Weaving together addictions and developmental disabilities: The “other” dual diagnosis Elizabeth Lin, Ph.D. Centre for Addiction & Mental Health University of Toronto Institute for Clinical Evaluative Sciences NADD November 2016 Plenary

Health Care Access Research and Developmental Disabilities (H-CARDD) Goal: enhance overall health and wellbeing of individuals with developmental disabilities (DD) through improved health care policy and improved services. Research: conducted by collaborative teams of scientists, policymakers, and health care providers across Ontario. Lead: Dr. Yona Lunsky DD definition: ID, DS, ASD (not CP, epilepsy) Funding: hcardd@camh.ca

The Triggers 2012 – creation of the H-CARDD cohort Population-based Merging health and income disability administrative data  66,000+ Ontario adults with developmental disabilities (DD) hcardd@camh.ca

The Triggers (continued) hcardd@camh.ca

The Triggers (continued) Primary Care Atlas results Prevalence of DD = 0.78% Higher rates, compared to gen. population of: Chronic illness (diabetes: 10 vs 7%) Using health care (primary care: 76 vs 75%; ED: 34 vs 20%; hospital: 6 vs 4%) Equal or poorer rates of recommended care e.g., Regular health exam (22 vs 26%) hcardd@camh.ca

The Triggers (continued) Priority group in Ontario = ‘dual diagnosis’ Do these same patterns apply to the dual diagnosis subgroup of the H-CARDD cohort? hcardd@camh.ca

What is (the other) dual diagnosis? (US: mental illness + substance abuse) CANADA: DD + mental illness H-CARDD: DD + mental illness and/or addictions hcardd@camh.ca

Why addictions? Historically, separate treatment & government-administered systems However: Addictions and psychiatric disorders grouped as ‘mental & behavioural disorders’ (ICD) or ‘mental disorders’ (DSM) Often intertwined and interacting Move to integrating care (1990s in Canada)* * Report of The Standing Senate Committee, 2004 hcardd@camh.ca

What are addictions? Substance-related & addictive disorders* Egs: drug abuse/dependence; pathological gambling Key features: Direct, intense activation of brain’s reward system via a substance or behaviour Plus maladaptive subsequent behaviour: continued use or inability to stop despite dangers to self or others Maybe just say: e.g., (instead of Egs) * American Psychiatric Association, 2013 hcardd@camh.ca

Literature Little research on SRAD in adults with DD Existing research: low rates of substance use or abuse (0.5--2.6%)* Limitations: small clinical samples, varying methods and definitions; inconsistent comparison groups  Maybe SRAD is not a problem for people with DD. Maybe it is. e.g., Cooper, et al., Br J Psychiatry, 2007; 190:27-35 Chaplin, et al., Res Dev Disabil [Internet]. Elsevier Ltd; 2011;32(6):2981-6 I WOULD GO BACK TO YOUR PAPER  I WOULD ADD SLAYTER AND I WOULD ADD THE NETHERLANDS PAPER LIT REVIEW 2014 Maybe another problem is that some studies only focus on specific substances: so issue of definitions is both the definiition of use versus ABUSE versus DISORDER, and also which addictions are included. NONE of the old dfns use gambling, and some may not have thought of prescription drugs like opiods either *Cooper 2007; Slayter, 2010; Chaplin 2011; To, 2014 hcardd@camh.ca

Methods Data source (fiscal 2009): Adults with DD -- H-CARDD cohort Divided into two groups DD-plus-SRAD = DD with addictions DD-no-SRAD = DD without addictions Analyses Describe prevalence of SRAD among adults with DD Compare sociodemographic & clinical profiles Compare health care use hcardd@camh.ca

Results: Prevalence of SRAD SOURCE POPULATION ESTIMATE Literature Developmental disabilities* 0.5 – 2.6% Canadian population ** 4.4% H-CARDD Adults without DD 3.5% Adults with DD 6.4% * Cooper 2007; Slayter, 2010; Chaplin 2011; To, 2014 ** Pearson, 2013 hcardd@camh.ca

Results: Sociodemographic & Clinical Profiles hcardd@camh.ca

gt 1.0 (really large) (our addition) Results: Age profile Effect sizes (Cohen, 1992) 0.2 (small) 0.5 (medium) 0.8 (large) (Cohen, 1992) gt 1.0 (really large) (our addition) AGE GROUP DD-PLUS-SRAD (%) DD-no-SRAD (%) EFFECT SIZE* 18-24 23.6 24.1 -- 25-34 22.6 20.0 35-44 19.5 20.4 45-54 23.2 22.3 55-64 11.0 13.3 Consider: REALLY LARGE? * 0.2 (small); 0.5 (medium); 0.8 (large) (Cohen, 1992); gt 1.0 (really large) (our addition) hcardd@camh.ca

Results: Neighbourhood Income Quintile DD-PLUS-SRAD (%) DD-no-SRAD (%) EFFECT SIZE 1 (lowest) 40.6 29.3 small 2 22.3 21.3 -- 3 14.9 17.6 4 11.2 16.3 5 (highest) 9.5 14.2 hcardd@camh.ca

