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Clinical Outcomes of a Specialised Inpatient Unit for Adults with Mild to Severe Intellectual Disability and Mental Illness

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Title: Clinical Outcomes of a Specialised Inpatient Unit for Adults with Mild to Severe Intellectual Disability and Mental Illness
Language: English
Authors: Lunsky, Y., White, S. E., Palucka, A. M., Weiss, J., Bockus, S., Gofine, T.
Source: Journal of Intellectual Disability Research. Jan 2010 54(1):60-69.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
Peer Reviewed: Y
Page Count: 10
Publication Date: 2010
Document Type: Journal Articles
Reports - Research
Education Level: Adult Education
Descriptors: Psychiatric Services, Health Needs, Mental Retardation, Mental Disorders, Patients, Foreign Countries, Cognitive Ability, Adults, Comparative Analysis, Behavioral Science Research, Outcomes of Treatment, Intervention
Geographic Terms: Canada
DOI: 10.1111/j.1365-2788.2009.01213.x
ISSN: 0964-2633
Abstract: Background: Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service. Method: Thirty-three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re-admission to hospital were explored. Results: Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning. Conclusions: This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.
Abstractor: As Provided
Number of References: 23
Entry Date: 2010
Accession Number: EJ867575
Database: ERIC
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  Value: <anid>AN0045671017;eul01jan.10;2019Jun04.10:46;v2.2.500</anid> <title id="AN0045671017-1">Clinical outcomes of a specialised inpatient unit for adults with mild to severe intellectual disability and mental illness. </title> <p>Background  Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service. Method  Thirty‐three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re‐admission to hospital were explored. Results  Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning. Conclusions  This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.</p> <p>Keywords: intellectual disability; mental health; psychiatric disorders; inpatient</p> <p>There has been increasing recognition that although many individuals with intellectual disability (ID) access mainstream psychiatry services, a certain subgroup of individuals requires and benefits from specialised inpatient care. Surprisingly, although many papers have argued this, only a handful of studies have provided outcome data on such programmes from around the world (see [<reflink idref="bib6" id="ref1">6</reflink>], [<reflink idref="bib7" id="ref2">7</reflink>] for review/critique). In our review of the literature, fewer than 10 papers have been published in the past 15 years reporting outcomes of psychiatric inpatients served by specialised units for adults with ID and mental illness. Earlier papers (e.g., [<reflink idref="bib16" id="ref3">16</reflink>]; [<reflink idref="bib8" id="ref4">8</reflink>]; [<reflink idref="bib4" id="ref5">4</reflink>]; [<reflink idref="bib10" id="ref6">10</reflink>]) were descriptive in nature and did not include standardised outcome measures. More recent studies have provided pre‐ and post‐treatment measures of client outcomes ([<reflink idref="bib11" id="ref7">11</reflink>]; [<reflink idref="bib15" id="ref8">15</reflink>]; [<reflink idref="bib22" id="ref9">22</reflink>]; [<reflink idref="bib23" id="ref10">23</reflink>]; [<reflink idref="bib9" id="ref11">9</reflink>]) and some have included comparison groups ([<reflink idref="bib11" id="ref12">11</reflink>]; [<reflink idref="bib23" id="ref13">23</reflink>]; [<reflink idref="bib9" id="ref14">9</reflink>]). Two additional studies of individuals in a specialised day hospital setting also used pre‐ and post‐intervention measures ([<reflink idref="bib5" id="ref15">5</reflink>]; [<reflink idref="bib18" id="ref16">18</reflink>]).</p> <p>[<reflink idref="bib15" id="ref17">15</reflink>]) followed 40 consecutive inpatients admitted to a specialised unit in Finland, 31 of whom (78%) were diagnosed with mild ID or borderline intellectual functioning. They offered 'need adapted treatment', where treatment plans were individualised for each patient and caregiver. In addition to regular therapy meetings with patient, caregivers and the inpatient team, patients participated in occupational therapy, group therapy, adaptive daily living skill groups and pharmacotherapy. Aftercare services were available to all patients, with the option of re‐admission for deterioration. With regard to outcome, patients' scores on the Brief Psychiatric Rating Scale reduced at discharge and were maintained at 6‐month follow‐up. Caregiver ratings on a visual analogue scale supported that they perceived patients to have improved from admission to discharge as well.</p> <p>[<reflink idref="bib9" id="ref18">9</reflink>]) compared community‐based patients to inpatients with mild ID and psychiatric disorder at three points in time on a number of clinical outcome measures assessing psychiatric symptoms, risk, need and level of functioning. They followed inpatients at admission, discharge and 6 months post admission. Outcome data included ratings by caregivers, clients and hospital staff. The 19 inpatients showed significant improvements over time on the Global Assessment of Functioning (GAF), the Health of the Nation Outcome Scales for people with Learning Disabilities and the Threshold Assessment Grid (TAG). The unmet needs of inpatients decreased over time according to staff and patient ratings on the Camberwell Assessment of Need for Adults with Developmental and Intellectual Disabilities – short version, and according to staff, met needs increased following treatment.