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Organising health care services for persons with an intellectual disability

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Referencias

References to studies included in this review

Ir a:

Allen 1998 {published data only}

Allen D. Brief report: changes in admissions to a hospital for people with intellectual disabilities following the development of alternative community services. Journal of Applied Research in Intellectual Disabilities 1998;11:156‐65.

Coelho 1993 {published data only}

Coelho RJ, Kelley PS, DeatsmanKelley C. An experimental investigation of an innovative community treatment model for persons with a dual diagnosis (DD/MI). Journal of Rehabilitation 1993;59:37‐42.

Dowling 2006 {published data only}

Dowling S, Hubert J, White S, Hollins S. Bereaved adults with intellectual disabilities: a combined randomized controlled trial and qualitative study of two community‐based interventions. Journal of Intellectual Disability Research 2006;50:277‐87.

Hassiotis 2001 {published data only}

Hassiotis A, Ukoumunne OC, Byford S, Tyrer P, Harvey K, Piachaud J, et al. Intellectual functioning and outcome of patients with severe psychotic illness randomised to intensive case management: report from the UK700 trial. British Journal of Psychiatry 2001;178:166‐71.

Lowe 1996 {published data only}

Lowe K, Felce D, Blackman D. Challenging behaviour: the effectiveness of specialist support teams. Journal of Intellectual Disability Research 1996;40:336‐47.

Martin 2005 {published data only}

Martin G, Costello H, Leese M, Slade M, Bouras N, Higgins S, et al. An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues. Journal of Intellectual Disability Research 2005;49:516‐24.

Oliver 2005 {published data only}

Oliver PC, Piachaud J, Tyrer P, Regan A, Dack M, Alexander R, et al. Randomized controlled trial of assertive community treatment in intellectual disability: the TACTILD study. Journal of Intellectual Disability Research 2005;49:507‐15.

Van Minnen 1997 {published data only}

Van Minnen A, Hoogduin CA, Broekman TG. Hospital versus outreach treatment of patients with mental retardation and psychiatric disorders: a controlled study. Acta Psychiatrica Scandinavica 1997;95:515‐22.

References to studies excluded from this review

Ir a:

Alexander 2001 {published data only}

Alexander RT, Piachaud J, Singh I. Two districts, two models: in‐patient care in the psychiatry of learning disability. British Journal of Developmental Disabilities 2001;47(93 Pt 2):105‐10.

Arana 1991 {published data only}

Arana JD, Hastings B, Herron E. Continuous care teams in intensive outpatient treatment of chronic mentally ill patients. Hospital and Community Psychiatry 1991;42(5):503‐7.

Aronow 2005 {published data only}

Aronow HU, Hahn JE. Stay well and healthy! Pilot study findings from an inhome preventive healthcare programme for persons ageing with intellectual and/or developmental disabilities. Journal of Applied Research in Intellectual Disabilities Special Issue: Health Inequalities and People with Intellectual Disabilities 2005;18(2):163‐73.

Arya 2002 {published data only}

Arya S. Delivery of services through itinerant service model. Journal of Personality and Clinical Studies 2002;18(1‐2):67‐72.

Barr 1999 {published data only}

Barr O, Gilgunn J, Kane T, Moore G. Health screening for people with learning disabilities by a community learning disability nursing service in Northern Ireland. Journal of Advanced Nursing 1999;29(6):1482‐91.

Baxter 2006 {published data only}

Baxter H, Lowe K, Houston H, Jones G, Felce D, Kerr M. Previously unidentified morbidity in patients with intellectual disability. British Journal of General Practice 2006;56(523):93‐8.

Bhaumik 2005 {published data only}

Bhaumik S, McDonnell V, Watson JM. Valuing people: evaluating referral systems. A study of a multidisciplinary single point of referral system to dedicated adult learning disability health services in Leicester, UK. British Journal of Developmental Disabilities 2005;51(2):155‐70.

Bollard 1999 {published data only}

Bollard M. Improving primary health care for people with learning disabilities. British Journal of Nursing 1999;8(18):1216‐21.

Calkins 1994 {published data only}

Calkins DR, Rubenstein LV, Cleary PD, Davies AR, Jette AM, Fink A, et al. Functional disability screening of ambulatory patients: a randomized controlled trial in a hospital‐based group practice. Journal of General Internal Medicine 1994;9(10):590‐2.

Camfield 2004 {published data only}

Camfield CS, Joseph M, Hurley T, Campbell K, Sanderson S, Camfield PR. Optimal management of phenylketonuria: a centralized expert team is more successful than a decentralized model of care. Journal of Pediatrics 2004;145(1):53‐7.

Carlsen 1994 {published data only}

Carlsen WR, Galluzzi KE, Forman LF, Cavalieri TA. Comprehensive geriatric assessment: applications for community residing, elderly people with mental retardation/developmental disabilities. Mental retardation 1994;32(5):334‐40.

Cassidy 2002 {published data only}

Cassidy G, Martin DM, Martin GHB, Roy A. Health checks for people with learning disabilities: community learning disability teams working with general practitioners and primary health care teams. Journal of Learning Disabilities (London) 2002;6(2):123‐36.

Chicoine 1994 {published data only}

Chicoine B, McGuire D, Hebein S, Gilly D. Development of a clinic for adults with Down syndrome. Mental retardation 1994;32(2):100‐6.

Chubb 1995 {published data only}

Chubb H, Kerr M, Joyce J. Out‐patient care for people with learning disability and epilepsy: evaluating the audit process. Psychiatric Bulletin 1995;19(11):686‐8.

Codling 2005 {published data only}

Codling M, Macdonald N, Chandler B. Integrated care pathway for people with epilepsy. Learning Disability Practice 2005;8(3):32‐7.

Cooray 1998 {published data only}

Cooray SE, Tolmac J. Antipsychotic medication in learning disability: impact of audit and evidence based medicine on quality of prescribing in a community assessment treatment unit. Psychiatric Bulletin 1998;22(10):601‐4.

Criscione 1993 {published data only}

Criscione T, Kastner TA, Walsh KK, Nathanson R. Managed health care services for people with mental retardation: impact on inpatient utilization. Mental Retardation 1993;31(5):297‐306.

