Psychiatric disorders and mental retardation dual diagnosis

A significant number of people with mental retardation, despite progress in care delivery systems, continue to pose major difficulties in their management. Many have undiagnosed psychiatric disorders.

The presence of severe behaviour or psychiatric disorders in people with mental retardation is one of the main reasons for the breakdown of community placements and retention in residential environments that are more restrictive than otherwise required. Behavioural or psychiatric disorders that may have been accepted by institutional staff are often not tolerated in community placements and pose a threat to social integration. They can impair the sufferer's quality of life, cause regression of adaptive and intellectual functioning, and create unnecessary escalation of family stresses.

It has become clear that such people need services from both the mental retardation network and the mental health system. However, few districts have community-based programmes to provide comprehensive, integrated mental health and mental retardation services. Often individuals with developmental disabilities are excluded from generic community-based mental health services. This may be due to organizational issues, such as restrictions on providing services to people with low IQs, or lack of expertise in addressing the needs of people with mental retardation and psychiatric disorders. Exclusion may also stem from the belief by mental health professionals that people with mental retardation may not benefit from mental health interventions, due either to an impaired ability to process information or to a lack of competence to participate in a therapeutic process.

In the United States the administrators of the Federal government programmes needed to distinguish whether the primary problem of this client group was mental retardation or mental illness, because the services were funded from separate sources.(6) Those who had mental retardation as their primary problem were entitled to services provided by developmental centres, whereas those whose diagnosis was primarily of mental illness received services through community mental health centres.

Menolascino introduced the concept of dual diagnosis as an alternative to that of primary versus secondary disabilities. (Z> He recommended that services be provided according to need rather than primary diagnosis, such as mental illness or mental retardation. Services could then be delivered in the context of two coexisting disabilities allowing for more appropriate treatment, support, service planning, and development. The result would be to create a partnership between the mental health and mental retardation service structures to ensure responsive supports and treatments to previously underserved individuals.

The development of this concept increased the awareness of professionals, service providers, and relatives. Unfortunately, the term 'dual diagnosis' has subsequently been used to refer to people who misuse drugs and also have psychiatric disorders. This has created confusion. Dual diagnosis is used in this chapter to mean 'mental retardation and psychiatric disorders including mental illness'.

Bouras and Szymanski(8,) in a comparative overview of the American and British services for people with dual diagnosis emphasized that specialist interdisciplinary community-based accessible mental health services should be available for people with mental retardation.

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