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Psychiatric Service Use and Psychiatric Disorders in Adults with Intellectual Disability

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Title: Psychiatric Service Use and Psychiatric Disorders in Adults with Intellectual Disability
Language: English
Authors: Bhaumik, S., Tyrer, F. C., McGrother, C., Ganghadaran, S. K.
Source: Journal of Intellectual Disability Research. Nov 2008 52(11):986-995.
Availability: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp
Peer Reviewed: Y
Page Count: 10
Publication Date: 2008
Document Type: Journal Articles
Reports - Research
Descriptors: Psychiatric Services, Health Services, Gender Differences, Incidence, Mental Retardation, Schizophrenia, Mental Health Programs, Mental Health, Psychiatry, Patients, Foreign Countries, Adults, Age, Residential Care, Epilepsy, Autism, Mental Disorders, Specialists, Cooperation
Geographic Terms: United Kingdom
DOI: 10.1111/j.1365-2788.2008.01124.x
ISSN: 0964-2633
Abstract: Background: UK policies aim to facilitate access to general psychiatric services for adults with intellectual disability (ID). If this is to be achieved, it is important to have a clear idea of the characteristics and proportion of people with ID who currently access specialist psychiatric services and the nature and extent of psychiatric disorders in this population. Methods: A cross-sectional study was carried out on all adults with ID using specialist services in Leicestershire and Rutland, UK, between 2001 and 2006. Characteristics of individuals seen by psychiatric services and the nature and prevalence of psychiatric disorders were investigated. Results: Of 2711 adults identified, 1244 (45.9%) accessed specialist psychiatric services at least once during the study period. Individuals attending psychiatric services were more likely to be older and to live in residential settings; they were less likely to be south Asian or to have mild/moderate ID. The prevalence of psychiatric disorders among the total study population was 33.8%; the most common disorders were behaviour disorder (19.8%) and autistic spectrum disorders (8.8%). Epilepsy was highly prevalent (60.8%) among those attending psychiatric services without a mental health diagnosis. Behaviour disorders and autistic spectrum disorders were more common in men and in adults with severe/profound ID, whereas schizophrenia and organic disorders were more common in women and in adults with mild/moderate ID. Depression was also more common in women with ID. Conclusions: Psychiatric disorders and specialist health problems are common among adults with ID and the profile of psychiatric disorders differs from that found in general psychiatry. Close collaboration between general and specialist service providers is needed if the current move towards use of general psychiatric services in this population is to be achieved. The measures should include a clear care pathway for people with ID and mental health problems to facilitate the smooth transfer of patients between specialist and generic mental health services and arrangements for joint working where input from both services is required. The commissioning framework for such processes should be in place with appropriate pooling of resources.
Abstractor: As Provided
Number of References: 42
Entry Date: 2008
Accession Number: EJ814218
Database: ERIC
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  Value: <anid>AN0034740813;eul01nov.08;2019Jun04.10:46;v2.2.500</anid> <title id="AN0034740813-1">Psychiatric service use and psychiatric disorders in adults with intellectual disability. </title> <p>Background  UK policies aim to facilitate access to general psychiatric services for adults with intellectual disability (ID). If this is to be achieved, it is important to have a clear idea of the characteristics and proportion of people with ID who currently access specialist psychiatric services and the nature and extent of psychiatric disorders in this population. Methods  A cross‐sectional study was carried out on all adults with ID using specialist services in Leicestershire and Rutland, UK, between 2001 and 2006. Characteristics of individuals seen by psychiatric services and the nature and prevalence of psychiatric disorders were investigated. Results  Of 2711 adults identified, 1244 (45.9%) accessed specialist psychiatric services at least once during the study period. Individuals attending psychiatric services were more likely to be older and to live in residential settings; they were less likely to be south Asian or to have mild/moderate ID. The prevalence of psychiatric disorders among the total study population was 33.8%; the most common disorders were behaviour disorder (19.8%) and autistic spectrum disorders (8.8%). Epilepsy was highly prevalent (60.8%) among those attending psychiatric services without a mental health diagnosis. Behaviour disorders and autistic spectrum disorders were more common in men and in adults with severe/profound ID, whereas schizophrenia and organic disorders were more common in women and in adults with mild/moderate ID. Depression was also more common in women with ID. Conclusions  Psychiatric disorders and specialist health problems are common among adults with ID and the profile of psychiatric disorders differs from that found in general psychiatry. Close collaboration between general and specialist service providers is needed if the current move towards use of general psychiatric services in this population is to be achieved. The measures should include a clear care pathway for people with ID and mental health problems to facilitate the smooth transfer of patients between specialist and generic mental health services and arrangements for joint working where input from both services is required. The commissioning framework for such processes should be in place with appropriate pooling of resources.