Title: Developing Best Practice Guidelines for Treating People with Co-Occurring Mental Illness and Mental Retardation Intellectual Disability The Basis for Models of Treatment
1Developing Best Practice Guidelines for Treating
People with Co-OccurringMental
IllnessandMental Retardation Intellectual
Disability The Basis for Models of Treatment
2Lisa S. Hovermale, MDMaryland Department of
Health and Mental HygieneLiaisonMental
Hygiene AdministrationDevelopmental Disabilities
Administrationlhovermale_at_dhmh.state.md.us
3Towards a best practice model
- of diagnosing mental illness and
- prescribing psychotropic medications
- in individuals with mental retardation
/intellectual disability
4Overview
- History Of Issues In Mental Retardation
- Definitions of MR vs. DD
- Diagnostic Issues
- Treatment Strategies
- Infrastructure Issues
5The History of Psychiatry and Mental Retardation
- A Story of Mutual Rejection
6The Tragic Interlude
Frank Menolascino, MD
7There is a belief that individuals with mental
retardation can not have mental illness.
8Prevalence of mental disorder in persons with
mental retardation
- Between 10 and 60
- depends on the method, definition, and sampling
strategies - general agreement that people with mental
retardation more likely to suffer mental illness - full range of mental illness-all types
9Developmental DisabilitiesDD
- Mental Retardation
- MR
- Pervasive Developmental Delay
- PDD
10Developmental Disability
- Manifest before age 22
- Likely to continue indefinitely
- Result in substantial Limitation in gt3 specific
areas of functioning - Requires specific and lifelong extended care
- Physical or mental
11Mental Retardation(Intellectual Disability)
- Widely accepted definition
- IQ less than 70
- Adaptive deficits in at least 2 of 10 specified
domains - Onset prior to age 18
Not Synonymous with Developmental Disability
1210 Domains of AdaptiveFunctioning (AAMR)
- communication
- self-care
- social skills
- home living
- use of community resources
- self-direction
- health and safety
- functional academics
- leisure
- and work
13Prevalence of Mental Retardation in the General
Population
- Depends on diagnostic criteria, study design, and
methods - Based on IQ alone, prevalence 3
- When tri-dimensional definition used,
prevalence 1 - 85 of people with MR thought to be mild
- remainder are moderate, severe, profound
14Etiology
- Not a disease in itself but the developmental
consequence of some pathogenic process - 350 known causes (partial list)
- 500 genetic causes (so far)
- Toxic, infectious, traumatic, congenital
15Intellectual Disability may be the term of the
future
16American Association on Mental Retardation
ClassificationsBased on supports needed
- Intermittent
- Limited
- Extensive
- Pervasive
- www.aamr.org
17Mental Retardation (Intellectual Disability)
is a big umbrella. It covers many
sub-populations.
- Pervasive Developmental Disorders
- Autism, Asperger's (not synonymous with MR)
- Implies severe social and communication
impairment
- Mental Retardation
- 85 mild
- (as degree of MR increases, the likelihood of
autistic traits increases)
Behavioral Phenotypes
18DSM III-IVTR were not written to specify the
unique presentations of mental illness that
individuals with mental retardation may exhibit.
- Relies heavily on a patients subjective report
of symptoms. - Hearing voices
- Feeling sad
- Feeling anxious
- Not sleeping well
- NADD working on companion manual for MIMR(ID)
19Diagnostic Overshadowing
- Refers to the tendency to explain symptoms as the
consequence of mental retardation rather than
possible expressions of mental illness. - This clearly leads to under-diagnosis.
20The Axis System
- Axis I
- Major Psychiatric Illness
- Axis II
- Mental Retardation, Personality Disorders
- Axis III
- Medical Issues
- Axis IV
- Psychosocial stressors
- Axis V
- Global Assessment of Functioning (GAF)30
21Axis IV
- Psychosocial and environmental stressors
- Losing job vs. changing workshop
- Moving vs. changing group home
- Holiday vs. Holidays
- Loss of friend vs. change in staff
22Axis V
- Global assessment of functioning
- Current
- Highest within the last year
- Mental Health Aspects of Developmental
Disabilities-2001, volume 4, number1
23General Safety Precautions in Prescribing for
individuals with MR/MISafety Precautions for
Persons with Developmental Disabilities-HCFA-1995
- Rule out other causes
- Collect baseline data
- State a reasonable Hypothesis
- Intervene in the least intrusive and most
positive way - Monitor for adverse drug reactions (ADRs)
- Collect outcome data
24General Safety Precautions in Prescribing for
individuals with MR/MI-cont.Safety Precautions
for Persons with Developmental Disabilities-HCFA-1
995
- Start low and go slow
- Periodically consider gradual dose reduction
- Maintain active treatment objectives
- Maintain optimal functional status
25Have a complete history of the client.