Criscione 1994 {published data only}

Criscione T, Kastner TA, O'Brien D, Nathanson R. Replication of a managed health care initiative for people with mental retardation living in the community. Mental Retardation 1994;32(1):43‐52.

Criscione 1995 {published data only}

Criscione T, Walsh KK, Kastner TA. An evaluation of care coordination in controlling inpatient hospital utilization of people with developmental disabilities. Mental Retardation 1995;33(6):364‐73.

Davidson 1995 {published data only}

Davidson PW, Cain NN, Sloan‐Reeves JE, Giesow VE. Crisis intervention for community based individuals with developmental disabilities and behavioral and psychiatric disorders. Mental Retardation 1995;33(1):21‐30.

Feldman 2002 {published data only}

Feldman MA, Condillac RA, Tough S. Effectiveness of community positive behavioral intervention for persons with developmental disabilities and severe behavior disorders. Behavior Therapy 2002;33(3):377‐98.

Fernando 2001 {published data only}

Fernando L, Cresswell J, Barakat F. Study of physical health needs of people with learning disabilities living in the community. British Journal of Developmental Disabilities 2001;47(92 Pt1):31‐7.

Findholt 1990 {published data only}

Findholt NE, Emmett CG. Impact of interdisciplinary team review on psychotropic drug use with persons who have mental retardation. Mental Retardation 1990;28(1):41‐6.

Galligan 1990 {published data only}

Galligan B. Serving people who are dually diagnosed: a program evaluation. Mental Retardation 1990;28(6):353‐8.

Gaskell 1995 {published data only}

Gaskell G, Dockrell J, Rehman H. Community care for people with challenging behaviours and mild learning disability: an evaluation of an assessment and treatment unit. British Journal of Clinical Psychology 1995;34(3):383‐95.

Goldsmith 2000 {published data only}

Goldsmith S, Cooray S, Johnston F, Williams G. Good practice, general practice: identifying the health needs of people with learning disabilities. Journal of Clinical Governance 2000;8(2):83‐8.

Greenswag 1990 {published data only}

Greenswag LR. A community outreach program for individuals with Prader‐Willi syndrome. Journal of Pediatric Health Care 1990;4(1):32‐8.

Guo 2001 {published data only}

Guo S, Biegel DE, Johnsen JA, Dyches H. Assessing the impact of community based mobile crisis services on preventing hospitalization. Psychiatric Services 2001;52(2):223‐8.

Hahn 2005 {published data only}

Hahn JE, Aronow HU. A pilot of a gerontological advanced practice nurse preventive intervention. Journal of Applied Research in Intellectual Disabilities Special Issue: Health Inequalities and People with Intellectual Disabilities 2005;18(2):131‐42.

Halstead 2000 {published data only}

Halstead SM, Bradley F, Milne S, Wright EC, Hollins SC. Annual primary health care contacts by people with intellectual disabilities: a comparison of three matched groups. Journal of Applied Research in Intellectual Disabilities 2000;13(2):100‐7.

Hassiotis 2003 {published data only}

Hassiotis A, Tyrer P, Oliver P. Psychiatric assertive outreach and learning disability services. Advances in Psychiatric Treatment 2003;9(5):368‐73.

Hatton 1995 {published data only}

Hatton C, Emerson E, Robertson J, Henderson D, Cooper J. The quality and costs of residential services for adults with multiple disabilities: a comparative evaluation. Research in Developmental Disabilities 1995;16(6):439‐60.

Holmes 2004 {published data only}

Holmes AM, Deb P. Performance assessment in community mental health care and at risk populations. Health Care Financing Review 2004;26(1):75‐84.

Jones 1997 {published data only}

Jones RG, Kerr MP. A randomized control trial of an opportunistic health screening tool in primary care for people with intellectual disability. Journal of Intellectual Disability Research 1997;41(5):409‐15.

Jurek 1994 {published data only}

Jurek GH, Reid WH. Oral health of institutionalized individuals with mental retardation. American Journal on Mental Retardation 1994;98(5):656‐60.

Kaufman 1995 {published data only}

Kaufman H, Overton G, Leggott J, Clericuzio C. Prader‐Willi syndrome: effect of group home placement on obese patients with diabetes. Southern Medical Journal 1995;88(2):182‐4.

Kerr 2003 {published data only}

Kerr AM, McCulloch D, Oliver K, McLean B, Coleman E, Law T, et al. Medical needs for people with intellectual disability require regular reassessment, and the provision of client and carer held reports. Journal of Intellectual Disability Research 2003;47(2):134‐45.

Kwok 2001 {published data only}

Kwok HWM. Development of a specialized psychiatric service for people with learning disabilities and mental health problems: report of a project from Kwai Chung hospital, Hong Kong. British Journal of Learning Disabilities 2001;29(1):22‐5.

Lennox 2001 {published data only}

Lennox NG, Green M, Diggens J, Ugoni A. Audit and comprehensive health assessment programme in the primary healthcare of adults with intellectual disability: a pilot study. Journal of Intellectual Disability Research 2001;45(3):226‐32.

Lepler 1993 {published data only}

Lepler S, Hodas A, CotterMack A. Implementation of an interdisciplinary psychotropic drug review process for community‐based facilities. Mental Retardation 1993;31(5):307‐15.

Litzinger 1993 {published data only}

Litzinger MJ, Duvall B, Little P. Movement of individuals with complex epilepsy from an institution into the community: seizure control and functional outcomes. American Journal on Mental Retardation 1993;98 Suppl 1:52‐7.

Lowe 1993 {published data only}

Lowe K, De Paiva S, Felce D. Effects of a community‐based service on adaptive and maladaptive behaviours: a longitudinal study Lowe K, De Paiva S, Felce D. Effects of a community‐based service on adaptive and maladaptive behaviours: A longitudinal study. Journal of Intellectual Disability Research 1993;37(1):3‐22. Journal of Intellectual Disability Research 1993;37(1):3‐22.

Luiselli 2001 {published data only}

Luiselli JK, Benner S, Stoddard T, Weiss R, Lisowski K. Evaluating the efficacy of partial hospitalization services for adults with mental retardation and psychiatric disorders: a pilot study using the Aberrant Behavior Checklist (ABC). Mental Health Aspects of Developmental Disabilities 2001;4(2):61‐7.

