Re: The other dual diagnosis

Although this article is an ex­cellent one that highlights the challenges of care for people with concurrent developmental disability and mental health disorders, there is an error in the article with respect to inpatient services for such patients in British Columbia. 

The article describes the decision by River­view not to admit clients with an IQ less than 70, which is further described as “the only facility that accepts violent psychiatric patients who cannot be managed in other hospital settings,” and thus concludes that “there is no acute mental health crisis resource for people with DD outside the usual emergency and inpatient psychiatric units.” 

Although this may be true for Vancouver and the Fraser Valley, it is not true for the interior of the province. Hillside Centre in Kamloops has been providing the acute tertiary services previously provided by River­view for the Interior Health Authority (IHA) for over 2 years, and for the Northern Health Authority (NHA) for the past year. 

We do not exclude people from admission on the basis of IQ and do admit clients with DD when they require inpatient services that cannot be provided by local secondary services. The small number of beds we have available to provide acute tertiary resources for both IHA and NHA (a total of 22 beds for a catchment area of about 1 million people) means that we cannot designate beds for any subpopulation, making beds available instead based on individual client need. 

We are nonetheless able to provide expert psychiatric, psychological, behavioral, and nursing care to patients with DD and concurrent mental disorders with quite complex presentations.

Funding issues are indeed important when working with populations such as these, but in many instances people with DD cannot access services even at the secondary level because of a growing tendency by psychiatrists to refuse to see people whose problems are defined as behavioral rather than psychiatric, with the latter used increasingly to mean people with schizophrenia or mood and anxiety disorders exclusively. 

This in turn arises from a failure to separate volitional behavior from behavior that is driven by various factors over which an individual has little or no control, including such things as developmental disability and brain injury. Sometimes willingness by clinicians to see people who need help, without getting into debates of whether something is psychiatric or not, may be more important, especially in the short term while larger turf issues are resolved.

—Paul K.B. Dagg, MD
Clinical Director, Tertiary Mental Health Services, IHA
Kamloops