</p> <p>Keywords: psychiatric disorders; prevalence; mental health services and access; intellectual disability</p> <p>Concern over health inequalities faced by adults with intellectual disability (ID) has led to a number of policy initiatives aimed at facilitating access to generic services, enabling adults with ID to feel socially valued and to live as independently as possible ([<reflink idref="bib12" id="ref1">12</reflink>], [<reflink idref="bib13" id="ref2">13</reflink>]; [<reflink idref="bib39" id="ref3">39</reflink>]). This includes improving access to general psychiatric services for adults with ID and co‐existing mental health problems. In the UK the move towards use of general psychiatric services has proved difficult, largely because of lack of experience, resources and skills needed in general psychiatry to treat the complex co‐existing health and behaviour problems in this client group ([<reflink idref="bib5" id="ref4">5</reflink>]; [<reflink idref="bib6" id="ref5">6</reflink>]). The prevalence of general and specialist psychiatric service use among adults with ID is currently unclear because a measure of the underlying ID population in individual catchment areas is generally not available. However, it is recognised that most people with moderate to profound ID are still seen by specialist psychiatric services ([<reflink idref="bib6" id="ref6">6</reflink>]), while those with mild ID, who generally have fewer complex health needs and greater potential for independence, may be more likely to benefit from access to general psychiatric services with support from specialist services ([<reflink idref="bib1" id="ref7">1</reflink>]; [<reflink idref="bib30" id="ref8">30</reflink>]).</p> <p>Undoubtedly psychiatry plays an important service role in this area. Psychiatric disorders are highly prevalent in adults with ID, with population‐based studies reporting rates of between 30% and 41% ([<reflink idref="bib22" id="ref9">22</reflink>]; [<reflink idref="bib7" id="ref10">7</reflink>]), which are higher than the prevalence estimates of 16–20% in the general population ([<reflink idref="bib38" id="ref11">38</reflink>]; [<reflink idref="bib31" id="ref12">31</reflink>]). Other studies show varying rates between 12% and 60% ([<reflink idref="bib20" id="ref13">20</reflink>]; [<reflink idref="bib19" id="ref14">19</reflink>]; [<reflink idref="bib28" id="ref15">28</reflink>]; [<reflink idref="bib11" id="ref16">11</reflink>]; [<reflink idref="bib34" id="ref17">34</reflink>]), depending on the case mix of the study populations and the identification and definitional criteria used. Making an accurate psychiatric diagnosis is difficult in this population because many people with ID have communication deficits and associated physical health problems, which complicate the use of available diagnostic criteria.</p> <p>In order for general psychiatric services to become more responsive to the mental health needs of adults with ID in the UK, it is important to have a clear idea of the characteristics and proportion of people with ID who currently access specialist psychiatric services and the nature and extent of psychiatric disorders in this population.</p> <p>The aims of this study were:</p> <p></p> <p>• 1</p> <p></p> <ulist> <item> To describe the prevalence of specialist psychiatric service use among adults with ID;</item> <p></p> </ulist> <p>• 2</p> <p></p> <ulist> <item> To describe the nature and prevalence of psychiatric disorders in adults with ID; and</item> <p></p> </ulist> <p>• 3</p> <p></p> <ulist> <item> To identify any differences in the nature and prevalence of psychiatric disorders between men and women and between different severity levels of ID.</item> </ulist> <hd id="AN0034740813-2">Methods</hd> <p></p> <hd id="AN0034740813-3">Description of the service and population served</hd> <p>This was a cross‐sectional study of all adults with administratively defined ID in Leicestershire (including the city of Leicester) and Rutland, UK. This geographic location has a population of 0.7 million adults (aged 19 years or over), of whom approximately 8% are of south Asian origin ([<reflink idref="bib26" id="ref18">26</reflink>]), and is similar in socio‐economic terms to the UK as a whole. The prevalence of psychiatric disorders in adults with ID was determined using information on adult inpatients and outpatients (aged 19 years or over) seen by specialist ID psychiatric services in this geographical location between 1 January 2001 and 31 December 2006. The Learning Disability Service in Leicestershire is hosted by the mental health trust and provides a range of specialist health interventions for adults with ID. These include psychiatry, psychology, speech and language therapy, occupational therapy and physiotherapy. Referrals to psychiatric services are routed through general practitioners. There is a 12‐bedded specialist ID inpatient unit and service users with mild ID are able to access general psychiatry inpatient beds where appropriate.