MacPherson 2002 {published data only}

MacPherson R, Cornelius F, Kilpatrick D, Blazey K. Outcome of clinical risk management in the Gloucester rehabilitation service. Psychiatric Bulletin 2002;26(12):449‐52.

Madianos 1999 {published data only}

Madianos MG, Economou M. The impact of a community mental health center on psychiatric hospitalizations in two Athens areas. Community Mental Health Journal 1999;35(4):313‐23.

Martin 1997 {published data only}

Martin DM, Roy A, Wells MB. Health gain through health checks: improving access to primary health care for people with intellectual disability. Journal of Intellectual Disability Research 1997;41 Pt 5:401‐8.

Martin 2003 {published data only}

Martin G. Annual health reviews for patients with severe learning disabilities: five years of a combined GP/CLDN clinic. Journal of Learning Disabilities (London) 2003;7(1):9‐21.

Martin 2004a {published data only}

Martin G, Axon V, Baillie S. A joint practice nurse/community learning disability nurse annual health check for primary care patients with learning disabilities. Learning Disability Practice 2004;7(9):30‐3.

Martin 2004b {published data only}

Martin G, Philip L, Bates L, Warwick J. Evaluation of a nurse led annual review of patients with severe intellectual disabilities, needs identified and needs met, in a large group practice. Journal of Learning Disabilities 2004;8(3):235‐46.

McCabe 2006 {published data only}

McCabe MP, McGillivray JA, Newton DC. Effectiveness of treatment programmes for depression among adults with mild/moderate intellectual disability. Journal of Intellectual Disability Research 2006;50(4):239‐47.

McKee 1994 {published data only}

McKee JR. Clinical pharmacy services in an intermediate care facility for the mentally retarded. Hospital Pharmacy 1994;29(3):228‐30.

Melville 2006 {published data only}

Melville CA, Cooper SA, Morrison J, Finlayson J, Allan L, Robinson N, et al. The outcomes of an intervention study to reduce the barriers experienced by people with intellectual disabilities accessing primary health care services. Journal of Intellectual Disability Research 2006;50(1):11‐7.

Merrick 2000 {published data only}

Merrick J, Shapira J. Preventive dental health for persons with Down syndrome. International Journal of Adolescent Medicine and Health 2000;12(1):81‐4.

Michael 2004 {published data only}

Michael DM, Bhaumik S, Nadkarni S, Raju LB, Watson JM. Misplaced or displaced? An audit of referred patients to an adult learning disability psychiatric service. The British Journal of Developmental Disabilities 2004;50(2):117‐24.

Moss 1993 {published data only}

Moss SC, Hogg J, Horne M. Individual characteristics and service support of older people with moderate, severe and profound learning disability with and without community mental handicap team support. Mental Handicap Research 1993;6(1):3‐17.

Nesbitt 1998 {published data only}

Nesbitt S, Collins G. What is 'special' about national health service residences for people with learning disabilities? An audit of residential needs. British Journal of Developmental Disabilities 1998;44(2):86‐93.

Patterson 1995 {published data only}

Patterson T, Higgins M, Dyck DG. A collaborative approach to reduce hospitalization of developmentally disabled clients with mental illness. Psychiatric Services 1995;46(3):243‐47.

Paxton 1998 {published data only}

Paxton D, Taylor S. Access to primary health care for adults with a learning disability. Health Bulletin 1998;56(3):686‐93.

Radler 1996 {published data only}

Radler G, Hudson A. The behavior intervention support team program: addressing challenging behavior of people with an intellectual disability in Victoria, Australia. The Institute for Applied Behavior Analysis Newsletter 1996;1(2):3‐8.

Roy 1997 {published data only}

Roy A, Martin DM, Wells MB. Health gain through screening ‐ mental health: developing primary health care services for people with an intellectual disability. Journal of Intellectual and Developmental Disability 1997;22(4):227‐39.

Rudolph 1998 {published data only}

Rudolph C, Lakin KC, Oslund JM, Larson W. Evaluation of outcomes and cost effectiveness of a community behavioral support and crisis response demonstration project. Mental Retardation 1998;36(3):187‐97.

Singh 1991 {published data only}

Singh TH, Radhakrishnan G, Richardson EM. A community based mental handicap out‐patient clinic: a 5‐year retrospective study. Journal of Mental Deficiency Research 1991;35(Pt 2):125‐32.

Singh 2002 {published data only}

Singh NN, Wahler RG, Sabaawi M, Goza AB, Singh SD, Molina EJ, et al. Mentoring treatment teams to integrate behavioral and psychopharmacological treatments in developmental disabilities. Research in Developmental Disabilities 2002;23(6):379‐89.

Tajuddin 2004 {published data only}

Tajuddin M, Nadkarni S, Biswas A, Watson JM, Bhaumik S. A study of the use of an acute inpatient unit for adults with learning disability and mental health problems in Leicestershire, UK. British Journal of Developmental Disabilities 2004;50(98 Pt1):59‐68.

Trower 1998 {published data only}

Trower T, Treadwell L, Bhaumik S. Acute inpatient treatment for adults with learning disabilities and mental health problems in a specialised admission unit. British Journal of Developmental Disabilities 1998;44(1):20‐9.

Van Loon 2005 {published data only}

Van Loon J, Knibbe J, Van Hove G. From institutional to community support: consequences for medical care. Journal of Applied Research in Intellectual Disabilities Special Issue: Health Inequalities and People with Intellectual Disabilities 2005;18(2):175‐80.

Van Minnen 1993 {published data only}

Van Minnen A, Hoogduin KAL, Peeters LAG, Smedts HTM. An outreach treatment approach of mildly mentally retarded with behavioral disorders. British Journal of Development Disabilities 1993;39(2):126‐33.

Van Minnen 1994 {published data only}

Van Minnen A, Hoelsgens I, Hoogduin K. Specialized treatment of mildly mentally retarded adults with psychiatric and/or behavioural disorders: inpatient or outreach treatment?. British Journal of Developmental Disabilities 1994;40(1):24‐31.

Webb 1999 {published data only}

Webb OJ, Rogers L. Health screening for people with intellectual disability: the New Zealand experience. Journal of Intellectual Disability Research 1999;43(6):497‐503.

Wells 1997 {published data only}

Wells MB, Turner S, Martin DM, Roy A. Health gain through screening ‐ coronary heart disease and stroke: developing primary health care services for people with intellectual disability. Journal of Intellectual and Developmental Disability 1997;22(4):251‐63.