- This should include
- Developmental History
- Psychiatric History
- Medical History
- Psychosocial History
- Behavioral History
- Family History (context,
context, context)
26Rule out other causes(medical, environmental,
behavioral, other)
- Check labs
- Look at pattern
- Brainstorm
- Gallbladder
- Menopause
- Headache
- Gynecologic issues
27Behavioral Assessment
- Functional Analysis
- Functional Assessment
- Having a psychologist skilled in behavioral
thinking on your multidisciplinary team is
extremely important.
28Collect baseline data
- What is different now and when did it change?
- Examples of intensity
- Ideas of frequency
- Use any forms you want
- Sleep
- Menses
- Bowel movements
- Ins and Outs
29State a Reasonable Hypothesis
- Look for an identifiable pattern
- Identify target signs and symptoms that you
expect to change with medication
30Intervene in the least intrusive and most
positive way
- Try behavioral approaches first,
- Address medical issues first,
- Make environmental changes first,
- Before giving and treating a psychiatric label
31Start low and go slow
- Goal of achieving symptom resolution with the
lowest effective dose. - A different twist on least restrictive alternative
32Monitor for Adverse Drug Reactions (ADRs)Drug
combinations risk increased side effects
- Diarrhea
- Headache
- Unsteadiness
- Anything different
33Collect outcome data
- If there is no demonstrable improvement with a
particular medication, -
- DONT CONTINUE TO USE IT
34Periodically consider gradual dose reduction
35Maintain active treatment objectives
- Is the individuals learning of new skills
improving, deteriorating, or staying the same.
36Maintain optimal functional status
- Use adaptive functioning scales as part of your
monitoring process.
37Evidence Based Practice
- Implies
- Randomized-matched population
- Placebo Controlled
- Double-blinded
- Therefore Generalizable
38MI/ID populations tend to be
- Very heterogeneous
- Very medically and behaviorally involved
- Compromised when it comes to informed consent
- Socially vulnerable-easily coerced
39Therefore, when it comes to psychiatric treatment
in MI/ID
- Best Practice is very dependant on
- Consensus opinion
- Case Studies
40There has got to be a better way
- Single subject research design
- Study the trajectory of the individual
- Develop a theory of the case
- Define measurable target symptoms on which data
can be collected (sleep, weight, aggression,
property destruction, disruption, disorganized
behavior, threats) - Observe whether the target symptoms change with
medication intervention-measure outcome - Prove or disprove your theory
41Unfortunately
- Community Medicaid pays for time spent face to
face with a patient - Doesnt allow for the extensive collateral
information collection and collaboration
necessary to provide a best practice model of
care. - DDA Administration Home and Community Based
Waiver may be helpful
42As neurochemistry continues to expand its base
of understanding, it may be possible that in the
future there will be no such dual diagnosis.
Mental illness may be no more than a
developmental disability in which 35 of the
patients are mentally retarded and there is only
one diagnosis with multiple manifestations.Fran
k P. Bongiorno, MDhttp//www.sma.org/smj/96dec2.h
tm
43A young, nonverbal man with severe to profound
mental retardation presents to the emergency room
with the new, self abusive behavior of slapping
his face on the left cheek area repeatedly with
great intensity. He is triaged to psychiatry
because of his aberrant behavior.
44A visual exam of his mouth reveals obvious dental
caries. An X-ray is obtained with great
difficulty due to the patients agitation.
Multiple abscesses are seen.
45The behavior resolves completely after the
abscessed teeth are pulled and the patient is
treated with antibiotics. (The psychiatrist
suffers vocal cord stress secondary to the
discussion required to get this patient seen by
individuals who could diagnose and treat his
problem.)
46A woman with mental retardation has spent most of
her life in an institution. In her late
thirties, she is discharged to a group home in
the community where she lives with eleven other
disabled individuals. Her discharge medications
include Phenobarbital and Dilantin for a seizure
disorder. She has taken these medications as
long as anyone can remember for seizures
diagnosed in childhood. Her behavior quickly
becomes problematic in the group home.
47There are frequent pseudo seizures (documented by
telemetry) that appear to be attention seeking.
She exhibits low frustration tolerance being
unable to tolerate minor delays or
disappointments without tantrums and/or becoming
aggressive toward staff and other clients. Her
behavior escalates to the point that
hospitalization is required.
48While hospitalized, she is begun on Depakote and
Phenobarbital is gradually tapered. Her behavior
improves dramatically. Upon discharge, she is
placed in a supervised apartment with a roommate
and attends a day program as before. A year
later, few staff remember that she ever had a
problem with aggressive outbursts. She is
invited to speak at a program about community
living for the developmentally disabled as a
model of success.
49http//psychiatry.com/mr/
http//www.sma.org/smj/96dec2.htm
http//www.mh.state.oh.us/index-dept.html
http//www.psychiatry.com/mr/assessment.html