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). …