Building workforce capacity in Australia and New Zealand: a profile of psychiatrists with an interest in intellectual and developmental disability mental health

Abstract

Objective:

To describe the characteristics of psychiatrists working in the area of intellectual and developmental disability mental health (IDDMH) across Australia and New Zealand.

Methods:

A secondary analysis of data collected by the Royal Australian and New Zealand College of Psychiatrists 2014 workforce survey. Characteristics of the IDDMH workforce (n=146 psychiatrists) were compared with those of the broader psychiatry workforce (n=1050 psychiatrists).

Results:

The IDDMH workforce were more likely than the broader psychiatry workforce to be working across both the public and private health sectors, be engaged in outreach work, endorse specialty practice areas pertinent to IDDMH, treat younger patients and work more clinical hours per week. Part-time status and retirement plans of the IDDMH workforce matched those of the broader psychiatry workforce.

Conclusions:

While some elements of the IDDMH workforce profile suggest this workforce is tailored to the needs of the population, the potential shortage of IDDMH psychiatrists highlights the need for the development of a specific training programme and pathway in this area.

Keywords

intellectual disability developmental disability mental health psychiatry workforce workforce characteristics

People with intellectual and developmental disabilities (IDD) experience high rates of mental disorders¹ and multiple barriers to appropriately equipped health services.² A key barrier to people with IDD receiving quality health services is a lack of workforce capacity.³ The availability of psychiatrists with specialist skills in the area of intellectual and developmental disability mental health (IDDMH) is a key component of an accessible mental health service for people with IDD.⁴ However, in the current training programme for Australian and New Zealand Psychiatrists, there is only minimal formal IDD content included in basic training, and there is currently no recognised subspecialty in the area of IDDMH. Here we describe the first phase of a project that will determine the feasibility and predicted utility of formal IDDMH subspecialty training for psychiatrists in Australia and New Zealand. The aim of this report is to describe the current psychiatry workforce characteristics across Australia and New Zealand in the area of IDDMH and compare these to the broader psychiatry workforce.

Materials and methods

A secondary analysis was performed on deidentified data from the Royal Australian & New Zealand College of Psychiatrists (RANZCP) 2014 workforce survey.^5,6 The survey collected information about: workforce characteristics; specialty practice areas; patient ages; hours worked; and retirement plans. The RANZCP provided raw, deidentified data for all Fellows and Affiliates who completed the survey. Information about membership with the RANZCP Section of Psychiatry of Intellectual and Developmental Disabilities (SPIDD) and specialty practice areas listed on the Find a Psychiatrist website was linked to survey data using unique identification numbers (provided by RANZCP) to ensure complete capture of psychiatrists with an interest in IDDMH. We considered the IDDMH workforce to be psychiatrists who: (a) listed IDD as a specialty practice area on the workforce survey; or (b) were a member of SPIDD in 2014; or (c) listed IDD as a specialty on Find a Psychiatrist in 2014. Retired respondents and those with extensive missing data were excluded.

Workforce characteristics of the IDDMH workforce were compared with those of the broader psychiatry workforce (respondents not meeting the above IDDMH workforce criteria) using independent t-tests or non-parametric equivalents. Odds ratios were calculated from 2×2 contingency tables for categorical variables. Ethics approval was granted by the UNSW Sydney Human Research Advisory Panel (approval number HC16853) with a waiver of the requirement for consent.

Results

Responses from 1196 psychiatrists were included (representing 33% of the entire RANZCP membership), of whom 146 (12%) were classified as the IDDMH workforce group.

Workforce characteristics

A greater proportion of psychiatrists within the IDDMH workforce were working across both the public and private health systems (χ²=4.416, p=.025; OR=1.495, 95% CI=1.026–2.181) and were engaged in outreach work (χ²=5.901, p=.010; OR=1.537, 95% CI=1.085–2.178) (Table 1).

Table 1.

