Transcript Document

Developing Best Practice
Guidelines for Treating People
with Co-Occurring
Mental Illness
and
Mental Retardation
Intellectual Disability
The Basis for Models of Treatment
Lisa S. Hovermale, MD
Maryland Department of Health and
Mental Hygiene
Liaison
Mental Hygiene Administration
Developmental Disabilities Administration
[email protected]
Towards a best practice model
• of diagnosing mental illness and
• prescribing psychotropic medications
in individuals with mental retardation
/intellectual disability
Overview
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History Of Issues In Mental Retardation
Definitions of MR vs. DD
Diagnostic Issues
Treatment Strategies
Infrastructure Issues
The History of Psychiatry and
Mental Retardation
A Story of Mutual Rejection
The Tragic Interlude
Frank Menolascino, MD
There is a belief that individuals
with mental retardation can not
have mental illness.
Prevalence 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
Developmental Disabilities
DD
Mental Retardation
MR
Pervasive Developmental Delay
PDD
Developmental Disability
• Manifest before age 22
• Likely to continue indefinitely
• Result in substantial Limitation in >3
specific areas of functioning
• Requires specific and lifelong extended
care
• Physical or mental
Mental 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
10 Domains of Adaptive
Functioning (AAMR)
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communication
self-care
social skills
home living
use of community resources
self-direction
health and safety
functional academics
leisure
and work
Prevalence of Mental
Retardation in the General
Population
• Depends on diagnostic criteria, study
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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
Etiology
• 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
Intellectual Disability
may be the term of the future
American Association on Mental
Retardation Classifications
Based on supports needed
• Intermittent
• Limited
• Extensive
• Pervasive
www.aamr.org
Mental 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
DSM III-IVTR were not written to specify the
unique presentations of mental illness that
individuals with mental retardation may
exhibit.
• Relies heavily on a patient’s subjective
report of symptoms.
– Hearing voices
– Feeling sad
– Feeling anxious
– Not sleeping well
• NADD working on companion manual for
MIMR(ID)
Diagnostic 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.
The 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
Axis 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
Axis V
• Global assessment of functioning
– Current
– Highest within the last year
Mental Health Aspects of Developmental
Disabilities-2001, volume 4, number1
General Safety Precautions in Prescribing for
individuals with MR/MI
Safety Precautions for Persons with
Developmental Disabilities-HCFA-1995
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Rule out other causes
Collect baseline data
State a reasonable Hypothesis
Intervene in the least intrusive and most
positive way
5. Monitor for adverse drug reactions
(ADRs)
6. Collect outcome data
General Safety Precautions in Prescribing for
individuals with MR/MI-cont.
Safety Precautions for Persons with
Developmental Disabilities-HCFA-1995
7. Start low and go slow
8. Periodically consider gradual dose
reduction
9. Maintain active treatment objectives
10. Maintain optimal functional status
Have a complete history of the
client.
This should include:
• Developmental History
• Psychiatric History
• Medical History
• Psychosocial History
• Behavioral History
• Family History
(context, context, context)
Rule out other causes
(medical, environmental,
behavioral, other)
• Check labs
• Look at pattern
• Brainstorm
– Gallbladder
– Menopause
– Headache
– Gynecologic issues
Behavioral Assessment
• Functional Analysis
• Functional Assessment
Having a psychologist skilled in behavioral
thinking on your multidisciplinary team is
extremely important.
Collect 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
State a Reasonable Hypothesis
• Look for an identifiable pattern
• Identify target signs and symptoms that
you expect to change with medication
Intervene 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
Start low and go slow
• Goal of achieving symptom resolution with
the lowest effective dose.
A different twist on least restrictive alternative
Monitor for Adverse Drug
Reactions (ADRs)
Drug combinations risk increased side effects
• Diarrhea
• Headache
• Unsteadiness
• Anything different
Collect outcome data
If there is no demonstrable improvement
with a particular medication,
DON’T CONTINUE TO USE IT
Periodically consider gradual
dose reduction
• Radical Concept
Maintain active treatment
objectives
• Is the individual’s learning of new skills
improving, deteriorating, or staying the
same.
Maintain optimal functional
status
• Use adaptive functioning scales as part of
your monitoring process.
Evidence Based Practice
• Implies
– Randomized-matched population
– Placebo Controlled
– Double-blinded
Therefore Generalizable
MI/ID populations tend to be:
• Very heterogeneous
• Very medically and behaviorally involved
• Compromised when it comes to informed
consent
• Socially vulnerable-easily coerced
Therefore, when it comes to
psychiatric treatment in MI/ID:
• Best Practice is very dependant on
– Consensus opinion
– Case Studies
There 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
Unfortunately:
• Community Medicaid pays for time
spent face to face with a patient
– Doesn’t 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
“As 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.”
Frank P. Bongiorno, MD
http://www.sma.org/smj/96dec2.htm
A 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….
A visual exam of his mouth reveals
obvious dental caries. An X-ray is
obtained with great difficulty due to the
patient’s agitation. Multiple abscesses are
seen.
The 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.)
A 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.
There 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.
While 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.
http://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