Developing Best Practice Guidelines for Treating People with Co-Occurring Mental Illness and Mental Retardation Intellectual Disability The Basis for Models.

Developing Best Practice Developing Best Practice Guidelines for Treating Guidelines for Treating

People with Co-OccurringPeople with Co-OccurringMental IllnessMental Illness

andand

Mental RetardationMental Retardation Intellectual DisabilityIntellectual Disability

The Basis for Models of The Basis for Models of TreatmentTreatment

Lisa S. Hovermale, MDLisa S. Hovermale, MDMaryland Department of Health and Maryland Department of Health and

Mental HygieneMental Hygiene

LiaisonLiaison

Mental Hygiene AdministrationMental Hygiene AdministrationDevelopmental Disabilities Developmental Disabilities

AdministrationAdministrationlhovermale@[email protected]

Towards a best practice Towards a best practice model model

• of diagnosing mental illness and of diagnosing mental illness and

• prescribing psychotropic medications prescribing psychotropic medications

in individuals with mental retardation in individuals with mental retardation /intellectual disability/intellectual disability

OverviewOverview

1.1. History Of Issues In Mental History Of Issues In Mental RetardationRetardation

2.2. Definitions of MR vs. DDDefinitions of MR vs. DD

3.3. Diagnostic Issues Diagnostic Issues

4.4. Treatment StrategiesTreatment Strategies

5.5. Infrastructure IssuesInfrastructure Issues

The History of Psychiatry The History of Psychiatry and Mental Retardationand Mental Retardation

A Story of Mutual A Story of Mutual RejectionRejection

The Tragic The Tragic InterludeInterlude

Frank Menolascino, MD

There is a belief that There is a belief that individuals with mental individuals with mental

retardation can not have retardation can not have mental illness.mental illness.

Prevalence of mental Prevalence of mental disorder in persons with disorder in persons with

mental retardationmental retardation

• Between 10% and 60%Between 10% and 60%– depends on the method, definition, and depends on the method, definition, and

sampling strategiessampling strategies– general agreement that people with general agreement that people with

mental retardation more likely to suffer mental retardation more likely to suffer mental illnessmental illness

– full range of mental illness-all typesfull range of mental illness-all types

Developmental DisabilitiesDevelopmental DisabilitiesDDDD

Mental RetardationMental Retardation

MRMR

Pervasive Developmental Pervasive Developmental DelayDelay

PDDPDD

Developmental DisabilityDevelopmental Disability

• Manifest before age 22Manifest before age 22

• Likely to continue indefinitelyLikely to continue indefinitely

• Result in substantial Limitation in Result in substantial Limitation in >>3 3 specific areas of functioningspecific areas of functioning

• Requires specific and lifelong Requires specific and lifelong extended careextended care

• Physical or mentalPhysical or mental

Mental RetardationMental Retardation(Intellectual Disability)(Intellectual Disability)

• Widely accepted definition:Widely accepted definition:– IQ less than 70IQ less than 70– Adaptive deficits in at least 2 of 10 Adaptive deficits in at least 2 of 10

specified domainsspecified domains– Onset prior to age 18Onset prior to age 18

Not Synonymous with Developmental Disability

10 Domains of Adaptive10 Domains of AdaptiveFunctioning (AAMR)Functioning (AAMR)

• communicationcommunication

• self-careself-care

• social skillssocial skills

• home livinghome living

• use of community resourcesuse of community resources

• self-directionself-direction

• health and safetyhealth and safety

• functional academicsfunctional academics

• leisureleisure

• and workand work

• 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

Prevalence of Mental Prevalence of Mental Retardation in the General Retardation in the General

PopulationPopulation

EtiologyEtiology

• Not a disease in itself but the Not a disease in itself but the developmental consequence of some developmental consequence of some pathogenic processpathogenic process– 350 known causes (partial list)350 known causes (partial list)– 500 genetic causes (so far)500 genetic causes (so far)– Toxic, infectious, traumatic, congenitalToxic, infectious, traumatic, congenital

Intellectual Disability

may be the term of the future

American Association on Mental American Association on Mental Retardation ClassificationsRetardation ClassificationsBased on supports neededBased on supports needed

• IntermittentIntermittent

• LimitedLimited

• ExtensiveExtensive

• PervasivePervasive

www.aamr.orgwww.aamr.org

Mental Retardation Mental Retardation ((Intellectual Disability)Intellectual Disability)

is a big umbrella.is a big umbrella.

It covers many sub-populations.It covers many sub-populations.

• Pervasive Pervasive Developmental Developmental DisordersDisorders– Autism, Asperger's (not Autism, Asperger's (not

synonymous with MR)synonymous with MR)– Implies severe social and Implies severe social and

communication impairmentcommunication impairment

• Mental RetardationMental Retardation– 85% mild 85% mild (as degree of MR increases, the (as degree of MR increases, the

likelihood of autistic traits likelihood of autistic traits increases)increases)

Behavioral Phenotypes

DSM III-IVTR were not written to specify DSM III-IVTR were not written to specify the unique presentations of mental the unique presentations of mental illness that individuals with mental illness that individuals with mental

retardation may exhibit.retardation may exhibit.

• Relies heavily on a patient’s subjective Relies heavily on a patient’s subjective report of symptoms.report of symptoms.– Hearing voicesHearing voices– Feeling sadFeeling sad– Feeling anxiousFeeling anxious– Not sleeping wellNot sleeping well

• NADD working on companion manual NADD working on companion manual for MIMR(ID)for MIMR(ID)

•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.

