17th December 2003
Ms. Angela Kerins
Chairperson
National Disability
Authority
25 Clyde Road
Dublin 4
Dear Ms. Kerins
The Learning Disability
Section of the Irish College of Psychiatrists very much welcomes
the NDA’s “Review of Access to Mental Health Services
for People with Intellectual Disabilities”.
As psychiatrists working in this area we agree that there
is a great deal of confusion and a lack of awareness of the
need for mental health services for people with intellectual
disabilities, in part due to diagnostic overshadowing.
The Executive Summary
notes “Individuals with a dual diagnosis often have distinct
mental health service needs from the general population”.
The Irish College of Psychiatrists would strongly concur
with this and one of the seven sections of the College is dedicated
to Psychiatry of learning disability/intellectual disability.
We strongly support
that;
§ there is “policy
confusion in the sector”.
To date we have been unable to find persons within the
health board in either learning disability or mental health
to take responsibility for the provision of mental health services
to people with intellectual disability.
§
the Department of Health
and Children should publish a national policy statement and
service framework.
§
the cornerstone of the
mental health service is the community based multidisciplinary
mental health of intellectual disability team.
In keeping with mental health services for the rest of
the population, clinical aspects of the service should be led
by a consultant psychiatrist specialising in the psychiatry
of learning disability.
§
the vast majority of
those with intellectual disability who are receiving psychiatric
treatment within the intellectual disability services are outside
the remit of the protective legislation.
This matter needs to be addressed with a degree of urgency.
Further to our discussions with Dr. John Owens, Mental
Health Commissioner, we are reassured that this matter is a
priority for the Mental Health Commission.
§
the Mental Health Commission
should provide for inspection of mental health services for
people with an intellectual disability.
§
the need to invest in
staff.
§ distinct forensic services
are required.
The report clearly states
people with intellectual disability who have a psychiatric illness
and or problem behaviours (challenging behaviour) require access
to a mental health service.
However when discussing problem behaviours (challenging
behaviour, pg. 25) it states that Cunningham found that two-thirds
of people with challenging behaviour also have a mental health
problem. (It is our understanding that Cunningham found two-thirds
to have an additional psychiatric disorder).
We recommend that all people with an intellectual disability
and problem behaviour (challenging
behaviour) require access to a mental health service and assessment
by a multidisciplinary mental health of intellectual disability
team. Following initial
assessment the multidisciplinary mental health of intellectual
disability team would deliver the same range of services that
any mental health service would deliver.
We would not see this team as specialists in “health
and social care needs” pp 56, but specialists in mental
health. In addition
referrals would be via the general practitioner in keeping with
other mental health services.
As challenging behaviour
is not a diagnosis we feel that the setting up of a distinct
service for a heterogeneous group of people who in the main
have Autistic Spectrum Disorder, formal psychiatric illness
and problem behaviours will not meet their needs.
People who exhibit challenging behaviour need to be assessed
by a multidisciplinary mental health of intellectual disability
team.
The mental health service
for people with intellectual disability needs to be delivered
as an integrated package so that all mental health problems
(challenging behaviour with or without formal psychiatric illness)
can be assessed, diagnosed and treated.
In addition the mental health service for people with
intellectual disability needs to be closely linked to the other
mental health services i.e. general adult, child and adolescent
, old age, forensic, substance misuse.
We concur with the need
to educate staff in the intellectual disability services in
the area of mental health in view of the high prevalence of
mental disorder among service users.
Under the section Specialist
Challenging Behaviour services the issue of beds appears to
be addressed. We believe
that acute in-patient assessment beds for formal psychiatric
illness need to be separated out from the need for assessment
beds for people with chronic problem behaviours (challenging
behaviour). The former
is an episodic illness whilst the latter, usually co-existing
with autistic spectrum disorder and formal mental illness, is
chronic in nature. To
discuss the number of beds that might be required is very difficult
and some would say meaningless without all elements of the mental
health service being known.
We welcome the suggestion
that clear protocol and service level agreements should be in
place. It is our understanding
that funding is provided to Intellectual Disability Services
for housing (residential) and employment (day) places and no
funding is provided specifically for the mental health services.
We would not view 8
community multidisciplinary teams and in addition separate teams
for in-patient facilities as insufficient to meet the need.
We would recommend one Consultant Psychiatrist for adults
and one Consultant Child & Adolescent Psychiatrist per 100,000
general population. Each
Consultant Psychiatrist should have a catchment area and in-patient
acute mental health beds and access to beds for chronic mental
health problems. The same model as pertains currently in adult
psychiatry. We would
not advocate some Consultant Psychiatrists not having their
own in-patient beds. We believe that it is impossible to accurately
state the number of in-patient beds that will be required bearing
in mind that “two types” of beds, one for episodic
acute mental illness and one for chronic severe problem behaviours
(challenging behaviour). The former beds will have a rather rapid turnover
whilst the function of the latter will determine the turnover
i.e. will the bed be used for assessment or long stay with ongoing
treatment.
It is questionable if
dispersing people who are chronically ill or who exhibit severe
problem behaviours (challenging behaviours) will have their
needs met by the approach recommended in the Report.
When it is recognised that a certain number of patients
are required to be treated by doctors (and presumably the same
applies to other clinical disciplines) to maintain their expertise,
it is difficult to see how or why mental health services should
be based on other premises.
In conclusion the Learning
Disability Section of the Irish College of Psychiatrists welcomes
this report and would like to thank the National Disability
Authority for designating their limited resources to the production
of this report. We would welcome the opportunity to work with
the National Disability Authority in developing the mental health
services for people with an intellectual disability.
Yours sincerely,
Dr.
Kate Ganter
Chair
Irish College of Psychiatrists
Dr. Verena Keane
Honorary Secretary
Learning Disability Faculty
|
