleash a chain of events that will lead to the development of quality mental health services for people with intellectual disabilities and their families.

For the purpose of this strategy document, the committee have decided to use the term ‘intellectual disability’ rather than ‘learning disability’, ‘mental handicap’ and ‘mental retardation’. The Committee have also decided to use the terms ‘ psychiatric disorder’ and ‘mental ill health’ interchangeably and view them as synonymous terms.

Summary of recommendations

1. 1. That significant reform of the mental health services in Ireland for the intellectual disability population should commence immediately.

2. 2. That funding be ring-fenced and prioritised to develop quality mental health services in all Health Board areas. Management and funding of mental health services for people with intellectual disabilities should ideally come from the same source as generic mental health funding.

3. 3. That the Department of Health and Children should be given prime responsibility for providing the resources necessary to implement, develop and monitor this reform.

4. 4. The Mental Health Commission and the National Disability Authority should oversee the implementation.

5. 5. The Mental Health Commission and the National Disability Authority should monitor the quality of mental health services provided to people with intellectual disabilities.

6. 6. People with intellectual disabilities have the right to the same type of mental health service as any other citizen, taking account of their special needs. That all safeguards offered to the general population in respect of the Mental Health Act 2001 be extended to intellectual disability mental health services. That use of time-out and mechanical restraint be used within the Mental Health Act. Consultant psychiatrists in intellectual disability are currently working in a legal vacuum, with respect to the Mental Health Act. This must be addressed as soon as possible by the implementation in full of the Mental Health Act 2001.

7. 7. All future appointments of consultant psychiatrists in intellectual disability should be catchment area-based with multidisciplinary mental health of intellectual disability teams - in close liaison with Health Board consultant psychiatrist colleagues in other specialties such as adult psychiatry, child and adolescent psychiatry and psychiatry of old age. This would integrate the psychiatry of intellectual disability with mainstream psychiatry and would involve partnership with the voluntary bodies.

8. 8. That a consultant psychiatrist led mental health multidisciplinary team for people with intellectual disabilities be established, and given priority, in each Health Board area, commencing in 2004. Two consultant psychiatrists are required - one in adult psychiatry and one in child and adolescent psychiatry, in accordance with the Irish College of Psychiatrists’ norms: i.e. one consultant adult psychiatrist per 100 000 population plus one consultant child and adolescent psychiatrist per 100 000 population. Current norms for consultant psychiatristled multidisciplinary teams of 1 per 100 000 population do not take into account European Working Time Directive, recent requirements for doctors to engage in mandatory continuing professional development. Thus, these norms will require upward revision.

9. 9. Coordination of the mental health services to people with intellectual disabilities requires a clinical director and an administrator/manager.

10. 10. It is recommended that all catchment areas have access to an in-patient mental health treatment unit specifically for people with intellectual disability and psychiatric disorder.

11. 11. That the transfer of all patients with intellectual disabilities from psychiatric hospitals should not take place until a designated consultant psychiatrist-led mental health multidisciplinary team has been identified that will continue to provide psychiatric assessment, treatment and management, if and when required.

12. 12. It is recommended that a joint working group within the Irish College of Psychiatrists, incorporating the general adult psychiatry section and the psychiatry of intellectual disability section, be set up to examine how best to deliver a comprehensive mental health service to individuals functioning in the mild range of intellectual disabilities.

13. 13. Adolescent mental health services need to be developed for people with intellectual disabilities.

14. 14. Forensic mental health services need to be developed for people with intellectual disabilities.

15. 15. A psychiatric service needs to be developed for people with intellectual disabilities and autistic spectrum disorder and mental health problems.

16. 16. That the number of senior registrar posts in learning disability psychiatry be increased.

17. 17. That representation from the Irish College of Psychiatrists’ Intellectual Disability Section be on all future Department of Health and Children mental health policy reviews, developments and initiatives.

18. 18. That representation from the Irish College of Psychiatrists’ Intellectual Disability Section be on all future mental health policy reviews, developments and initiatives of any Health Board.

19. 19. That substantial resources be directed towards research in this area, looking for example at the incidence and prevalence of psychiatric disorder, to assist service development. To further this, a professor of psychiatry of intellectual disability needs to be appointed.

20. 20. The Intellectual Disability Section of the Irish College of Psychiatrists should formally review this policy in 2009.