Results: Physical Comorbidities (age-sex adjusted) Condition DD-PLUS-SRAD (%) DD-no-SRAD (%) EFFECT SIZE Diabetes 12.6 9.8 -- Hypertension 15.3 13.8 COPD 13.6 5.2 medium Asthma 27.3 16.5 small Congestive Heart Failure 2.0 1.0 hcardd@camh.ca

Results: Psychiatric Comorbidities (age-sex adjusted) Condition DD-PLUS-SRAD (%) DD-no-SRAD (%) EFFECT SIZE Any MI* 78.8 41.0 large Psychotic 35.8 9.8 Mood 44.6 10.5 really large Anxiety 67.6 29.4 Personality 23.5 3.3 * Excluding SRAD hcardd@camh.ca

Results: Health Services Utilization hcardd@camh.ca

Results: Use of Health Services (all cause) (1 year) DD-PLUS-SRAD (%) DD-no-SRAD (%) EFFECT SIZE MD visit 88.2 81.5 small psychiatrist 34.2 13.5 medium other specialist 59.5 45.6 ED visit 61.2 32.0 IP admission 27.1 9.4 Just be sure to check for these over WHAT TIME PERIOD. I am pretty sure that this is over 1 year because ER visit for the whole cohort is about 34% in one year. hcardd@camh.ca

Results: Reuse of Health Services (all cause) DD-PLUS-SRAD (%) DD-no-SRAD (%) EFFECT SIZE 30-day repeat ED visit 19.4 6.8 medium 30-day readmission 4.7 1.1 large ALC days* 0.9 0.6 -- * Alternate Level of Care = still in hospital even after cleared for discharge hcardd@camh.ca

Conclusions & Implications (1) Prevalence of SRAD in persons with DD is higher than we thought: between 2.4 and 12.8 times higher than previous literature also higher than adults without DD (H-CARDD analyses) or the general population. hcardd@camh.ca

Conclusions & Implications (2) Problem not just limited to having an addiction. SRAD associated with -- Higher risk for poor determinants of health (e.g., living in poor neighbourhoods) Higher risk for physical comorbidities Much higher risk for psychiatric comorbidities hcardd@camh.ca

Conclusions & Implications (3) Individuals with DD & SRAD do access health care. Compared to DD-no-SRAD: Higher rates of visiting doctors and using emergency and inpatient services And higher rates of ‘less desirable’ patterns of health care use  DD plus SRAD associated with needs not well addressed by current health care system. hcardd@camh.ca

Acknowledgements - team H-CARDD project team Robert Balogh, co-PI Tiziana Volpe, research coordinator Avra Selick, research coordinator Kristin Dobranowski, grad. research assistant Andrew Wilton, senior analyst Yona Lunsky, H-CARDD program director hcardd@camh.ca

Acknowledgments - funders We gratefully acknowledge the Province of Ontario for their support of this study through their research grants program. The opinions, results and conclusions in this study are those of the authors and do not reflect that of the Province or the data providers. No endorsement by the Province or the Institute for Clinical Evaluative Sciences (ICES) is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI. hcardd@camh.ca

References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA, American Psychiatric Association, 2013 Cooper S-A, Smiley E, Morrison J, Williamson A, Allan L. Mental ill-health in adults with intellectual disabilities: prevalence and associated factors. Br J Psychiatry. 2007;190:27–35. Chaplin E, Gilvarry C, Tsakanikos E. Recreational substance use patterns and co-morbid psychopathology in adults with intellectual disability. Res Dev Disabil [Internet]. Elsevier Ltd; 2011;32(6):2981–6. Available from: http://dx.doi.org/10.1016/j.ridd.2011.05.002 Pearson C, Janz T, Ali J. Health at a Glance: Mental and substance use disorders in Canada [Internet]. Ottawa, ON; 2013. Available from: http://www.statcan.gc.ca/pub/82-624- x/2013001/article/11855-eng.pdf Report of The Standing Senate Committee On Social Affairs, Science And Technology, November 2004 (http://www.parl.gc.ca/Content/SEN/Committee/381/soci/rep/report1/repintnov04vol1part3-e.htm) Slayter EM. Disparities in access to substance abuse treatment among people with intellectual disabilities and serious mental illness. Health Soc Work. 2010;35(1):49–59. To WT, Neirynck S, Vanderplasschen W, Vanheule S, Vandevelde S. Substance use and misuse in persons with intellectual disabilities (ID): Results of a survey in ID and addiction services in Flanders. Res Dev Disabil [Internet]. Elsevier Ltd; 2014;35(1):1–9. Available from: http://dx.doi.org/10.1016/j.ridd.2013.10.015 hcardd@camh.ca

Centre for Addiction and Mental Health Toronto, Ontario Canada Thank you! Elizabethbetty.lin@camh.ca Centre for Addiction and Mental Health 33 Russell Street, #4075 Toronto, Ontario Canada M5S 2S1 Published Results available at: http://bmjopen.bmj.com/content/6/9/e011638.full hcardd@camh.ca

@HCARDD HCARDD is a research partnership to improve the health of Ontarians with developmental disabilities funded by HSRF and CIHR. Visit our website to find health care tools for clinicians and patients, as well as to watch our health care practice videos. Follow us on twitter for news and research updates. Please contact us for more information. www.hcardd.ca hcardd@camh.ca (416) 535-8501 ext. 37813 www.hcardd.ca