</p> <hd id="AN0034740813-4">Data collection</hd> <p>Starting from year 2000, all psychiatric diagnoses (more than one per patient where appropriate) of patients using specialist psychiatric services for people with ID have been recorded using International Classification of Disease (ICD)‐10 diagnostic criteria ([<reflink idref="bib41" id="ref19">41</reflink>]). These diagnoses were based on clinical assessments by the respective consultant psychiatrists and were recorded in a database along with other details, including age, sex, ethnicity, residential status of the patient, comorbidity (epilepsy, mobility problems, visual and hearing impairments) and any prescribed medication.</p> <p>A measure of the underlying population was assessed using individuals on the Leicestershire Learning Disability Register who had participated in a home interview over the same 6‐year study period. The register has been described in detail elsewhere ([<reflink idref="bib24" id="ref20">24</reflink>]); briefly it is an open cohort of adults (aged 19 years or over) living in and using specialist services (notified via a wide range of service providers) in Leicestershire and Rutland, UK. Notification to the register is based on a diagnosis of ID ([<reflink idref="bib41" id="ref21">41</reflink>]) with deficits in adaptive functioning ([<reflink idref="bib16" id="ref22">16</reflink>]) and a probable need for long‐term support. As the register can only capture information of people with ID who require support from social, health, voluntary or independent sector services, the number of people recorded in the register comprise the administrative prevalence of ID in Leicestershire and Rutland. All adults seen by specialist psychiatric services in Leicestershire are on the register. Some people with mild ID may access mainstream services without being identified as having ID and are therefore not known to the register. Currently it is not possible to identify the size of this population.</p> <p>The register supports a programme of structured home interviews, for which the current acceptance rate is 91%, that are carried out with carers and clients every 5 to 7 years. Interviews incorporate the Disability Assessment Schedule ([<reflink idref="bib17" id="ref23">17</reflink>]) and include questions on demographic details, skill level, behaviour and carer stress. Severity level of ID is determined from seven questions on communication, skill level and dependency, which have been validated against scores from the Vineland scale (survey form) ([<reflink idref="bib33" id="ref24">33</reflink>]; [<reflink idref="bib37" id="ref25">37</reflink>]). Using this assessment, developmental age was estimated and the sample was categorised into four severity levels following the World Health Organisation's ICD‐10 criteria ([<reflink idref="bib41" id="ref26">41</reflink>]): mild (approx. IQ 50–69), moderate (approx. IQ 35–49), severe (approx. IQ 20–34) and profound (approx. IQ < 20). Individuals with an unknown or borderline level of ID (approx. IQ ≥ 70) (<emph>n</emph> = 134) were excluded from the analysis.</p> <p>At the time of being interviewed by register staff, people with ID and their families are informed that the information in an anonymised format may be used for research purposes. We did not seek consent specifically for this study as seeking consent retrospectively was felt to be inappropriate in this situation. ICD diagnostic coding is routinely carried out during psychiatric interviews in order to fulfill performance objectives set out by the Department of Health and to inform primary care physicians. After considering the above information, the Derbyshire Research Ethics Committee gave ethical approval for this study.</p> <hd id="AN0034740813-5">Statistical methods</hd> <p>The population was stratified by psychiatric service attendance and described for sex, age group, residential status and level of ID. The prevalence and nature of the psychiatric disorders were reported by sex and severity of ID. Data were analysed using the chi‐squared test (or a two‐tailed Fisher's exact test where the expected cell frequency was below 5). Analyses were carried out in Stata version 9.0.</p> <hd id="AN0034740813-6">Results</hd> <p>In the 6‐year period between 2001 and 2006, 1244 (45.9%) adults were seen by specialist psychiatric services in Leicestershire, of whom 707 (56.8%) were men and 537 (43.2%) were women (Table 1). Most adults were living in residential homes (38.4%) and had severe or profound ID (72.1%). Among those seen by services, 479 (38.5%) adults had epilepsy and 814 (65.4%) adults were prescribed psychotropic medication (including anti‐epileptic drugs). No sex differences were observed between adults who accessed specialist psychiatric services and those who did not. However, those who saw a psychiatrist were less likely to be aged <30 years, more likely to be living in residential accommodation, and less likely to have mild or moderate ID (Table 1).