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

Medical expenses of patients with severe mental disorders in Beijing, China

OBJECTIVES

Mental health has become a significant public health problem that impacts both economic and social development, with severe mental disorders (SMDs) being the top priority. Over recent years, Beijing, China, has introduced several policies to reduce the economic burden on patients with mental health disorders. The aim of this study was to investigate the current status and composition of patients' medical expenses following the introduction of multiple medical policies, explore the factors that may impact the utilisation of medical services and provide a reference and basis for subsequent policy improvements.

STUDY DESIGN

Multistage sampling was used to select a representative study population. A retrospective survey was used to collect patient information and data on medical expenses in 2019.

METHODS

Descriptive statistics were applied to analyse the current status of patients' medical expenses, and a two-part model was used to examine the factors influencing healthcare utilisation and to model predicted expenses.

RESULTS

Among 4940 participants, the average outpatient expenses of patients with SMD who incurred medical expenses were 8373.61 Yuan, and the average hospitalisation expenses were 81,594.05 Yuan. The out-of-pocket expenses were 29.22% of outpatient expenses and 8.13% of inpatient expenses. Factors such as age, household status, economic status, marital status, participation in the Community Free-Medication Service (CFMS) and the type of disease diagnosed influenced the differences in medical expenses and utilisation of services.

CONCLUSIONS

The medical expenses of patients with SMD in Beijing are high, but a number of introduced policies have effectively reduced these costs for patients. Future studies should focus on the impact of factors such as age, economic status, participation in the CFMS and the type of disease diagnosed on medical expenses.

A systematic review of in-patient psychiatric care for people with intellectual disabilities and/or autism: effectiveness, patient safety and experience

BACKGROUND

An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists.

AIMS

The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care.

METHOD

A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services).

RESULTS

A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates.

CONCLUSIONS

There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.

Effect of Peer Victimization on the Long-Term Mental Health Status among Adults Users of Intellectual Disability Services: A Longitudinal Follow-Up Study

Caregiving for mental health among people with intellectual disabilities (IDs) in the ID services was reported as insufficient. The purposes of this study were to investigate five types of peer victimization (PV) experiences among adults with ID using ID services, and to gain a deeper understanding of the influence of PV experience on adults with ID’s long-term mental health status. A one-year longitudinal follow-up study was conducted from eight long-term care ID services (n = 176). Logistic regression analysis was applied to variables comprising personal characteristics, various types of PV experience and polyvictimization to predict period prevalence of psychiatric symptoms. The data indicated that nearly one-third of individuals with ID experienced at least one psychiatric symptom. The three most common psychiatric symptoms prevalent after one year were adjustment disorder, anxiety disorder, and somatoform disorder. Over the 1-year study period, approximately 40% of adults with ID reported experiencing PV. The most frequently reported types of PV were physical force (26%) and verbal victimization (22%). Polyvictimization was experienced by approximately a quarter of adults with ID. The findings suggest that PV is a common experience among adults in ID services. Thus, for a clearer understanding of mental health risks, caregivers should pay attention to adults with ID who experienced PV.

Psychiatric diagnoses in relation to severity of intellectual disability and challenging behaviors: a register study among older people

OBJECTIVE

To investigate the possible association between severity of intellectual disability (ID) and presence of challenging behavior, respectively, on diagnoses of psychiatric disorders among older people with ID.

METHODS

People with a diagnosis of ID in inpatient or specialist outpatient care in 2002-2012 were identified (n = 2147; 611 with mild ID, 285 with moderate ID, 255 with severe or profound ID, and 996 with other/unspecified ID). Moreover, using impairment of behavior as a proxy for challenging behavior, 627 people with, and 1514 without such behavior were identified.

RESULTS

Severe/profound ID was associated with lower odds of diagnoses of psychotic, affective, and anxiety disorders than was mild/moderate ID. People with moderate ID had higher odds than those with mild ID of having diagnoses of affective disorders. Diagnoses of psychotic, affective, and anxiety disorders, and dementia were more common among people with challenging behavior than among those without.

CONCLUSIONS

People with severe/profound ID had lower odds of receiving psychiatric diagnoses than those with mild and moderate ID. Whether this is a result of differences in prevalence of disorders or diagnostic difficulties is unknown. Further, challenging behaviors were associated with diagnoses of psychiatric disorders. However, the nature of this association remains unclear.

