Mental Health Services for People with Intellectual Disability in Israel - A Review of Options
Stawski, Mike, Merrick, Joav, The Israel Journal of Psychiatry and Related Sciences
Abstract: Intellectual disability (ID) (often also referred to as "mental retardation," "development disability," "mental handicap," "learning disability" or as "generalized learning difficulties") is common in all countries. Many people with ID suffer from psychiatric/behavioral/emotional disturbances (known as "dual diagnosis"). Specialist psychiatric services are needed to address these problems effectively, but are not currently available in most countries, including Israel. This article sets out to describe the problems, current services in Israel, approaches in other countries and proposed solutions for Israel. We believe it important to enforce laws against discrimination based on disability, to raise the general awareness, knowledge and skills among generic mental health professionals on the topic of intellectual disability by inclusion in university, postgraduate and in-service training curricula, to work towards a form of sub-specialty within psychiatry along the lines of the model in the United Kingdom and to establish specialized psychiatric services, possibly functioning as back-up to the generic psychiatric services.
The European Association for Mental Health in Mental Retardation at its 4th European Congress in Rome, Italy, in September 2003, adopted a policy statement designed to help promote greater awareness of the mental health aspects and needs of people with intellectual disabilities (ID). The statement (Declaration of Rome 2003) asserts that all persons with ID have a right to the best available mental health care that is part of the health and social care system of every nation. The Declaration targeted public policy makers, administrators, politicians, professionals, researchers, and relatives or friends of people with ID in order to promote increased access and more equitable provision of mental health services to people with ID (1).
Intellectual disability affects 0.5-1.5% of the population in developed countries (2-5). In Israel the Divison for Mental Retardation (DMR) of the Ministry of Social Affairs provides service to 25,000 people (about 0.4 % of the general population), who are legally recognized as persons with ID. Of these, about 8,000 live in residential care settings, while the rest live at home with their families but are provided with services from the Ministry (6).
The definitions of ID (or MR) in ICD-IO, DSMIV and of the American Association on Mental Retardation (7), as well as the legal definition used by the DMR, are very similar, and contain two essential elements, namely low performance on standardized IQ testing, and below than expected performance in tasks of everyday life. They all specify that the problems must have arisen during the developmental period (thus excluding, for instance, the results of traumatic brain injury in adulthood) and they specifically exclude cognitive impairment secondary to schizophrenia. A common feature to all definitions is delayed, not deviant, development, hence putting the treatment of deviance in the presence of ID into the purview of mental health professionals.
The Psychiatric "Angle"
People with ID are generally at increased risk for a range of health problems (8). With particular reference to psychiatric problems, there is general agreement that the rate of psychopathology in people with ID is substantially raised when compared with the general population, with increased vulnerability over the whole spectrum of psychopathology but with emphasis on certain groups of diagnoses, such as the autistic spectrum disorders. Reported rates of psychopathology vary significantly from study to study, from 10% to 60% (3, 9-12). By virtue of this high rate of psychopathology (as well as of physical pathology), people with ID should be considered a population at-risk. Dual diagnosis and other health problems are often an influential factor when a family is considering placement in residential care for a family member with ID (13).
Management of Psychiatric Problems
Though one might reasonably expect that people with ID and psychiatric problems would be treated by the generic psychiatric services like the rest of the population, in practice this typically does not happen. Both physical and psychiatric illnesses can be difficult to detect in this population, because of problems in communication and atypical presentations. Hence, trained and experienced staff are required to meet the health needs of this group (14). Some specific reasons why the psychiatric needs of this group are very often not met can be:
* The problems are often not recognized by caretakers as deviating from "normal" mental retardation.
* If the problems are recognized as representing deviance, they are often not seen as being treatable.
* The same reluctance to using psychiatric services that is seen in the general population is seen also in the families of people with ID and at times also with people with mild ID themselves (8).
* If a person with mental retardation is finally brought to the attention of a psychiatrist, a clinician lacking training and experience in the field may well ascribe any problem identified as being purely due to the mental retardation itself, which is known as "diagnostic overshadowing."
* Problems that have been correctly identified as representing potentially treatable deviance, rather than part and parcel of the mental retardation, may still be incorrectly diagnosed or, if correctly diagnosed, incorrectly treated. The scenario of a person with ID being brought to a psychiatric outpatient department, being briefly assessed by a rather unenthusiastic psychiatrist and then prescribed, in a somewhat knee-jerk fashion, a major tranquillizer, which will be continued for years to come without any appropriate follow-up (and, possibly, despite the lack of any demonstrable benefit for the patient), unfortunately still appears to be common from our everyday clinical experience in Israel.
