A comparison of outpatients with intellectual disability receiving specialised and general services in Ontario's psychiatric hospitals

Brief reportjir_1307 242..247

A comparison of outpatients with intellectual disabilityreceiving specialised and general services in Ontario’spsychiatric hospitals

Y. Lunsky,1 C. Gracey,2 E. Bradley,3 C. Koegl4 & J. Durbin5

1 Centre for Addiction and Mental Health, Dual Diagnosis,Toronto, Ontario, Canada2 University of Manchester, Manchester, England, United Kingdom3 Surrey Place Centre,Toronto, Ontario, Canada4 University of Cambridge, Institute of Criminology, Cambridge, United Kingdom5 Centre for Addiction and Mental Health,Toronto, Ontario, Canada

Abstract

Background This study compares outpatients withintellectual disability (ID) receiving specialised ser-vices to outpatients with ID receiving general ser-vices in Ontario’s tertiary mental healthcare systemin terms of demographics, symptom profile,strengths and resources, and clinical service needs.Methods A secondary analysis of Colorado ClientAssessment Record data collected from all tertiarypsychiatric hospitals in the province was completedfor a stratified random sample of 246 outpatientsidentified as having ID, from both specialised andgeneral programmes.Results Individuals with ID in specialised pro-grammes differed from patients with ID in generalprogrammes with regard to demographics, diagnos-tic profile, symptom presentation and recom-mended level of care.Conclusions Further research is required to deter-mine why individuals access some services overothers and to evaluate whether specialised services

are more appropriate for certain subgroups with IDthan others.

Keywords outpatients, intellectual disabilities,mental health, psychiatric services

Introduction

Studies among persons with an intellectual disabil-ity (ID) and comorbid psychiatric conditions havecompared the effectiveness of specialised intensiveoutpatient programmes with less specialised/intensive or standard specialised outpatient pro-grammes (Coelho et al. 1993; Hassiotis et al. 2001;Martin et al. 2005; Oliver et al. 2005; Hassiotis et al.2009). A recent Cochrane review of these studiesconcluded that there is not yet enough evidence todemonstrate the advantage of one type of pro-gramme over another and that further research isrequired (Balogh et al. 2008). The review foundinconsistent results, with some studies reportingbetter outcomes for specialised intensive pro-grammes (Coelho et al. 1993; Hassiotis et al. 2001)while others did not (Martin et al. 2005; Oliveret al. 2005). Persons with ID are a heterogeneous

Correspondence: Dr Yona Lunsky, 501 Queen St. West, Toronto,Ontario, Canada M5V2B4 (e-mail: [email protected]).

Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2010.01307.x

volume 55 part 2 pp 242–247 february 2011242

© 2010 The Authors. Journal Compilation © 2010 Blackwell Publishing Ltd

group; it is therefore possible that certain subgroupsbenefit more from intensive programmes deliveredfor the general population whereas others benefitfrom intensive services provided by specialists in thefield of ID.

The reviewed studies assume that both types ofservices are accessible to persons with an ID. Thereality is that some individuals may be better suitedto one service vs. another and that some individu-als, whether appropriate or not, tend to access onetype of service over another. Prior to determiningwhich model of care is better for whom, moreresearch is required to better understand howpatients currently accessing the two types of ser-vices differ from each other. This research can onlybe completed by comparing the two groups in ahealth system where there are both types ofservices.

The Comprehensive Assessment Projects(Lunsky et al. 2003; Lunsky & Puddicombe 2005)explored the clinical profile and service needs ofindividuals with intellectual disabilities receivingtertiary level mental health care in Ontario,Canada (estimated population of 12.39 million). Ina previous paper (Lunsky et al. 2008), inpatientswith ID and psychiatric diagnoses in specialisedprogrammes were compared with inpatients ingeneral programmes. Inpatients with ID weremore likely to have a diagnosis of mood disorderand were less likely to have a substance abuse orpsychotic disorder. Individuals receiving specialisedservices had higher ratings of challenging behav-iour than inpatients in general programmes.Although more inpatients in specialised pro-grammes were rated as requiring more intensiveoutpatient support (level 4), the two groups didnot differ in terms of overall distribution of care.However, this study was limited in that it focussedonly on inpatients.

