European service perspectives for people with intellectual disabilities and mental health problems.

Services for people with intellectual disabilities, in the UK as elsewhere, have changed dramatically over the last 30 years; deinstitutionalisation has probably been the largest experiment in social policy in our time. The vast majority of people with intellectual disabilities, their families and carers have benefited from having a better quality of life as a result of deinstitutionalisation. However, much still needs to be done to integrate this population more into society and to ensure they are offered the appropriate supports to meet their needs.

There has been considerable variation nationally in the provision of services, particularly for those people with intellectual disabilities who have additional mental health problems. There is a relative lack of provision in some regions, despite the fact that evidence-based practice has shown that there is a high prevalence of undiagnosed and untreated mental disorder among people with intellectual disabilities. We also know that mental illness among people with intellectual disabilities often presents in atypical ways and that it may coexist with a wide range of neurodevelopmental disorders. Finally, we are aware that many people with intellectual disabilities have impaired communication and hence are unable to describe subjective symptoms; these individuals are particularly at risk of being overlooked or misdiagnosed.

Despite the uneven provision of services for people with intellectual disabilities, an international consensus has emerged and most countries have been trying to develop relevant policies and services for them. Although models of care are changing, the pace of change varies dramatically between countries. This issue’s thematic papers provide an insight into services for people with intellectual disabilities and mental health problems in Greece, Austria and Switzerland. The three papers provide interesting comparisons.

In Greece, services have been undergoing radical reform in recent years, starting from a rather low base. An increasing number of community-based services and support schemes have been developed, while the proportion of the population with intellectual disabilities who were formerly confined to institutions has been greatly diminished. In Austria there are no national registers of intellectual disabilities, a state of affairs that has arisen partly for historic political reasons. Austria offers a dramatic example of how a country’s history (in this case the close association with Nazi Germany) can shape its policies, legislation and services. New, supported community-based services have been developed away from the large psychiatric institutions. In contrast, in Switzerland most adults with intellectual disabilities seem to be still living in institutions, although some smaller community-based residential units have also been set up recently.

In all three of these European services there is a disparity for the provision of people with intellectual disabilities and mental health problems. The UK has also been struggling with this state of affairs. The assumption that mainstream psychiatric services are able to address the complex mental health needs of the heterogeneous population with intellectual disabilities is obviously flawed. Although evidence about the effectiveness of provision is limited, research suggests that some individuals with intellectual disabilities have particularly complex needs, which cannot be met as effectively or even as quickly by generic services as they could by specialised services (Xenitidis et al, 2004).

The need for specialist training for those professional workers who are supporting adults with intellectual disabilities and mental health problems is recognised in Greece, Austria and Switzerland. To be effective, these workers should aim to function within a policy framework that enables collaboration between the relevant agencies. There should be clear care pathways, so that service users, their supporters and service providers all understand the roles and responsibilities of different professionals (Holt et al, 2005).

We hope that with the emerging evidence base, these thematic papers will stimulate debate about how to institute a European initiative on planning effective services for people with intellectual disabilities and mental health problems.