RESUMEN Tipos de juntas
4. Limpie cada vez finalice el cordón
• Pharmacotherapy used in conjunction with above.
Treatment efficacy is substantially reduced, WHO suggests, if not delivered within the context of a comprehensive and coordinated delivery service. The “ideal” mental health service model for people with an intellectual disability needs to include WHO principles. Services should be:
• Community based and locally accessible;
• Multi professional including input from psychiatrists, psychology, nursing, social work and other therapists;
• Integrated with generic mental health services and generic disability services; • Integrated with primary health care services;
• Linked with academic and university faculties with research capacity.
3.1
Models
Critical review of the literature and contemporary service responses to adults with an intellectual disability and cc-existing mental illness across OECD nations reveals an array of different models of service provision. Consideration of both the national and international perspectives reveals little consensus regarding the ideal model of service provision that address the needs of adults with an intellectual disability who have complex problems. A number of service models and configurations are evolving and few approaches have been systematically or objectively evaluated.
There is sparse empirical evidence that demonstrates the most effective approach to meeting the needs of this vulnerable group. However, there is some anecdotal agreement across the OECD nations that demarcation and disputation between agencies is having serious
consequences upon the health and well-being of adults of an intellectual disability. Cross agency collaboration and partnerships are required. The United Kingdom has gone so far as to legislate to ensure government agencies work together to meet the needs of adults with a dual diagnosis.
Most nations generally concur that the majority of people with an intellectual disability can and do live satisfactory lives within a range of community based living options. There is also widespread agreement that some of this group will require inpatient assessment and treatment within a mental health facility sometime during their lifetime. Although there is no broad
consensus within the literature or the field as to whether generic or specialist mental health service provision is warranted (Chaplin & Flynn, 2000), there is strong anecdotal evidence that most service providers and clinicians believe that specialist or tertiary responses are required. Uncertainty regarding the most appropriate model of service provision for adults with a dual diagnosis is reflected within the available literature (Trower et al, 1998). Although elements of
service provision can be identified, how they are combined remains the subject of considerable debate (Day, 1994). Three approaches can be identified although there is considerable overlap:
• Residential service provision;
• Non-residential community based service provision; and • Partnerships and interrelationships.
3.1.1 Generic Services
The generic approach to the provision of mental health and disability services is based upon the assumption that services and treatment programmes are most appropriately provided within the wider community as opposed to institutions. For example, generic mental health services are inclusive of both primary and secondary health care provision.
This approach assumes that adults with an intellectual disability can and should be supported by ordinary mental health services within the broader community (Day, 1994). Specialised services are refuted on the basis that these services result in stigma, labelling and negative professional attitudes (Newman & Emerson, 1994). Regardless, many professionals, including psychiatrists argue that generic service provision to adults with a dual diagnosis (for example within Sweden, Denmark and the USA) has not been successful. Reasons have included negative attitudes, inappropriate settings, and poor staff knowledge about the mental health needs of adults with an intellectual disability lack of psychiatric input.
3.1.2 Specialised or Tertiary Services
The literature suggests that adults with an intellectual disability who have mental health needs cannot be effectively served by generic services because their complex needs are beyond the capacity of mental health service provision (Day, 1994). Problems relate to deficiencies in availability, accessibility and adequacy. Generic service provision only tends to occur because there are no alternatives eg specialist service responses are simply not available.
In response, some nations such as Canada and the USA have responded to the need for a specialised response and developed tertiary services. Tertiary services can be defined as specialised interventions that are delivered by highly trained professionals (Wasylenki et al, 2000). These interventions can be provided when adults with an intellectual disability have a dual diagnosis, mental health problems or challenging behaviours that are complex and refractory to primary and secondary care. Often the mental health sector, the disability sector and other community sectors struggle to provide appropriate service responses. Reasons for referral revolve around the need for higher levels of specialised assessment and then guidance in regard to ongoing support or management.
Tertiary services can be provided flexibly and do not need to be tied to particular settings, time frames or even inpatient assessment and treatment (Wasylenki et al, 2000). For example, a mobile or portable tertiary care model such as assertive community treatment means the location is irrelevant. The level of care is linked to the person in need rather than being dependent upon a particular setting. Services can be provided for contracted timeframes or specific purposes, ie negotiated between the providers and the client or their carers. Tertiary services may be delivered through clinics that exercise mobile outreach, assertive community treatment and/or specialised outreach teams, community based residential programmes eg day services, or inpatient assessment and treatment services. This approach is an important strategy for maintaining community placement options. Other advantages include the ability of tertiary services to develop high levels of dual diagnosis expertise, to train and educate a range of professionals including medical practitioners, and finally to expand the
capacity of primary care and secondary care systems to respond to the needs of adults with an intellectual disability who have co-existing mental illness.