The deinstitutionalization of people with mental retardation in the United States, United Kingdom, and other parts of the world is well advanced. A variety of service models are provided. However, comprehensive local services systems for those with additional mental health needs and/or challenging behaviours have often not been developed. The old institutions represented a complete system of care, inasmuch as they provided accommodation, health care, social care, and occupation in a single setting. Current provision, by contrast, involves a range of agencies and settings. This requires that care is integrated and organized around an individual. This is not an easy task for those with complex needs (Table !)

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Table 1 Components of an effective psychiatric service for people with mental retardation

There has been considerable debate as to whether specialized dual diagnosis services should be established or existing mental health service providers should serve this population. However, it is clear that whatever strategy is undertaken it should be based on high professional standards. Standardized diagnostic and assessment tools should be used. Appropriate, individually tailored treatments should be given in the least restrictive environments. Staff must have the necessary expertise, training, and support.

Mixed results have been obtained for both residential and non-residential services, but overall many of the projected strengths and problems of both approaches have been substantiated in practice. No direct studies of comparative treatment effectiveness exist, and many of the studies on single specialist services contain major methodological weaknesses. While more convincing demonstrations of the clinical effectiveness of both approaches are required, the research focus also needs to be expanded to include other services, such as private residential services and psychiatric services.

It is essential that the quality of services be monitored, to maintain and improve standards of care. Increasing fragmentation of provision makes this a complex but essential task.

Often dual diagnosis services are provided in a crisis. This highlights and amplifies the existing deficiencies in care. In order to become more effective and accessible dual diagnosis services will have to address both individual needs and service systems complexities for children, adolescents, and adults with mental retardation and mental health problems. The challenge for the immediate future, in many nations, will be to work towards the reconciliation of philosophical positions that have hindered provision of dual diagnosis services within the increasing financial constraints that exist internationally.

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