Xenitidis 1999 {published data only}

Xenitidis KI, Henry J, Russell AJ, Ward A, Murphy DGM. An inpatient treatment model for adults with mild intellectual disability and challenging behaviour. Journal of Intellectual Disability Research 1999;43(2):128‐34.

Xenitidis 2004 {published data only}

Xenitidis K, Gratsa A, Bouras N, Hammond R, Ditchfield H, Holt G, et al. Psychiatric inpatient care for adults with intellectual disabilities: generic or specialist units?. Journal of Intellectual Disability Research 2004;48(1):11‐8.

Zhang 1994 {published data only}

Zhang M, Yan H, Phillips MR. Community‐based psychiatric rehabilitation in Shanghai. Facilities, services, outcome, and culture‐specific characteristics. British Journal of Psychiatry 1994;Suppl 1(24):70‐9.

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Alborz 2005

Alborz A, McNally R, Glendinning C. Access to health care for people with learning disabilities in the UK: mapping the issues and reviewing the evidence. Journal of Health Services and Research Policy 2005;10:173‐82.

Alexander 2002

Alexander R, Regan A, Gangadharan S, Bhaumik S. Psychiatry of learning disability ‐ a future with mental health?. Psychiatric Bulletin 2002;26:299‐301.

Allen 2008

Allen D. Personal Communication April 21, 2008.

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Aspray 1999

Aspray TJ, Francis RM, Tyrer SP, Quilliam SJ. Patients with learning disability in the community. British Medical Journal 1999;318:476‐7.

Bouras 2004

Bouras N, Holt G. Mental health services for adults with learning disabilities. British Journal of Psychiatry 2004;184:291‐2.

Burns 1999

Burns T, Creed F, Fahy T, Thompson S, Tyrer P, White I. Intensive versus standard case management for severe psychotic illness: a randomised trial. The Lancet 1999;353:2185‐9.

Campbell 2000

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Chaplin R. General psychiatric services for adults with intellectual disability and mental illness. Journal of Intellectual Disability Research 2004;48:1‐10.

Chaplin 2006

Chaplin R. Assertive outreach for people with intellectual disability and mental disorders. Journal of Intellectual Disability Research 2006;50:615‐6.

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Cooper SA, Smiley E, Morrison J, Williamson A, Allan L. Mental ill‐health in adults with intellectual disabilities: prevalence and associated factors. British Journal of Psychiatry 2007;196:27‐35.

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Durvasula S, Beange H. Health inequalities in people with intellectual disability: strategies for improvement. Health Promotion Journal of Australia 2001;11:27‐31.

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Durvasula S, Beange H, Baker W. Mortality of people with intellectual disability in northern Sydney. Journal of Intellectual & Developmental Disability 2002;27:255‐64.

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Fisher K. Health disparities and mental retardation. Journal of Nursing Scholarship 2004;36:48‐53.

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Fletcher, RJ. Mental illness‐mental retardation in the United States: policy and treatment changes. Journal of Intellectual Disability Research 1993;37 Suppl:25‐33.

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Hassiotis, A. Community mental health services for individuals with intellectual disabilities issues and approaches to optimizing outcomes. Disease Management and Health Outcomes 2002;10:409‐17.

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Kelley P. Personal communication 11 October 2006.

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Larson SA, Anderson L, Dlojanac R. Health Promotion for Persons with Intellectual and Developmental Disabilities. In: Nehring W editor(s). Access to Health Care. Washington: American Association on Mental Retardation, 2005:129‐84.

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Lennox N, Chaplin R. The psychiatric care of people with intellectual disabilities: the perceptions of trainee psychiatrists and medical officers. Australian and New Zealand Journal of Psychiatry 1995;29:632‐37.

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Lennox NG, Kerr MP. Primary health care and people with an intellectual disability: the evidence base. Journal of Intellectual Disability Research 1997;41:365‐72.

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Lennox 2005

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Moss S, Bouras N, Holt G. Mental health services for people with intellectual disability: a conceptual framework. Journal of Intellectual Disability Research 2000;44:97‐107.

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O'Hara J. Learning disabilities services: primary care or mental health trust?. Psychiatric Bulletin 2000;24:368‐9.

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Characteristics of studies

Characteristics of included studies [ordered by study ID]

Ir a:

Allen 1998

Methods

Study Design: ITS

Types of interventions: Multidisciplinary team + Change to site of service delivery + Change in scope and nature of services

Participants

Clinical Problem: Focus is on persons with ID and any of the following alone or in combination: challenging behaviour, psychiatric needs, offending against the law)

Setting: Wales

Sample size and demographics not reported

Interventions

No C group.  Compares results from three intervention time periods:

I1: Baseline (1975 ‐ 1982).   Specialty hospital for persons with an ID

I2: Community support teams (1983 ‐ 1989).  Multiple agencies (health, social services, and volunteer sectors) provide care from broad range of professions (e.g. social work, occupational therapy, physiotherapy, psychology) specific to persons with ID

I3: Intervention includes I2 plus additional specialist services specific to with an ID including Intensive Support Services, Emergency Intervention Service and weekly outpatient clinics (1990 ‐ 1995). I3 differs from I2 in three ways:  1) The specialist services focuses on the needs of persons with an intellectual disability and complex behavioural and/or psychiatric needs, 2) with a less broad complement of professions consisting primarily of psychologists and nurses, and 3) the services are more intensive and practical (as opposed to consultative)
(D. Allen, personal communication, April 21, 2008: Allen 2008).

