“We like to imagine … that psychiatry will sometime in the future give mental deficiency the attention that she is so much in need of” (1). Since those words 80 years ago, the cognitive dysfunction originally known as mental deficiency came to be known as mental retardation (in the 1960s), and most recently has evolved again into intellectual disability (2, 3). Throughout this evolution, a small group of physician educators have struggled to provide psychiatrists with knowledge and experience in working with individuals with intellectual disability (ID) (4, 5). Subsequent scholars have confirmed this relative lack of education in ID (6, 7), made recommendations for its remedy (8–10), or described programs or curricula in current use (11, 12). In spite of these efforts, there is consensus among both psychiatrists in practice and many in academic settings that the exposure and education of psychiatrists in the field of ID, and in the dual diagnosis of ID and psychiatric illness in particular, is inadequate (13).
Most reports in the area of ID education for psychiatrists hypothesize that the lack of sufficient educational opportunity in ID may lead psychiatric graduates in the United States to avoid the field following completion of resident training. Educational gaps persist in spite of a Task Force report calling for more training, and a general psychiatry ACGME requirement that some instruction take place in this clinical area (13, 14).
Most epidemiologic studies of intellectual disability describe an overall population prevalence of approximately 1% (15). For these persons, estimates of psychiatric illness range from 10–90%, with most authors concluding that 15–40% of individuals with intellectual disabilities have a comorbid psychiatric disorder (16). Since its peak in the 1960s, the number of individuals with ID in the US living in large, segregated state institutions has dramatically decreased (15). Today, more than 80% of adults with ID are living in smaller, community-based locations, which include both group homes and supported congregate or individual settings (17). With this transition of persons with ID into community living, it will be necessary to have general psychiatrists adequately prepared and confident in their abilities to serve the needs of these individuals (13, 18). Such preparation and exposure may already exist in the United Kingdom (19) but does not appear to be the case in many parts of the United States (13).
Since 1995, the department of psychiatry at the Case School of Medicine/MetroHealth program has provided a required rotation in Dual Diagnosis (DD) Psychiatry for PGY-IV residents (20). There were two primary goals of the DD rotation. The first was to enhance the clinical competence of psychiatrists (resident graduates) in providing service to individuals with intellectual and developmental disabilities. The second goal was to increase the willingness, comfort, and perhaps number of psychiatrists providing such service at the local level (12).
The rotation is part-time (12–16 hours per week), typically for 3–4 months, for residents in the PGY-3 or PGY-4 year. Institutional support is provided by the hospital, which as a county facility serving public-sector patients already has overlapping programs in developmental pediatrics, medical and dental clinics, and a positive working relationship with the county board of mental retardation/developmental disabilities. The county board provides financial support to the residency program supporting the ID rotation, with a short-term goal of facilitating clinical services for adults with ID who have psychiatric illness and a long-term goal of increasing the number of local psychiatrists willing to serve individuals with ID in the community.
The clinical rotation consists of two parts, one hospital-based and the other in the community. In the hospital-based clinic, residents care for a cohort of adult patients with ID and a variety of psychiatric disorders, under the supervision of a faculty psychiatrist whose primary clinical focus is ID psychiatry. At the outset, residents participate as observers; later they function as primary physicians, under observation and supervision. Typically, patient visits include caregivers from the patient’s residential and/or vocational settings, and/or family members. The model utilized is that found in most child psychiatry settings, in which the resident learns to balance time spent with the identified patient (individual with ID) and primary/corroborating historians (family; residential/vocational caregivers). Patients are referred to the clinic from a variety of settings in the community, including group homes, sheltered worksites, families, and directly from the county ID board. Some referrals come from within the county hospital medical clinics. Patients present for a variety of psychiatric and behavioral problems. Most commonly, these include mood, psychotic, and anxiety disorders, OCD, ADHD, and pervasive developmental disorders. Aggression to others, self-injurious behavior, and dangerous impulse control are also common presenting problems. Treatment focus combines psychopharmacological and psychotherapeutic approaches, with modifications appropriate for individuals with ID (and their caregivers).
In the community, residents experience individuals with ID where they live and work. This component of the rotation includes visits to group homes, sheltered worksites, and other county board programs. Supervision is provided by several clinical faculty psychologists. In these settings, residents learn the basics of applied behavioral analysis, intellectual/developmental testing, and specific behavioral programming as practiced in community, residential, educational, and vocational settings. Although some focus of the community rotation remains clinical, it also provides residents an opportunity to experience individuals with ID who do not have comorbid psychiatric illness or behavioral disorders. The community-based experience concludes with each resident preparing and presenting an individual case conference to staff at the county board of ID. The patient chosen is typically someone who has presented a diagnostic or therapeutic challenge, demonstrates an application of behavioral analysis/treatment, or has been referred to the hospital clinic for psychiatric assessment. One additional byproduct of the case conference has been increased familiarization with psychiatry for county board professional staff, which has facilitated referral and follow-up.
Didactic instruction and supervised reading is provided by both faculty psychiatrists and psychologists and follows the basic guide offered by King et al. in the 1995 APA Psychiatry and Mental Retardation: A Curriculum Guide (8). The guide outlines seven core areas of instruction and describes three levels of attainable clinical competence in ID, based on hours of didactic and clinical instruction.
The didactic areas of instruction include:
Basic concept and definitions of ID
Epidemiology of ID
Historical and modern context of psychiatry in ID
Patterns of care
Laws pertaining to treatment and services
Biomedical aspects of ID and principles of biomedical evaluation
Approaches to the patient with ID
Combined didactic instruction and clinical experience for the rotation typically average 140–180 hours, providing a combination of Level II and Level III competencies, per the King et al. Curriculum Guide (8).
