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Better services needed for clients with dual diagnosis

the front cover of a crosscurrents magazine- the main image is a vase with bold coloured flowers


By: Kim Goggins

Summer 2005, Vol 8 No 4


Developmental disability is more common than any other disability in Ontario’s psychiatric hospital population, affecting approximately 19 per cent of inpatients, but reaching as high as 36 per cent at some sites. Yet the needs of this unique population are largely unmet.  

This gap in services was the impetus for a three-year study spearheaded by the Centre for Addiction and Mental Health (camh) in Toronto that is examining this population’s patient profile and clinical and support needs. “Caregivers and support staff are very frustrated about the lack of resources available to these clients,” says study lead Dr. Yona Lunsky, a psychologist with the Dual Diagnosis Program at camh.

People with developmental disabilities are more likely than the general population to have a mental illness, but few specialized services exist at psychiatric hospitals, and staff are often ill prepared to deal with clients with dual diagnosis (co-occurring developmental disabilities and psychiatric issues). Currently, there exist only five specialized dual diagnosis inpatient units and eight outpatient programs in Ontario’s psychiatric institutions. They serve only 20 per cent of clients with a dual diagnosis.

Lunsky, who is also an assistant professor of psychiatry at the University of Toronto, indicates several factors that are compromising care: inadequate specialized community resources, limited funding, insufficient training for mental health professionals around developmental disabilities and lack of co-ordination between the Ministry of Health and Long-Term Care, which funds psychiatric services, and the Ministry of Community and Social Services, which funds developmental disability services.

The first phase of the study examined the characteristics and needs of almost 13,000 inpatients and outpatients of Ontario’s psychiatric hospitals using the provincial comprehensive assessment projects database from 1998 to 2002. Phase two has been seeking input from Ontario’s nine psychiatric hospitals, as well as community stakeholders, through site visits, regional focus groups and key informant interviews. What has emerged is a concern that most staff receive little or no dual diagnosis training. This lack of training leads to poor care, for example, misunderstanding aggressive behaviour, or even to misdiagnosis, which can result in inappropriate treatment.

“These people get mixed into either the schizophrenia, mood disorders or more generic rehabilitation ward and get no specialized services,” says Phil Burge, associate professor of psychiatry and a social worker in the Department of Psychiatry at Queen’s University in Kingston, Ontario.

Alex Conant, manager of the Dual Diagnosis Consultation Outreach Team at Providence Continuing Care Centre in Kingston, agrees that more specialized services are needed: “Patients with a dual diagnosis may not always be able to report accurately on symptoms. They may be getting more medication than they need and may not be able to report on side-effects, which presents a challenge to everyone involved in their care.”

The study has also found that individuals with a dual diagnosis tend to have longer inpatient stays than other patients in psychiatric hospitals. Although these individuals need higher levels of care and support than the general population, only about 12 per cent of the approximately 400 dual diagnosis inpatients in Ontario psychiatric hospitals should be there. “Overall, patients with a dual diagnosis have a higher recommended level of care than other patients, but they don’t have a greater need for tertiary-level inpatient care than other patients,” says Lunsky. Yet 37 percent have been in hospital for more than five years. They continue to stay, not because of the severity of their difficulties, but because appropriate alternatives in the community do not exist.

This is why dual diagnosis experts are calling for more community-based services. The study’s preliminary findings point to the need for more intensive community mental health supports, such as assertive community treatment teams and residential treatment facilities that offer support for daily needs along with such specialized services as nursing staff at the residence, crisis interventions and direct links to trained clinicians. Shorter-term crisis and respite beds are also needed in the community, along with greater capacity in local general hospitals.

Providing appropriate care, of course, relies on adequate resources. Some new health funding has emerged in the past two years and has allowed the development of dual diagnosis teams like Conant’s, which covers six counties in south-eastern Ontario. Conant’s team provides clinical consultation regarding treatment for clients with dual diagnosis, as well as training and education, but resources are stretched.

The final report for the study, which is in its second year, will be released by June 2006. Lunsky is optimistic that stakeholders will heed the recommendations and revisit how to better serve this population. The study has already helped by bringing stakeholders together: “Going to each region and getting people to talk has allowed important networking to happen and has put the issues on the table,” says Lunsky. “People have told me they’ve decided to meet more regularly to get a better perspective from one another.”

Read the Phase 1 report


People with developmental disabilities are more likely than the general population to have a mental illness, but few specialized services exist at psychiatric hospitals, and staff are often ill prepared to deal with clients with dual diagnosis.