</p> <p>[<reflink idref="bib23" id="ref19">23</reflink>]) evaluated 33 individuals (29 with mild ID) admitted to a specialist inpatient unit over a 35‐month period, using the Psychiatric Assessment Schedule for Adults with Developmental Disabilities Checklist, the Disability Assessment Scale, the GAF and the TAG. Inpatients showed improvement on each of the four measures at discharge.</p> <p>[<reflink idref="bib22" id="ref20">22</reflink>]) conducted a retrospective analysis on the 72 adults with ID treated in a specialised inpatient unit over a 24‐month period. This study included the largest subgroup of individuals in the moderate to severe range of all the studies reviewed (41.7%). Reiss Screen for Maladaptive Behavior total scores were significantly lower at discharge than at admission for the group. Seventy‐six per cent of individuals returned to their original residence. In the 2‐year time period of the study, only 22% of individuals discharged were re‐admitted to the unit.</p> <p>[<reflink idref="bib11" id="ref21">11</reflink>]) examined hospital‐based and home‐based treatment for clients with ID and psychiatric disorder referred to their 48‐bed inpatient unit. Patients were referred over a 19‐month period, and were assessed at admission and at 7‐week intervals over a 28‐week period using the Reiss Screen, Psychopathology Inventory for Mentally Retarded Adults and the Global Rating Scale for Improvement. Although the authors compared scores on these measures between groups at each time period and found that, overall, the groups were equivalent in their ratings, they did not examine whether either group improved significantly with treatment.</p> <p>Each of the papers reviewed above argued that some type of specialised service was required to serve the most vulnerable of clients. Specialised inpatient services may lead to fewer out of area placements, although treatment may require a longer length of stay (LOS) than what is seen in mainstream psychiatry ([<reflink idref="bib19" id="ref22">19</reflink>]; [<reflink idref="bib23" id="ref23">23</reflink>]). Although the benefits of specialised inpatient programmes should apply across levels of disability, the outcome studies reviewed above focused primarily on individuals with mild disability. In the one reviewed study where lower functioning individuals were included ([<reflink idref="bib22" id="ref24">22</reflink>]), their outcome was not analysed separately from other patients. Outcome research for people with more severe disabilities using specialised services is especially important given that general inpatient services are most underutilised by this group ([<reflink idref="bib7" id="ref25">7</reflink>]). Unfortunately, few studies have reported on the benefits of such units for those individuals, or compared outcomes of those with more severe to less severe ID.</p> <p>In Ontario (Canada's most populated province of 11 million individuals), five inpatient units currently operate within tertiary level mental healthcare facilities that are targeted specifically towards inpatients with ID and mental health needs. These programmes differ from other inpatient units in terms of the level of expertise in ID, as well as staff complement (high ratio and interdisciplinary), and types of individual and group therapy available (see [<reflink idref="bib12" id="ref26">12</reflink>] for detailed summary of programme characteristics). To date, no studies have examined clinical outcomes of patients in these units in a Canadian context.</p> <p>The purpose of this paper is to describe the clinical presentation of all individuals discharged from a Canadian specialised dual diagnosis inpatient unit at the Centre for Addiction and Mental Health (CAMH) between 2006 and 2008, and to report on patient outcomes in terms of symptom improvement, change of diagnosis, LOS, place of discharge and re‐admission rates. Because the unit admits both individuals with mild disabilities and those with more severe disabilities, a secondary purpose of this paper was to compare the outcomes of these two groups.</p> <hd id="AN0045671017-2">Method</hd> <p></p> <hd id="AN0045671017-3">Description of the specialised unit</hd> <p>Opened in 1997, the dual diagnosis inpatient unit at the CAMH is a 15‐bed, locked unit. It has a capacity for 12 to 15 inpatients of both genders, aged 16 years and older, and is exclusively for patients with an ID and mental health problem. Inpatient admission is offered as part of a continuum of care. When possible, admissions to the unit are planned by way of triage through a parallel interdisciplinary outpatient consultation service. Clients are typically considered for admission when they are in need of intensive interdisciplinary assessment and/or their recommended treatment cannot easily be completed in the community. In addition, comorbid medical concerns may exist for individuals offered inpatient admission, which require a high level of observation and clinical safety. The interdisciplinary clinical team is led by a psychiatrist, and includes psychology, social work, nursing, recreation therapy, behaviour therapy and occupational therapy. Within 2 weeks of admission, the team conducts a clinical planning meeting, at which time, the Aberrant Behavior Checklist (ABC) and the Reiss Screen for Maladaptive Behavior are completed by the primary nurse(s) who works most closely with the client. The psychiatrist, with team input, determines a diagnosis and GAF score. When it is evident to the team that the patient has improved clinically and is ready for discharge, he or she is re‐assessed using the Reiss Screen, ABC and GAF, in the same manner as admission, and ideally, by the same raters.