The two original goals of the program (enhancing competence and increasing comfort, willingness, and actual work in the ID field) are outlined above. Although both of these goals may be difficult to measure in objective terms, a project was undertaken to contact all graduates of the residency who had completed the program (and DD rotation), in order to assess not only comfort and perceived competence, but also actual work in the area of DD following graduation.
Following IRB approval, graduates were asked to complete an anonymous general survey addressing whether, and to what extent, they had engaged in professional work with persons with DD following graduation, and the degree to which they felt competent and confident in working with persons with DD, regardless of actual contact.
Forty residents have completed the DD rotation since its inception. Thirty-two of 40 (80%) could be located and were invited to participate by letter or E-mail. An anonymous code number system was used for identifying responders. Graduates were mailed a 16-item survey, consisting of two parts. Initial nonresponders were mailed a second request after an interval of 2 months.
Ten questions addressed respondents’ interest, confidence, and postresidency clinical activity with persons with ID; e.g., “Compared to my colleagues, more of my practice is devoted to individuals/patients with ID.” Responses were ranked with a 6-point Likert Scale (1= disagree strongly, 6= agree strongly). Additional questions sought narrative information regarding graduates’ post-residency education and employment and sought feedback about the DD rotation. Surveys were returned via US mail. Survey responses were anonymous, and only group results were examined.
Twenty-three of 32 (72%) resident graduates returned surveys.
A neutral (neither agree nor disagree) response would generate a score of 3.5. Four questions averaged<3.5 (disagree); 7 questions averaged>3.5 (agree). Rank-ordered, group mean responses ranged from 2.74–5.78. These are outlined in Table 1.
We then reexamined the responses after separating respondents into two cohorts: those who identified themselves as having substantive contact with patients with ID following graduation (N=8), and those who did not (N=15). The former were identified either by reporting a score of 5 or 6 on the question, “Compared to colleagues, more of my practice is devoted to patients with ID,” or by responding with narrative information that identified specifically that they had such clinical contact following graduation.
These results are displayed in Table 2.
Small differences appeared to emerge between the two groups in the areas of seeking further education in ID, making a decision, and planning to work in the ID field, considering one’s self a leader, and letting the community know of one’s interest in the field. There was little difference between the groups in the areas of satisfaction with the residency rotation, capacity, confidence, or letting the community know.
The Mann-Whitney U Test was utilized to compare differences between the group means (21). None of the differences reached statistical significance at the 0.05 level (Table 2).
In spite of repeated recommendations for increasing both curricular content and clinical contact with persons with ID and DD in general medical and psychiatric residency training, the topic remains poorly addressed, and practitioners undereducated (13). Nearly every survey, of either educators or trainees, dating back over 25 years, describes a lack of curricular attention to the area and the subsequent opinion of graduates that they are not sufficiently familiar with these individuals to address their medical and/or psychiatric needs (6, 13, 22). This also appears true in some Canadian, European, and Australian settings (22–24). Exceptions to this deficit are represented by programs that appear to offer specific experience and training in ID (11, 12, 25). It appears that providing clinical rotations and didactic instruction in ID can produce graduates who feel adequately educated and competent clinically (25). Reinblatt et al. described their residency rotation on a specialized inpatient unit serving adults with ID and co-occurring psychiatric disorders. They subsequently surveyed current residents and resident graduates who had experienced this rotation. The authors reported that 98% of respondents viewed their training in ID as valuable, but only 9% reported that they had a post-residency career interest in working with this group of patients (25).
Our findings appear to mirror those of Reinblatt (25). Residents value the specialized education and experience that they obtain in working with patients with ID and feel more confident as a result. In our survey, responses to questions that sought feedback about preparation, capacity to serve, and confidence ranged from 5.37–5.78 (strongly agree). This is contrasted, however, by responses to questions that sought information from graduates about actual work with patients with ID (contact initiated by me, let community know of interest, percentage of practice), which ranged from 2.74–3.3 (disagree). It appears that although nearly all graduates endorsed having good preparation and expressed confidence in their abilities, for most this preparation and confidence had not actually translated into specifically seeking out practice opportunities in the ID field.
One item of possible interest was the difference in whether graduates let colleagues know of their interest and expertise in ID (4.24) compared to letting the ID community know (3.22). This may indicate that graduates will identify to colleagues that they are able and willing to care for persons with ID, but are still somewhat reluctant to present themselves to persons in the ID community as having expertise and willingness to serve.
Separating respondents based on whether they had worked in the ID field following graduation did not substantively change outcomes. Respondents (N=8) who had been or were working in the field reported that they had made specific plans and decisions to do so, were more likely to seek continuing education in this clinical area, and were more likely to view themselves as leaders. But even they were relatively neutral (3.63) about letting the community know about their interest or work in the field. These differences did not reach statistical significance.
Limitations of the study included the small sample size and possible sample bias in survey research design. It surveyed the graduates of a single residency program. Our 72% response rate is good for survey research and comparable to Reinblatt et al. (25). Based on the anonymous methodology, no comparison between respondents and nonrespondents is possible, so it is possible that respondents were more favorably inclined toward the rotation and clinical area than nonrespondents.
Although a fully identified and credentialed subspecialty in the U.K., the psychiatry of ID is much less represented in US residency programs (19). Although some education in the area of DD psychiatry is required by the ACGME RRC for Psychiatry (14), many programs do not have specific rotations or specialized educational or clinical experiences with such patients. As a result, many graduates report they feel poorly prepared and uncomfortable in caring for persons with ID after graduation (13, 18, 22). Our rotation was initiated as an attempt to increase exposure to persons with ID and psychiatric illness and, as a result, comfort and confidence in caring for such individuals. A secondary goal was to perhaps increase the number of psychiatrists willing to practice with this population of patients. Our data appear to support success with the first goal but yields mixed results concerning the second.