(Neither caseload nor frequency of intervention reported)

Outcomes

Mean number of annual admissions at hospital for persons with an intellectual disability for short‐term and long term (i.e. > 6 months) stays

Quality of life and burden measures NR

Notes

Presence of co‐interventions may bias results 

Lacks control group for comparison

Mann‐Whitney U test used to compare mean results from different time periods: does not account for time trend and auto‐correlation 

Coelho 1993

Methods

Study Design: RCT

Types of interventions: Multidisciplinary team + Continuity of care + Change to setting/site of service

Participants

Clinical Problem: Persons with moderate to mild ID with a DSM‐III‐R diagnosis of mental illness or behavioral complications concerning mental illness; residing in community

Setting: Michigan, USA

Sample Size: N = 23 I; 23 C
Gender: 61% male
Average age: Intervention 34, Control 33

Interventions

C: Standard case management specializing in ID.  Community mental health agency administers range of multidisciplinary mental health services coordinated by case manager specializing in ID. 
(Caseload average 35 participants per case manager.  Approximately 0.5 episodes of direct care per week)

I: Intensive case management specializing in ID.  Intervention provides services described in C as well as greater direct contact services with participants in their natural environment.  Team members specialised in ID
(Caseload between 7‐10 participants per professional.  Approximately 2 episodes of direct care per week)

Outcomes

Behaviour:
Adaptive behaviour:

Relevant section of American Association of Mental Deficiency Adaptive Behaviour Scale (AAMD‐ABS)

Maladaptive behaviour:

Relevant section of AAMD‐ABS
Michigan Maladaptive Behaviour Scale (MMBS)

Quality of life and burden measures NR

Notes

Stratified by level of maladaptive behaviour before randomised ensuring similarity between groups

Used repeated measures analysis of variance to identify significant interaction term
Dowling 2006

Methods

Study Design: RCT

Types of interventions: Revision of professional roles

Participants

Clinical Problem: Adults with ID who experienced significant bereavement (death of sibling or parent); excluded persons with dementia or psychosis

Setting: United Kingdom

Sample Size: N = 11 I; 23 C
Gender: 41% male
Only age range reported:
Intervention < 30 ‐ >60
Control 30‐60

Interventions

C:  Standard mainstream control group.  Trained bereavement counselors with no experience working with persons with ID deliver counseling in fixed setting of client’s choice. 
(Initially 1 episode of direct care per week, then every other week:  Average of 15 episodes of care per client) 

I: Bereavement work provided by carers (family or paid worker) who know client well but have no bereavement counseling experience. 
(Frequency of care not reported)

Outcomes

Behaviour:
Aberrant Behaviour Checklist‐

Community (ABC‐C) comprising scales for 1) irritability, 2) lethargy, 3) stereotypy, 4) hyperactivity, 5) inappropriate speech

Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS‐LD)

Quality of life and burden measures NR

Notes

t‐test used to compare magnitude of change between pre and post intervention scores
Hassiotis 2001

Methods

Study Design: RCT

Types of interventions: Multidisciplinary  team + Continuity of care 

Participants

Clinical Problem: Patients with severe psychotic illness with mild intellectual disability (IQ range 51‐70) or borderline IQ (IQ range 71‐85)

Setting: London and Manchester, England

Sample size: N = 50 I; 54 C
Gender: 65% male

Median age: 36.5

Interventions

C: Standard mainstream case management:  Case manager is trained mental health professional responsible for direct care and coordinating health and social inputs outside of hospital; member of multidisciplinary team
(1 case manager: 30‐35 clients) 

I: Intensive mainstream case management.  Same as C but smaller case load
(1 case manager: 10‐15 clients). 

Outcomes

Mean number of days in hospital for psychiatric reasons

Quality of life:
Lancashire quality of life profile

Burden measures NR

Notes

Results are from larger study including persons without low IQ score.

95% confidence intervals show effect of intervention in persons with lower IQ
Lowe 1996

Methods

Study Design: CBA

Types of interventions: Multidisciplinary team + Change in setting/site of service

Participants

Clinical Problem: Persons with intellectual disability and challenging behaviour

Setting: Wales

Sample size: N = 14 I; 12 C
Gender: 50% male

Average age: Intervention 29, Control 33

Interventions

C: Standard community treatment team specializing in ID.  Persons with ID exhibit challenging behaviour, but are not referred for specialist input.  Persons with ID had very little behavioural support, no written plans, and their carers had no specific training in challenging behaviour (K. Lowe, personal communication, April 16, 2008)
(Neither caseload nor frequency of intervention reported) 

I: In addition to C, multidisciplinary specialist support team for persons with ID.  Provides intensive, individually tailored support to people with ID and their carers in natural setting over short to medium term. 
(Neither caseload nor frequency of intervention reported)

Outcomes

Problem behaviour:
Disability Assessment Schedule (DAS)
Aberrant Behavior Checklist (ABC)

Quality of life:
Index of Community Involvement (ICI)
average score

Carer burden:
Maslach Burnout Inventory (MBI)

Notes

Mann‐Whitney U test used to compare distributions of I vs. C
Martin 2005

Methods

Study Design: RCT

Types of interventions: Multidisciplinary team + continuity of care

Participants

Clinical Problem: Persons with mild to moderate intellectual disability and psychiatric disorder

Setting: South‐east London, England

Sample size: N = 10 I, 10 C
Gender: 50% male

Average age: 45

Interventions

C: Standard community treatment team specializing in ID.  (One member of team has direct contact no more than once per week)

I: Assertive community treatment team specializing in ID.  Same as C but, with as many contacts as needed from two professionals, one of whom acts as case‐coordinator.  Author note: Frequency of contact was main criterion for identifying assertive community treatment
(Frequency of contact not reported)

Outcomes

Function and problem behaviour:
Global Assessment of Function (GAF)
Symptomatolgy; Disability
Aberrant Behaviour Checklist (ABC)

Quality of Life:
Quality of Life Questionnaire (QOLQ)

Carer burden:
Uplift/Burden scale

Notes

Differences in baseline measurement between groups adjusted using ANCOVA
Oliver 2005

Methods

Study Design: RCT

Types of interventions: Multidisciplinary team 

Participants

Clinical Problem: Persons with mild to moderate intellectual disability and a (1) serious mental health disorder or (2) challenging behaviour, or both (1) and (2)

Setting: England

Avergae age: N = 15 I; 15 C
Gender: 43% Male

Average age: 40.53

Interventions

C: Standard community treatment team specializing in ID.  Author note: standard= no more than one visit per week from any one professional
(Average 9.87 intervention events from a professional over 3 weeks)

I: Assertive community treatment team specializing in ID.  Same as C, but more frequent contact.   Author note: assertive = more than one visit per week from one or more professionals
(Average 16.8 intervention events from a professional over 3 weeks)

Outcomes

Function:
Global Assessment of Function (GAF)      Symptomatology; Disability

Quality of Life:
World Health Organisation
Quality of Life‐Bref (WHOQOL‐Bref)