Assessing the Confidence of Australian Mental Health Practitioners in Delivering Therapy to People With Intellectual Disability

Research supports the use of psychological therapies among people with mild to moderate intellectual disability (ID). One barrier to people with ID accessing psychological treatments is the confidence of mental health practitioners. This article explores the confidence of Australian clinicians in providing therapy to people with ID. One hundred and fifty-two psychologists and counselors in Australia completed a survey exploring self-reported confidence when working with clients who have ID and mental health difficulties. Clinicians were most confident with generic counseling skills, but less confident with elements of assessments and interventions. The use of treatment protocols was endorsed as helpful particularly among those with low confidence. This highlights the need for dissemination of treatment guides and training to help increase clinician confidence.

Psychiatric care utilization among older people with intellectual disability in comparison with the general population: a register study

BACKGROUND

People with intellectual disability have been found to have higher prevalence of psychiatric disorders than the general population. However, they do not seem to have a corresponding increase in psychiatric care utilization. The aim of the present study was to investigate psychiatric care utilization among older people with intellectual disability.

METHODS

We used a cohort of people with intellectual disability, 55+ years in 2012 (n = 7936), and an equally sized age and sex matched reference cohort from the general population. Psychiatric care utilization was measured using registrations in the Swedish National Patient register during 2002-2012, where each registration corresponds to a psychiatric care occasion.

RESULTS

About 20 % of those with intellectual disability had at least one registration during the study period, compared to some 6 % in the general population sample. In the whole cohort as well as stratified by sex, people with intellectual disability were 3-4 times more likely than those in the general population sample to have had at least one registration during the study period. The effect was, however, only consistent in age groups comprising people younger than 65 years. Among people with intellectual disability, men were more likely than women to have had at least one registration, and people living in special housing (group home or service home) during the entire study period were less likely than those who only lived in special housing for parts of the study or not at all. People with intellectual disability had longer stays per inpatient registration compared with the general population sample. When stratifying on sex, the effect was found only among men, although there were no sex differences within the cohort of people with intellectual disability. Among people with intellectual disability, living in special housing during the entire study period was associated with shorter stays per inpatient registration.

CONCLUSIONS

Although people with intellectual disability had higher psychiatric care utilization than the general population during the 11 year study period, it does not correspond to the high prevalence of psychiatric disorders in this population. Future research is required to establish if the level of care utilization is appropriate among older people with intellectual disability.

Systemwide Initiative Documents Robust Health Screening for Adults With Intellectual Disability

It is well documented that adults with intellectual disability (ID) experience higher rates of a series of health conditions compared to their peers without disability. These health conditions include cardiovascular disease, obesity, diabetes, gastrointestinal disorders, and psychiatric and behavioral disorders. With life expectancy approximating the general population, adults with ID are also now experiencing health conditions related to aging, further increasing their risk for diminished function and well-being. This increased morbidity poses new challenges in geriatric healthcare planning for this population. Relatively simple health prevention practices, such as the implementation of a health screening tool, can substantially increase disease detection and clinical activities directed toward improved health outcomes for people with ID. This study examines data collected from the District of Columbia Developmental Disabilities Administration's (DC DDA's) health screening component of its Health and Wellness Standards. Findings are presented, along with recommendations and implications for improving preventive health screening practices in the ID population.

Intellectual developmental disorder in adult psychiatry: A 24-year register study

BACKGROUND

Intellectual developmental disorder (IDD) may pre-dispose for mental health disorders. It is sometimes debated whether the needs of this group are adequately met in general psychiatry. However, little is known about patients with IDD in the psychiatric clinical setting-occurrence, clinical diagnoses, or service use.

AIMS

This study aimed to assess the number of adult patients diagnosed with IDD in a psychiatric clinic, their psychiatric diagnoses, and their use of psychiatric services.

METHODS

Individuals with registered IDD diagnoses were identified in a university hospital adult psychiatric clinic register comprising 67 384 patients.

RESULTS

IDD had been diagnosed in 0.6% of the patients. Psychotic disorders were the most common co-existing psychiatric diagnoses (25.5%). In 21.8% no psychiatric diagnosis other than IDD was registered. More than 50% had been inpatients; 21% had been compulsorily admitted. Patients with IDD had required a mean of five hospital beds per day.