</p> <p>1 Characteristics of the study population</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Characteristic</bold></th><th><bold>Psychiatric assessment</bold></th><th><bold>No psychiatric assessment</bold></th><th><bold><italic>P</italic>‐value</bold></th></tr><tr><th><italic><bold>n</bold></italic></th><th><bold>(%)</bold></th><th><italic><bold>n</bold></italic></th><th><bold>(%)</bold></th></tr></thead><tbody valign="top"><tr><td>All individuals</td><td>1244</td><td>(100.0)</td><td>1467</td><td>(100.0)</td><td /></tr><tr><td>Sex</td><td /><td /><td /><td /><td /></tr><tr><td> Men</td><td>707</td><td>(56.8)</td><td>819</td><td>(55.8)</td><td>0.60</td></tr><tr><td> Women</td><td>537</td><td>(43.2)</td><td>648</td><td>(44.2)</td></tr><tr><td>Age group*</td><td /><td /><td /><td /><td /></tr><tr><td> 19–29</td><td>254</td><td>(20.4)</td><td>515</td><td>(35.1)</td><td><0.001</td></tr><tr><td> 30–39</td><td>296</td><td>(23.8)</td><td>346</td><td>(23.6)</td></tr><tr><td> 40–49</td><td>291</td><td>(23.4)</td><td>287</td><td>(19.6)</td></tr><tr><td> 50–59</td><td>238</td><td>(19.1)</td><td>168</td><td>(11.5)</td></tr><tr><td> 60+</td><td>165</td><td>(13.3)</td><td>151</td><td>(10.3)</td></tr><tr><td>Ethnic group</td><td /><td /><td /><td /><td /></tr><tr><td> White</td><td>1082</td><td>(87.0)</td><td>1196</td><td>(81.5)</td><td><0.001</td></tr><tr><td> South Asian</td><td>111</td><td>(8.9)</td><td>237</td><td>(16.2)</td></tr><tr><td> Other/unknown</td><td>51</td><td>(4.1)</td><td>32</td><td>(2.2)</td></tr><tr><td>Residential status†</td><td /><td /><td /><td /><td /></tr><tr><td> Independent</td><td>53</td><td>(4.3)</td><td>153</td><td>(10.4)</td><td><0.001</td></tr><tr><td> Living with family</td><td>341</td><td>(27.4)</td><td>817</td><td>(55.7)</td></tr><tr><td> Supported living/voluntary</td><td>116</td><td>(9.3)</td><td>113</td><td>(7.7)</td></tr><tr><td>Residential home</td><td>478</td><td>(38.4)</td><td>245</td><td>(16.7)</td></tr><tr><td>Social services hostel</td><td>38</td><td>(3.1)</td><td>25</td><td>(1.7)</td></tr><tr><td>NHS accommodation</td><td>130</td><td>(10.5)</td><td>22</td><td>(1.5)</td></tr><tr><td>Other/not known</td><td>88</td><td>(7.1)</td><td>84</td><td>(5.7)</td></tr><tr><td>Level of ID</td><td /><td /><td /><td /><td /></tr><tr><td> Mild</td><td>160</td><td>(12.9)</td><td>377</td><td>(25.7)</td><td><0.001</td></tr><tr><td> Moderate</td><td>187</td><td>(15.0)</td><td>368</td><td>(25.1)</td></tr><tr><td> Severe</td><td>414</td><td>(33.3)</td><td>466</td><td>(31.8)</td></tr><tr><td> Profound</td><td>483</td><td>(38.8)</td><td>256</td><td>(17.5)</td></tr></tbody></table> </ephtml> </p> <p>1 *  Age at assessment or date of home interview (for individuals without an assessment).</p> <ulist> <item>2 †   Residence on date of assessment or date of home interview (for individuals without an assessment).</item> <item>3 ID, intellectual disability; NHS, National Health Service.</item> </ulist> <p>The prevalence of psychiatric disorders in the study population was 33.8% (<emph>n</emph> = 915) (Table 2). The most common psychiatric disorders were behaviour disorder, diagnosed in 19.8% of adults, followed by autistic spectrum disorders (8.8%) (autism, Asperger's syndrome, atypical autism and unspecified pervasive developmental disorders), depression (4.3%) and bipolar affective disorders (3.0%). Of interest, 12.1% (<emph>n</emph> = 329) of individuals who attended specialist psychiatric services did not have a diagnosis of a psychiatric disorder; the majority of these individuals (60.8%; <emph>n</emph> = 200) had epilepsy.</p> <p>2 The prevalence of psychiatric disorders (per cent) in adults with intellectual disabilities by sex</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Diagnostic category</bold></th><th><bold>ICD‐10 diagnoses</bold></th><th><bold>Males</bold> 
 <bold>(<italic>n</italic> = 1526)</bold> 
 <bold>%</bold></th><th><bold>Females</bold> 
 <bold>(<italic>n</italic> = 1185)</bold> 
 <bold>%</bold></th><th><bold><italic>P</italic>‐value</bold></th><th><bold>All</bold> 
 <bold>(<italic>n</italic> = 2711)</bold> 
 <bold>%</bold></th></tr></thead><tbody valign="top"><tr><td>Psychotic disorders</td><td /><td /><td /><td /><td /></tr><tr><td> Schizophrenia</td><td>F20.x</td><td>1.7</td><td>3.0</td><td>0.02</td><td>2.2</td></tr><tr><td> Other psychotic disorders</td><td>F21–F23.x, F25.x, F28–F29.x</td><td>1.8</td><td>1.7</td><td>0.77</td><td>1.8</td></tr><tr><td>Affective disorders</td><td /><td /><td /><td /><td /></tr><tr><td> Depressive disorder</td><td>F32–F33.x</td><td>3.2</td><td>5.7</td><td>0.001</td><td>4.3</td></tr><tr><td> Bipolar affective disorder</td><td>F30–F31.x</td><td>2.7</td><td>3.4</td><td>0.30</td><td>3.0</td></tr><tr><td> Other/unspecified</td><td>F34.x, F38–F39.x</td><td>0.9</td><td>1.4</td><td>0.15</td><td>1.1</td></tr><tr><td>Anxiety disorders</td><td /><td /><td /><td /><td /></tr><tr><td> Obsessive compulsive disorder</td><td>F42.x</td><td>0.3</td><td>0.4</td><td>0.76</td><td>0.4</td></tr><tr><td> Other anxiety disorder</td><td>F40–F41.x, F43–F45.x</td><td>2.4</td><td>1.8</td><td>0.24</td><td>2.1</td></tr><tr><td>Other psychiatric disorders</td><td /><td /><td /><td /><td /></tr><tr><td> Organic disorder</td><td>F00–F03.x, F05–F07.x, F09.x</td><td>1.5</td><td>2.9</td><td>0.01</td><td>2.1</td></tr><tr><td> Alcohol/substance use disorder</td><td>F10.x, F12.x, F18.x, F19.x</td><td>0.1</td><td>0.1</td><td>0.59</td><td>0.1</td></tr><tr><td> Sleep disorder</td><td>F51.x</td><td>0.2</td><td>0.1</td><td>0.64</td><td>0.2</td></tr><tr><td> Autistic spectrum disorder</td><td>F84.x</td><td>10.4</td><td>6.7</td><td>0.001</td><td>8.8</td></tr><tr><td> Behaviour disorder</td><td>F70.1, F71.1, F72.1, F73.1</td><td>22.0</td><td>16.9</td><td>0.001</td><td>19.8</td></tr><tr><td> Personality disorder</td><td>F60.x, F61.x</td><td>1.1</td><td>1.6</td><td>0.20</td><td>1.3</td></tr><tr><td> Other</td><td>F50.x, F52.x, F59.x, F62–F63.x, F65–F66.x</td><td>1.1</td><td>0.1</td><td>0.001</td><td>0.7</td></tr><tr><td>Psychiatric disorders of any type</td><td>Any of above</td><td>34.0</td><td>33.4</td><td>0.75</td><td>33.8</td></tr><tr><td>Total presenting to psychiatric services</td><td>–</td><td>46.3</td><td>45.3</td><td>0.60</td><td>45.9</td></tr></tbody></table> </ephtml> </p> <p>4 ICD, International Classification of Disease.