Carer burden:
Uplift/Burden scale

Notes

Authors used two way ANOVA. Differences in outcome were compared using time x intervention type interaction term in model

Van Minnen 1997

Methods

Study Design: RCT

Types of interventions: Multidisciplinary team + Changes to the setting/site of service delivery + Continuity of care

Participants

Clinical Problem: Persons with mild or borderline intellectual disability and serious mental illness (i.e. require in‐patient hospitalization)

Setting: Netherlands

Sample size: N = 25 I; 25 C
Gender: 76% Male

Average age: Intervention: mean 31.4, SD 12.6
Control: mean 31.0, SD 10.8

Interventions

C: Standard hospital treatment: 48‐bed facility specializing in treatment of people with dual diagnosis.  Interventions include: psychopharmacological medication, behavioral therapy, social skills training, education, structured daily activities.
(Patient contact 24 hours/day)   

I: Outreach treatment team:  One member of team visits patient in home environment; works with care givers involved in daily life.  Other interventions similar to C. 
(Interventions average 1 hour per week per patient)

Outcomes

Psychiatric symptoms:
Psychopathology Inventory for Mentally Retarded Adults Subject Response (PIMRA‐SR)
Psychopathology Inventory for Mentally Retarded Adults Informant response (PIMRA‐I)
Reiss Screen for Maladaptive Behaviour

Quality of life measure NR

Carer burden:
Nijmegen Child‐Rearing Situation Questionnaire (NCSQ)

Notes

Differences in baseline measurement between groups adjusted using ANCOVA

Authors also conducted equivalence testing

Characteristics of findings tables:

C: Control group conditions.

I: Intervention group conditions.

ID: intellectual disability.

ITS: interrupted time series.

RCT: randomised controlled trial.

CBA: controlled before and after study.

NR: not reported.

NS: not significant.

SD: standard deviation.

CI 95% confidence interval.
* primary outcome was either identified by original study author or identified by review authors as best reflecting intervention

Characteristics of excluded studies [ordered by study ID]

Ir a:

Study

Reason for exclusion

Alexander 2001

After only design with a control group
No pre and post intervention comparison of data

Arana 1991

Before and after study with no control group for comparison
Only 3 patients with intellectual disability out of 39 in study

Aronow 2005

Pilot for upcoming RCT study
Outcome measure is being tested
No data available comparing intervention to control group

Arya 2002

Study participants are children

Barr 1999

After only design with no control group for comparison

Baxter 2006

After only design with no control group for comparison

Bhaumik 2005

Descriptive study

Bollard 1999

Before and after study with no control group
Qualitative responses before and after health checks

Calkins 1994

Persons with intellectual disability not identified in study
Participants must speak and read English

Camfield 2004

Before and after study with no baseline for comparison

Carlsen 1994

Before and after study with no control group

Cassidy 2002

Before and after study with non‐comparable controls (persons without intellectual disability)

Chicoine 1994

Descriptive study of health problems and diagnoses

Chubb 1995

Before and after study with not control group

Codling 2005

Descriptive study

Cooray 1998

Before and after study with no control group

Criscione 1993

After only study comparing care coordination to a control group. Adjusted length of stay results using diagnosis‐related standard. Did not compare outcomes at baseline

Criscione 1994

Describes costs and review of Criscione 1993

Criscione 1995

Same methods as Criscione 1993 using updated data

Davidson 1995

Descriptive study of individuals with dual diagnosis

Feldman 2002

Interrupted time series with insufficient data points for adults

Fernando 2001

Descriptive study of physical health needs

Findholt 1990

Interrupted time series
Insufficient number of pre‐intervention data points

Galligan 1990

Before and after study with no control group

Gaskell 1995

Interrupted time series Insufficient number of pre‐admission data points

Goldsmith 2000

Impact of intervention not studied

Greenswag 1990

Study of Children with Prader‐Willi syndrome

Guo 2001

Does not evaluate effect of intervention on persons with intellectual disability alone
Evaluation of mobile services on hospitalization outcomes

Hahn 2005

Before and after study with no control group

Halstead 2000

'Naturalistic' study (i.e. no attempt to influence interventions) with no baseline comparison

Hassiotis 2003

Review article on assertive community treatment

Hatton 1995

Descriptive study of residential models

Holmes 2004

Persons with intellectual disability not identified in study
Comparisons of community mental health centres

Jones 1997

Randomised controlled trial of opportunistic health screening tool
Published study is missing relevant and interpretable data
Study authors contacted to obtain unpublished analysis

Jurek 1994

Cross sectional study of oral health needs at Texas state facilities

Kaufman 1995

Before and after study with no control group or
Interrupted time series with insufficient pre‐intervention data points

Kerr 2003

Descriptive study
Profile of medical needs

Kwok 2001

Descriptive study of specialised hospital psychiatric unit

Lennox 2001

Descriptive study of educational intervention to improve communication between stakeholders

Lepler 1993

Before and after study with no control group

Litzinger 1993

Before and after study with no control group
Compares cohort moving from institution to community based residences at different times

Lowe 1993

Study of impact of multidimensional service provision
Does not focus on impact of health care service

Luiselli 2001

Before and after study with no control group

MacPherson 2002

Study sample does not include persons with intellectual disability

Madianos 1999

Cross sectional study of impact of Community Mental Health Centre on contact with inpatient psychiatric services
Only ˜ 2% of sample has intellectual disability

Martin 1997

Descriptive study using comprehensive health check in primary care

Martin 2003

Descriptive study with no control group
Health checks used to highlight treatable conditions

Martin 2004a

Qualitative description of general practice using annual health review

Martin 2004b

Before and after study with no control group

McCabe 2006

Randomised controlled trial of cognitive behavioural programme
Outside scope of review

McKee 1994

Pharmacy intervention in institution based residential setting. Controlled before and after with no control group and interrupted time series

Melville 2006

Before and after study with control group
Nurse training intervention outside scope of current review

Merrick 2000

Study participants are children

Michael 2004

Descriptive and retrospective evaluation of referrals and referral letters evaluated for appropriateness

Moss 1993

Descriptive study of persons with intellectual disability with and without support from community intellectual disability team

Nesbitt 1998

Descriptive study of residential setting options

Patterson 1995

After only study with no control group
Evaluation of collaborative system of care for persons with dual diagnosis