The Situation in Israel
For all the above reasons, the treatment of psychiatric disturbance in people with ID is clearly deficient also in this country, both in terms of the number of people who should be reaching treatment facilities but are not doing so, and in the quality of the treatment received. There are currently (almost) no dedicated psychiatric outpatient services for people with ID in Israel. As noted above, people with ID have the same right as anyone else to turn to generic inpatient/outpatient services, but the problems with this approach have been outlined above. Because mental health professional training in the field of developmental disabilities is largely nonexistent, readiness to treat is very low and almost exclusively medicationbased. Patients, families and their direct carers have in fact been told by staff of public outpatient and inpatient departments that these departments do not treat people with ID.
Other Partial Solutions
Residential care centers (currently 58) of the Division for Mental Retardation in Israel, where only a portion of the people with ID live (currently 6,500), typically have a visiting psychiatrist (consultants equivalent to 14 full-time positions) and psychologist, as do some special schools (15).
Families and other carers are often willing to turn to private psychiatric consultation in the hope of finding a better service. This hope is not always justified, and this approach is obviously expensive and inequitable.
The Situation in Other Countries
Some scant comfort may be found in the fact that the failure of generic services to fulfill the mental health needs of this population is not specific to Israel (9). Thus, Day (16) points out that "attempts to cater for psychiatrically disordered people with mental retardation within ordinary mental health services in Sweden and Denmark have proved unsuccessful... lnappropriateness of setting, lack of staff knowledge and expertise and particularly a lack of psychiatric input are the main problems." Similarly, in the United States, the psychiatric needs of persons of all ages with intellectual disabilities are largely unmet (3, 17), though some of the European countries, North America and Australia are starting to form the specialty of learning disability in an informal way.
In the United Kingdom relevant specialist services are better established than in many other countries and the Department of Health (8) has stated that "Mental health services should have the multidisciplinary skills required for the diagnosis, treatment and care of and rehabilitation of people with learning disabilities who become mentally ill." Multidisciplinary Community Learning Disability Teams in the United Kingdom, which are funded by the departments of health and social services, require local interagency collaboration and consist of psychiatrists, psychologists, community nurses, speech and language therapists, physiotherapists, occupational therapists, music, art and drama therapists, and social workers. The Royal College of Psychiatrists recommends one consultant in learning disabilities per 100,000 population (14), which in a country like Israel would mean that there should be about 65 psychiatric specialists working full-time in the field. The Office of the Medical Director of the Ministry of Social Affairs have over the years tried to interest several universities in the establishment of a subspecialty both in general medicine and psychiatry on the topic of intellectual disability, but so far not found any interested partners.
Possible Ways Forward
The following points may be considered as parts of the way forward from the situation described above:
* Enforcement of laws against discrimination based on disability;
* Raising of general awareness, knowledge and skills among generic mental health professionals by inclusion in university, postgraduate, and in-service training curricula. The Ministries of Health and Social Affairs, as well as Beit Issie Shapiro, a nonprofit center focused on developmental disabilities, are currently developing a pilot project in this area, which could develop into a form of sub-specialty within psychiatry along the lines of the model in the United Kingdom;
* Establishment of specialized psychiatric services, possibly functioning as back-up to the generic psychiatric services.
People with ID are at high risk of mental disturbances. Diagnosis and management of these problems require specialized skills and knowledge, which can be acquired. At the moment these problems are not being adequately addressed in Israel. Possible ways to remedy this situation are suggested.
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Mike Stawski, MB, BS, MRCPsych,1 and Joav Merrick, MD, DMSc2,3,4,5
1 Outpatient Unit for Neurodevelopmental Psychiatry, Department of Psychological Medicine, Schneider Children's Medical Center in Israel, Petach Tikva, Israel
2 National Institute of Child Health and Human Development, Jerusalem, Israel
3 Division of Pediatrics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
4 Center for Multidisciplinary Research in Aging, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
5 Office of the Medical Director, Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel
Address for Correspondence: Mike Stawski, Director, Outpatient Unit for Neurodevelopmental Psychiatry, Department of Psychological Medicine, Schneider Children's Medical Center in Israel, 14 Kaplan St, 49202 Petach Tikva, Israel. E-mail: email@example.com…
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Publication information: Article title: Mental Health Services for People with Intellectual Disability in Israel - A Review of Options. Contributors: Stawski, Mike - Author, Merrick, Joav - Author. Journal title: The Israel Journal of Psychiatry and Related Sciences. Volume: 43. Issue: 4 Publication date: October 1, 2006. Page number: 237+. © Gefen Publishing House Ltd. 2008. Provided by ProQuest LLC. All Rights Reserved.
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