</p> <p>No differences were observed in the overall prevalence of psychiatric disorders between men and women. However, there were substantial sex differences in diagnoses of individual psychiatric disorders. Men were more likely to have a diagnosis of autistic spectrum disorder, behaviour disorder or other psychiatric disorders. Women were more likely to have a diagnosis of schizophrenia depression or organic disorder.</p> <p>Psychiatric service attendance was more common as individuals' severity of ID increased; the proportion of adults with mild, moderate, severe and profound ID who accessed psychiatric services was 29.8%, 33.7%, 47.1% and 65.4%, respectively. These proportions were reflected in the prevalence of psychiatric disorders in this population; just under one‐quarter (24.2%) of adults with mild ID had a diagnosis of psychiatric disorders, compared with 27.4%, 34.3% and 44.8% in people with moderate, severe and profound ID, respectively. Psychiatric diagnoses varied among adults with different levels of ID. Those with mild and moderate ID generally had more diagnoses of schizophrenia and personality disorders, whereas those with severe and profound ID had higher rates of organic disorders, autistic spectrum disorders and behaviour disorders (Table 3).</p> <p>3 The prevalence of psychiatric disorders (per cent) in adults with intellectual disabilities (ID) by severity of ID</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Diagnostic category</bold></th><th><bold>Mild</bold> 
 <bold>(<italic>n</italic> = 537)</bold> 
 <bold>%</bold></th><th><bold>Moderate</bold> 
 <bold>(<italic>n</italic> = 555)</bold> 
 <bold>%</bold></th><th><bold>Severe</bold> 
 <bold>(<italic>n</italic> = 880)</bold> 
 <bold>%</bold></th><th><bold>Profound</bold> 
 <bold>(<italic>n</italic> = 739)</bold> 
 <bold>%</bold></th><th><bold><italic>P</italic>‐value</bold></th></tr></thead><tbody valign="top"><tr><td>Psychotic disorders</td><td /><td /><td /><td /><td /></tr><tr><td> Schizophrenia</td><td>3.7</td><td>3.8</td><td>1.9</td><td>0.5</td><td><0.001</td></tr><tr><td> Other psychotic disorders</td><td>1.9</td><td>2.0</td><td>2.5</td><td>0.7</td><td>0.05</td></tr><tr><td>Affective disorders</td><td /><td /><td /><td /><td /></tr><tr><td> Depressive disorder</td><td>4.5</td><td>5.1</td><td>4.8</td><td>3.0</td><td>0.22</td></tr><tr><td> Bipolar affective disorder</td><td>2.4</td><td>3.4</td><td>2.8</td><td>3.3</td><td>0.75</td></tr><tr><td> Other/unspecified</td><td>1.5</td><td>0.5</td><td>0.8</td><td>1.6</td><td>0.18</td></tr><tr><td>Anxiety disorders</td><td /><td /><td /><td /><td /></tr><tr><td> Obsessive compulsive disorder</td><td>0.0</td><td>0.5</td><td>0.7</td><td>0.1</td><td>0.11</td></tr><tr><td> Other anxiety disorder</td><td>1.7</td><td>2.7</td><td>2.1</td><td>2.2</td><td>0.70</td></tr><tr><td>Other psychiatric disorders</td><td /><td /><td /><td /><td /></tr><tr><td> Organic disorder</td><td>0.2</td><td>1.6</td><td>2.5</td><td>3.4</td><td>0.001</td></tr><tr><td> Alcohol/substance use disorder</td><td>0.2</td><td>0.4</td><td>0.0</td><td>0.0</td><td>0.09</td></tr><tr><td> Sleep disorder</td><td>0.0</td><td>0.0</td><td>0.2</td><td>0.3</td><td>0.61</td></tr><tr><td> Autistic spectrum disorder</td><td>4.3</td><td>4.5</td><td>8.1</td><td>16.1</td><td><0.001</td></tr><tr><td> Behaviour disorder</td><td>10.4</td><td>11.9</td><td>20.1</td><td>32.1</td><td><0.001</td></tr><tr><td> Personality disorder</td><td>3.0</td><td>1.8</td><td>1.0</td><td>0.0</td><td><0.001</td></tr><tr><td> Other</td><td>0.7</td><td>1.3</td><td>0.5</td><td>0.4</td><td>0.25</td></tr><tr><td>Psychiatric disorders of any type</td><td>24.2</td><td>27.4</td><td>34.3</td><td>44.8</td><td><0.001</td></tr><tr><td>Total presenting to psychiatric services</td><td>29.8</td><td>33.7</td><td>47.1</td><td>65.4</td><td><0.001</td></tr></tbody></table> </ephtml> </p> <hd id="AN0034740813-7">Discussion</hd> <p>Specialist psychiatric service use was common among adults with ID living in Leicestershire and Rutland, UK. Of 2711 individuals, 45.9% accessed psychiatric services at least once during the 6‐year study period. More than one‐third (33.8%) of adults in the study population had a psychiatric diagnosis. However, the most common disorders were behaviour disorder (19.8%) and autistic spectrum disorders (8.8%).