NADD Bulletin Volume IV Number 1 Article 1

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Creating a Continuum of Intensive Psychiatric Services for Individuals with Dual Diagnosis: A Perspective on the Massachusetts Experience I. Introduction

Edwin J. Mikkelsen, M.D.

During the last decade a number of intensive, specialized psychiatric services have been developed in Massachusetts to serve individuals with dual diagnosis. Although the programs are not all specifically linked to each other, they do provide an overall continuum of psychiatric services which can be accessed by clinicians, families, and individuals.

As a consultant to the Massachusetts Department of Mental Retardation and an active clinician in this state, I have observed the collaboration between officials of the Department and the provider community, which has led to the evolution of these services over the last decade.

This manuscript will provide an overview of this continuum, discuss factors related to its development, and provide a clinical perspective on the utilization of these services. Two additional papers will separately discuss the development and operation of a partial psychiatric hospitalization program for individuals with developmental disabilities and a specialized psychiatric inpatient unit.

Specialized Outpatient Services

It can be difficult to make an accurate psychiatric diagnosis in individuals with developmental disabilities (Silka & Hauser, 1997), and the diagnostic ambiguity often increases as intelligence decreases (Mikkelsen, 1997). In addition to the diagnostic difficulties, individuals with developmental disabilities often present treatment issues that are not commonly encountered in the general population (Hauser, 1997). The lack of a careful diagnosis can lead clinicians to overlook common disorders, such as anxiety (Kreim & Mikkelsen, 1997) and depression (Charlot, 1997; Mikkelsen, Albert, Emens, & Rubin, 1997), or misdiagnose them as psychotic in nature.

Outpatient Services

In the last decade, a number of specialized outpatient services have been developed in Massachusetts, which are specifically dedicated to providing services to individuals with dual diagnosis. These specialized clinics often utilize a team approach, which makes it possible to develop thorough behavioral plans and pharmacological algorithms (Mikkelsen & McKenna, 1999).

For several years, the Massachusetts Office of Medical Assistance has subcontracted the management of its mental health benefits. The current agency, which administers the Mental Health Services, has established an Advisory Panel composed of representatives from the Department of Mental Retardation and other recognized experts in the field to ensure that reimbursement guidelines are sensitive to the special requirements of individuals with developmental disabilities. One outgrowth of this collaboration has been the establishment of a higher reimbursement rate for “complex” psychiatric outpatient visits, and the recognition that the majority of psychopharmacological services to individuals with developmental disabilities qualify for this higher rate, due to the complex nature of their presentations and the necessity of communicating with multiple providers of services which may include residential staff, day program staff, case managers, and family. There are also other factors that have increased the general recognition of the need for specialized outpatient services, which will be discussed below.

Partial Hospitalization

In her paper, Dr. Karen Shedlack describes operational aspects involved with a partial psychiatric hospitalization unit for individuals with dual diagnosis. From the clinical perspective of an outpatient psychiatrist, I have found that one of the advantages of partial hospitalization is a somewhat longer length of stay in a setting that is less artificial than an inpatient unit, as the individuals spend nights and weekends in their community residence. The longer length-of-stay, coupled with the daily exposure to their community residence, contributes to more complex and gradual evaluations of psychopharmacological interventions.

Inpatient Psychiatric Hospitalization

There are now three specialized psychiatric inpatient units for individuals with dual diagnosis within Massachusetts. Each unit has a specific subspecialty capability, and the sites are geographically distributed throughout the state. The article by Drs. Charlot and Silka provides more specific information on one of these units. They have also published a more detailed account on this subject (Charlot, Silka, Abend,& Bonney-Kuropatkin, 2000).

The clinical importance of specialized inpatient units for this population would be obvious to most clinicians. The specific nature of this population often makes admission to a general psychiatric unit unproductive or counter-productive. Inpatient psychiatrists who are not familiar with individuals with dual diagnosis are prone to simply add on additional psychotropic medications, rather than carry out a careful diagnostic assessment, which may lead to actually reducing the number of pharmacological agents being used. The unit described by Drs. Charlot and Silka is located within a major university teaching hospital. This makes it possible to carry out sophisticated assessment of comorbid and/or contributory medical problems.

Contributions of the Department of Mental Retardation

Although different private-sector vendors provide all these specialized services, representatives of the Massachusetts Department of Mental Retardation have contributed significantly to their development. These contributions fall into three broad categories. The first of these is an increase in the recognition of the need for specialized services through a state-sponsored series of Continuing Education presentations.

An additional second factor has been the Commonwealth Fellowship in Mental Retardation (Mikkelsen & Silka, 1993). This collaborative project provided the funds and programmatic support to develop a post-graduate training program for psychiatrists who were interested in acquiring the skills necessary to provide expert services to individuals with dual diagnosis. This program has been successful, in that the majority of graduates continue to spend a significant amount of time providing specialized psychiatric services to individuals with developmental disabilities in Massachusetts.

A third factor has been an ongoing dialogue between regional and local representatives of the Department with providers concerning the types of services needed. Representatives of the Department have also been active in working with funding sources to educate them about the special needs of this population.


Over the past decade, the continuum of specialized psychiatric services available to individuals with developmental disabilities within Massachusetts has expanded significantly to include several specialized outpatient clinics, a partial hospitalization program, and three specialized inpatient units. The development of this continuum has been contributed to by educational endeavors undertaken by the Massachusetts Department of Mental Retardation, and also an ongoing dialogue between the Department and providers of services, as well as funding sources.


Charlot, L R. (1997). Irritability, aggression, and depression in adults with mental retardation: A developmental Perspective. Psychiatric Annals, 27, 190-197.

Charlot, L., Silka, V. R., Abend, S., & Bonney-Kuropatkin, B. (June, 2000). A short-stay inpatient psychiatric unit for adults with developmental disabilities: One year’s experience. Proceedings of the NADD International Congress IV (pp. 68-72). Kingston, NY: NADD Press.

Hauser, M. J. (1997). The role of the psychiatrist in mental retardation. Psychiatric Annals, 27, 170-174.

Khreim, I. & Mikkelsen, E. (1997). Anxiety disorders in adults with mental retardation. Psychiatric Annals, 27, 175-181.

Mikkelsen, E. J. (1997). Risk-benefit analysis in the use of psychopharmacologic interventions for difficult-to-diagnose behavioral disorders in individuals with mental retardation. Psychiatric Annals, 27, 207-212.

Mikkelsen, E. J., Albert, L. G., Emens, M., & Rubin, E. (1997). The efficacy of antidepressant medication for individuals with mental retardation. Psychiatric Annals, 27, 198-206.

Mikkelsen, E. J. & McKenna, L. (1999). Psychopharmacologic algorithms for adults with developmental disabilities and difficult-to-diagnose behavioral disorders. Psychiatric Annals, 29, 302-314.

Mikkelsen, E. J. & Silka, V. R. (1993, March). The Commonwealth Fellowship in Mental Retardation: A post-graduage training program for psychiatrists. Paper presented at the International Conference of Dual Diagnosis, Boston, MA.

Silka, V. R. & Hauser, M. J. (1997). Psychiatric assessment of the person with mental retardation. Psychiatric Annals, 27, 162-169.

For further information:

Edwin J. Mikkelsen, M.D.
67 Yarmouth Road
Wellesley Hills, MA 02481