It is important to examine whether, similar to the2008 study of inpatients, differences are found inoutpatients directed towards specialised servicescompared with general services. The goals of thepresent study were to compare socio-demographicand symptom profile of outpatients with ID receiv-ing specialised and general tertiary mental healthcare in a large geographical region and to compareservice needs and recommended levels of care forpatients in the two groups.

Methods

Sample and data collection

The analytic sample for this study was drawn froma larger mental health services planning study(Comprehensive Assessment Projects) conducted inOntario during 1998–2003 of all nine psychiatrichospitals responsible for providing tertiary outpa-tient mental health services to individuals aged 16

years and older in urban, semi-urban and ruralcommunities. Tertiary outpatient programmes aremandated to provide services to individuals withchronic or complex mental health issues and repre-sent the middle ground between tertiary level inpa-tient and community-based mental health care (forfurther details on sample selection, see Lunsky et al.2006). The planning study employed a cross-sectional design, assessing a stratified randomsample of outpatients. The final analytic sample forthis study included 246 outpatients with ID, ofwhich 103 (41.9%) were in specialised programmesand 136 (55.3%) were in general programmes.Details regarding data collection, the ColoradoClient Assessment Record (Ellis et al. 1984; Elliset al. 1991) and level of care assessment aredescribed in an earlier paper (Lunsky et al. 2008).

Programmes were considered specialised if ser-vices were exclusively for individuals with ID andmental health issues. At the time of data collection,there were six specialised outpatient programmesfor individuals with ID. All specialised programmeswere interdisciplinary with services tailored to theneeds of patients with ID and mental health needs,although the staff complement varied by pro-gramme (for details on programmes see Lunsky &Puddicombe 2005). General programmes, althoughspecialised in some cases (e.g. forensic, schizophre-nia), did not focus on treating individuals with IDbut also did not exclude individuals with ID fromtheir service.

Analyses

Differences between outpatients with ID receivingspecialised and general psychiatric services ondemographics, diagnoses and recommended level ofcare were compared using c2-tests. Differences onsymptom severity and strengths/resources werecompared using t-tests. Analyses were performed

243Journal of Intellectual Disability Research volume 55 part 2 february 2011

Y. Lunsky et al. • A comparison of outpatients


with spss version 15 (SPSS Inc. 2007). Institutionalethics review board approval for conducting thesesecondary analyses was obtained.

Results

Patient characteristics and symptom profile

Outpatients receiving specialised services were com-pared with outpatients receiving general mentalhealth services on the basis of patient characteristicsand psychiatric diagnoses. Outpatients in specialisedprogrammes were significantly younger ( X = 39 5. ,SD = 11.2) than their counterparts accessing generalservices [ X = 46 7. , SD = 13.7; t(1, 236) = 4.39,P < 0.05]. Table 1 presents patient characteristicsand psychiatric diagnoses. Outpatients in specialisedprogrammes were more likely to be male and singleand less likely to have a comorbid medical diagnosisas well as history of suicide attempts than theircounterparts receiving general services. Regardingpsychiatric diagnoses, outpatients in specialised pro-grammes were more likely to have a mood oranxiety disorder diagnosis and were less likely tohave a psychotic disorder diagnosis.

Table 2 compares mean Colorado Client Assess-ment Record ratings for outpatients from the twotypes of programmes. Outpatients in specialised

programmes had higher scores on attention prob-lems (d = 0.37) and self-care/basic needs (d = 0.46)than their counterparts in general programmes. Inregards to challenging behaviour, outpatients in spe-cialised programmes had higher ratings on six ofthe seven domains; aggressiveness (d = 0.62), anti-social behaviour (d = 0.38), resistiveness (d = 0.43),security/management risk (d = 0.73), danger to self(d = 0.27) and danger to others (d = 0.38). In termsof lack of resources, outpatients receiving special-ised services received lower ratings on economic(d = 0.62), social support (d = 0.50) and overall lackof resources (d = 0.29), meaning that outpatients ingeneral services actually had fewer resources thanthose in specialised services.