</p> <p>While on the unit, patients receive interdisciplinary assessment and intervention, and there are often significant changes made in the type and dosage of psychotropic medications. Psychosocial interventions include relaxation training, anger management, counselling, recreation therapy, social skills and community skills training, and can be administered in a group or individual context. Caregivers from community settings (family and paid staff who will support the patient once discharged) meet regularly with the inpatient team to discuss patient progress and goals for discharge; the outpatient consultation programme assists with the transition process and provides time limited post‐discharge support in the community. On some occasions, patients are assessed as ready for discharge, but because of a lack of available community placements, their reintegration into the community can be delayed.</p> <hd id="AN0045671017-4">Participants</hd> <p>Thirty‐seven inpatients were discharged from the specialised dual diagnosis unit at the CAMH between January 2006 and December 2008. Four patients were discharged prematurely, and were therefore excluded from analyses (see Fig. 1). Although there were some changes in staffing (primarily nursing staff) within that time frame, the nurse manager, psychiatrist, psychologist, behaviour therapist, recreation therapist and occupational therapist were consistent. Characteristics of the final sample (<emph>n</emph> = 33) are presented in Table 1. Upon discharge, 51.5% (<emph>n</emph> = 17) of the sample was assessed with mild ID, 42.4% (<emph>n</emph> = 14) with moderate ID and 6.1% (<emph>n</emph> = 2) with severe ID.</p> <p>Graph: 1 Inpatient flow.</p> <p>1 Demographic characteristics (n = 33)</p> <p> <ephtml> <table><thead valign="bottom"><tr><th /><th><bold>Mild</bold></th><th><bold>Moderate/Severe</bold></th><th><bold>Total</bold></th></tr><tr><th><bold><italic>n</italic> (%)</bold></th><th><bold><italic>n</italic> (%)</bold></th><th><bold><italic>n</italic> (%)</bold></th></tr></thead><tbody valign="top"><tr><td>Gender – male</td><td>6 (35.5)</td><td>8 (50.0)</td><td>14 (42.4)</td></tr><tr><td>Age [mean (SD)]</td><td>36.06 (11.18)</td><td>33.38 (6.98)</td><td>35.19 (9.15)</td></tr><tr><td>Ethnic group</td><td /><td /><td /></tr><tr><td> White</td><td>14 (82.4)</td><td>14 (87.5)</td><td>28 (84.8)</td></tr><tr><td> Non‐white</td><td>3 (17.6)</td><td>2 (12.5)</td><td>5 (15.2)</td></tr><tr><td> Black</td><td>2 (11.8)</td><td>1 (6.3)</td><td>3 (9.1)</td></tr><tr><td> Mixed</td><td>–</td><td>1 (6.3)</td><td>1 (3.0)</td></tr><tr><td> Middle Eastern</td><td>1 (5.9)</td><td>–</td><td>1 (3.0)</td></tr><tr><td>English as a second language for patient and/or parents</td><td>5 (29.4)</td><td>4 (25.0)</td><td>9 (27.3)</td></tr><tr><td>Patient either visual minority <italic>or</italic> ESL</td><td>6 (35.3)</td><td>6 (37.5)</td><td>12 (36.3)</td></tr><tr><td>Forensic involvement – past or current</td><td>11 (64.7)</td><td>5 (31.3)</td><td>16 (48.5)</td></tr><tr><td>Primary reason for referral</td><td /><td /><td /></tr><tr><td> Aggressive/challenging behaviour</td><td>5 (29.4)</td><td>8 (50.0)</td><td>13 (39.4)</td></tr><tr><td> Clarification of Axis I/II diagnosis</td><td>5 (29.4)</td><td>3 (18.8)</td><td>8 (24.2)</td></tr><tr><td> Threat/danger to self or others</td><td>1 (5.9)</td><td>3 (18.8)</td><td>4 (12.1)</td></tr><tr><td> Support/crisis planning required</td><td>–</td><td>2 (12.5)</td><td>2 (6.1)</td></tr><tr><td> Involvement with legal system</td><td>2 (11.8)</td><td>–</td><td>2 (6.1)</td></tr><tr><td> Review of medication</td><td>2 (11.8)</td><td>–</td><td>2 (6.1)</td></tr><tr><td> Other reasons</td><td>2 (11.8)</td><td>–</td><td>2 (6.1)</td></tr><tr><td>Medical diagnoses</td><td /><td /><td /></tr><tr><td> Seizure disorder</td><td>3 (17.6)</td><td>1 (6.3)</td><td>4 (12.1)</td></tr><tr><td> Genetic syndromes</td><td>2 (11.8)</td><td>4 (25.0)</td><td>6 (18.2)</td></tr><tr><td> Hearing/visual impairment</td><td>2 (11.8)</td><td>3 (18.8)</td><td>5 (15.2)</td></tr><tr><td> Gastrointestinal condition</td><td>1 (5.9)</td><td>3 (18.8)</td><td>4 (12.1)</td></tr><tr><td> Bone/joint condition</td><td>4 (23.5)</td><td>–</td><td>4 (12.1)</td></tr><tr><td> Any comorbid medical condition</td><td>9 (52.9)</td><td>7 (43.8)</td><td>16 (48.5)</td></tr><tr><td>Axis I diagnosis (discharge)</td><td /><td /><td /></tr><tr><td> Autism/PDD‐NOS</td><td>4 (23.5)</td><td>7 (43.8)</td><td>11 (33.3)</td></tr><tr><td> Psychotic disorder</td><td>8 (47.1)</td><td>1 (6.3)</td><td>9 (27.3)</td></tr><tr><td> Mood disorder</td><td>3 (17.6)</td><td>2 (12.5)</td><td>5 (15.2)</td></tr><tr><td> Anxiety disorder</td><td>–</td><td>–</td><td>–</td></tr><tr><td> No Axis I diagnosis</td><td>1 (5.9)</td><td>6 (37.5)</td><td>7 (21.2)</td></tr></tbody></table> </ephtml> </p> <p>1 English as a second language, pervasive developmental disorder‐Not otherwise specified.</p> <p>Prior to admission, 19 patients (57.6%) lived in group homes, three (9.1%) resided in Supported Independent Living and five (15.2%) with family. Two patients (6.1%) lived alone, three (9.1%) in boarding homes or long‐term care facilities and one (3.0%) in a correctional treatment facility for youth. At the time of admission, none of the patients were gainfully employed. Twenty‐two patients (67.7%) had previously exhibited violent behaviour towards others, 15 of these within the year preceding their admission. Also, four patients (12.1%) had a history of sexual violence. Some patients also had a history of self‐injurious behaviour; nine (27.3%) had attempted self‐injury within the year before their admission, and an additional five (15.2%) had done so more than 1 year prior. Of these 14 patients, four (12.1%) had engaged in these behaviours with the perceived attempt to kill themselves. In terms of recent life events, 13 of the 33 patients (39.4%) had experienced the death of a close family member or friend (for 12 of these, this occurred more than 1 year prior to admission). Also of note is the proportion of patients who had been victims of physical (7; 21.2%), emotional (9; 27.3%) and sexual (10; 30.2%) assault or abuse in the past. Of the 16 patients with previous legal involvement, four were admitted under Ontario Review Board status, as they were found unfit to stand trial or were not criminally responsible because of their ID.