Psychiatrists' knowledge, training and attitudes regarding the care of individuals with intellectual disability
Abstract
Background Psychiatrists are responsible for providing proper care for people with intellectual disability who have psychiatric disorders. This study examined psychiatrists' perceptions of their own training, knowledge and therapeutic skills, as well as their attitudes towards this population.
Methods Questionnaires were distributed to 679 psychiatrists working within the public sector in Israel.
Results Completed questionnaires were returned from 256 psychiatrists (38% response rate). Most (90%) participants reported having had limited training in the diagnosis and treatment of people with intellectual disabilities, while between 34% and 72% reported having inadequate knowledge in specific areas.
Conclusion The findings of limited training and self-perceived inadequate knowledge are at least partially explained by the service model, wherein people with intellectual disabilities are cared for by general mental health services. The identified inadequacies could be overcome through the implementation of a model in which specially trained psychiatrists are deployed within generic services.
Introduction
Epidemiological studies worldwide have estimated the prevalence rate of intellectual disability (ID) to be between 1% and 3% of the general population (Szymanski & King 1999). Studies conducted in many Western countries (e.g. the UK, the USA, Australia) have consistently found that prevalence rates of psychiatric disorders among people with intellectual disability (PWID) are higher than among normal-intelligence population individuals, with a point prevalence rate of ICD-10 psychiatric disorders estimated at 32–40% of the ID population (Emerson 2003; Chen et al. 2006; Cooper et al. 2007; Morgan et al. 2008; Baker et al. 2010).
This dual diagnosis (DD) has a compound impact on PWID and their families. On average, the severity of psychiatric disorder is greater among people with DD than among people with psychiatric disorders only (Bouras & Holt 2004; Morgan et al. 2008). Moreover, onset of contact with psychiatric services is earlier, and the frequency of hospitalisation among this population higher and duration of hospitalisation longer (Morgan et al. 2008). A study conducted in Belgium showed that improperly treated psychiatric disorders in PWID lead to decreased quality of life, poorer community integration and more out-of-home placement (Maes et al. 2003). In a similar vein, studies from the USA and the UK have shown that proper treatment may ensure successful rehabilitation outcomes, including improvement in adaptive behaviour (Coelho et al. 1993) and shorter psychiatric hospitalisations (Tyrer et al. 1999). Providing appropriate care to persons with DD is likely to have a positive effect on the caregivers, as caring for an individual with DD may overtax the family resources (Maes et al. 2003).
In most countries, psychiatrists carry the chief responsibility for the diagnosis and treatment of individuals with DD. The UN Convention on the Rights of Persons with Disabilities (CRPD) (UN General Assembly 2007) states that PWID have the right to receive optimal health services without discrimination on the basis of their disability. Signatory states commit themselves to implementing all means necessary to ensure their access to health (UN General Assembly 2007). However, doubts have risen regarding the utility and quality of care of generic services, the adequacy of specific training and the ability of many psychiatrists to discharge this responsibility adequately (Turner 1989).
The DD problems are compounded by diagnostic overshadowing, that is, the attribution of abnormal behaviour to ID rather than to the psychiatric comorbidity (Jopp & Keys 2001). Importantly, diagnostic overshadowing may negatively affect the individual's right to obtain proper treatment (Fletcher 1993). The need to ensure that all psychiatrists-in-training are familiar with problems in the care of PWID, including diagnosis, treatment, education and rehabilitation, has been stressed across the globe (Potter 1965; Israel Psychiatric Association 2003; Royal College of Psychiatrists 2003). However, to our knowledge, no study has examined whether the training requirements are indeed met.
Psychiatrists and dual diagnosis
Several factors influence psychiatrists' care of PWID, such as training, professional experience and general attitudes, including therapeutic attitudes (Burge et al. 2002; Edwards et al. 2007). Only a few studies have been conducted in this field, and these studies have emerged mainly from the UK and Australia. For example, in an Australian study, psychiatrists (n = 175) admitted the need for more knowledge and skills (Edwards et al. 2007), a likely result of insufficient training during residency (Burge et al. 2002). Another study, which compared Australian psychiatrists (a country that relies on a generic model of psychiatric service provision) with British learning disability psychiatrists (a country where specialised services exist), found that the perceived adequacy of training and confidence at work evidenced by the latter were lacking among their Australian colleagues (Jess et al. 2008).