Patient need: recommended level of care

As can be observed from Table 3, outpatients in thetwo types of programmes differed in terms of recom-mended level of care.The majority of outpatients inboth types of programmes were rated as requiringlevel 3 care (43.6% vs. 47.0%), but more individualsin specialised programmes were rated as requiringlevel 4 care than individuals in general programmes(34.6% vs. 17.2%). Conversely, more outpatients ingeneral programmes were rated as requiring level 2

care than those in specialised (19.8% vs. 35.1%).

Table 1 Comparison of patientcharacteristics and psychiatric diagnosesfor those in specialised and generalprogrammesCategory

Specialised General

c2 P-value(N = 103) (N = 136)% (n) % (n)

Patient characteristicsGender (male) 65.7 (67) 50.0% (68) 5.84 0.018Never married 93.1% (95) 68.1% (92) 20.32 0.000Psychotropic medication 97.1% (100) 93.8% (106) 1.32 0.338Comorbid medical condition 27.1% (23) 51.9% (56) 12.09 0.001History of legal problems 5.9% (6) 12.3% (16) 2.75 0.117History of fire setting/ property 9.2% (9) 5.3% (6) 1.23 0.294History of suicide attempt 1.9% (2) 23.5% (32) 22.39 0.000

Psychiatric diagnoses*Mood disorder 31.1% (32) 16.9% (23) 6.63 0.013Anxiety disorder 17.5% (18) 5.9% (8) 8.13 0.006Substance abuse 1.0% (1) 5.9% (8) 3.90 0.082Psychotic disorder 28.2% (29) 64.0% (87) 30.10 0.000Personality disorder 6.8% (7) 14.0% (19) 3.11 0.094Organic disorder 2.9% (3) 4.4% (6) 0.36 0.736

* Patients could receive more than one diagnosis.




Discussion

The present study was conducted to contrast thepatient characteristics and clinical needs of outpa-tients with ID receiving specialised services to those

receiving general services within the tertiary carepsychiatric hospital system in Ontario. Many ofthese same trends were also observed in the 2008

inpatients study, with a few exceptions that areelaborated upon below. Individuals in both typesof programmes have complex needs that warrantspecial attention.

In the current study, psychiatric outpatientsreceiving general services were older, more likely tohave a comorbid medical condition, with fewerresources. These findings paint a picture of a mar-ginalised, hard to support group. They have a needfor more intensive services, but general outpatientstypically only receive level 2 type care. This studyadds to the literature suggesting that individuals ingeneric programmes with ID and serious mentalillness could benefit from more intensive servicesbeyond what is provided in the standard outpatientmental health care (Hassiotis et al. 2001; Chaplin2004, 2009; Reid 1995).

Table 2 Comparison of mean problem severity and resources of outpatients in specialised and general programmes

CCAR domain

Specialised General

t-score df * P Cohen’s dMean SD Mean SD

Adaptive behaviour and cognitionAttention problems 5.11 1.89 4.38 2.02 -2.82 237 0.005 0.37Cognitive problems 4.54 1.73 4.32 1.96 -0.82 200 0.416 0.12Role performance 5.53 2.68 5.41 3.16 -0.31 223 0.756 0.04Self-care/basic needs 5.94 2.19 4.93 2.25 -3.47 237 0.001 0.46

