1. 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

2. 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:

3. 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)

4. The Triggers (continued)

5. 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%)

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

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

8. 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

9. 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

10. Literature
Little research on SRAD in adults with DD
Existing research: low rates of substance use or abuse ( %)*
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

11. 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

12. 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

13. Results: Sociodemographic & Clinical Profiles

14. 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)

15. 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

16. 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

17. 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

18. Results: Health Services Utilization

19. 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.

20. 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

21. 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.

22. 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

23. 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.

24. 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

25. 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.

26. 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: Pearson C, Janz T, Ali J. Health at a Glance: Mental and substance use disorders in Canada [Internet]. Ottawa, ON; Available from: x/ /article/11855-eng.pdf Report of The Standing Senate Committee On Social Affairs, Science And Technology, November 2004 ( 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:

27. Centre for Addiction and Mental Health Toronto, Ontario Canada
Thank you!
Centre for Addiction and Mental Health
33 Russell Street, #4075
Toronto, Ontario Canada
M5S 2S1
Published Results available at:

28. @HCARDD
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