Journal Scan: The Other Dual Diagnosis
Ashley Durkee, M.A.

Editor's Note: The Journal Scan column is designed to share information from professional journals that might be useful to The Baddour Center's staff and families. The citation for this quarter's article is as follows: Werges, D. (2007). The other dual diagnosis: Intellectual disability and mental illness. The NADD Bulletin, 10(5), 95-101.

For this quarter's journal scan, I chose to discuss an article about the coexistence of mental illness and intellectual disabilities, because it is an issue that in the past, has received limited attention. According to Daniel Werges, the author of this article, there is a general lack of awareness and knowledge about the mental health issues that affect individuals with intellectual disabilities. As a result, problem behaviors are often handled without considering potential causes relating to mental illness.

Definition & Prevalence. With regard to persons with intellectual disabilities, dual diagnosis is a term used to describe a person who has both a diagnosis of a mental illness and an intellectual disability. There is some debate regarding the prevalence of dual diagnosis. Estimates range from as few as 10% to as many as 70% of individuals with intellectual disabilities. The most commonly accepted prevalence rate is 30-35%, as reported by the National Association for the Dually Diagnosed (NADD). At any rate, it is safe to say that individuals with intellectual disabilities seem to be more prone to mental illness than the general population. Possible reasons for this include: reduced capacity to manage social and cognitive demands, problem-solving difficulties, poor social judgment, and communication limitations. Other explanations include biological risk factors, such as genetic abnormalities and brain damage, psychological factors, such as low self esteem, and social factors, such as peer rejection, limited support, and stigmatization.

Historical Background. The concept of dual di agnosis is fairly recent. According to the article, "...prior to the 1960s, intellectual disability and mental illness were seen as mutually exclusive conditions. At that point in history, affective and behavioral issues were regarded as relating to maladaptive learning and adverse psychosocial experiences rather than psychiatric disorders," (p. 96). This view was in line with stereotypes about individuals with intellectual disabilities – that they are worry free or not able to experi ence emotional stress. Behaviors associated with mental illness were considered to be symptom atic of the intellectual disability and nothing more. These behaviors were therefore consid ered untreatable and were addressed through punishment as well as physical and chemical restraint. It was only after the deinstitutionaliza tion movement of the 1960s and 1970s that dual diagnosis was considered a possibility.

Current Perspectives and Debates

Underserved and Underdiagnosed. Often, indi viduals with intellectual disabilities fall victim to diagnostic overshadowing, which means that cli nicians overlook or minimize the signs of psychi atric disturbances in a person with an intellec tual disability. Mental illness may be considered less important than the intellectual disability or may be attributed to intellectual disability rather than a psychiatric illness (For example, saying, "he behaves in that way because he is intellec tually disabled" rather than "he is intellectually disabled and behaves in a way consistent with this psychiatric diagnosis also"). Another issue is that it is difficult to diagnose mental illness in people with intellectual disabilities because symptoms manifest differently and deficits in communication skills make identifying symp toms difficult. Furthermore, it appears that anxi ety disorders, mood disorders, and personality disorders are underdiagnosed, while psychotic disorders are overdiagnosed in this population.

Treatment Options. The overdiagnosis of psychotic disorders among individuals with intellectual disability leads to the overuse and misuse of antipsychotic medications. In the past, these medications were used in place of adequate staff and behavior programming. In recent years, those who treat individuals with intellectual disability have been attempting to decrease reliance on these drugs (many of which have harmful side-effects) and to only use them when absolutely necessary. The current trend is a combi-nation treatment of mental illness in this population, which includes behavioral programming, social skills training, psychotherapy, and, when needed, medication.

Falling Through the Cracks? Often, the dually diagnosed do not get the treatment they need due to certain barriers. Barriers to treatment include lack of services for this unique population, the tendency for service providers to bounce the dually diagnosed from one program to another, confusion regarding diagnosis, separate treatment providers refusing to work together, and lack of professional training. The problem of in-adequate training is two-sided: people who work with individuals with intellectual disabilities are typically not trained in recognizing mental health problems, while people working in the mental health field are often not familiar enough with the intellectually disabled to know how to recognize and treat mental illness in this unique population.

The Larger Picture: Stigma, Culture, and other Psychosocial Issues. Some suggest that the tendency toward mental illness among the intellectually disabled may be made worse by various psychosocial issues, such as the social stigma of being disabled, social rejection, and being dependent on others. Other stressors, such as restricted independence and economic issues may also contribute to anxiety, low self-esteem, or depression. Finally, perhaps the big-gest psychosocial contributor to mental illness among the intellectually disabled is that this population is at very high risk for exploitation and abuse.

Best Practices and Solutions. There is currently a movement for conducting research with intellectually disabled populations so that evidence-based treatments for use with individuals with intellectual disabilities can be developed. Mental health professionals are be-ginning to consider new criteria for diagnosing mental illness among the intellectually disabled developed by the NADD and the American Psychiatric Association. Service providers are increasingly relying upon interdisciplinary teams, which utilize input from psychiatrists, behavior specialists, case managers, vocational specialists, and others in order to ensure that individuals with dual diagnosis get the treatment they need. Finally, there is also a movement for individuals from the fields of mental health and intellectual disabilities to train and educate one another. This way, mental health professionals will get increased knowledge about individuals with intellectual disabilities, while professionals in the area of intellectual disabilities will increase their knowledge about mental health issues. Through this method, dually diagnosed individuals should get appropriate treatment from service providers who are knowledgeable about their special needs.

What Does This Have to do With Baddour?

A cursory review of resident data indicates that the statistics on psychiatric disorders runs parallel with those reported by NADD (about 30%). Though the history of dual diagnosis was dark, the future is looking bright. By utilizing knowledge from people with different professional backgrounds, we can work together to ensure that our residents get the services they need. Here at Baddour we have a great staff of DSPs, case managers, nurses, vocational workers, a behavior specialist, consulting physicians (and maybe even a few fabulous Education and Research interns!) working together to try to determine the best treatment methods for our beloved residents.