Using data generated from nine combined Comprehensive Assessment Projects (CAPs) in Provincial Psychiatric and Specialty Hospitals in Ontario from 1998 to 2002 (12960 patients), individuals with a dual diagnosis were examined in terms of demographic and diagnostic characteristics and clinical/support needs. The study cites the following limitations that should be considered when interpreting its findings:

• Findings are based on a treatment population, the subgroup of individuals with a dual diagnosis being served by Ontario’s tertiary level care psychiatric hospitals and may not be applicable to the individuals with a dual diagnosis who have not accessed services through the Provincial Psychiatric Hospital (PPH) system.
• Data reported are based on secondary analyses of data developed for another reason. Issues such as accuracy of developmental disability and psychiatric diagnosis cannot be addressed using the database.

Approximately three percent of Canada’s population has a developmental disability. The number of people receiving services is significantly lower, falling between .56% and 1%, because individuals with milder disabilities may slip in and out of, or may never enter, the service system. It is estimated that 85% of individuals with a developmental disability are in the mild range (IQ between 55 and 70), with 10% falling in the moderate range (IQ between 40-54) and 5% falling in the severe to profound range of disability (IQ below 40). The numbers in the severe category are more accurate because they are more likely to receive services.

Dual Diagnosis: A "dual diagnosis" refers to the presence of a psychiatric diagnosis and/or serious behavior difficulty in a person with a developmental disability. Estimates for dual diagnosis vary widely from 10% to 80%, with conservative estimates ranging between 30% and 40% compared to 20% in the general population. Psychotic disorders, mood disorders, anxiety disorders and personality disorders have all been reported to occur in individuals with developmental disabilities at a higher rate than the general population. People with a developmental disability are more likely to be diagnosed with psychotic disorders, more likely to use psychotropic medications and less are likely to be diagnosed with mood and anxiety disorders. A person should be assessed and treated on the basis of predisposing and perpetuating risk factors. Theses factors are divided into three categories: biological factors, social factors, and psychological factors. Challenging behavior is defined as behavior likely to limit or delay access to and use of ordinary community facilities, or behavior which, because of its intensity, frequency, or duration, puts the physical safety of the person or others in serious jeopardy. Individuals receiving services by the psychiatric hospitals may not always be known to the developmental disability sector and consequently may not be included in its estimates of dual diagnosis rates, although it seems likely that these individuals are among the most severely impaired.

As institutions across the province closed, the 8,500 individuals with a dual diagnosis were forced to access generic mental health services without appropriate structures. In some areas, specialized dual diagnosis programs were developed within the Provincial Psychiatric Hospital system to meet the needs of these individuals. In a study new onset psychiatric disorders were noted in 17% of adolescents with a developmental disability (not autism) and in 44% of adolescents with autism, depression and other mood disorders are the most common. The research also suggested that 46.8% of adolescents and adults with developmental disabilities randomly sampled in community settings and institutions displayed aggression and depression. Outside of the seven specialized dual diagnosis programs and the three remaining institutions, tertiary and acute care hospital staff are not trained to work with people with a dual diagnosis, nor are they properly compensated for the additional time, leading to misdiagnosis, inappropriate treatment, and an over-reliance on medication.

Although many individuals with mental health problems can function in their community with case management and outpatient psychiatry services, and the occasional inpatient hospital admission, a subgroup of individuals, with severe mental illness require tertiary services provided by psychiatric hospitals. Treating such individuals in secondary care level settings with inadequately trained staff can be detrimental and dangerous, requiring system reform decisions affecting people with serious difficulties.

• To examine the dual diagnosis subgroup of the CAPs database in closer detail,
• Identify the unique needs of the dual diagnosis subgroup, compared to the general provincial psychiatric hospitals (PPH)
• To make evidence-based recommendations on the treatment for adults with a dual diagnosis.

Colorado Client Assessment Record (CCAR) is a tool for conducting a comprehensive functional client assessment. It was developed during the 1970’s in Colorado and has been revised over subsequent decades. The CCAR has been used across the U.S. for making decisions related to level of care and for assessing change over time in hospital and community mental health patients/ clients. The tool, adapted for the 9 community regions of mental health, provides basic client information such as current diagnosis and history of illness; legal, marital, employment, and education status; and residential stability. It then assesses impairment and strengths in 26 domains related to symptoms, behaviors, and social and community functioning. Each of these is rated on a 9-point scale from 1 (high functioning/no special problem) to 9 (low functioning/extreme problems of difficulty). The CCAR ratings rely on program staff’s knowledge of the client, input from other staff, as well as program records/charts. Interviews of the client are not required.

Support/Service Use and Needs Profile: The Support/Service Use and Needs Profile deals with information about client service needs and current use. Generally, program staff are asked to describe the client’s use of service in two broad categories: residential and case management-based treatment. Staff also assess the client’s use and need for 19 specific supports and services, encompassing treatment, rehabilitation and basic supports.

