CANADIAN RESEARCH IN DUAL DIAGNOSIS: TRANSLATING INTO ACTION November 16, 2012 Susan Morris, BSW, MSW, RSW Clinical Director Dual Diagnosis Service Krish Dhir, BComm, BSW, MSW (Candidate)
Workshop Objectives To review recent Canadian clinical and system research findings in relation to dual diagnosis To discuss the application of these findings in day to day practice 1 1
My story I m a KU = Knowledge User 2 2
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A review of Canadian research on intellectual and developmental disabilities and mental health issues, Journal of Mental Health Research in Intellectual Disabilities, Lunsky, Y., Lake, J., Balogh, R., Weiss, J., Morris, S. (In press) 4 4
Autism and mental illness in young adults Aging family caregivers Paid caregiver burn out Emergency department visits Aging, Depression and Alzheimer s disease Dual Diagnosis policy Topic Areas 5
Caveats A statistic can be found to support just about any argument All studies have strengths and limitations e.g. size, tools, where sample is drawn from Today is just a taste 6 6
Autism & Mental Ilness in Young Adults 1. Individuals aged 14-20 with ASD and IDD are more likely to experience anxiety, mood, sleep, organic syndromes and steriotypies/tics than those with IDD without Autism (Bradley et al, 2004) 2. Autism with Severe ID (< 40 IQ) 4 x more likely to experience clinically significant disturbances in relation to anxiety, mood, sleep, organic syndromes and steriotypies/ticks (Bradley et al, 2004) 3. Teenagers with ID and autism have higher rates of episodic psychiatric disorders (mood, psychosis) than those with ID alone (Bradley, 2006) 4. Individuals with autism often present with a complex mix of behavioural and psychiatric problems that require treatment with several drugs (Bradley, 2006) 7 7
Knowledge Uses Inquire about adult persons history of mental illness, behaviours, and medication use regardless of functioning level Obtain discharge summaries or assessments from previous services and health care providers to understand history and facilitate information exchange with new providers Understand the purpose of medications and expected impact on symptoms Establish good relationships with specialists Watch for clinical screening tools Advocate for more research on adults!! 8 8
Aging Family Caregivers 1. Three most stressful concerns of parents, regardless of parent age: accommodation (84%) formal supports e.g. emotional and social support (64%) opportunities to make friends and participate ( 56%) 2. Living in community or family home did not change these concerns 3. Clinical depression associated with maladaptive behaviour of adult child, self perceptions of aging and service use (Minnes et al, 2004) 4. Complex relationship between social / formal supports, maladaptive behaviour, carer self-appraisal of stress, aging and health e.g. effect of services on the relationship between maladaptive behaviour and caregiver depression (Minnes et al, 2007) 9 9
Knowledge uses Awareness that parents continue to worry about the future even after an adult child is placed Learn about family caregivers perception of own aging, health and stress Encourage self-care and provide support for family caregivers to to access services Learning about earlier family experiences with services and funders may help to achieve positive relationship between caregiver and service providers Use clinical screening tools 10 10
Paid Caregiver Burn Out 1. Residential/Respite/Day Programs experience more frequent and severe aggression (= injury) 2. Day Program and SIL staff most represented among the highest burn out scores nearly daily aggression and more severe aggression 3. Approximately half of all paid caregivers report experiencing emotional problems. 4. Between 7% and 24% may be burnt out or at risk, and. 5. Only 50% of those with emotional difficulties accessed agency resources (Hensel et al., 2011; 2012) 11
Knowledge Uses Debriefing protocol after incidents to check-in on emotional well-being, trouble shoot and adjust environment and/or protocols Regular discussion and assessment of staff needs through clinical supervision, team meetings, questionnaires Organization level monitoring of frequency and severity of incidents Offer skill training and staff development re self-care 12 12
Emergency Department Visits 1. 1 out of 2 adults with dual diagnosis are likely to visit the ED at least once in a 2 year period (medical/psychiatric) (Lunsky et al, 2011) 2. Adults with a dual diagnosis are 3-4 x more likely to be frequent visitors to ED than the general population (Lunsky et al, 2011) 3 Most frequent life events associated with ED visit Move of house or residence Serious problem with family, friend or caregiver Problem with police or other caregiver Unemployed for more than a month Recent trauma or abuse Drug or alcohol problem (Lunsky & Elserafi, 2011) 13 13
Knowledge uses Pre-planning for crisis prevention and management of anticipated life events Recognize the first emergency visit is an indictor of possibly more in the future take a step back and review individual needs, access specialized assessment / treatment, and/or better prepare for the next visit, should it need to occur People with DD need crisis prevention and management plans and access to appropriate community support and resources. 14 14
Aging, Depression & Alzheimer's Disease Dementia 5 % prevalence among 20 54 age group with Dev. Dis (vs 1.3 % Non DD) 4 % prevalence among 55 + age group with Dev. Dis (vs 3.4% Non DD) Depression 42 % prevalence among 20 54 age group with Dev. Dis (vs. 20% Non DD) 39% prevalence of depression among 55 + age group (vs. 20 % Non DD) (Shooshtari, 2011) 15
Knowledge Uses Share this information with health care professionals, including family physicians to encourage early detection, screening and assessment of mental health conditions and problems common among persons with developmental disabilities Engage persons with Dev. Dis. in healthy lifestyles to prevent or deter early onset of mental health conditions e.g. physical activity, mental leisure activities, and social inclusion and participation, job opportunities and good nutrition Learn about indicators of depression and dementia in developmental disabilities e.g. DM-ID adapted criteria Watch for clinical screening tools 16 16
Dual Diagnosis Policy Only 4 of 13 Canadian provinces/territories have specific IDD legislation 6 regions have broad disability legislation that may include IDD All regions have mental health legislation and 5 exclude IDD. Only 4 regions have dual diagnosis policies (Gough & Morris, 2012) 17 17
Knowledge uses Statutory gap is another example of marginalization Advocate for inclusion in legislation regions with specific IDD legislation may fare better in relation to dual diagnosis services and supports than those with broader legislation or no legislation Consider the benefits of broad disability legislation (provides strict equality across disabilities) in relation to the potential lack of benefits for those with more complex needs 18 18
Strengths Epidemiological study (Bradley) Large sample size (Bradley, Shooshtari, Lunsky; Hensel) Administrative data (Shooshtari, Lunsky) Multiple and validated measures used to assess target population (Bradley, Minnes, Hensel) Results that are consistent and/or add to existing evidence (all) 19 19
Limitations Small sample sizes (Minnes, Bradley) Administrative data (Lunsky, Shooshtari) Accuracy of diagnosis Excludes those not accessing services Administrative vs. True prevalence Convenience sample or voluntary subjects (Minnes, Hensel, Gough) 20
To be an effective knowledge user Read peer reviewed journals Read more than 1 article on a subject Look for opportunities to discuss readings, hear researchers speak Review the bibliography for related articles 21
What can you do over the next 3 months to become a more effective knowledge user? 22 22