</p> <hd id="AN0045671017-5">Measures</hd> <p>The following measures of clinical outcome were used:</p> <hd id="AN0045671017-6">Global Assessment of Functioning Scales (American Psychiatric Association, 1994)</hd> <p>This single rating scale evaluates overall functioning, in terms of 'psychological, social and occupational functioning on a hypothetical continuum of mental health‐illness', and ranges from 1 to 100. This scale correlates with other measures of symptoms and social functioning, and has good inter‐rater reliability and convergent validity. It has been found to be useful in measuring symptom change following clinical intervention in some samples (i.e. [<reflink idref="bib20" id="ref27">20</reflink>]; [<reflink idref="bib18" id="ref28">18</reflink>]). It has also been criticised in the ID population because of 'floor effects' ([<reflink idref="bib13" id="ref29">13</reflink>]; [<reflink idref="bib18" id="ref30">18</reflink>]).</p> <hd id="AN0045671017-7">Reiss Screen for Maladaptive Behavior (Reiss 1986)</hd> <p>Comprising 38 items, this measure is used as a screening tool for mental health problems in individuals with mild, moderate or severe ID. This screen is independently completed by two or more raters, who rate each item on a 3‐point scale ('no problem', 'a problem' or 'a major problem'). The scale demonstrates good internal reliability, inter‐rater reliability and validity ([<reflink idref="bib17" id="ref31">17</reflink>]; [<reflink idref="bib14" id="ref32">14</reflink>]). The scale provides a 26‐item total score, and includes eight sub‐scales and six special items, each with clinical cut‐offs that have been validated. In their study reviewed above, [<reflink idref="bib22" id="ref33">22</reflink>]) cite the 'usefulness of the Reiss scale in measuring the outcome of psychiatric intervention' in their sample.</p> <hd id="AN0045671017-8">Aberrant Behavior Checklist (Aman & Singh 1986)</hd> <p>This scale was originally developed to assess treatment effects on behaviour, and includes 58 items, categorised into five sub‐scales: Irritability, Agitation and Crying (15 items); Lethargy and Social Withdrawal (16 items); Stereotypic Behavior (7 items); Hyperactivity and Noncompliance (16 items) and Inappropriate Speech (4 items). Possible ratings for each item range from 0 (not a problem at all) to 3 (the problem is severe in degree). The ABC sub‐scales have been found to have high internal consistency (mean alpha = 0.91) and test–retest reliability (mean <emph>r</emph> = 0.98), good inter‐rater reliability (mean <emph>r</emph> = 0.63), and moderate correlations with measures of adaptive behaviour (mean <emph>r</emph> = 0.60) ([<reflink idref="bib2" id="ref34">2</reflink>]). Two prior studies ([<reflink idref="bib5" id="ref35">5</reflink>]; [<reflink idref="bib18" id="ref36">18</reflink>]) have examined ABC scores prior to and following partial hospitalisation programmes for adults with ID and psychiatric needs, and found reductions in scores following treatment. [<reflink idref="bib18" id="ref37">18</reflink>]) also reported that the ABC is more sensitive to change than standard GAF scores.</p> <hd id="AN0045671017-9">Procedure</hd> <p>Retrospective chart reviews for patients discharged between January 2006 and December 2008 were conducted. Charts were reviewed with respect to: age upon admission, gender, referral source, reasons for referral, place of residence, psychiatric diagnoses upon admission and discharge, level of ID, medical diagnoses, and admission and discharge scores on the Reiss, ABC and GAF. Baseline data were collected by nursing staff within 2 weeks of each individual's admission, and patients were re‐assessed prior to discharge from the unit.</p> <hd id="AN0045671017-10">Data analysis</hd> <p>This study was approved by the Research Ethics Board at the CAMH. All statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS) for Windows, version 15.0 ([<reflink idref="bib21" id="ref38">21</reflink>]). For all analyses that examined relations to IQ, individuals with moderate and severe ID were collapsed into one group, yielding two comparison groups [Mild (<emph>n</emph> = 17) and Moderate/Severe (<emph>n</emph> = 16)].</p> <hd id="AN0045671017-11">Results</hd> <p></p> <hd id="AN0045671017-12">Demographics and behavioural history</hd> <p>Patients in the Mild ID group were more likely to be diagnosed with psychotic disorder at discharge (<emph>P</emph> < 0.01), and to have previously engaged in self‐injurious behaviour with the intent to kill themselves (<emph>P</emph> < 0.05). There was a trend for a greater likelihood of previous legal involvement (<emph>P</emph> = 0.055) and emotional abuse (<emph>P</emph> = 0.065) in the Mild ID group. The Moderate/Severe group was more likely to have a history of violence towards others (<emph>P</emph> < 0.05). No other between‐group differences in demographics or behavioural history were found.</p> <hd id="AN0045671017-13">Measures of outcome</hd> <p>Global Assessment of Functioning scores at both admission and discharge were available for 31 of the 33 patients in our sample (one patient was admitted prior to the regular implementation of GAF scores in our programme, and another was not assessed using this scale at discharge). To assess GAF score change, a two‐way repeated measures anova was calculated, with GAF scores as the two‐level within‐subjects factor, and degree of ID (Mild, Moderate/Severe) as the two‐level between‐subjects factor. Results indicated a significant GAF × IQ interaction, <emph>F</emph>(<reflink idref="bib1" id="ref39">1</reflink>, 29) = 5.37, <emph>P</emph> = 0.03, η<sups>2</sups> = 0.16. <emph>Post hoc</emph> analyses of the interaction revealed a significant improvement in GAF scores for patients with mild ID (mean difference = 11.31, <emph>P</emph> < 0.001) and minimal improvement for individuals with moderate/severe ID (mean difference = 2.13, <emph>P</emph> = 0.46). Individuals with mild ID tended to have higher GAF scores than individuals with moderate/severe ID at admission (mean difference = 7.19, <emph>P</emph> = 0.07), and a greater difference at discharge (mean difference = 16.37, <emph>P</emph> < 0.001) (see Fig. 2). In general, patients with mild ID improved in their overall level of functioning (Table 2).