In Victoria, Australia, Torr et al. (2008) compared psychiatrists' perceptions in 2004 regarding training, services and the role of psychiatry in ID to their perceptions on these issues in 1994 (Lennox & Chaplin 1996) given that a number of training initiatives had taken place during this decade. Findings of this study showed a small increase in professional confidence and a greater sense of being better trained in assessment and management of DD. However, respondents in 2004 still did not feel confident, specifically in assessing people with autism. Results also showed that the high concern about the quality of mainstream mental health services remained in 2004.
In addition to knowledge, the care provided to individuals with DD may be influenced by psychiatrists' attitudes and perceptions towards this population (Edwards et al. 2007), including with regard to their care. In Australia, about 40% of psychiatrists expressed negative attitudes, reflected, inter alia, in a low interest in having a rotation through a service caring for this population (Lennox & Chaplin 1996; Edwards et al. 2007), and in a belief that working with PWID is frustrating and not satisfying (Kuehn 2003). This set of attitudes may have a negative impact (Beckwith & Mathews 1995), inasmuch as attitudes exert a dynamic influence upon an individual's response (Eagly & Chaiken 1993).
Although the above cited studies are highly important, no study has yet been conducted to examine the attitudes, training and knowledge of psychiatrists in Israel, where a system of generic services exists. Additionally, the above studies were based solely on subjective measures of knowledge and training. None have employed an objective measure of knowledge in the field of DD. Further, all have examined overall perception of knowledge and have not attempted to focus on specific ID-related knowledge fields.
The objective of this study was to examine the opinions of senior and resident psychiatrists regarding their training, subjective knowledge in various ID-related fields, objective knowledge, skills and attitudes with regard to the care of PWID.
Methods
Population
The research population included all psychiatrists (n = 870) working in the public sector in Israel.
Procedure
First, a letter was sent to the directors of all psychiatric facilities, hospitals, community clinics and departments in general hospitals, explaining the study aims and methods and requesting permission to contact their psychiatric staff. Directors of all 10 psychiatric hospitals, 43 of 73 outpatient clinics, and five of 13 general hospitals with psychiatric wards in the country agreed to have their psychiatric staff participate in the study. Second, self-administered questionnaires were provided to all psychiatrists who agreed to participate. Various means were used to enhance participation, including the use of the Israel Psychiatric Association website to prompt participants to complete the questionnaire.
Participants
Overall, 256 psychiatrists returned completed questionnaires, representing a response rate of 38% of all those who had agreed to participate (n = 679), or 29.5% (256/870) of the total potential participants.
Instruments
A structured questionnaire that included four sections was used:
Demographic (age, gender) and occupational background (year of residency completion and position).
Subjective knowledge: Subjective appraisal of level of knowledge and skills regarding diagnosis and treatment of PWID using a Likert scale (from 1 = very low, to 5 = very high). In addition, psychiatrists rated their level of knowledge on nine specific PWID-related topics using a 3-point scale ranging from ‘unsatisfactory’ to ‘comprehensive’. These items were based on the Resident Survey Questionnaire (Burge et al. 2002) and the local syllabi for specialist training in psychiatry. Also, psychiatrists were asked ‘what is the optimal level a professional should have’.
Objective knowledge: Based on their assessment of two vignettes (tailored to general or to child/adolescent psychiatrists) describing a PWID who had been referred to a psychiatrist for treatment. Psychiatrists were asked to provide the three most likely diagnoses (open question). The correct answers had been determined by consensus among three psychiatrists specialised in PWID. For each participant, an index was calculated for the number of correct diagnoses provided (of a maximum of three).
Attitudes were measured by different means. Thirteen items regarding the role of psychiatry in ID were adapted from Lennox & Chaplin's survey (Lennox & Chaplin 1995), previously utilised in Australia and the UK. In addition, psychiatrists were asked to rate the main problems in the mental health services for PWID (three items, staff's lack of knowledge, lack of skilled human resources, and prejudice). Psychiatrists rated their opinions regarding the improvement of existing services from a list of four options. Lastly, attitudes towards PWID were measured by four items from the Psychiatric Disability Attribution Questionnaire (Corrigan et al. 2001), one item from Lennox & Chaplin's questionnaire (Lennox & Chaplin 1995) and six items developed by us to represent specific attitudes which may be relevant to psychiatrists (rated on a 4-point scale ranging from 1 = strongly disagree, to 4 = strongly agree). An overall index of all these items was created by calculating the mean scale. The internal consistency for this scale was good (Cronbach's alpha = 0.73).
Ethical considerations
The study's protocol was approved by the Hebrew University of Jerusalem Ethics Committee.