Challenging behaviourAggressiveness 4.12 2.17 2.79 2.16 -4.68 235 0.000 0.62Antisocial behaviour 3.12 1.98 2.40 1.88 -2.79 224 0.006 0.38Legal issues 1.34 1.27 1.40 1.30 0.33 211 0.740 0.05Resistiveness 4.39 1.60 3.62 1.91 -3.26 231 0.001 0.43Security/management risk 4.78 1.95 3.27 2.19 -5.51 237 0.000 0.73Suicide/danger to self 2.63 2.17 2.09 1.89 -1.99 224 0.048 0.27Violence/danger to others 3.04 2.19 2.28 1.89 -2.80 228 0.006 0.38

Lack of resourcesEducational and social 7.50 1.81 7.73 1.59 0.97 202 0.333 0.14Economic 4.67 1.53 5.80 2.07 4.43 203 0.000 0.62Personal (social support) 4.85 2.17 5.95 2.24 3.58 204 0.000 0.5Personal strengths 6.36 1.99 6.66 1.89 1.11 204 0.267 0.16

Global rating of problem severity 5.45 1.43 5.18 1.56 -1.39 235 0.167 0.18Global rating of lack of resources 5.99 1.60 6.48 1.77 2.19 234 0.030 0.29

Ratings on a 1- to 9-point Likert scale where 1 = high functioning/no special problem and 9 = low functioning/extreme problem ofdifficulty.* Overall sample size varies because of missing information; some variables were not collected at all sites.CCAR, Colorado Client Assessment Record.

Table 3 Recommended level of care for patients in specialised andgeneral programmes

Specialised General(N = 103) (N = 136)% (n) % (n)

Level 1 5.9% (6) 11.2% (15)Level 2 13.9% (14) 23.9% (32)Level 3 43.6% (44) 47.0% (63)Level 4 34.6% (35) 17.2% (23)Level 5 2.0% (2) 0.7% (1)

c2 = 12.71, P < 0.05 (P = 0.013).




Patients in specialised programmes were younger,more likely to be diagnosed with a mood or anxietydisorder, displayed more aggression and were recom-mended for higher levels of care than other patients.With the exception of anxiety disorder diagnoses,these findings are similar to what was found amonginpatients in specialised programmes when com-pared with their counterparts in general programmes(Lunsky et al. 2008). Higher recommended level ofcare for individuals in specialised programmes sug-gests that overall patients with greater needs areapparently being directed to the specialised services.

As was suggested in the earlier paper (Lunskyet al. 2008), diagnostic differences may be due inpart to differing skill sets between the two types ofservices. Clinicians with specialised training in IDmay be more likely to recognise mood and anxietydisorders, hence the higher rate of these diagnosesand lower rate of schizophrenia diagnoses (See alsoHurley, Folstein and Lam 2003). That being said,the higher rate of schizophrenia in general servicesmay also be reflective of a subgroup of individualswith schizophrenia who are low functioning, such asthose described in the UK700 trial (Hassiotis et al.2001). These individuals do not tend to get referredto specialised services, but may not get as muchsupport as they need in general schizophrenia out-patient programmes and evidence would suggestthat they benefit from more intensive services(Hassiotis et al. 2001).

This study has several limitations, which shouldbe taken into consideration when interpreting itsfindings. First, information regarding ethnicity, raceand level of ID was not available and issues such asaccuracy of ID and psychiatric diagnosis cannot beaddressed using this database, as the data weredeveloped for another purpose. Second, this studydoes not address the needs of outpatients whoaccess services outside of tertiary level care psychi-atric hospitals or who are not receiving any services.Third, findings here may be unique to Ontario, andnot generalisable to other jurisdictions. Only com-parable research in other places will address thisissue. Finally, the level of care algorithm adoptedhere has demonstrated good concurrent validity, yetis still relatively new and would benefit from furthertesting, especially in psychiatric populations withcomplex conditions such as those with ID andmental health needs.

Acknowledgement

This research was supported by an Ontario MentalHealth Foundation New Investigator Award.

References

Balogh R., Ouellette-Kuntz H., Bourne L., Lunsky Y. &Colantonio A. (2008) Organizing health care servicesfor persons with an intellectual disability. CochraneDatabase of Systematic Reviews 4, Art. No.: CD007492,DOI: 10.1002/14651858.CD007492

Chaplin R. (2004) Generic psychiatric services for adultswith intellectual disability and mental illness. Journal ofIntellectual Disability Research 48, 1–10.

