By Nick Hagiliassis MAPS (Scope), Mark DiMarco MAPS (Scope), Hrepsime Gulbenkoglu (Scope), Teresa Iacono (Centre for Developmental Disability Health Victoria, Monash University), Helen Larkin (Scope) and Joanne Watson (Scope)

People with developmental physical disabilities are recognised as experiencing a complex and compounded set of personal challenges. By physical disabilities, we refer predominantly to people with cerebral palsy (CP), which is the client group that we most frequently service in the context of our role as psychologists working with Scope (Note 1). Intellectual or learning disabilities occur in approximately 75 per cent of individuals with CP (Evans et al., 1985), while a significant proportion of people with CP will experience complex communication needs (CCN). People with CCN may have reduced or altered ability to express needs and convey information, may employ different communication strategies in conjunction with their speech, or use alternative communication approaches (such as, speech output devices, pictures or symbols, gestures or sign).

Research into the mental health needs of people with physical disabilities is decidedly lacking. The need for further information in this area lead us to establish The Bridging Project, a joint initiative of Scope and the Centre for Developmental Disability Health Victoria, Monash University. The objective is to progress the knowledge and services base in relation to people with physical disabilities and mental health needs.

As perhaps the first step in the process of better understanding the mental health needs of people with physical disabilities, we turned to a fundamental issue: the prevalence and types of mental health conditions experienced by these people. Surprisingly, there are very few clinical and epidemiological studies that have examined this issue. There is certainly reason to suspect that people with physical disability will experience a higher rate of mental health conditions compared to people without disabilities. Epidemiological studies have reliably shown that other primary disability groups (for example, intellectual disability) have a substantially increased rate of emotional and behavioural difficulties (for example, Deb et al., 2001), and a similar picture could be argued in the case of physical disability. Additionally, our clinical observations suggest that a complex and characteristic set of biological (for example, neurological, physical impairments), psychological (for example, cognitive difficulties, CCN) and social factors (for example, negative life experiences, lack of meaningful opportunities, carer stress) are associated with physical disability, and these are likely to mediate mental health outcomes (Holland & Jacobson, 2001).

In order to more closely examine this issue, an audit of 390 central files of clients with physical disabilities was conducted, seeking to clarify for each person any mental health diagnosis in the last 12 months, the type or types of mental health condition experienced, and services that were being accessed in support of any identified mental health condition.

All clients had a physical disability; a portion of these also had an intellectual disability (approximately 70 per cent), a CCN (approximately 80 per cent), or both (approximately 56 per cent).

Some of the key findings

Overall, 11 per cent of people had a diagnosed mental health condition of some type, in contrast to 18 per cent of the general population (ABS, 1998).

Prevalence rates for specific mental health conditions are consistently lower when contrasted against general population statistics (as documented in a range of epidemiological studies). For example, depression, which occurs at a rate of 7.1 to 12 per cent for the general population (ABS, 1998), was identified in five per cent of the people identified in the audit. Table 1 (below) reports this information.

Table 1

Mental health condition

% of people
with physical disabilities

% of people
from general population

Depression

5.0

7.1-12 (1)

Dysthymia

0.3

1.6 (2)

Bipolar disorder

0.3

1.2 (2)

Generalised anxiety disorder

2.6

4.2-7.4 (1)

Obsessive compulsive disorder

0.3

2.3 (2)

Social phobia

0.3

3.7 (2)

Schizophrenia

1.3

1 (3)

Personality disorder

0.5

10-13 (4)

(1) Australian Bureau of Statistics
(2) National Institute of Mental Health
(3) American Psychiatric Association
(4) de Girolamo & Dotto (2000)

With respect to service access, of those people diagnosed with a mental health condition, 22 per cent were accessing generic mental health services (such as, GPs, psychiatrists, mental health services, community health centres), as compared with 38 per cent of people from the general population (ABS, 1998); 86 per cent were accessing specialist services (Scope psychology services);12 per cent accessed no services at all.