</p> <p>It is difficult to make direct comparisons between this study and the prevalence of psychiatric service use among adults in the general population because the majority of the literature in this area is restricted to people with emotional or mental health problems. However, using data from the general population presented in two large‐scale questionnaire studies, the proportion of adults who reported having seen a psychiatrist in the preceding 12 months was approximately 1.2% in Europe ([<reflink idref="bib35" id="ref27">35</reflink>]) and 2.8% in the United States ([<reflink idref="bib40" id="ref28">40</reflink>]). Direct comparisons are limited as both studies used weighted prevalence figures, and their populations relied on self‐report among non‐institutionalised adults who saw a psychiatrist over a 1‐year period (as opposed to 6 years for our study). Nonetheless, given that our prevalence figure is more than 15 times higher than these estimates, it is reasonable to assume that psychiatric service use is more common in adults with ID. Greater access to services in this population is likely to reflect increased prevalence of behaviour disorder ([<reflink idref="bib14" id="ref29">14</reflink>]), autistic spectrum disorders ([<reflink idref="bib15" id="ref30">15</reflink>]) and co‐existing health problems, such as epilepsy ([<reflink idref="bib25" id="ref31">25</reflink>]). We found that individuals with epilepsy comprised the greatest proportion (60.8%) of those who attended services but did not have a psychiatric diagnosis, which illustrates that not all conditions treated in specialist psychiatry are mental health‐related.</p> <p>The prevalence of psychiatric disorders in this study was 33.8%. The most comparable studies that report on the prevalence of psychiatric disorder in adults with ID are population‐based. These studies report figures of 29.9% (when restricted to adults with a known IQ ≤ 67) ([<reflink idref="bib22" id="ref32">22</reflink>]) and 40.9% ([<reflink idref="bib7" id="ref33">7</reflink>]). Both prevalence figures are based on clinical diagnoses, but neither study used ICD‐10 criteria. The latter study by [<reflink idref="bib7" id="ref34">7</reflink>]) found that the prevalence of psychiatric disorders lowered when other diagnostic criteria (using two psychopathology tools) were adopted [35.2% for DC‐LD ([<reflink idref="bib29" id="ref35">29</reflink>]), 16.6% for ICD‐10‐DCR ([<reflink idref="bib42" id="ref36">42</reflink>]) and 15.7% for DSM‐IV‐TR ([<reflink idref="bib2" id="ref37">2</reflink>])]. The higher prevalence of psychiatric disorders reported in Cooper <emph>et al.</emph>'s study is also likely to reflect their screening all adults with ID, whereas we were only able to assess those who presented to psychiatric services. In keeping with the principles of inclusion, it is likely that many adults with mild ID were treated in the primary care sector or by mainstream psychiatric services, sometimes without the knowledge of the specialist service concerned. Further, access to support is likely to be affected by confidence in healthcare professionals, stigma and awareness of mental health problems. These influences may be particularly relevant to adults living in family settings who were less likely to access specialist psychiatric services in this study.</p> <p>Comparisons between the prevalence of psychiatric disorders in adults with ID and the general population are again limited because there are substantial differences in diagnoses between the two populations. Behaviour disorder, for example, is not treated as a psychiatric diagnosis in the general population. On excluding individuals with behaviour disorder from the study, the prevalence of psychiatric disorders was 20.2%, and was 28.3% in [<reflink idref="bib7" id="ref38">7</reflink>]) study, which is closer to the rates found in the general population ([<reflink idref="bib38" id="ref39">38</reflink>]; [<reflink idref="bib31" id="ref40">31</reflink>]). It is probable, however, that some behaviours mask undetected psychiatric disorders, particularly personality disorders, which have been found to overlap considerably with behaviour disorder in people with ID ([<reflink idref="bib8" id="ref41">8</reflink>]; [<reflink idref="bib10" id="ref42">10</reflink>]). This may in part explain why the prevalence of personality disorders was lower in our study (1.3%) and Cooper <emph>et al.</emph>'s study (1.0%) ([<reflink idref="bib7" id="ref43">7</reflink>]) than in the general population (4.4%) ([<reflink idref="bib31" id="ref44">31</reflink>]).</p> <p>One of the surprise findings was the higher prevalence of schizophrenia in women. It is possible that women with ID felt more comfortable accessing specialist psychiatric services than men. They were also more likely to have a diagnosis of depression than men, which follows the pattern found in the general population ([<reflink idref="bib31" id="ref45">31</reflink>]). However, we observed no differences in the presence of anxiety disorders between men and women with ID, which differs from the general population ([<reflink idref="bib31" id="ref46">31</reflink>]) and which may be explained by the higher prevalence of autistic spectrum disorders among men who present with anxiety‐like symptoms. We also found that men were more likely to display behaviour problems, whereas most of the literature in this area suggests that there are no differences in the overall prevalence of behaviour problems between men and women with ID ([<reflink idref="bib32" id="ref47">32</reflink>]; [<reflink idref="bib7" id="ref48">7</reflink>]). It is well recognised that the manifestation of behaviour problems tends to be different in men and women with ID; men are more likely than women to show overtly aggressive behaviour such as physical or verbal aggression or destructive behaviour ([<reflink idref="bib23" id="ref49">23</reflink>]; [<reflink idref="bib36" id="ref50">36</reflink>]). These types of behaviours may be more difficult for carers to manage and lead to their seeking specialist psychiatric service support.