Chaplin R. (2009) New research into general psychiatricservices for adults with intellectualdisability and mentalillness. Journal of Intellectual Disability Research 53, 189–99.

Coelho R., Kelley P. & Deatsman-Kelley C. (1993) Anexperimental investigation of an innovative communitytreatment model for persons with a dual diagnosis (DD/MI). Journal of Rehabilitation 54, 37–42.

Ellis R., Wilson N. & Foster F. (1984) State wide treat-ment outcome assessment in Colorado: the Coloradoclient assessment record. Community Mental HealthJournal 20, 72–89.

Ellis R. J., Wackwitz J. H. & Foster M. (1991) Uses of anempirically derived client typology based on level offunctioning: twelve years of the CCAR. Journal ofMental Health Administration 18, 88–100.

Hassiotis A., Ukoumunne O., Byford S., Tyrer P., HarveyK., Piachaud J. et al. (2001) Intellectual functioning andoutcome of patients with severe psychotic illness ran-domized to intensive case management: report from theUK700 trial. British Journal of Psychiatry 178, 166–71.

Hassiotis A., Robotham D., Canagasabey A., Romeo R.,Langridge D., Blizard R. et al. (2009) Randomized,single-blind, controlled trial of a specialist behaviortherapy team for challenging behavior in adults withintellectual disabilities. The American Journal of Psychia-try 166, 1278–85.

Hurley A., Folstein M. & Lam N. (2003) Patients withand without intellectual disability seeking outpatientspsychiatric services: diagnoses and prescribing pattern.Journal of Intellectual Disability Research 47, 39–50.

Lunsky Y. & Puddicombe J. (2005) Dual Diagnosis inOntario’s Specialty (Psychiatric) Hospitals: QualitativeFindings and Recommendations (Phase II SummaryReport). Centre for Addiction and Mental Health,Toronto. Available at: http://www.camh.net/Care_Treatment/Program_Descriptions/Mental_Health_Programs/Dual_Diagnosis/dual_diagnosis_ontpsyhos_ph2dec05.pdf




Lunsky Y., Bradley E., Durbin J., Koegl C., Canrinus M.& Goering P. (2003) Dual Diagnosis in Provincial Psychi-atric Hospitals: A Population Based Study. Centre forAddiction and Mental Health, Toronto. Available at:http://www.camh.net/Publications/Resources_for_Professionals/dualdiagnosis_provpsychhosp_1styr2003.pdf

Lunsky Y., Bradley E., Durbin J., Koegl C., Canrinus M.& Goering P. (2006) The clinical profile and serviceneeds of hospitalized adults with mental retardation anda psychiatric diagnosis. Psychiatric Services 57, 77–83.

Lunsky Y., Bradley E., Durbin J. & Koegl C. (2008) Acomparison of patients with intellectual disability receiv-ing specialised and general services in Ontario’s psychi-atric hospitals. Journal of Intellectual Disability Research52, 1003–12.

Martin G., Costello H., Leese M., Slade M., Bouras N.,Higgins S. et al. (2005) An exploratory study of asser-tive community treatment for people with intellectualdisability and psychiatric disorders: conceptual, clinical,and service issues. Journal of Intellectual DisabilityResearch 49, 516–24.

Oliver P., Piachaud J., Tyrer P., Regan A., Dack M., Alex-ander R. et al. (2005) Randomized controlled trial ofassertive community treatment in intellectual disability:the TACTILD study. Journal of Intellectual DisabilityResearch 49, 507–15.

SPSS Inc. (2007) SPSS Base 15.0 forWindows. SPSS Inc.,Chicago, IL.

Accepted 19 June 2010




Documents

A comparison of outpatients with intellectual disability receiving specialised and general services in Ontario's psychiatric hospitals