Workforce characteristics

Characteristic	All	IDDMH workforce	Broader workforce
Age: mean (range)	55 (32–86)	54 (35–84)	55 (32–86)
	n (%)	n (%)	n (%)
Primary country of work
Australia (primary)	981 (82%)	121 (83%)	860 (82%)
New Zealand (primary)	215 (18%)	25 (17%)	190 (18%)
Health system setting
Public system only	322 (27%)	38 (26%)	284 (27%)
Private system only	467 (39%)	49 (34%)	418 (40%)
Both public and private systems	293 (24%)	46 (32%)*	247 (24%)
Service type
Public hospital/area health service	603 (50%)	70 (48%)	533 (51%)
Ambulatory mental health or drug and alcohol	494 (41%)	62 (42%)	432 (41%)
Residential aged and mental health care services	65 (5%)	11 (8%)	54 (5%)
Private practice, medical centre or consulting rooms	599 (50%)	79 (54%)	520 (50%)
Private hospital	183 (15%)	28 (19%)	155 (15%)
Health service management	61 (5%)	9 (6%)	52 (5%)
Correctional services	34 (3%)	6 (4%)	28 (3%)
Defence forces	4 (<1%)	0 (0%)	4 (<1%)
University or other educational institution	131 (11%)	22 (15%)	109 (11%)
Government department or agency	50 (4%)	8 (5%)	42 (4%)
Rehabilitation	30 (3%)	4 (3%)	26 (2%)
Not-for-profit organisation	30 (3%)	4 (3%)	26 (2%)
Other^a	85 (7%)	12 (8%)	73 (7%)
Outreach	448 (37%)	68 (47%)*	380 (36%)

‘Other’ category includes the Mental Health Review Tribunal; training administration; medicolegal consulting; immigration detention centres; Aboriginal Mental Health Services and telehealth services.

p<.05.

Primary practice location

Most psychiatrists were based in major cities (Figure 1). There were no differences between the workforce groups for the distribution of primary practice location by State/Territory in Australia (χ²=5.449, p=.605) or by Island (North/South) in New Zealand (χ²=.070, p=.479) (Table 2).

Table 2.

Primary practice location

Location	All	IDDMH workforce	Broader workforce
	n (%)	n (%)	n (%)
Australia
New South Wales	294 (30%)	38 (26%)	256 (30%)
Australian Capital Territory	22 (2%)	1 (1%)	21 (2%)
Victoria	272 (28%)	32 (22%)	240 (28%)
Queensland	193 (20%)	28 (19%)	165 (19%)
South Australia	84 (9%)	12 (8%)	72 (8%)
Western Australia	89 (9%)	6 (4%)	83 (8%)
Northern Territory	9 (1%)	1 (1%)	15 (1%)
Tasmania	18 (2%)	3 (2%)	15 (1%)
New Zealand ^a
North Island	158 (73%)	18 (72%)	140 (74%)
South Island	55 (26%)	7 (28%)	48 (26%)

n=2 missing.

Specialty practice areas

A greater proportion of the IDDMH workforce practised in the following specialty areas: Neuropsychiatry (χ²=44.905, p<.001; OR=4.528, 95% CI=2.814–7.286); Child and Adolescent (χ²=45.364, p<.001; OR=3.438, 95% CI=2.362–5.003); Youth Mental Health (χ²=35.372, p<.001; OR=3.235, 95% CI=2.161–4.843); Addictions (χ²=25.695, p<.001; OR=3.005, 95% CI=1.931–4.677); Indigenous (χ²=14.230, p<.001; OR=2.873, 95% CI=1.624-5.083); Psychiatry of Old Age (χ²=15.063, p<.001; OR=2.214, 95% CI=1.470-3.334); Rural (χ²=8.507, p=.005; OR=2.094, 95% CI=1.262-3.475); ECT and Neurostimulation (χ²=7.658, p=.006; OR=1.941, 95% CI=1.205–3.128); Social and Cultural Psychiatry (χ²=7.067, p=.039; OR=1.825, 95% CI=1.009–3.301); Forensic (χ²=7.067, p=.007; OR=1.780, 95% CI=1.158–2.737); and Consultation-Liaison (χ²=3.223, p<.05; OR=1.474, 95% CI=0.963–2.255). Fewer psychiatrists in the IDDMH workforce practised in General Adult (χ²=4.503, p=.022; OR=.682, 95% CI=0.478–0.973) and ‘Other’ (χ²=6.064, p=.006; OR=.363, 95% CI=0.156–0.840) specialty areas (Figure 2).