Data analyses
Descriptive statistics (mainly percentages) were used to examine the perception of training, skills, knowledge and attitudes. Chi-squared tests were utilised to examine differences in perceived levels of knowledge (recoded into three categories – low, average, high) according to participants' background characteristics.
Results
Demographic and professional variables
Of the participants, 53.6% were men; mean age, 47.9 years, range, 28 to 68 years. The mean number of years since completion of medical studies was 21.6 (SD = 11.1) and, for seniors, a mean of 14.1 years (SD = 8.4) since completion of residency. Of the participants, 38.2% were directors of hospitals or clinics, 38.6% were treating senior psychiatrists and 23.2% were resident psychiatrists. General psychiatry was the main field of practice for 80.7%, while 19.3% practised child and adolescent psychiatry. Only 10.2% of participants did not dedicate any working time to PWID; 60.2% reported up to 5% dedication, and 29.4%, more than 5%. Of the participants, 17% worked in hospitals that have a specialised unit for autism or ID.
Psychiatrists' perceptions of training, skills and knowledge
The majority of the respondents (90.2%) agreed that they lack specific training in diagnosis and treatment of PWID, but 86.9% strongly or very strongly agreed of such a need. Higher levels of self-perceived knowledge were reported by male than female psychiatrists (χ2(2) = 16.0, P < 0.001); younger (aged 28–48) than older (aged 49–68) psychiatrists (χ2(2) = 12.4, P < 0.05); child/adolescent than general psychiatrists (χ2(2) = 6.2, P < 0.05); those with greater time dedication (χ2(2) = 14.1, P < 0.001); those who had been specially trained (χ2(2) = 21.8, P < 0.001); and among senior than among resident psychiatrists (χ2(4) = 47.3, P < 0.001).
Specific knowledge on dual diagnosis
Many psychiatrists admitted to lacking adequate levels of knowledge in specific DD-related areas. For example, 34.3% reported unsatisfactory knowledge about psychotropic treatment, and 40.0% about the diagnosis of psychiatric disorders among PWID. However, most respondents perceived each of these topics to be important to a high degree. For example, 80.4% noted the importance of commanding knowledge of psychotropic treatment (Table 1).
| PWID-related knowledge items | Reported level of knowledge in the field | n (%) | Required level of knowledge in the field | n (%) |
|---|---|---|---|---|
| Medical treatment for children/adults with ID | Unsatisfactory | 82 (34.3) | None | 5 (2.0) |
| Satisfactory | 124 (51.9) | Partial | 44 (17.6) | |
| Comprehensive | 33 (13.8) | High level | 201 (80.4) | |
| Diagnosis of psychiatric illness among children/adults with ID | Unsatisfactory | 96 (40.0) | None | 6 (2.4) |
| Satisfactory | 110 (45.8) | Partial | 46 (18.3) | |
| Comprehensive | 34 (14.2) | High level | 200 (79.4) | |
| Different treatment option for PWID | Unsatisfactory | 146 (61.3) | None | 1 (0.4) |
| Satisfactory | 79 (33.2) | Partial | 75 (30.0) | |
| Comprehensive | 13 (5.5) | High level | 174 (69.6) | |
| Diagnosis of ID | Unsatisfactory | 94 (39.3) | None | 0 |
| Satisfactory | 123 (51.5) | Partial | 85 (33.7) | |
| Comprehensive | 22 (9.2) | High level | 167 (66.3) | |
| Differential diagnosis between different factors related to ID | Unsatisfactory | 117 (48.5) | None | 3 (1.2) |
| Satisfactory | 108 (44.8) | Partial | 84 (33.2) | |
| Comprehensive | 16 (6.6) | High level | 166 (65.6) | |
| Communication problems among children/adults with DD | Unsatisfactory | 132 (55.9) | None | 4 (1.6) |
| Satisfactory | 85 (36.0) | Partial | 90 (36.1) | |
| Comprehensive | 19 (8.1) | High level | 155 (62.2) | |
| Behavioural phenotypes connected to specific syndromes | Unsatisfactory | 144 (60.5) | None | 9 (3.6) |
| Satisfactory | 82 (34.5) | Partial | 92 (36.9) | |
| Comprehensive | 12 (5.0) | High level | 148 (59.4) | |
| Dealing with personal attitudes towards ID | Unsatisfactory | 80 (33.9) | None | 9 (2.5) |
| Satisfactory | 137 (58.1) | Partial | 89 (36.6) | |
| Comprehensive | 19 (8.1) | High level | 148 (60.9) | |
| Psychotherapy for PWID | Unsatisfactory | 172 (72.0) | None | 24 (9.6) |
| Satisfactory | 61 (25.5) | Partial | 145 (57.8) | |
| Comprehensive | 6 (2.5) | High level | 82 (32.7) |
- DD, dual diagnosis; ID, intellectual disability; PWID, people with intellectual disability.