</p> <p>Graph: 2 Change in GAF scores based on IQ. GAF, Global Assessment of Functioning.</p> <p>2 Outcome of inpatient unit admissions</p> <p> <ephtml> <table><thead valign="bottom"><tr><th /><th><bold>Admission mean (SD)</bold></th><th><bold>Discharge mean (SD)</bold></th></tr><tr><th><bold>Mild</bold></th><th><bold>Moderate/Severe</bold></th><th><bold>Mild</bold></th><th><bold>Moderate/Severe</bold></th></tr></thead><tbody valign="top"><tr><td>GAF</td><td /><td /><td /><td /></tr><tr><td> Total score</td><td>31.13 (10.52)</td><td>23.81 (10.30)</td><td>42.29 (7.78)</td><td>26.07 (8.42)</td></tr><tr><td>Reiss</td><td /><td /><td /><td /></tr><tr><td> 26‐item score</td><td>15.08 (8.39)</td><td>18.00 (6.00)</td><td>9.32 (4.56)</td><td>12.31 (3.96)</td></tr><tr><td>ABC</td><td /><td /><td /><td /></tr><tr><td> Irritability</td><td>15.67 (11.67)</td><td>20.75 (9.08)</td><td>9.50 (8.01)</td><td>14.00 (7.51)</td></tr><tr><td> Lethargy</td><td>8.50 (7.61)</td><td>15.17 (12.27)</td><td>5.92 (6.36)</td><td>12.00 (11.20)</td></tr><tr><td> Stereotypy</td><td>1.92 (2.07)</td><td>5.17 (6.12)</td><td>1.17 (1.75)</td><td>2.57 (3.23)</td></tr><tr><td> Hyperactivity</td><td>16.33 (13.79)</td><td>20.00 (12.34)</td><td>4.67 (5.28)</td><td>11.71 (6.27)</td></tr><tr><td> Inappropriate Speech</td><td>2.50 (2.15)</td><td>4.42 (4.21)</td><td>2.00 (2.37)</td><td>4.07 (3.77)</td></tr></tbody></table> </ephtml> </p> <p>2 GAF, Global Assessment of Functioning; Reiss, Reiss Screen for Maladaptive Behavior; ABC, Aberrant Behavior Checklist.</p> <p>Admission and/or discharge Reiss scores were not available for patients who were admitted before this measure was adopted and regularly used by our programme in 2007; therefore, admission scores were missing from analyses for seven such patients, and discharge scores missing for 4. In addition, scores for two patients who were assessed more than 1 month after their respective dates of admission in 2007 and 2008 were not included.</p> <p>To examine Reiss score change, a two‐way repeated measures anova was calculated, with Reiss scores as the two‐level within‐subjects factor, and degree of ID (Mild, Moderate/Severe) as the two‐level between‐subjects factor. Results indicated a significant main effect for Reiss scores, <emph>F</emph>(<reflink idref="bib1" id="ref40">1</reflink>, 20) = 15.07, <emph>P</emph> = 0.001, η<sups>2</sups> = 0.43, and a lack of significance for IQ main effect, <emph>F</emph>(<reflink idref="bib1" id="ref41">1</reflink>, 20) = 1.59, <emph>P</emph> = 0.22, η<sups>2</sups> = 0.07, or interaction effect, <emph>F</emph>(<reflink idref="bib1" id="ref42">1</reflink>, 20) = 0.004, <emph>P</emph> = 0.95, η<sups>2</sups> < 0.001, indicating that across levels of ID, behavioural and psychiatric symptoms, as rated by the Reiss Screen, improved from admission to discharge.</p> <p>A similar set of two‐way 2 × 2 repeated measures anovas were calculated for the ABC sub‐scales. Nine patients who were admitted and seven who were discharged prior to the consistent use of the ABC in our programme, or whose assessments were not performed at admission/discharge were excluded from analyses. The 22 patients for whom both admission and discharge scores were available showed significant improvement on the Hyperactivity sub‐scale, <emph>F</emph>(<reflink idref="bib1" id="ref43">1</reflink>, 20) = 10.10, <emph>P</emph> = 0.05, η<sups>2</sups> = 0.34. No other main effects or interactions were significant.</p> <hd id="AN0045671017-14">Length of stay</hd> <p>The median LOS in hospital for patients in our sample was 119 days. Because of the positive skewness of the data, a Mann–Whitney <emph>U</emph> test was used to compare LOS for patients with mild vs. moderate/severe ID. The groups did not differ significantly, <emph>U</emph> = 106.00, <emph>Z</emph> = −1.081, <emph>P</emph> = 0.280. Nine patients were discharged within 3 months [four Mild (23.5%), five Moderate/Severe (31.3%)], 11 were discharged between 3 and 6 months [four Mild (23.5%), seven Moderate/Severe (43.8%)], five were discharged within 6 to 12 months [three Mild (17.6%), two Moderate/Severe (12.5%)] and eight patients [six Mild (35.3%), two Moderate/Severe (12.5%)] had an extended stay of more than 1 year. Of the patients with mild ID, four were hospitalised for longer than two and a half years, whereas only one patient with moderate/severe ID was in hospital for as long. All five of these long‐stay patients had previous forensic involvement, presented with significant treatment complications, and were difficult to discharge to an environment willing and able to support them.</p> <hd id="AN0045671017-15">Other outcomes</hd> <p></p> <hd id="AN0045671017-16">Diagnostic change</hd> <p>Based on extensive case review by the inpatient psychologist, as well as comprehensive psychological testing, seven patients (21.2%) received a change in their ID diagnosis by discharge, four of whom (12.1%) were diagnosed with a less severe form of ID (moderate to mild) than was recorded in their file at admission. Further, three new cases (9.1%) of Autistic Disorder/pervasive developmental disorder‐not otherwise specified were diagnosed in patients previously diagnosed with mood and anxiety disorders (two Mild, one Moderate/Severe), and five patients (15.2%) admitted with a diagnosis of either schizophrenia or psychotic disorder NOS had that diagnosis removed at discharge (three Mild, two Moderate/Severe). In the latter case, these five patients had exhibited psychotic symptoms prior to admission, as part of a transient reaction to situations of extreme anxiety, grief or psychological distress while in the community.