CONCLUSIONS

The percentage, 0.6%, of IDD diagnoses was lower than estimates of the prevalence of IDD in the general population. This may reflect a lower need for psychiatric care, barriers to access services, or diagnostic over-shadowing. One fifth of the patients in this study had no psychiatric diagnosis beside IDD, which may be due to diagnostic difficulties, or other problems (e.g. somatic or behavioural disorders) leading to psychiatric contact. Since patients with IDD use the equivalent of five inpatient beds every year, it is suggested that it may be worthwhile to consider specialized psychiatry with expertise in IDD, even though this group is small.

Exposure to life events as a risk factor for psychological problems in adults with intellectual disabilities: a longitudinal design

BACKGROUND

Several cross-sectional studies have shown an association between exposure to life events and psychological problems in adults with intellectual disability (ID). To establish life events as a risk factor, prospective designs are needed.

METHODS

Support staff informants provided data on the psychological problems of 68 adults with ID and their recent exposure to life events. Using data collected on the same sample 3.5 to 4 years earlier, prospective analysis of the relationships between life events exposure and psychological problems over time was explored.

RESULTS

Hierarchical linear regression analyses demonstrated a contribution of life events to the prediction of later psychological problems after controlling for earlier psychological problems. Exploratory analyses showed that the relationship between life events and psychological problems might be unidirectional, and non-spurious; remaining present once the impact of other correlates of psychological problems was controlled.

CONCLUSIONS

These data offer support for the status of life events (with a negative valence) as a risk factor for psychological problems in adults with ID. To establish life events as a causal risk factor, research is needed to examine the mechanisms via which life events have their impact on psychological well-being.

The French version of the Reiss Screen for Maladaptive Behavior: factor structure, point prevalence and associated factors

The main aims of the present study were to examine the factor structure and the internal consistency of the factors in the French version of the Reiss Screen of Maladaptive Behavior in a French-speaking European sample. The prevalence of psychopathology and the influence of associated factors were also examined. The Reiss Screen was administered to 467 adults (age range: 18-73) with intellectual disability living in the French-speaking regions of Switzerland and Belgium. A confirmatory factor analysis was performed to replicate the original factor structure. Internal consistency was examined by using Cronbach's alpha. Analyses of variance were computed to study the influence of gender, age and Down syndrome etiology. The original factor structure of the Reiss Screen was replicated. The overall rate of psychopathology in the sample was 37%. No linear relationship between age and psychopathology was found. However, adults aged less than 26 years had lower scores than older adults on several psychopathological domains. Males had higher scores than females on the Autism and the Avoidant Disorder subscales. Participants with Down syndrome had lower scores on all domains, with the exception of the Autism subscale. The results of this study suggest that the French version of the Reiss Screen can be a useful tool to detect psychopathology in adults with intellectual disability.

Behaviour profile of Hungarian adolescent outpatients with a dual diagnosis

The behaviour dimensions of 244 Hungarian adolescent psychiatric outpatients with a dual diagnosis (intellectual disability and psychiatric diagnosis) were examined by means of the adapted version of the Behaviour Problem Inventory (BPI, Rojahn, Matson, Lott, Esbensen, & Smalls, 2001). Four IQ subgroups were created: borderline, mild, moderate and profound ID subsamples. Significantly higher means were found in the self-injury/stereotyped behaviour/summarized scale categories both in the frequency and severity of symptoms in the more disabled groups against the samples having milder IQ impairment. Adolescents with a dual diagnosis showed much higher BPI scale means than an adult residential ID sample. ADHD and emotional disorders were the most frequent psychiatric diagnostic comorbidities of ID (20.67% and 11.73%). Academic achievement disorder, depression and psychosis had low occurrences (3.35, 2.23 and 1.17%, respectively) but showed convergency with other authors' data. The comorbid emotional disorders may create challenges for the care of the mildly intellectually disabled group.

Psychiatric disorders in adolescents and adults with autism and intellectual disability: a representative study in one county in Norway

Few studies assess psychiatric disorders in representative samples of individuals with autism and ID. Symptoms of autism and psychiatric disorders have been confounded. PAC, a conceptually analysed and validated screening instrument, was used.