Patient age groups

A greater proportion of the IDDMH workforce treated patients in younger age groups (Figure 3) including: 0–11 years (χ²=37.678, p<.001, OR=3.174, 95% CI=2.163–4.658); 12–15 years (χ²=37.342, p<.001, OR=2.965, 95% CI=2.068–4.251); 16–18 years (χ²=31.655, p<.001, OR=2.776, 95% CI=1.924–4.004); and 18–25 years (χ²=3.727, p<.031, OR=1.676, 95% CI=0.987–2.847).

Hours, part-time status and retirement plans

The IDDMH workforce worked significantly more clinical hours than the broader psychiatry workforce (t₍₁₁₉₄₎=2.266, p=.024; Table 3). The proportions of psychiatrists working part-time (38%) and those considering retirement or semi-retirement within the next 5 years (32%) were the same for both workforce groups.

Table 3.

Clinical and non-clinical hours per week

		All	IDDMH workforce	Broader workforce
Clinical hours	Mean	29	31*	29
	Range	0–80	6–70	0–80
Non-clinical hours	Median	8	8	8
	Range	0–100	0–55	0–100

p<.05.

Discussion

This report indicates that the IDDMH workforce is characterised by greater engagement in outreach work, greater bridging of public and private health systems, relevant breadth of specialty practice areas and experience across the lifespan. While these characteristics indicate this workforce is well-tailored to the needs of people with IDD, there are clear areas requiring further development, particularly around current and future workforce capacity. The potential shortage of psychiatrists is not an issue unique to IDDMH, but one that is acknowledged in the general psychiatrist workforce.⁷ However, a critical issue for the IDDMH workforce is that there is currently no specific training programme and pathway in this area, and as such there is no strategy in place to manage the training of appropriately skilled practitioners to replace the substantial proportion approaching retirement.

The greater engagement in outreach work by the IDDMH workforce is consistent with the development of models of service in IDD health⁸ and existing multidisciplinary clinical pilots and services (e.g. the Victorian Dual Disability Service). Outreach work is essential to overcome barriers experienced by people from rural and remote areas and to ensure that service provision is flexible and mobile.⁹ Greater bridging of the public and private health sectors by the IDDMH workforce may be in part due to difficulties in meeting the needs of this group within a private setting, or alternatively, due to the limited IDDMH specialist positions available in the public sector. Nevertheless, this cross-over offers opportunities for partnership, joint training and mapping of service pathways in and out of public mental health facilities. This is important as people with IDD stay longer in hospital and experience higher rates of readmission and presentation to the emergency department after hospitalisation.¹⁰

A greater proportion of the IDDMH workforce endorsed specialty practice areas that focus on vulnerable populations in which IDD and mental health disorders are over-represented, including Indigenous and forensic populations,^11
-13 and those experiencing notable barriers to accessing mental health services.¹⁴ Emphasis on younger patient groups aligns with the high rates of psychiatric disorder among children and adolescents with IDD.¹ The higher rates of treatment of patients transitioning into adult services corresponds with the increased vulnerability and demands on people with IDD during transition to adulthood.¹⁵ Greater representation of the IDDMH workforce in the specialty area of Psychiatry of Old Age indicates that this workforce is equipped with cross-over skills and expertise in communication and cognitive impairment. These are of direct relevance to people with IDD, given that effective communication is a key component of accessible mental health services⁴ and that people with IDD experience higher rates of dementia.¹⁶

The significantly longer clinical hours worked per week by the IDDMH workforce could indicate an undersupply of psychiatrists working clinically with people with IDD, although the mean difference between groups was marginal (2 hours per week). The proportion of psychiatrists engaged in part-time employment and those planning retirement has important implications for future capacity, as it is acknowledged that the general psychiatry workforce is underdeveloped and in short supply to meet the demands of the population over the coming decades.⁷ Most senior psychiatrists in the current IDDMH workforce will have been trained in institutions that have since been decommissioned. Without specific training or recruitment of overseas trained psychiatrists, attrition through retirement cannot be buffered.

Limitations of this report include: (a) lack of capture of the experiences of the most recent graduates of the competency-based Fellowship programme (introduced in 2012), but it should be noted there is little IDD content in stage one and two of this programme, and compared with previous training programmes, the amount of increase in IDD training is minimal; and (b) details related to workforce capacity (e.g. the number of referrals received for people with IDD and appointment slots available) and the capacity to train new psychiatrists in this field were not collected. This information is required to determine the feasibility of developing a formal training programme in the area of IDDMH.