Of the 187 (91%) psychiatrists answering the general psychiatry vignette, only four diagnosed correctly all three most likely diagnoses; 76 (40.6%), two; 107 (57.2%), one or none. Of the 54 psychiatrists who diagnosed the child vignette, 12 (22.2%) provided the three correct diagnoses; 31 (57.4%), two; and 11 (20.4%), one.
Attitudes towards the role of psychiatry in intellectual disability
The majority of respondents (95.6%) were aware that psychiatric problems are common among PWID, with 91.7% agreeing that psychiatrists have a role in diagnosing and treating those problems; 85.2% thought that training in the field should be mandatory for all psychiatry residents; and 68.2% believed that people with DD receive a relatively poor standard of psychiatric care (Table 2) In addition, 94.4% agreed that there is a lack of skilled personnel; 82.5% stated that adequate knowledge was lacking among mental health professionals; and 47.4%, that there is prejudice among mental health workers. Regarding possibilities for improvement (from a list of three), 52.2% thought that there is a need to provide theoretical and practical knowledge on DD to all psychiatrists; 30.4%, that it is best to establish local specialist posts in every mental health setting; and 36.4% perceived a need to establish separate specialised psychiatric services.
| Role of psychiatry in ID items | Agree – strongly agree | Disagree – strongly disagree |
|---|---|---|
| n (%) | n (%) | |
| PWID are vulnerable to exploitation by other patients in general psychiatric department | 222 (88.1) | 30 (11.9) |
| Psychiatric training in the field of ID should be offered as a training option for all residents | 218 (85.2) | 32 (12.8) |
| People with DD receive a relatively poor standard of psychiatric care | 172 (68.2) | 80 (31.8) |
| The acute admission ward is adequately suited to people with mild ID and mental health needs | 167 (66.3) | 85 (33.7) |
| Inpatient psychiatric care should be provided in units dedicated to PWID | 162 (64.3) | 90 (35.7) |
| PWID often stay too long in psychiatric hospitalisation | 154 (62.3) | 93 (37.6) |
| I can easily access multidisciplinary input for my patients with DD | 150 (59.8) | 101 (40.3) |
| My training has trained/is training me to diagnose and treat people with DD | 108 (43.0) | 143 (57.0) |
| The acute hospitalisation ward is adapted to people with severe ID and psychiatric problems | 60 (24.0) | 187 (76.0) |
| Insufficient community psychiatric services may lead to inappropriate prescription of antipsychotic medicines | 213 (84.6) | 39 (15.5) |
| It is easy to refer to and liaise with social services for PWID | 55 (22.2) | 193 (77.8) |
| Psychiatrists seldom take a role in diagnosing or treating behavioural problems among PWID | 21 (8.3) | 231 (91.7) |
| Psychiatric problems are not common among PWID | 11 (4.4) | 240 (95.6) |
- DD, dual diagnosis; ID, intellectual disability; PWID, people with intellectual disability.
Attitudes towards people with intellectual disability
A high proportion of respondents thought that PWID can benefit from counselling (97.6%) and psychotropic medication (93.2%). Yet, 61.8% reported pity towards PWID and 59.3% expressed a preference for treating other people than PWID (59.3%) (Table 3).
| Attitudes | Agree and strongly agree | Disagree and strongly disagree |
|---|---|---|
| n (%) | n (%) | |
| I believe that PWID can benefit from consultation services and guidance | 245 (97.6) | 6 (2.4) |
| I believe that PWID can benefit from medical treatment | 232 (93.2) | 17 (6.8) |
| It is better that PWID will live outside the community in institutional settings | 33 (13.6) | 210 (86.5) |
| Providing PWID services like sheltered accommodation or sheltered employment is a waste of the public funding | 13 (5.2) | 238 (94.8) |
| There is no point in investing in non-medical treatment for PWID | 12 (4.7) | 242 (95.3) |
| I feel pity for PWID | 154 (61.8) | 95 (38.1) |
| Treating PWID gives me satisfaction | 122 (50.0) | 122 (50.0) |
| I prefer to treat other patients rather than PWID | 150 (59.3) | 103 (40.7) |
| I prefer not to work with PWID | 105 (41.5) | 148 (58.5) |
| Treating PWID is frustrating | 115 (45.8) | 136 (54.2) |
| I avoid PWID | 34 (13.6) | 216 (86.4) |
- PWID, people with intellectual disability.
