From the Irish College of Psychiatrists,
Dublin
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 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.
Recommendations
1. That significant reform of the mental health services in
Ireland for the intellectual disability population should commence
immediately.
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. 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. The Mental Health Commission and the National Disability
Authority should oversee the implementation.
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. 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. 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. 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 psychiatrist-led
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 continual professional
development. Thus these norms will require upward
revision.
9. Coordination of the mental health services to people with
intellectual disabilities requires a clinical director and an
administrator/manager.
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. 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. 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. Adolescent mental health services need to be developed for
people with intellectual disabilities.
14. Forensic mental health services need to be developed for
people with intellectual disabilities.
15. A psychiatric service needs to be developed for people
with intellectual disabilities and autistic spectrum disorder and
mental health problems.
16. That the number of senior registrar posts in learning
disability psychiatry be increased.
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. 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. 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. The Intellectual Disability Section of the Irish College
of Psychiatrists should formally review this policy in 2009.