The findings of this report indicate that psychiatrists with an interest in IDDMH represent a substantial part of the current RANZCP psychiatric workforce, are well represented binationally and across most jurisdictions, and are diverse in terms of other specialty areas of practice. The potential shortage of IDDMH psychiatrists highlights an urgent need to prioritise the development of a formal Australasian training programme and pathway for psychiatrists in this area.

Footnotes

Acknowledgements

The authors thank the Royal Australian and New Zealand College of Psychiatrists, especially Chad Bennett, Jon Cullum, Joanne Phillips, Katherine Douglas and Jessica Stephens, for providing necessary membership datasets and contributing to the interpretation of findings. The authors also thank Dr Erin Cvejic, Sydney School of Public Health, University of Sydney, for producing .

Disclosure

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

Funding

This work was supported by The Department of Family & Community Services, Ageing, Disability and Home Care, NSW Government.

ORCID iD

Rachael C. Cvejic

References

Einfeld

Ellis

Emerson

Comorbidity of intellectual disability and mental disorder in children and adolescents: a systematic review. J Intellect Dev Disabil 2011; 36: 137–143.

Whittle

Fisher

Reppermund

et al . Barriers and enablers to accessing mental health services for people with intellectual disability: a scoping review. J Ment Health Res Intellect Disabil 2018; 11: 69–102.

Weise

Trollor

JN.

Preparedness and training needs of an Australian public mental health workforce in intellectual disability mental health. J Intellect Dev Disabil 2017: 1–10. Epub ahead of print 25 June 2017. DOI: 10.3109/13668250.2017.1310825.

Department of Developmental Disability Neuropsychiatry. Accessible mental health services for people with an intellectual disability: a guide for providers. Sydney: Department of Developmental Disability Neuropsychiatry, 2014.

The Royal Australian & New Zealand College of Psychiatrists. The Australian Psychiatric Workforce: RANZCP Workforce Survey Report (Australian Membership). Melbourne, VIC: RANZCP, 2014

The Royal Australian & New Zealand College of Psychiatrists. The New Zealand Psychiatric Workforce: RANZCP Workforce Survey Report (New Zealand Membership). Melbourne, VIC: RANZCP, 2014.

Australian Institute of Health and Welfare. Mental health services in Australia – Psychiatric workforce. https://mhsa.aihw.gov.au/resources/workforce/psychiatric-workforce/ (2016, accessed 21 May 2018).

NSW ACI. Building capability in NSW health services for people with intellectual disability: the essentials. Chatswood, NSW: NSW Agency for Clinical Innovation, 2017.

NSW Ministry of Health. Service framework to improve the health care of people with intellectual disability. Sydney, NSW: NSW Ministry of Health, 2012.

10.

Srasuebkul

Reppermund

et al . Emergency department presentation and readmission after index psychiatric admission: a data linkage study. BMJ Open;8:e018613. doi: 10.1136/bmjopen-2017-018613.

11.

Glasson

Sullivan

Hussain

et al . An assessment of intellectual disability among Aboriginal Australians. J Intellect Disabil Res 2005; 49: 626–634.

12.

Baxter

Kingi

Tapsell

et al . Prevalence of mental disorders among Ma¯ori in Te Rau Hinengaro: the New Zealand Mental Health Survey. Aust N Z J Psychiatry 2006; 40: 914–923.

13.

Butler

Allnutt

Kariminia

et al . Mental health status of Aboriginal and non-Aboriginal Australian prisoners. Aust N Z J Psychiatry 2007; 41: 429–435.

14.

Judd

Humphreys

JS.

Mental health issues for rural and remote Australia. Aust J Rural Health 2001; 9: 254–258.

15.

Young-Southward

Rydzewska

Philo

et al . Physical and mental health of young people with and without intellectual disabilities: cross-sectional analysis of a whole country population. J Intellect Disabil Res 2017; 61: 984–993.

16.

Strydom

Chan

King

et al . Incidence of dementia in older adults with intellectual disabilities. Res Dev Disabil 2013; 34: 1881–1885.