Psychiatric Bulletin (2004) 28: 345-346. doi: 10.1192/pb.28.9.345
© 2004 The Royal College of Psychiatrists
Psychiatric Bulletin (2004) 28: 345-346
© 2004 The Royal College of Psychiatrists
Proposed model for the delivery of a mental health service to people with intellectual disability
Occasional Paper OP58, July 2004, Irish College of Psychiatrists, £10, 42 pp.
This report can be downloaded in full from the College website:
http://www.rcpsych.ac.uk/publications/op/op58.htm.
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:
- 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.
- Special expertise, experience and treatment is required in the management
of chronic and persistent problem behaviours.
- Special expertise is needed in diagnosing autistic spectrum disorder and
treating comorbid mental health problems in this group.
- Drug therapy may be complicated by a high frequency of side-effects and
atypical responses.
- Co-existing epilepsy and other medical conditions need to be taken into
consideration.
- 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
- That significant reform of the mental health services in Ireland for the
intellectual disability population should commence immediately.
- 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.
- That the Department of Health and Children should be given prime
responsibility for providing the resources necessary to implement, develop and
monitor this reform.
- The Mental Health Commission and the National Disability Authority should
oversee the implementation.
- The Mental Health Commission and the National Disability Authority should
monitor the quality of mental health services provided to people with
intellectual disabilities.
- 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.
- 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.
- 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.
- Coordination of the mental health services to people with intellectual
disabilities requires a clinical director and an administrator/manager.
- 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.
- 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.
- 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.
- Adolescent mental health services need to be developed for people with
intellectual disabilities.
- Forensic mental health services need to be developed for people with
intellectual disabilities.
- A psychiatric service needs to be developed for people with intellectual
disabilities and autistic spectrum disorder and mental health problems.
- That the number of senior registrar posts in learning disability psychiatry
be increased.
- 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.
- 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.
- 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.
- The Intellectual Disability Section of the Irish College of Psychiatrists
should formally review this policy in 2009.