Paxton 1998

Descriptive study of health and health education needs

Radler 1996

Before and after study with no control group

Roy 1997

Descriptive study of unmet needs in persons with dual diagnosis

Rudolph 1998

Follow up study with no control group

Singh 1991

Descriptive retrospective study of out‐patient clinic for persons with intellectual disability

Singh 2002

Interrupted time series
Teaching and training of professionals outside scope of current review

Tajuddin 2004

Descriptive study of acute specialist inpatient unit for persons with dual diagnosis

Trower 1998

Descriptive study of admissions to specialist inpatient unit for persons with dual diagnosis

Van Loon 2005

Descriptive study of general practitioners views on specialist physician support

Van Minnen 1993

Case studies of outreach treatment for persons with dual diagnosis

Van Minnen 1994

Descriptive study of patients with dual diagnosis in outreach and inpatient setting

Webb 1999

Follow up study with no control group

Wells 1997

Follow up study using general population as control

Xenitidis 1999

Follow up study with no control group
Evaluates inpatient model for persons with intellectual disability and challenging behaviour

Xenitidis 2004

Before and after study with no control group
Evaluates specialist inpatient unit for dual diagnosis
Missing baseline information when comparing specialist to mainstream service using length of stay

Zhang 1994

Evaluation of sheltered workshop
Outside scope of current review

Data and analyses

Open in table viewer
Comparison 1. Assertive community treatment versus standard community treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Global assessment of function (symptomatology) Show forest plot

2

50

Mean Difference (IV, Fixed, 95% CI)

‐0.76 [‐6.07, 4.55]
Analysis 1.1
Comparison 1 Assertive community treatment versus standard community treatment, Outcome 1 Global assessment of function (symptomatology).

Comparison 1 Assertive community treatment versus standard community treatment, Outcome 1 Global assessment of function (symptomatology).

2 Global assessment of function (Disability) Show forest plot

2

50

Mean Difference (IV, Fixed, 95% CI)

1.05 [‐4.05, 6.16]
Analysis 1.2
Comparison 1 Assertive community treatment versus standard community treatment, Outcome 2 Global assessment of function (Disability).

Comparison 1 Assertive community treatment versus standard community treatment, Outcome 2 Global assessment of function (Disability).

3 Carer uplift/burden Show forest plot

2

50

Mean Difference (IV, Fixed, 95% CI)

0.03 [‐3.48, 3.54]
Analysis 1.3
Comparison 1 Assertive community treatment versus standard community treatment, Outcome 3 Carer uplift/burden.

Comparison 1 Assertive community treatment versus standard community treatment, Outcome 3 Carer uplift/burden.

4 Quality of life Show forest plot

2

50

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.20 [‐0.75, 0.36]
Analysis 1.4
Comparison 1 Assertive community treatment versus standard community treatment, Outcome 4 Quality of life.

Comparison 1 Assertive community treatment versus standard community treatment, Outcome 4 Quality of life.

EMBASE = Excerpta Medica Database 
 MEDLINE = United States National Library of Medicine's bibliographic database 
 EBMZ = Evidence Based Medicine Reviews Multifile 
 Social Sci.= Social sciences database 
 CINAHL = Cumulative Index to Nursing & Allied Health Literature 
 EPOC = Effective Practice and Organisation of Care registry
Figuras y tablas -
Figure 1

EMBASE = Excerpta Medica Database
MEDLINE = United States National Library of Medicine's bibliographic database
EBMZ = Evidence Based Medicine Reviews Multifile
Social Sci.= Social sciences database
CINAHL = Cumulative Index to Nursing & Allied Health Literature
EPOC = Effective Practice and Organisation of Care registry

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Comparison 1 Assertive community treatment versus standard community treatment, Outcome 1 Global assessment of function (symptomatology).
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Analysis 1.1

Comparison 1 Assertive community treatment versus standard community treatment, Outcome 1 Global assessment of function (symptomatology).

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Comparison 1 Assertive community treatment versus standard community treatment, Outcome 2 Global assessment of function (Disability).
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Analysis 1.2

Comparison 1 Assertive community treatment versus standard community treatment, Outcome 2 Global assessment of function (Disability).

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Comparison 1 Assertive community treatment versus standard community treatment, Outcome 3 Carer uplift/burden.
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Analysis 1.3

Comparison 1 Assertive community treatment versus standard community treatment, Outcome 3 Carer uplift/burden.

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Comparison 1 Assertive community treatment versus standard community treatment, Outcome 4 Quality of life.
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Analysis 1.4

Comparison 1 Assertive community treatment versus standard community treatment, Outcome 4 Quality of life.

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Table 1. Quality criteria results of protection against bias for randomised clinical trials

Author, year

Concealment of allocation

Follow up of study participants

Blinded assessment of outcome

Baseline measurement

Reliable primary outcome

Protection against contamination

Coelho, 1993

Not clear

Done

Not done

Done

Not clear

Not clear

Dowling, 2006

Done

Not done

Not done

Done

Done

Not done

Hassiotis, 2001

Not clear

Not clear

Not done

Done

Not Done

Done

Martin, 2005

Done

Done

Not clear

Done

Done

Not done

Oliver, 2005

Done

Done

Done

Done

Done

Not done

VanMinnen, 1997

Not clear

Done

Not clear

Done

Done

Done

Not clear: not reported in study

Not done: study authors specifically describe item and does not meet EPOC criteria

Done: study authors specifically describe item and it meets EPOC criteria

Scoring criteria provided by EPOC (Cochrane 2006b; Cochrane 2006a)

Figuras y tablas -
Table 1. Quality criteria results of protection against bias for randomised clinical trials
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Table 2. Results and Summary of Included Studies

Author, Year

Main results

Summary

Allen,
1998

I1 vs I2 Short term stays:

mean (SD): pre = 142.5 (42.0); post = 124.7 (20.7)

change: 17.8 less admission/year for I2
change in level: ‐3.3 (P = 0.94)
change in slope: ‐14.6 (P 0.49)

Long term stays:

mean (SD): pre = 16 (4.5); post = 9.0 (2.1)

change: 7 less admissions/year for I2
change in level: ‐43.5 (P = 0.07)
change in slope: 11.7 (P = 0.26)

I2 vs I3
Short term stays:

mean (SD): pre = 124.7 (20.7); post = 30.7 (30.7)

change: 94.0 less admissions/year for I3  
change in level : ‐6.1 (P = 0.21)
change in slope: ‐0.6 (P = 0.57)

Long term stays:

mean (SD): pre = 9 (2.1); post = 3.5 (2.4)

change: 5.5 less admissions/year for I3
change in level: 2.5 (P = 0.62)
change in slope: ‐0.3 (P = 0.90)

Reanalysis of results showed no evidence that community support teams alone or in combination with specialist services decreases short stay admissions

  

 

 

 

 

 

 

 

Reanalysis of results showed no evidence that community support teams alone or in combination with specialist services decreases long term stay admissions.