AIMS

Assess prevalence of psychiatric disorders in individuals with intellectual disability only (ID-only) and with combination of autism and ID (autism). Sixty-two (autism) and 132 (ID-only) participants were screened for psychiatric disorders with the Psychopathology in Autism Checklist (PAC); included general adjustment problems (GAP), and severe adjustment problems (SGAP) in one county in Norway. Psychosis, depression, anxiety, and OCD were addressed. Both SGAP and a high psychiatric disorder score were required to screen a psychiatric disorder. "Diagnostic overlap" was defined as more than one psychiatric disorder concurrent with autism. Psychiatric disorders and SGAP were found to be high both in the autism (53.2%) and ID-only group (17.4%). More than 50% of the autism and approximately 20% of ID-only group had SGAP. The differences were significant. The autism-psychiatric disorder interaction was significant. The largest differences between the prevalence in the autism and the ID-only group were shown in individuals with anxiety. The majority of the individuals in both study groups were afflicted with more than one psychiatric disorder. About 60% were found to have more than one disorder. The individuals with more severe psychiatric symptoms had higher degrees of diagnostic overlap. Having an intellectual disability seem to imply high risk for developing adjustment problems, and it seems especially difficult for individuals with autism to master every-day challenges.

Forensic psychiatric perspective on criminality associated with intellectual disability: a nationwide register-based study

BACKGROUND

Contrasting views exist over the association of intellectual disability (ID) and criminal offending. This nationwide study attempts to shed further light to expand understanding to substantiate the relation between socio-demographic characteristics, psychiatric co-morbidity and criminal behaviour among the Finnish forensic population with ID.

METHOD

We reviewed all forensic psychiatric examination reports of individuals with ID who underwent a pre-trial forensic psychiatric evaluation in Finland during an 11-year period (1996-2006).

RESULTS

One-third of the offenders had been regularly and sufficiently treated as outpatients. Half of the offenders had previous criminality, and the single most common crime was arson. Almost half of the offenders were diagnosed with alcohol abuse/dependence and two-thirds with any substance abuse/dependence. Furthermore, almost half were intoxicated during the index crime. Antisocial personality disorder was diagnosed in 25% of the offenders. Almost half of the offenders were placed in involuntary special care for the ID, which lasted ca 2 years. Among the last-mentioned, two-thirds of the nursing care plans lacked recommended structure.

CONCLUSIONS

The offenders with so-called triple diagnosis - substance abuse, mental illness and ID - form a small subgroup of criminal offenders with complex needs. The results of the present study underline the importance of close, long-term cooperation among specialists in the field of ID, addiction service, mental health services and forensic psychiatry.

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.

Risk of mental disorders in subjects with intellectual disability in the Lundby cohort 1947-97

The Lundby Study is a prospective cohort study, which has followed a Swedish unselected community sample between 1 July 1947 and 1 July 1997. The aim was to study the risks of mental morbidity and different DSM-IV disorders in subjects with intellectual disability (ID) in the Lundby cohort between 1 July 1947 to 30 June 1997. The diagnosis of ID was re-evaluated according to DSM-IV in subjects who had been considered to have ID between 1947 and 1997. Multiple sources of information were used to obtain best estimate consensus diagnoses of mental disorders. The relative risk of mental disorder was 1.34 in subjects with ID as compared with the reference group. Dual diagnosis was more prevalent in mild ID than in moderate ID. No subject with severe ID was diagnosed with mental disorder. The cumulative incidence of any mental disorder in subjects with ID was 44%. The most common DSM-IV diagnoses were: Mood Disorders (11.5%), Anxiety Disorders (11.5%), Schizophrenia and Other Psychotic Disorders (8%), Mental Disorder NOS Due to a General Medical Condition (8%), Dementia (3.8%) and Alcohol Abuse (1.9%). Mental disorders were more common in subjects with ID than in the reference group.