According to the data collated in the present study, the overall prevalence of mental health conditions for people in the study (11 per cent) was lower than that reported by the National Mental Health Survey for the general population (18 per cent) (ABS, 1998). There are a number of possible explanations for this somewhat unexpected finding, including:

  1. Methodological limitations of the present study (for example, method of data extraction, lack of objective confirmation of diagnosis).
  2. People with physical disability are less vulnerable to biopsychosocial stressors and hence are less prone to developing mental illness. We consider this to be unlikely (for the reasons given earlier) and suggest that people with physical disability experience a higher rate of mental health conditions compared to people without disabilities.
  3. Mental health conditions for this population are under-diagnosed (Jenkins & Gulbenkoglu, 1998). We believe this to be the most plausible account for these findings. Some reasons for this under-identification phenomenon may include:
    • Accurate diagnosis of mental illness in people with disabilities is fraught with difficulties, compounded by communication difficulties, which makes information about symptomatology (for example, thought content) difficult to elicit.
    • Symptoms that are normally ascribed to a mental illness being attributed to a behavioural manifestation of disability or 'challenging behaviour'.
    • Poor early detection of emerging mental health condition and mild-to-moderate cases being overlooked entirely.
    • Attitudinal barriers in recognising symptoms, based on the belief that people with disabilities do not posses the intellectual or personal capacity to be affected by everyday psychosocial stressors and, therefore, are protected from mental illness.

In terms of access to services, people with disabilities with mental health conditions are less likely to be seen by generic mental health services (22 per cent) as compared to the general population (38 per cent) (ABS, 1998), and are more likely to use specialist services (86 per cent). Our anecdotal experience is that the likelihood of using generic or specialist health services for a mental health problem is related to type, severity and complexity of the presenting issue, perceived service role and capacity, as well as client preferences. A consideration in this regard will be the policy shift towards strengthening access to generic services for people with disabilities (for example, Victorian State Disability Plan 2002-2012).

There are certainly a number of future research and service directions that emerge from this study and from our clinical experiences more broadly. Formal epidemiological studies are required to explore the question of the rates of mental health conditions in people with physical disabilities, in comparison to the general community, but also in comparison to other primary disability types (for example, intellectual disability). However, it is important to emphasise that although epidemiological studies are a very worthy pursuit, researchers also need to look beyond this, and to questions such as the factors that have significant effects on mental health within this population. Tackling the apparent under-identification of mental health conditions in this population also appears important. Useful strategies include addressing attitudinal barriers, further education and training, improved screening and identification processes, and improved early detection and intervention. This process would be aided through the development of assessment tools that are accessible to people with complex communication needs and that reflect the range of needs of people with disabilities. Finally, bridging the divide between generic and specialist mental health services, whilst acknowledging the value and contribution from each service sector, would promote better health outcomes for people with disabilities.

Note 1

Scope is a not-for-profit organisation providing disability services throughout Victoria to over 3500 children and adults with physical and multiple disabilities.

References

Australian Bureau of Statistics (1998). Mental Health and Wellbeing: Profile of Adults, Australia, 1997. ABS: Canberra, ACT.

de Girolamo, G. & Dotto, P. (2000). Epidemiology of personality disorders. In M. G. Gelder, J. J. Lopez-Ibor, & N. C.

Andreasen (Eds.), New Oxford Textbook of Psychiatry (pp. 959-964). Oxford University Press: NY.

Deb, S., Thomas, M. & Bright, C. (2001). Mental disorder in adults with intellectual disability: prevalence of functional psychiatric illness among a community-based population aged between 16 and 64 years. Journal of Intellectual Disability Research, 45, 495 -505.

Evans, P., Elliott, M., Alberman, E., & Evans, S. (1985). Prevalence and disabilities in 4 to 8 year olds with cerebral palsy. Archives of Disease in Childhood, 60, 940-945.

Holland, T. & Jacobson, J. (2001). Mental health and intellectual disabilities - addressing the mental health needs of people with intellectual disabilities: Report by the Mental Health Special Interest Group of IASSID to the WHO. IASSID: Clifton Park, NY.

Jenkins, W. & Gulbenkoglu, H. (1998). Physical and sensory/psychiatric disability. Paper presented at VICSERV Conference, Melbourne, Australia.