MH in NDIS Presentation

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Delivering effective mental health services for people with disabilities in the NDIS: were starting behind the eight-ballBrent HaywardSenior Practice Advisor MEd PGDACN(Psych) BN

Mandy Donley Practice Leader MEd PGDACN(MentHlth) RMN

Office of Professional Practice Department of Human Services, Victoria

[email protected]

The context30-40% of people with ID will experience mental illness People with ID access mental health services proportionately less than the general population (10 vs. 35%)People with ID experience a poor standard of care from mental health services Challenging behaviour occurs in 7-15% of people with IDIt is disputed whether challenging behaviour is indicative of an underlying mental illnessAccessible mental health services for people with ID lags behind internationally accepted practice Specialist ID mental health services in Australia are uncommon

Exploring the issue (1)Determination of models of best practice in dual disability Benefits and challenges associated with implementation in Victoria

Issues with access to mental health services for people with IDCurrent service modelsCore components of service provision Stakeholder consultation Moving forward in Victoria

Exploring the issue (2) Developed by Department of Developmental Disability Neuropsychiatry (UNSW)Core reference groupNational Roundtable on Mental Health of People with Intellectual Disability Funded by the Australian Government Department of Health

An overview of intellectual disability mental healthWhy accessible services are important, the principles that should guide service deliveryPractical strategies for inclusive and accessible services and Implications for the service system

Interface of person with ID and mental health service NOT accepted for serviceAccepted for serviceTherapeutic serviceDiagnostic overshadowingCant identify symptoms of mental illness ENDChemical restraintNo ID serviceA proposed model for access and outcomes for people with ID accessing mental health services

Reliance upon emergency departments Mediation between services Lack of guidance, leadership and policySkill and quality of behaviour analysis and intervention Limited utility of publically-funded private practitionersMedicare billing privileges limited assessment Reliance upon private psychiatrists

Interface of person with ID and mental health service

are less likely to seek help for symptoms of mental illness present symptoms of mental illness differently Demarcation between mental health and disability services silosEligibility for services, arbitrary criteria, labelling as behaviouralChief complaint reflects view of caregivers (Hurley et al. (2003) J Int Dis Res, 47(1): 39)

NOT accepted for service

Lack of experience in public mental health servicesLack of specialist knowledge and trainingMultiple obstacles to effective inpatient treatment Variability of client information presented to clinicians

No ID service

A bias negatively affecting the accuracy of clinicians judgments about concomitant mental illness in persons with ID (Jopp & Keys (2001) Am J Men Retar, 106(5): 416)Long waiting times in unfamiliar environments often exacerbates behaviour prior to, and during consultation Lack of training and education of clinical staff Chief complaint reflects view of caregivers (Hurley et al. (2003) J Int Dis Res, 47(1): 39)

Diagnostic overshadowing

Reliance upon diagnostic criteria not developed for ID population Unfamiliarity with assessment toolsInability to verbalise symptoms Reliance upon cross-sectional rather than longitudinal assessment Diagnostic information relayed by caregivers (Hurley et al. (2013) J Int Dis Res, 47(1): 39)Insufficient time allotted for consultation Detailed background and history not made availableOver-reliance upon (often incorrect or incomplete) history orally reported by direct support staffAccess to historical and archived files not provided to clinical services Cant identify symptoms of mental illness

Lack of experience in public mental health servicesLack of specialist knowledge and training of clinicians Ineffective public behaviour intervention services Direct support worker knowledge, education and training Insufficient implementation of organisational-wide positive behaviour support Lack of data presented to prescribers Subjective interpretations relayed by carers at consultationsPsychiatric overshadowing - attributing behaviours driven and maintained by environmental contingencies to internal psychological dysfunction (Allen (2008), J of Intell Dis, 12(4): 267)Pressure to prescribe medication despite lack of overt psychopathology (Tsakanikos et al. (2007). J Aut Dev Dis, 37: 1080)Chemical restraint

Chemical restraint The population of people with ID is regarded as one of the highest medicated groups in societyPsychotropic medication used as chemical restraint of persons with ID reported internationally Little evidence of efficacy (Matson & Neal (2009), Res Dev Dis, 30: 572)Not cost effective (Romeo et al. (2009), JIDR, 53: 633)Off-label prescribing frequent (Glover et al. (2014) BJP, 205: 6)Frequent use of NOS diagnoses to obtain authority prescriptions Polypharmacy common (Habler et al. (2014), J Neu Trans, in press; Haider et al. (2014), Res Dev Dis, 35: 3071)Adverse effects common (de Leon et al. (2009), Res Dev Dis, 30: 613)

Chemical restraint of people with ID in Victoria 90% of restrictive interventions in Victoria are medication for behavioural control (defined as chemical restraint in the Act)The widespread use of antipsychotics exceeds the database regarding efficacy, safety and tolerability (Correll (2008) J. Am Acad Child Adol Psych, 47(1): 9)A high likelihood of staying medicated over time (Esbensen et al. (2009). J Autism Dev Disord, 39: 1339)77% remain subject to chemical restraint in subsequent yearsBehaviour disorder predicts a higher maximum and mean dose of risperidone than in psychosis (Hayward & Pridding, 2012)

Addressing chemical restraint (1)98% prescribed psychotropic medication (54% of these without mental illness)Quality of prescribing (see table)

Addressing chemical restraint (2) No clinical guidelines in use across AustraliaThe Office of the Senior Practitioner (DHS, Victoria) engaged the Royal Australian and New Zealand College of Psychiatrists (Vic Branch)A roundtable to discuss the issues of prescribing psychotropic medication to people with IDIdentifying available guidelinesEndorsing guidelines Implementing guidelines Recommendations: World Psychiatric Guidelines (Deb et al. (2009) World Psychiatry, 8: 181)

People with ID in the NDISRisks of marginalisation for those with existing complex disadvantage (Soldatic et al. (2014), 1(1): 6)Potential problem areas and practical limitations (OConnor (2014), 1(1): 17)Access for those involved with the criminal justice system (Clift (2014), 1(1): 24)Hearing the voices of people with ID in the NDIS (Bigby (2014), 1(2): 93)

[How to] integrate mental health into the NDIS [for people with ID] Accreditation and/or registration of providers in the NDISEstablishing safeguards which at a minimum, meet existing best practice in Australia (Disability Act 2006 (Vic))Acknowledge that public mental health services in Australia are generally not designed to support people with IDAcknowledge that people with ID are actively excluded from mental health services Acknowledge that individual clinicians are generally ill-equipped to provide effective mental health services to people with ID Acknowledge that people with ID are often medicated for behavioural control (chemical restraint), not for therapeutic treatment (National Framework; National mental health policy should adopt established core components for ID mental health services