2. Background
Speech pathologists are the allied health professionals who specialise in treating human communication disorders (e.g. speech and language) and swallowing difficulties across the lifespan. The majority of people living with a mental illness experience significant communication difficulties, and many have difficulty swallowing food or drinking safely. The links between communication and swallowing skills and mental illness are complex and multifactorial.
Speech pathologists aim to improve a person’s communication and swallowing skills, and reduce environmental barriers, to facilitate participation across multiple environments including home, education, workplace, social and community services (such as mental health programs). Speech pathologists enhance the health, wellbeing and participation of people with mental health conditions through prevention, early detection and treatment of communication and swallowing disorders. Currently, there is inconsistent and inadequate speech pathology service provision for individuals living with a mental illness across Australia. In some states, there are speech pathologists employed within child and adolescent mental health services, while in others there are none. Similarly, inclusion of speech pathology in the staffing profile of adult mental health services is inconsistent, varying across individual services even within the same local health district, let alone across different states and territories.
The following provides a brief explanation of communication and swallowing disorders and their association with mental health conditions.
Communication disorders
Communication disorders are problems with hearing, speaking, understanding, reading, writing, voice, fluency and using language and communication in social contexts (known as pragmatics). There can be a wide range of causes of communication disorders, for example, autism spectrum disorder, hearing impairment, developmental language disorder, intellectual disability, or brain injury, or there may be no known cause of the difficulty. Social class, family history of language/literacy disorders, environmental, and biological/genetic factors all influence communication development (AlHammadi, 2017). Indeed, a study by Hughes, Sciberras, & Goldfield (2016) showed that five factors (the child having witnessed violence, a history of parental mental illness, living in more deprived communities, and, independently, the educational attainment of each parent) were predictive of a child entering school with co-morbid communication and socioemotional/behavioural difficulties.
The consequences of communication difficulties cross all developmental, psychosocial and environmental aspects of infancy, childhood, adolescence and adulthood, and impact families, carers, educational staff and fellow students, workplace colleagues, and the community (Conti-Ramsden, Durkin, Mok, Toseeb, & Botting, 2016; Law, Reilly, & Snow, 2013). Such consequences may be interrelated and influence each other. Individuals with communication difficulties who do not receive adequate intervention are more likely to experience life-long problems (see, for example, Clegg, Hollis, Mawhood, & Rutter, 2005).
The relationship between communication disorders and mental health
Communication disorders frequently co-occur with mental illness. There is evidence that over 80% of children with emotional and behavioural disorders have a co-existing and previously unidentified language difficulty (Hollo, Wehby, & Oliver, 2014) and that 60% of adults accessing mental health services experience communication difficulties (Emerson & Enderby, 1996; Walsh, Regan, Sowman, Parsons, & McKay, 2007).
Individuals with communication difficulties are at a significantly greater risk of developing a mental illness than the general population (Beitchman et al., 1996; Beitchman et al., 2001; Botting, Durkin, Toseeb, Pickles, & Conti-Ramsden, 2016; Clegg, Hollis, Mawhood, & Rutter, 2005; Mouridsen & Hauschild, 2009). Alternatively, communication difficulties may develop as a result of the mental illness itself, and are included in the diagnostic criteria for a range of mental health disorders, such as attention deficit disorders, psychotic disorders (including schizophrenia) and dementia (American Psychiatric Association, 2013; Boudewyn et al., 2017; Colle et al., 2013). Snow (2009) identified that socially disadvantaged groups in society are at greater risk for both communication and mental health problems along with the potential for intergenerational transfer of such problems, and those who have experienced childhood trauma are at a greater risk of developing both mental illness (Perry, 2005) and communication disorders (Lum, Powell, & Snow, 2018; Lum, Powell, Timms, & Snow, 2015; Sylvestre, Bussières, & Bouchard, 2016). Similarly, there is a strong relationship between mental illness, communication difficulties, and an individual’s interactions with the criminal justice system (Snow, Woodward, Mathis, & Powell, 2015).
Swallowing disorders
Swallowing disorders, known as dysphagia, are problems with eating, drinking and swallowing. Dysphagia may result in life-threatening choking episodes (Berzlanovich, Fazeny-Dorner, Waldhoer, Fasching, & Keil, 2005), contribute to aspiration pneumonia (Langmore, et al.,1998), compromise nutrition and hydration (Vivanti, Campbell, Suiter, Hannen-Jones, & Hulcombe, 2009; Hays & Roberts, 2006), and/or lead to reduced quality of life (Ekberg, Hamdy, Woisard, Wuttge-Hannig, & Ortega, 2002). Potential causes of swallowing disorders include brain injury, physical impairments, and medications (including some psychotropic medications used to treat mental illness). The speech pathologist’s role in establishing safe and effective eating/drinking facilitates adequate nutrition and hydration, reduces the risk of choking and aspiration pneumonia, and improves quality of life.
The relationship between swallowing disorders and mental health
While the prevalence of dysphagia in the general population is approximately 6% (Regan, Sowman & Walsh, 2006), the prevalence within mental health settings ranges from 30% to 65%, depending on diagnosis (Aldridge & Taylor, 2012; Muir, 1996; Regan, Sowman, & Walsh, 2006; Walsh, Regan, Sowman, Parsons, & McKay, 2007). Individuals living with mental illness have been reported to have higher rates of aspiration, with an increased risk of death from a resulting pneumonia, than the general population (Bazemore, Tonkology, & Anath, 1991), and the mortality rate of inpatients in psychiatric settings due to choking has been found to be between eight and 100 times higher than that of the general population (Corcoran & Walsh, 2003; Yim & Chong, 2009).
Swallowing disorders experienced by people with mental illness are largely due to the side effects of medications (e.g. as a result of extra-pyramidal side effects), factors associated with institutionalisation (e.g. dependency), the presence of co-morbidities (e.g. brain injury or intellectual disability), and/or behavioural or physiological characteristics of the mental illness itself (Aldridge & Taylor, 2012, Baheshree & Jonas, 2012, Kulkarni, Kamath, & Stewart, 2017). Other risk factors include movement disorders, seizures, poor dentition, and poor eating habits (Regan, Sowman, & Walsh, 2006).
The role of speech pathologists in mental health
Speech pathologists are critical members of the mental health team as they identify communication and/or swallowing difficulties and develop appropriate treatment targets to help an individual’s recovery, their functioning in daily activities, and their participation in all aspects of life. Speech pathologists diagnose communication and swallowing disorders and, as part of the mental health team, can play an important role in contributing to the differential diagnosis of conditions such as dementia, schizophrenia, affective disorders such as depression, and autism spectrum disorder (ASD). They also help to determine whether communication or swallowing difficulties are part of the current mental health issue or whether there is an underlying communication disorder. Speech pathologists provide intervention to improve communication and swallowing difficulties, including:
- providing individual or group therapy to develop an individual’s speech, language, and social communication skills;
- collaborating with other mental health professionals, such as occupational therapists, social workers, psychologists, mental health nursing, and psychiatrists, to
- ensure communication difficulties are considered in the context of other mental health interventions;
- supporting an individual’s communication (including using visual resources, where appropriate) to enable them to understand and participate in their treatment and recovery;
- establishing safe and effective eating, drinking and swallowing practices to help make sure people have adequate nutrition and hydration, as well as to reduce the risk of choking or pneumonia; and
- referring appropriate individuals to mental health teams (or other services) when it is suspected that their communication difficulties may be associated with a mental illness.