</p> <hd id="AN0045671017-17">Changes in housing</hd> <p>For 11 individuals (six Mild, five Moderate/Severe), following inpatient admission, a new residential setting was sought. These patients were placed in more supportive environments, moving from living independently or with family to group homes or transitional treatment homes. One patient moved from a treatment home in the youth sector to the adult sector, and one patient moved from a nursing home to a group home.</p> <hd id="AN0045671017-18">Re‐admissions</hd> <p>Following discharge, seven individuals were re‐admitted to the inpatient unit during the study period (five Mild, two Moderate/Severe). Patients were re‐admitted within an average of 134 days (SD = 103.3) from the previous discharge. With the exception of one re‐admitted patient who was still on the unit at the time of this report, the median length of re‐admission was 30 days. Of these patients, four were re‐admitted because of aggressive behaviour towards others and/or property destruction. Other reasons for re‐admission included self‐injury and behaviours that created a significant risk for self‐harm, as well as increased paranoia and general psychiatric deterioration. For these individuals, the re‐admission allowed for staff to re‐assess their mental status and make adjustments to the home setting as needed. The adjustments at home were particularly relevant to four individuals (three Mild, one Moderate/Severe), who were re‐admitted to hospital because supports in place were inadequate. This was arguably due, in each case, to the need for greater understanding of clients' behavioural and mental health challenges on the part of caregiving staff in the community.</p> <hd id="AN0045671017-19">Discussion</hd> <p>This is one of the first studies to consider outcomes of higher and lower functioning individuals with ID in a specialised dual diagnosis inpatient unit. The two groups differed in some respects at admission (psychiatric diagnosis, forensic involvement) but both groups benefited from their inpatient stay. The GAF was not sensitive enough to detect change in individuals with more severe disability, but both the Reiss Screen and the Hyperactivity sub‐scale of the ABC showed significant improvement for both groups from admission to discharge. Individuals in both groups were equally likely to be re‐admitted and to change residence from admission to discharge, and the groups did not differ in LOS.</p> <p>This paper demonstrates that individuals with mild and more severe disability can be served within the same programme. A larger proportion of inpatients had more severe disability than what has been reported in other studies, perhaps because it is a clear mandate of our programme to serve such individuals. Of course, there are complexities in serving both groups on the same unit, and some safety concerns. Every admission is considered in light of who is on the unit at the time, and how such an admission will impact the milieu. In addition, a range of psychosocial interventions need to be available on a daily basis, with the understanding that certain interventions will be more utilised by some patients than by others, depending on their functioning level.</p> <p>The GAF continues to be an important measure of functioning within the broader psychiatric community and is a requirement within our hospital, even though it was only sensitive enough to detect changes in overall functioning for those with more mild disability. There was minimal improvement in GAF scores for clients with moderate to severe ID in our sample, which is likely reflective of the limitations of using the GAF with individuals who present with very significant social, occupational and psychological impairments because of their ID ([<reflink idref="bib13" id="ref44">13</reflink>]; [<reflink idref="bib18" id="ref45">18</reflink>]). The Reiss Screen, in contrast, could detect changes in both groups, suggesting that it may be a more appropriate and detailed measure of problem areas for patients with ID. [<reflink idref="bib18" id="ref46">18</reflink>]) and [<reflink idref="bib5" id="ref47">5</reflink>]) also reported that the ABC detected significant differences in their day hospital clients with ID. Our study failed to detect these differences with the exception of scores on the Hyperactivity sub‐scale.</p> <p>The median LOS for mild clients was 203 days and, for moderate/severe clients, was 118 days. These numbers are higher than what was reported in hospital programmes in the UK and Sweden [23.2 weeks ([<reflink idref="bib23" id="ref48">23</reflink>]), 8 weeks ([<reflink idref="bib9" id="ref49">9</reflink>]), 2.91 months ([<reflink idref="bib15" id="ref50">15</reflink>]), 70.8 days ([<reflink idref="bib22" id="ref51">22</reflink>])]. This may be due, in part, to 39.4% of our sample staying in hospital for more than 6 months, and four individuals with mild ID being in hospital for an average of 1319 days. Rather than seeing shorter LOS in individuals with milder cognitive impairments as was reported in the studies cited above, in our sample patients with mild ID were as likely, if not more likely, to have prolonged admissions. Individuals with a history of forensic involvement had the most difficult time finding appropriate discharge placements, and more of those individuals had mild disability (11 Mild vs. five Moderate/Severe).