Anxiety disorders in persons with developmental disabilities: empirically informed diagnosis and treatment. Reviews literature on anxiety disorders in DD population with practical take-home messages for the clinician

Anxiety disorders are common in individuals with developmental disabilities (DDs), although they may not be diagnosed and treated as often as they are in patients without DDs. Patients with mental retardation, autism, and other pervasive developmental disorders may exhibit comorbid anxiety disorders, such as generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), phobias, and other anxiety symptoms at much higher rates than in the general population, but identification of these comorbid anxiety disorders may be made more difficult by the presence of the DD and concurrent difficulties with communication, other behavior problems, the lack of standardized assessments specific to diagnosing patients with DDs and psychiatric comorbidities, and the need for greater collateral sources of assessment information. In addition, systematic study of the treatment of anxiety in patients with DD is limited to a relatively small number of empirical studies done specifically in these patients along with case reports and theoretical reviews on the extension and modification of more well-studied treatments used for anxiety in patients without DDs. The present article reviews the literature on the prevalence, features, assessment and diagnosis of anxiety disorders in individuals with DDs, and also reviews empirical studies of pharmacological and psychological treatment of patients with comorbid anxiety and DD and summarizes the findings. Recommendations are made to guide treatment and further research in this area.

Psychopathology in young people with intellectual disability

CONTEXT

Comorbid severe mental health problems complicating intellectual disability are a common and costly public health problem. Although these problems are known to begin in early childhood, little is known of how they evolve over time or whether they continue into adulthood.

OBJECTIVE

To study the course of psychopathology in a representative population of children and adolescents with intellectual disability.

DESIGN, SETTING, AND PARTICIPANTS

The participants of the Australian Child to Adult Development Study, an epidemiological cohort of 578 children and adolescents recruited in 1991 from health, education, and family agencies that provided services to children with intellectual disability aged 5 to 19.5 years in 6 rural and urban census regions in Australia, were followed up for 14 years with 4 time waves of data collection. Data were obtained from 507 participants, with 84% of wave 1 (1991-1992) participants being followed up at wave 4 (2002-2003).

MAIN OUTCOME MEASURES

The Developmental Behaviour Checklist (DBC), a validated measure of psychopathology in young people with intellectual disability, completed by parents or other caregivers. Changes over time in the Total Behaviour Problem Score and 5 subscale scores of the DBC scores were modeled using growth curve analysis.

RESULTS

High initial levels of behavioral and emotional disturbance decreased only slowly over time, remaining high into young adulthood, declining by 1.05 per year on the DBC Total Behaviour Problem Score. Overall severity of psychopathology was similar across mild to severe ranges of intellectual disability (with mean Total Behaviour Problem Scores of approximately 44). Psychopathology decreased more in boys than girls over time (boys starting with scores 2.61 points higher at baseline and ending with scores 2.57 points lower at wave 4), and more so in participants with mild intellectual disability compared with those with severe or profound intellectual disability who diverged from having scores 0.53 points lower at study commencement increasing to a difference of 6.98 points below severely affected children by wave 4. This trend was observed in each of the subscales, except the social-relating disturbance subscale, which increased over time. Prevalence of participants meeting criteria for major psychopathology or definite psychiatric disorder decreased from 41% at wave 1 to 31% at wave 4. Few of the participants (10%) with psychopathology received mental health interventions during the study period.

CONCLUSION

These results provide evidence that the problem of psychopathology comorbid with intellectual disability is both substantial and persistent and suggest the need for effective mental health interventions.

A follow-up study of mortality, health conditions and associated disabilities of people with intellectual disabilities in a Swedish county

BACKGROUND

In the planning of services and health care for individuals with intellectual disability (ID), information is needed on the special requirements for habilitation and medical service and associated disabilities.

MATERIAL AND METHODS

An unselected consecutive series of 82 adult persons with ID was studied. The medical examination consisted of the individual's health condition, associated impairments and disabilities. Medical and habilitation services and support were studied.

RESULTS

The results indicated that 71% of the persons in the series had severe and 29% mild ID. Forty-seven per cent of the persons with severe ID and 35% of those with mild ID had one or more additional central nervous system (CNS) disabilities. Of the persons with ID, 99% had access to a family doctor and 84% attended regular health visits. Notably, half of persons were referred to a specialist examination as a consequence of their present medical examination. Half of the persons with mental health problems were previously undiagnosed and only a few of these had access to a psychiatrist.

CONCLUSION

Our study clearly demonstrates the magnitude and importance of neurological and psychiatric impairments in ID. The findings suggest a strong need for multidisciplinary health service.