</p> <p>The higher prevalence of psychiatric disorders observed in adults with severe and profound ID is somewhat supported in previous population‐based research ([<reflink idref="bib3" id="ref51">3</reflink>]; [<reflink idref="bib4" id="ref52">4</reflink>]; [<reflink idref="bib7" id="ref53">7</reflink>]). However, this relationship is difficult to ascertain because the ability to make accurate diagnoses also depends on the patient's ability level. There is a danger that the prevalence of psychiatric disorders in adults with severe and profound ID is under‐estimated because these patients often present with unremarkable symptoms [known as 'psychological masking' ([<reflink idref="bib9" id="ref54">9</reflink>])] and generally have greater communication deficits, thus are unable to report their own symptoms. In the latter situation, diagnoses are reliant on clinicians' judgement and on secondary information from carers. Schizophrenia in particular is often difficult to identify in people with ID because symptoms such as hallucinations and delusions are extremely difficult to detect ([<reflink idref="bib27" id="ref55">27</reflink>]). This may explain why diagnoses of schizophrenia were more common in adults with mild and moderate ID.</p> <p>This is a large study and has the advantage of being population‐based. A wide range of service providers are used within the Leicestershire Learning Disability Register notification network and the prevalence rate of 3.9 per 1000 population for the administrative prevalence of ID compares favourably with other UK studies ([<reflink idref="bib21" id="ref56">21</reflink>]; [<reflink idref="bib7" id="ref57">7</reflink>]) and provides a representative sample of adults with moderate to profound ID ([<reflink idref="bib18" id="ref58">18</reflink>]). It is recognised, however, that register studies do not contain a representative sample of adults with mild ID because these adults are less likely to access specialist support. Nonetheless, 6% (<emph>n</emph> = 160) of the total study population had mild ID and attended specialist psychiatric services, which suggests that in some cases adults may have had more complex mental health needs that generic services felt less able to manage effectively.</p> <p>Our findings indicate that adults with ID have a range of complex mental health problems for which they seek support from specialist psychiatric services. The move towards general psychiatric service use in this population needs careful consideration, particularly with regard to the necessary resources, skills and expertise in the management of co‐existing behaviour problems and the additional health needs of this client group.</p> <hd id="AN0034740813-8">Practical solutions identified locally</hd> <p>The Learning Disability Service being part of a mental health trust locally has helped us to secure a commitment from generic psychiatric services in allowing access for people with mild ID. Through an interface group between Learning Disability and General Adult psychiatric services, we have developed a protocol to facilitate appropriate transfer of patients between services where possible and joint working where management by a single service is unlikely to be of help for the service user. Development of an ID clinical network to facilitate the joint working, pooling of resources in certain areas such as crisis interventions and appropriate level of training and support is currently underway.</p> <hd id="AN0034740813-9">Limitations of the study</hd> <p>The sample includes only people who access specialist ID services and therefore individuals with mild ID and psychiatric disorders are likely to be are under‐represented in this population. There is no current system to capture those with mild ID who access mainstream services, as these individuals are not always identified as having ID. However, a short screening tool has recently been developed in Leicestershire to help health professionals to determine ID in this client group.</p> <p>In this study psychiatric diagnoses were based on clinical assessment and were not subject to the use of a structured diagnostic tool. However, ICD‐10 criteria were used to facilitate the process and in our opinion, this reflects real‐life clinical practice.</p> <p>Future research would benefit from identifying the complex process of accessing mainstream services by people with mild ID and service users' and carers' experiences of this process. The development of short validated screening tool to help professionals to identify people with mild ID in mainstream services may also be important.</p> <hd id="AN0034740813-10">Ethical approval</hd> <p>This study has Derbyshire Research Ethics Committee approval.</p> <hd id="AN0034740813-11">Acknowledgements</hd> <p>The authors gratefully acknowledge Leicestershire Partnership NHS Trust and the Department of Health Policy Research Programme who provided funding for this study and all clients and carers who participated in the register home interviews.</p> <ref id="AN0034740813-12"> <title> References </title> <blist> <bibl id="bib1" idref="ref7" type="bt">1</bibl> <bibtext> Alexander R. T., Piachaud J. & Singh I. (2002) Two districts, two models: in‐patient care in the psychiatry of learning disability. 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  Data: <searchLink fieldCode="DE" term="%22Psychiatric+Services%22">Psychiatric Services</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Differences%22">Gender Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Incidence%22">Incidence</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Schizophrenia%22">Schizophrenia</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health+Programs%22">Mental Health Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Psychiatry%22">Psychiatry</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Age%22">Age</searchLink><br /><searchLink fieldCode="DE" term="%22Residential+Care%22">Residential Care</searchLink><br /><searchLink fieldCode="DE" term="%22Epilepsy%22">Epilepsy</searchLink><br /><searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Specialists%22">Specialists</searchLink><br /><searchLink fieldCode="DE" term="%22Cooperation%22">Cooperation</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22United+Kingdom%22">United Kingdom</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1365-2788.2008.01124.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0964-2633