Level of Care Assessment: A level of care template is a systematic approach for linking the individual’s need to a particular level of care. There are five levels of assessment. People who are capable of self-management and attend an outpatient clinic and receive a range of core community services and supports are at level one; while people who have complex, difficult to treat psychiatric conditions that may be complicated by coexisting disorders (medical illness and developmental disabilities) and need care from a multidisciplinary team with high levels of expertise and support and the capacity to do comprehensive assessment in a secure setting are at level five.

CCAR also have six domains that are important indicators of a person’s need for structure, individual support and clinical services, including, safety maintenance, both personally and in the community, overall problem severity; self care, overall strengths or resources; suicide or danger to self; and violence or danger to others. Persons who scored high on safety maintenance and overall problem severity risk (need for high structure) were categorized in Levels 4 or 5. Those whose maintenance needs were rated as "no" or "low" were placed in Levels 1 or 2.

• 1714 of 12960 (13.1%) PPH patients were determined to have a dual diagnosis.
• Of the 1714 patients, 416 individuals (18,8%) are inpatients, 1036 (11.2%) individuals are outpatients and 262 (17.8%) individuals are living in Homes for Special Care (HSCs).
• The majority (67%) individuals have borderline ability to mild disabilities, 27 % had a moderate disability and only 6% had a severe or profound developmental disability.
• Patients with a dual diagnosis are younger, less educated and more likely to be unemployed.
• A smaller proportion of individuals with a dual diagnosis are outpatients when compared to those without a dual diagnosis (60% versus 73%).
• Dual diagnosis patients have more severe symptoms when compared to patients without a dual diagnosis and have higher recommended levels of care.

Gender:

• 55% are male.
• Women with a dual diagnosis are more likely to have a phobic disorder and organic disorder, and they are more likely to have experienced a loss or grief with a higher rate of suicide attempts.
• Men have higher rates of substance abuse and personality disorder, and are more likely to have a history of unstable employment, and have been involved in property destruction or fire setting in the past.

Age:

• The average age of the dual diagnosis patient is 47 years old, with the majority between the ages of 25 and 55. · Individuals older than 65 years make up 11.2% of the dual diagnosis population served by the PPH system.
• Older people have lower rates of mood disorder and psychotic disorder but higher rates of organic disorders than younger patients.
• Older individuals are less likely to have a documented experience of loss, or to have cultural concerns, and are less likely to have documented past sexually or physically abusive experiences or to have attempted suicide in the past.
• There is a documented increased risk for medical problems in older adults with a dual diagnosis compared to younger adults, although whether rates of psychiatric difficulties increase with age is unclear.

Psychiatric Diagnoses and Problematic Symptoms:

• 52% of patients with a dual diagnosis are diagnosed with psychosis.
• 20% were diagnosed with a mood disorder.
• 13% were diagnosed with a personality disorder.
• The most problematic symptoms were attention problems, aggression, resistive behavior, cognitive problems, interpersonal difficulties and problems with self-care.

Service and Support Needs of Patients with a Dual Diagnosis:

• One third of dual diagnosis patients require very intensive supports and services and 25% of patients only need occasional contact or case management.
• Only 12% of inpatients with dual diagnosis were determined to require the inpatient hospital care they are currently receiving. Most inpatients would be able to succeed in the community-based settings if available.
• 15% of patients are receiving services that are at least two levels below what they require, 33% of patients are receiving services 1 level below what is recommended and 16% of patients are receiving a higher level of support than is recommended. Only 36% are receiving services matched to their current level of need.

Individuals with a Dual Diagnosis and Legal Issues:

• 12% of patients with a dual diagnosis had legal issues.
• 68% have a diagnosis of mental retardation recorded as a primary or secondary diagnosis.
• 86% of patients with legal issues and a dual diagnosis are male, 55% are outpatients and 43% are inpatients.
• 48% had a psychotic disorder, followed by personality disorder (39%) and substance abuse (19%).

Specialized Dual Diagnosis Programs:

• 19% of people with a dual diagnosis were part of a specialized dual diagnosis program.
• The group was younger, more likely to be male and more likely to be violent or aggressive.
• They are more likely to receive a diagnosis of mood or anxiety disorder than other people with a dual diagnosis.
• Although they had a higher level of recommended care than those served in generic programs, they were poorly matched to current services suggesting that the few existing specialized programs could not meet the severe needs of this specialized group with their current resources.

Patients with Psychotic Disorders with and without a Dual Diagnosis:

• Of those patients with a psychotic disorder diagnosis, nearly 1 in 7 also has a dual diagnosis (13.3%), evenly split between men and women but 66% of patients with a psychotic disorder did not have a developmental disability
• A psychotic disorder diagnosis is as common in patients with a developmental disability as in patients without a developmental disability.
• 74% percent of patients with a dual diagnosis require level 3 or 4 care compared to 54% of patients with a diagnosis of psychotic disorder and no developmental disability.
• People with a dual diagnosis had fewer resources than the other patients with psychotic disorder. However, needs of patients with a dual diagnosis of psychotic disorder and developmental disability were consistently rated as higher than the needs of patients without developmental disability.