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7.0 Defining the Population to be Served

7.1 Individuals with a Dual Diagnosis

The definition of the population for whom this Guideline applies remains the same as it was in the 1997 Guideline stated below:

“ ‘Adults with a Dual Diagnosis’ are those persons 18 years of age and older with both a developmental disability and mental health needs.”

This definition was acceptable in 1997 both to the developmental and mental health sectors
as well as families and consumers because it was considered broader and more inclusive< than previous definitions. It is unchanged in this Guideline.

7.2 Individuals with a Developmental Disability

The Ministry of Community and Social Services uses the definition of developmental disability described in the Developmental Services Act R.S.O. 1990, c. D.11 (DSA):

“ ‘Developmental Disability’ means a condition of mental impairment, present or occurring during a person’s formative years, that is associated with limitations in adaptive behaviour.”

The health system uses the definition of mental retardation contained in the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR) which is published by the American Psychiatric Association:"

“ ‘Mental Retardation’ – this disorder is characterized by significantly
sub-average intellectual functioning (an IQ of 70 or below) with onset< before age 18 years and concurrent deficits or impairments in adaptive functioning.”

The DSM-IV-TR and DSA definitions are comparable in most aspects with the key distinction
between the two being the explicit statement of required IQ level in the DSM-IV-TR definition.

7.3 Individuals with Mental Health Needs

For the purposes of this Dual Diagnosis Guideline, “mental health needs” are defined as diagnosed mental illness or symptoms consistent with mental illness.

7.3.1 Individuals with Serious Mental Illness

In 1999 the MOHLTC released "Making It Happen: Implementation Plan for Mental Health Reform and Making It Happen: Operational Framework for the Delivery of Mental Health Services and Supports". These documents provided the framework to guide mental health reform in Ontario and stated that the priority population to be served by community mental health services and supports is people with a serious mental illness. The documents describe three categories to identify individuals with a serious mental illness: disability, anticipated duration and/or current duration, and diagnosis. The critical dimension is the extent of disability and serious risk of harm to themselves or others, related to a diagnosable disorder.

  • Disability: lack of ability to perform basic living skills that interferes with or severely limits an individual’s capacity to function in one or more major life activities;
  • Duration: the acute and ongoing nature of the problems including intermittent episodes between which there are periods of full recovery, and
  • Diagnosis: including schizophrenia, mood disorders, organic brain disorders, paranoid psychosis or other psychoses, severe personality disorder, concurrent disorder and dual diagnosis.

The two “Making It Happen” documents define populations to be served according to their need for services: first-line, intensive and specialized:

  • First-line: prevention, assessment and treatment provided by front-line health care providers including general practitioners, mental health services, social services, hospital emergency services and hospital primary care clinics. Services include: information and referral, crisis telephone services, mobile crisis teams, safe beds, mental health counselling and emergency services in Schedule 1 hospitals;
  • Intensive: mental health assessment, treatment and support services which are provided in community or hospital settings and are focused on people with serious mental illness. Services include: intensive case management and housing supports, skill development, psychosocial rehabilitation programs, medication clinics, Schedule 1 inpatient and outpatient services;

  • Specialized: highly specialized mental health programs provided in community or hospital settings and which focus on serving people with serious mental illness who have complex, rare and unstable mental disorders. Services include: assertive community treatment teams, mobile outreach teams, residential treatment, specialized inpatient and outpatient services and forensic services.

Each level describes a flexible or variable combination of specific service functions that differ in terms of level of resource intensity, specialization, and/or service duration. For individuals with serious mental illness, “levels of need” serve as a guide to mental health resource utilization which must be applied in conjunction with sound clinical judgment. The services a client receives will usually be based on client choice and offered in accordance with the client’s functional needs.

Given that groups of clients share many common needs and will benefit from similar service approaches, people will receive most of their services from within a particular level but are not limited to accessing services from only within one level.

8. Provincial Roles and Functions

The Ministry of Health and Long-Term Care (MOHLTC) is responsible for stewardship of the provincial health system. It sets overall policy direction for health and mental health services. Until April 1, 2007, MOHLTC directly funded hospitals and other transfer payment agencies to provide adult mental health services. Effective April 1, 2007, the MOHLTC provides funding to Local Health Integration Network (LHINs). LHIN legislation enabled 14 LHINs across the province to become the planners and direct funders of community and inpatient mental health services. Most physicians are not included in the LHIN mandate.

The Ministry of Community and Social Services (MCSS) funds and has responsibility for setting the overall policy direction and planning guidelines for a broad range of social services for adults with a developmental disability and their families.

Together, through a coordinated interministerial approach and based on the knowledge, skills and expertise that currently exist in both sectors, MOHLTC and MCSS will:

  • Provide policy direction and develop corporate linkages that strengthen the range and capacity for a continuum of mental health and developmental services;
  • Coordinate planning and monitor the impact of changes on service access and availability at the provincial level;
  • Monitor and evaluate mechanisms for inter/intra-ministerial planning and coordination at a provincial level;
  • Encourage availability of appropriate training and education for service providers in both the developmental and mental health sectors.