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: UK policies aim to facilitate access to general psychiatric services for adults with intellectual disability (ID). If this is to be achieved, it is important to have a clear idea of the characteristics and proportion of people with ID who currently access specialist psychiatric services and the nature and extent of psychiatric disorders in this population. Methods: A cross-sectional study was carried out on all adults with ID using specialist services in Leicestershire and Rutland, UK, between 2001 and 2006. Characteristics of individuals seen by psychiatric services and the nature and prevalence of psychiatric disorders were investigated. Results: Of 2711 adults identified, 1244 (45.9%) accessed specialist psychiatric services at least once during the study period. Individuals attending psychiatric services were more likely to be older and to live in residential settings; they were less likely to be south Asian or to have mild/moderate ID. The prevalence of psychiatric disorders among the total study population was 33.8%; the most common disorders were behaviour disorder (19.8%) and autistic spectrum disorders (8.8%). Epilepsy was highly prevalent (60.8%) among those attending psychiatric services without a mental health diagnosis. Behaviour disorders and autistic spectrum disorders were more common in men and in adults with severe/profound ID, whereas schizophrenia and organic disorders were more common in women and in adults with mild/moderate ID. Depression was also more common in women with ID. Conclusions: Psychiatric disorders and specialist health problems are common among adults with ID and the profile of psychiatric disorders differs from that found in general psychiatry. Close collaboration between general and specialist service providers is needed if the current move towards use of general psychiatric services in this population is to be achieved. The measures should include a clear care pathway for people with ID and mental health problems to facilitate the smooth transfer of patients between specialist and generic mental health services and arrangements for joint working where input from both services is required. The commissioning framework for such processes should be in place with appropriate pooling of resources.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 42
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2008
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ814218
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ814218
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/j.1365-2788.2008.01124.x
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 986
    Subjects:
      – SubjectFull: Psychiatric Services
        Type: general
      – SubjectFull: Health Services
        Type: general
      – SubjectFull: Gender Differences
        Type: general
      – SubjectFull: Incidence
        Type: general
      – SubjectFull: Mental Retardation
        Type: general
      – SubjectFull: Schizophrenia
        Type: general
      – SubjectFull: Mental Health Programs
        Type: general
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Psychiatry
        Type: general
      – SubjectFull: Patients
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Age
        Type: general
      – SubjectFull: Residential Care
        Type: general
      – SubjectFull: Epilepsy
        Type: general
      – SubjectFull: Autism
        Type: general
      – SubjectFull: Mental Disorders
        Type: general
      – SubjectFull: Specialists
        Type: general
      – SubjectFull: Cooperation
        Type: general
      – SubjectFull: United Kingdom
        Type: general
    Titles:
      – TitleFull: Psychiatric Service Use and Psychiatric Disorders in Adults with Intellectual Disability
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Bhaumik, S.
      – PersonEntity:
          Name:
            NameFull: Tyrer, F. C.
      – PersonEntity:
          Name:
            NameFull: McGrother, C.
      – PersonEntity:
          Name:
            NameFull: Ganghadaran, S. K.
    IsPartOfRelationships:
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          Dates:
            – D: 01
              M: 11
              Type: published
              Y: 2008
          Identifiers:
            – Type: issn-print
              Value: 0964-2633
          Numbering:
            – Type: volume
              Value: 52
            – Type: issue
              Value: 11
          Titles:
            – TitleFull: Journal of Intellectual Disability Research
              Type: main
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