Mental health services for people with learning disabilities

Mental health services in the United Kingdom are set for dramatic restructuring in the light of recent government initiatives to improve quality of care and equity of provision. National standards for promoting mental health and treating mental illness are designed to reduce the risk of future tragedies and improve the quality of life of people with mental illness.¹ But little thought has been given to the well documented mental health needs of people with learning disabilities.

In the age of institutional care the disturbed and challenging behaviour of people with learning disabilities was thought to be due to their living environment and their learning disability. Their care was greatly influenced by humanistic and philosophical ideas.² The widespread closure of “long stay” hospitals for people with learning disabilities was accompanied by the creation of multidisciplinary community teams that tried to manage a wide range of physical and mental health needs.³ Unfortunately, over the years, the specialist mental health provision for this group has remained fragmented, outside the mainstream mental health services, and delivered by organisations that have a poor understanding of the special needs of people with learning disabilities.⁴

Between 30% and 50% of people with learning disabilities may show a variety of behaviours, particularly challenging behaviour, that are precipitated by problems such as communication disabilities and physical and mental illness.⁵ Challenging behaviour is a common reason why people with learning disabilities are relocated to costly residential facilities that are often far away from their families.

Mental disorders are also more prevalent in people with learning disabilities. In particular, rates of schizophrenia are three times higher than in the general population although there are few data about other types of mental illness.² In addition, there is evidence for a subgroup of patients with mental illness and borderline intellectual functioning who are difficult to treat in standard psychiatric services.⁶ Attempts to integrate mental health provision for people with learning disabilities with generic mental health services have had only a limited impact in changing professional or service attitudes.⁷

A few joint inpatient schemes have been developed that admit people with learning disabilities who are mentally ill to adult mental health beds and provide extra support from a multidisciplinary learning disabilities team.⁸ No systematic evaluation of these schemes has been carried out: anecdotal evidence suggests that this scheme provided well for the mental health needs of people with mild learning disabilities but did not provide for those with more severe levels of cognitive impairment. This system has also been criticised because people with learning disabilities may need longer admissions, which may not be possible with the current pressure on acute psychiatric wards.⁹ In the newly published national service framework for mental health there is no mention of the mental health needs of people with learning disabilities.¹⁰

There is generally poor provision for children and the elderly who have dual diagnoses of learning disabilities and mental illness. There is a dearth of data on service evaluation and patients' outcomes and insufficient involvement and education of service users and their carers. The continued existence of the separate system of care perpetuates the marginalisation and social exclusion of people with learning disabilities.¹¹

A modern and comprehensive mental health service for people with learning disabilities and mental illness must identify the needs of this group but keep its roots within mainstream mental health services. Mental health services for people with learning disabilities need a separate or modified national framework of standards to combat the lottery that is now in operation, with some areas offering innovative services of high quality while neighbouring areas offer no service at all for similar disorders.¹²

Unless the forthcoming strategic review of services for people with learning disabilities, commissioned by the Department of Health, boldly recommends a reform of the specifications for the existing mental health services for people with learning disabilities, this vulnerable group of patients will remain out in the cold.