</p> <p>Discharges for patients in both groups are likely more complicated in Canada than in other countries like the UK, where there are local 'community learning disability teams', as well as health professionals with specialised training in ID. Community mental health services for people with ID in Ontario are limited in comparison, and preparing community teams to reintegrate inpatient clients is a more demanding enterprise. Our programmatic response to this shortage in appropriate service has been to adopt a stronger continuity of care model between our inpatient and outpatient services. In this way, our programme is better able to support reintegration beyond the point of discharge, with the option of re‐admission. It would be important for us to evaluate LOS as well as re‐hospitalisation rates of clients in the future, to see whether a greater emphasis on continuity of care is helping to reduce inpatient LOS.</p> <p>There are a number of limitations in this study that need to be taken into account. First, the sample size was relatively small, and statistical analyses lacked the power to reflect significant changes in admission and discharge scores, or differences between patient groups. Second, because of the nature of research with a clinical population, data from some measures were not collected for all patients. Future studies should include follow‐up data on patients once discharged from the unit into the community, to allow us to comment on longer‐term outcomes of treatment, and to track, for example, whether patients are later re‐admitted to other hospitals for psychiatric reasons. Given the potential difficulties with the GAF in this population, another measure of overall psychiatric improvement, perhaps rated by a psychiatrist, should be incorporated. Finally, this study did not include a standardised assessment of the strengths, resources and quality of life of patients or caregivers. It is important to know more about internal and external resources that patients and their families bring into hospital, or develop during the inpatient admission.</p> <ref id="AN0045671017-20"> <title> References </title> <blist> <bibl id="bib1" idref="ref39" type="bt">1</bibl> <bibtext> Aman M. G. & Singh N. N. (1986) Aberrant Behavior Checklist: Manual. Slosson Educational Publications, East Aurora, NY.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref34" type="bt">2</bibl> <bibtext> Aman M. G., Singh N. N., Stewart A. W. & Field C. J. (1985) Psychometric characteristics of the Aberrant Behavior Checklist. American Journal of Mental Deficiency 89, 492 – 502.</bibtext> </blist> <blist> <bibl id="bib3" type="bt">3</bibl> <bibtext> American Psychiatric Association (1994) Global Assessment of Functioning Scale. In: Diagnostic and Statistical Manual of Mental Disorders, 4th edn. (DSM‐IV), p. 32. American Psychiatric Association, Washington, DC.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref5" type="bt">4</bibl> <bibtext> Ballinger B. R., Ballinger B., Reid A. H. & McQueen E. (1991) The psychiatric symptoms, diagnoses and care needs of 100 mentally handicapped patients. British Journal of Psychiatry 158, 251 – 4.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref15" type="bt">5</bibl> <bibtext> Carminati G. G., Gerber F. & Constantin N. (2005) A day hospital for adults with intellectual disabilities and psychiatric disorders. Psychiatric Services 56, 609.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref1" type="bt">6</bibl> <bibtext> Chaplin R. (2006) General psychiatric services for adults with intellectual disability and mental illness. Journal of Intellectual Disability Research 48, 1 – 10.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref2" type="bt">7</bibl> <bibtext> Chaplin R. (2009) New research into general psychiatry services for adults with intellectual disability and mental illness. Journal of Intellectual Disability Research 53, 189 – 99.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref4" type="bt">8</bibl> <bibtext> Day K. (1985) Psychiatric disorder in the middle‐aged and elderly mentally handicapped. British Journal of Psychiatry 147, 660 – 667.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref11" type="bt">9</bibl> <bibtext> Hall I., Parkes C., Samuels S. & Hassiotis A. (2006) Working across boundaries: clinical outcomes for an integrated mental health service for people with intellectual disabilities. Journal of Intellectual Disability Research 50, 598 – 607.</bibtext> </blist> <blist> <bibtext> Hurst J., Nadarajah J. & Cumella S. (1994) In‐patient care for people with learning disability and mental illness. The first eight years of a specialist unit. Psychiatry Bulletin 18, 29 – 31.</bibtext> </blist> <blist> <bibtext> van Minnen A., Hoogduin C. A. L. & Broekman T. G. (1997) Hospital vs. outreach treatment of patients with mental retardation and psychiatric disorders: a controlled study. Acta Psychiatrica Scandinavica 95, 515 – 22.</bibtext> </blist> <blist> <bibtext> Morris S. (2005) Specialized inpatient mental health units in Ontario: their history and program characteristics. Mental Health Aspects of Developmental Disabilities 8, 69 – 76.</bibtext> </blist> <blist> <bibtext> Oliver P., Cooray S., Tyrer P. & Cicchetti D. (2003) Use of the Global Assessment of Function scale in learning disability. British Journal of Psychiatry 182, 32 – 5.</bibtext> </blist> <blist> <bibtext> Prout H. T. (1993) Assessing psychopathology in persons with mental retardation: a review of the Reiss scales. Journal of School Psychology 31, 535 – 40.</bibtext> </blist> <blist> <bibtext> Raitasuo S., Taiminen T. & Salokangas R. K. R. (1999) Inpatient care and its outcome in a specialist psychiatric unit for people with intellectual disability: a prospective study. Journal of Intellectual Disability Research 43, 119 – 27.