 

Coelho, 1993

Intervention with time shows significantly better results in all behaviour measures:
AMD‐ABS:

mean (SD) for I: pre = 199.4 (28.5); post = 211.9 (30.9)

mean (SD) for C: pre = 206.0 (30.0); post = 201.3 (29.0)
Adaptive behaviour increases more for I (P = 0.001)

AAMD‐ABS:

mean (SD) for I: pre = 53.7 (22.5); post = 40.1 (20.3)

mean (SD) for C: pre = 53.4 (27.5); post = 53.0 (29.0)

Maladaptive behaviour decreases more for I (P = 0.001)

MMBS:

mean (SD) for I: pre = 12.7 (7.0); post = 6.5 (4.6)

mean (SD) for C: pre = 12.0 (7.6); post = 11.5 (6.4)

Maladaptive behaviour decreases more for I (P = 0.001) 

Supports the use of decreased caseloads by professionals in a team and greater frequency of episodes of direct care with persons with dual diagnosis in their natural environment

Dowling, 2006

Improvements in behaviour for standard practice control group ONLY.  Significant difference in change in all measures except speech:

1) ABC irritability: mean change (SD) for I = ‐0.9 (5.8); for C = 6.1 (4.4); Greater improvement for C (P > 0.001)

2) ABC lethargy: mean change (SD) for I = ‐1.8 (4.5); for C = 5.7 (6.4); Greater improvement for C (P = 0.001)
3) ABC stereotypy: mean change (SD) for I = ‐0.8 (3.4); for C = 1.5 (2.0); Greater improvement for C (P = 0.020)
4) ABC hyperactivity: mean change (SD) for I = ‐0.3 (4.5); for C 6.2 (6.5); Greater improvement for C (P = 0.005)
5) ABC inappropriate speech: mean change (SD) for I = 0.4 (2.1); for C = ‐0.1 (5.5); NS difference (P = 0.781)
HoNOS‐LD: mean change (SD) for I = 0.4 (6.7); for C = 7.4 (7.0); Greater improvement for C (P = 0.009)

 

Supports mainstream bereavement counselling over grief work provided by carers at home and during day activities

Hassiotis, 2001

Persons with IQ of 85 or lower in intervention group were hospitalised for shorter lengths than those in control:

mean days in hospital (SD): I = 47.2 (98.0); C = 104.8 (159.5)

difference = 57.5 days; CI 110.9 to 4.2

Study reports no significant difference for quality of life scores for persons with IQ of 85 or less (results NR)

 

Supports intensive case management to decrease hospital length of stays for persons with a borderline or mild intellectual disability and psychotic illness

 

Lowe, 1996

DAS shows I group has significantly more behaviour problems (P < 0.05), but shows no difference in percentage rated severe + frequent (SD and P‐value NR)

ABC shows no difference in average score and no difference for number of problem behaviours (SD and P‐values NR)

No difference in ICI score (SD and P‐value NR)

MBI not used for this comparison

 

No evidence that specialist support services team is better than standard community treatment alone for persons with intellectual disability and challenging behaviour

Martin, 2005

No difference in GAF scores:
Symptoms (P = 0.263)
Disability (P = 0.209)

No difference in ABC score (P = 0.447)

Difference in QOLQ score favours C (P < 0.023)

No difference in Uplift/Burden score (P = 0.151)

(See figures 2‐5 for details)

No evidence that assertive community treatment is better than standard community treatment for persons with ID and mental health disorders

Oliver, 2005

No difference in GAF scores:

Symptomalogy (P = 0.080),

Social function and performance (P = 0.79)

No difference in any dimension of WHOQOL‐Bref or of Uplift/Burden Scale

(See figures 2‐5 for details)

No evidence that assertive community treatment is better than standard community treatment for persons with ID and mental health disorders

VanMinnen,

1997

No difference in psychiatric symptoms at endpoint:

PIMRA‐I mean: I = 15.6 (SD NR); C = 14.4 (SD NR)
difference = ‐1.2 (CI ‐4.9 to 2.6) (P = 0.53)

PIMRA‐SR mean: I = 16.7 (SD NR); C = 16.8 (SD NR); difference = 0.1 (CI ‐3.7 to 3.9) (P = 0.96)

Reiss mean: I = 12.7 (SD NR); C = 13.7 (SD NR)
difference = 1.0 (CI ‐4.4 to 6.4) (P = 0.71)

Carer burden not measured at endpoint for C group

Home based treatment of patients with dual diagnosis is as effective as hospital based treatment

* primary outcome was either identified by original study author or identified by review authors as best reflecting intervention
NR: not reported.

NS: not significant.

I: intervention.

C: control.

ID: intellectual disability.

SD: standard deviation.

CI 95% confidence interval.
Figuras y tablas -
Table 2. Results and Summary of Included Studies
Ir a la tabla de la revisión
Comparison 1. Assertive community treatment versus standard community treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Global assessment of function (symptomatology) Show forest plot

2

50

Mean Difference (IV, Fixed, 95% CI)

‐0.76 [‐6.07, 4.55]

2 Global assessment of function (Disability) Show forest plot

2

50

Mean Difference (IV, Fixed, 95% CI)

1.05 [‐4.05, 6.16]

3 Carer uplift/burden Show forest plot

2

50

Mean Difference (IV, Fixed, 95% CI)

0.03 [‐3.48, 3.54]

4 Quality of life Show forest plot

2

50

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.20 [‐0.75, 0.36]
Figuras y tablas -
Comparison 1. Assertive community treatment versus standard community treatment
Ir a la tabla de la revisión