Discussion
This study examined the opinions of public sector psychiatrists regarding their knowledge, skills, training and attitudes concerning the care of people with a DD of ID and psychiatric disorder, and the suitability of the current psychiatric services for this population.
The results identified limited subjective and objective knowledge and skills. One-third of respondents felt that their knowledge and skills in the field were low, and almost all perceived a need to improve their professional training. Importantly, in each of the specific topics there was a gap between participants' self-perceived level of knowledge and what they consider necessary to possess, showing that psychiatrists were aware of their relative lack of knowledge.
These are not isolated findings; they were reported in other countries, such as Australia, the UK and Canada (Burge et al. 2002; Holt et al. 2008; Jess et al. 2008). The reports are worrying, as they cast a shadow on the implementation of the CRPD in Israel and, perhaps, elsewhere. Simply, lack of adequate knowledge and skills risks hindering PWID's right to access optimal health services. The local psychiatrists expressed dissatisfaction with the mental health services as currently organised in generic settings, as in Australia. Most participants opted for specialised mental health units, as in the UK (Torr et al. 2008).
In light of these findings, it seems reasonable to conclude that the elicited inadequacies in knowledge and training may result, at least in part, from problems arising in the services provided within the generic service model.
Views regarding possibilities to improve the current situation
Possible approaches to improving the current situation include a ‘horizontal’ approach, that is, to raise the level of knowledge and skills and to foster more favourable attitudes among psychiatrists in general. At the other extreme, another option is to organise, wherever possible, the establishment of a specialised and separate mental health system for PWID. These two options reflect an ongoing debate in the existing literature regarding the optimal way, at least in high-income countries, to achieve satisfactory service standards for people with DD. For example, Holt et al. (2008), in discussing the European services for DD, argued that generic psychiatric services lack the ability to provide for the complex mental health needs of this heterogeneous population. On the other hand, provision of a separate mental health system for PWID contradicts the normalisation principle, and may also inadvertently lead to a lower level of other services, particularly in countries with limited number of psychiatrists (World Health Organization 2011). Given the problems in the above two service systems, a third option, involving a system of tertiary service specialists embedded within the generic services (for intensive discussions in the subject see Bouras & Holt 2004 and Hassiotis et al. 2000) may be preferable and is supported by findings from Torr et al. (2008). This reorganisation in psychiatric services may be the optimal solution in bringing about change in training, knowledge, skills and attitudes among psychiatrists.
Limitations
Several limitations of the research should be noted. First, the sample was not random and, similar to other studies among psychiatrists, the response rate was low (e.g. Alfonso & Olarte 2011), about 30% of all psychiatrists. Second, the psychiatrists' opinions regarding other special populations of service users were not examined, such as comorbid substance abuse and other psychiatric disorders. Third, factors such as social desirability must be taken into consideration. Fourth, psychiatrists' skills in real situations were not examined. Without undermining these limitations, the current study has several strengths: it includes psychiatrists working within various public sector services and at various levels (i.e. directors, other senior psychiatrists, residents); it explores a variety of issues regarding the psychiatric care of PWID along with an objective measure of knowledge. Finally, although the response rate was low, it is equal or higher than that obtained in other studies among psychiatrists (Kullgren et al. 1996; Szabo et al. 2000).
Conclusions
Our findings identified limited knowledge, skills and training in the field of DD among both senior and resident psychiatrists. This insufficiency was evident both through subjective self-appraisal as well as through objective knowledge measures. Also, prejudice was noted by psychiatrists as well as a preference for treating other service population. The current findings point to the inadequacy of the existing generic service model, that is, the problems stated are most likely anchored within the service system. Given similar findings from other countries, we tend to conclude that the origin of the problem is in the model itself, and not only in its local implementation. Thus, a change in the service system is advisable if we wish to alleviate these inadequacies. However, it is not possible, at this point, to make a definitive statement concerning the optimal treatment model. One could envision a compromise between ‘only generic’ and ‘only specialised’ services, one in which DD specialists working within the generic services might support the generic services in their treatment of people who have mild ID and relatively simple mental health problems, while taking direct clinical responsibility for people with more severe ID and/or more complex mental health problems.
Acknowledgements
This study was completed with a grant provided by the Israel National Institute for Health Policy Research (Grant No. R/132/2009).