</bibtext> </blist> <blist> <bibtext> Reid A. H., Ballinger B. R., Heather B. B. & Melvin S. J. (1984) The natural history of behavioural symptoms among severely and profoundly mentally retarded patients. British Journal of Psychiatry 145, 289 – 93.</bibtext> </blist> <blist> <bibtext> Reiss S. (1986) Reiss Screen for Maladaptive Behavior. International Diagnostic Systems, Inc, Orland Park, IL.</bibtext> </blist> <blist> <bibtext> Shedlack K. J., Hennen J., Magee C. & Cheron D. M. (2005) A comparison of the Aberrant Behavior Checklist and the GAF among adults with mental retardation and mental illness. Psychiatric Servies 56, 484 – 6.</bibtext> </blist> <blist> <bibtext> Sovner R., Beasley J. & Hurley A. D. (1995) How long should a psychiatric inpatient stay be for a person with developmental disabilities? The Habilitative Mental Healthcare Newsletter 14, 1 – 6.</bibtext> </blist> <blist> <bibtext> Startup M., Jackson M. C. & Bendix S. (2002) The concurrent validity of the global assessment of functioning (GAF). British Journal of Clinical Psychology 41, 417 – 22.</bibtext> </blist> <blist> <bibtext> Statistical Package for Social Sciences (2007) SPSS Base 15.0 for Windows. SPSS Inc, Chicago, IL.</bibtext> </blist> <blist> <bibtext> Tajuddin M., Nadkarni S., Biswas A., Watson J. M. & Bhaumik S. (2004) A study of the use of an acute inpatient unit for adults with learning disability and mental health problems in Leicestershire, UK. The British Journal of Developmental Disabilities 50, 59 – 68.</bibtext> </blist> <blist> <bibtext> Xenitidis K., Gratsa A., Bouras N., Hammond R., Ditchfield H., Holt G. et al (2004) Psychiatric inpatient care for adults with intellectual disabilities: generic or specialist units? Journal of Intellectual Disability Research 48, 11 – 8.</bibtext> </blist> </ref> <aug> <p>By Y. Lunsky; S. E. White; A. M. Palucka; J. Weiss; S. Bockus and T. Gofine</p> <p>Reported by Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib16" firstref="ref3"></nolink> <nolink nlid="nl2" bibid="bib10" firstref="ref6"></nolink> <nolink nlid="nl3" bibid="bib11" firstref="ref7"></nolink> <nolink nlid="nl4" bibid="bib15" firstref="ref8"></nolink> <nolink nlid="nl5" bibid="bib22" firstref="ref9"></nolink> <nolink nlid="nl6" bibid="bib23" firstref="ref10"></nolink> <nolink nlid="nl7" bibid="bib18" firstref="ref16"></nolink> <nolink nlid="nl8" bibid="bib19" firstref="ref22"></nolink> <nolink nlid="nl9" bibid="bib12" firstref="ref26"></nolink> <nolink nlid="nl10" bibid="bib20" firstref="ref27"></nolink> <nolink nlid="nl11" bibid="bib13" firstref="ref29"></nolink> <nolink nlid="nl12" bibid="bib17" firstref="ref31"></nolink> <nolink nlid="nl13" bibid="bib14" firstref="ref32"></nolink> <nolink nlid="nl14" bibid="bib21" firstref="ref38"></nolink>
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  Data: Clinical Outcomes of a Specialised Inpatient Unit for Adults with Mild to Severe Intellectual Disability and Mental Illness
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  Data: <searchLink fieldCode="AR" term="%22Lunsky%2C+Y%2E%22">Lunsky, Y.</searchLink><br /><searchLink fieldCode="AR" term="%22White%2C+S%2E+E%2E%22">White, S. E.</searchLink><br /><searchLink fieldCode="AR" term="%22Palucka%2C+A%2E+M%2E%22">Palucka, A. M.</searchLink><br /><searchLink fieldCode="AR" term="%22Weiss%2C+J%2E%22">Weiss, J.</searchLink><br /><searchLink fieldCode="AR" term="%22Bockus%2C+S%2E%22">Bockus, S.</searchLink><br /><searchLink fieldCode="AR" term="%22Gofine%2C+T%2E%22">Gofine, T.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Intellectual+Disability+Research%22"><i>Journal of Intellectual Disability Research</i></searchLink>. Jan 2010 54(1):60-69.
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  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
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  Data: <searchLink fieldCode="DE" term="%22Psychiatric+Services%22">Psychiatric Services</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Needs%22">Health Needs</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</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="%22Cognitive+Ability%22">Cognitive Ability</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Behavioral+Science+Research%22">Behavioral Science Research</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink>
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  Data: 10.1111/j.1365-2788.2009.01213.x
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  Data: 0964-2633
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  Data: Background: Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service. Method: Thirty-three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re-admission to hospital were explored. Results: Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning. Conclusions: This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.
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  Data: 2010
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      – Text: English
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        PageCount: 10
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      – SubjectFull: Psychiatric Services
        Type: general
      – SubjectFull: Health Needs
        Type: general
      – SubjectFull: Mental Retardation
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      – SubjectFull: Canada
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    Titles:
      – TitleFull: Clinical Outcomes of a Specialised Inpatient Unit for Adults with Mild to Severe Intellectual Disability and Mental Illness
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              Value: 0964-2633
          Numbering:
            – Type: volume
              Value: 54
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Journal of Intellectual Disability Research
              Type: main
ResultId 1