Diagnostic OvershadowingDiagnostic Overshadowing

The Axis SystemThe 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 IVAxis IV

• Psychosocial and environmental Psychosocial and environmental stressorsstressors– Losing job vs. changing workshopLosing job vs. changing workshop– Moving vs. changing group homeMoving vs. changing group home– Holiday vs. HolidaysHoliday vs. Holidays– Loss of friend vs. change in staffLoss of friend vs. change in staff

Axis VAxis V

• Global assessment of functioningGlobal assessment of functioning– CurrentCurrent– Highest within the last yearHighest within the last year

Mental Health Aspects of Developmental Mental Health Aspects of Developmental Disabilities-2001, volume 4, number1Disabilities-2001, volume 4, number1

General Safety Precautions in General Safety Precautions in Prescribing for individuals with MR/MIPrescribing for individuals with MR/MISafety Precautions for Persons with Safety Precautions for Persons with

Developmental Disabilities-HCFA-1995Developmental Disabilities-HCFA-1995

1.1. Rule out other causesRule out other causes2.2. Collect baseline data Collect baseline data 3.3. State a reasonable HypothesisState a reasonable Hypothesis4.4. Intervene in the least intrusive and Intervene in the least intrusive and

most positive waymost positive way5.5. Monitor for adverse drug reactions Monitor for adverse drug reactions

(ADRs)(ADRs)6.6. Collect outcome dataCollect outcome data

General Safety Precautions in General Safety Precautions in Prescribing for individuals with MR/MI-Prescribing for individuals with MR/MI-

cont.cont.Safety Precautions for Persons with Safety Precautions for Persons with

Developmental Disabilities-HCFA-1995Developmental Disabilities-HCFA-1995

7.7. Start low and go slowStart low and go slow

8.8. Periodically consider gradual dose Periodically consider gradual dose reductionreduction

9.9. Maintain active treatment Maintain active treatment objectivesobjectives

10.10. Maintain optimal functional statusMaintain optimal functional status

Have a complete history of the Have a complete history of the client. client.

This should include:This should include:• Developmental HistoryDevelopmental History• Psychiatric HistoryPsychiatric History• Medical HistoryMedical History• Psychosocial HistoryPsychosocial History• Behavioral HistoryBehavioral History• Family HistoryFamily History

(context, context, context)(context, context, context)

Rule out other causesRule out other causes(medical, environmental, (medical, environmental,

behavioral, other)behavioral, other)• Check labsCheck labs

• Look at patternLook at pattern

• BrainstormBrainstorm– GallbladderGallbladder– MenopauseMenopause– HeadacheHeadache– Gynecologic issuesGynecologic issues

Behavioral AssessmentBehavioral Assessment

• Functional AnalysisFunctional Analysis

• Functional AssessmentFunctional Assessment

Having a psychologist skilled in Having a psychologist skilled in behavioral thinking on your behavioral thinking on your multidisciplinary team is extremely multidisciplinary team is extremely important.important.

Collect baseline dataCollect baseline data

• What is different now and when did it change?What is different now and when did it change?– Examples of intensityExamples of intensity– Ideas of frequencyIdeas of frequency

– Use any forms you wantUse any forms you want•SleepSleep•MensesMenses•Bowel movementsBowel movements• Ins and OutsIns and Outs

State a Reasonable State a Reasonable HypothesisHypothesis

• Look for an identifiable patternLook for an identifiable pattern

• Identify target signs and symptoms Identify target signs and symptoms that you expect to change with that you expect to change with medicationmedication

Intervene in the least Intervene in the least intrusive and most intrusive and most positive waypositive way

• Try behavioral approaches first,Try behavioral approaches first,

• Address medical issues first,Address medical issues first,

• Make environmental changes first,Make environmental changes first,

Before giving and treating a psychiatric Before giving and treating a psychiatric labellabel

Start low and go slowStart low and go slow

• Goal of achieving symptom Goal of achieving symptom resolution with the lowest effective resolution with the lowest effective dose.dose.

A different twist on least restrictive A different twist on least restrictive alternativealternative

Monitor for Adverse Drug Monitor for Adverse Drug Reactions (ADRs)Reactions (ADRs)

Drug combinations risk increased side Drug combinations risk increased side effectseffects

• DiarrheaDiarrhea

• HeadacheHeadache

• UnsteadinessUnsteadiness

• Anything differentAnything different

Collect outcome dataCollect outcome data

If there is no demonstrable If there is no demonstrable improvement with a particular improvement with a particular

medication, medication,

DON’T CONTINUE TO USE ITDON’T CONTINUE TO USE IT

Periodically consider Periodically consider gradual dose reductiongradual dose reduction

• Radical ConceptRadical Concept

Maintain active Maintain active treatment objectivestreatment objectives

• Is the individual’s learning of new Is the individual’s learning of new skills improving, deteriorating, or skills improving, deteriorating, or staying the same.staying the same.

Maintain optimal functional Maintain optimal functional statusstatus

• Use adaptive functioning scales as Use adaptive functioning scales as

part of your monitoring process.part of your monitoring process.

Evidence Based PracticeEvidence Based Practice

• ImpliesImplies– Randomized-matched populationRandomized-matched population– Placebo Controlled Placebo Controlled – Double-blindedDouble-blinded

Therefore Therefore GeneralizableGeneralizable

MI/ID populations tend to MI/ID populations tend to be:be:

• Very heterogeneousVery heterogeneous

• Very medically and behaviorally Very medically and behaviorally involvedinvolved

• Compromised when it comes to Compromised when it comes to informed consentinformed consent

• Socially vulnerable-easily coercedSocially vulnerable-easily coerced

Therefore, when it comes to Therefore, when it comes to psychiatric treatment in psychiatric treatment in

MI/ID: MI/ID:

• Best Practice is very dependant on Best Practice is very dependant on – Consensus opinionConsensus opinion– Case StudiesCase Studies

There has got to be a better There has got to be a better way:way:

• Single subject research designSingle subject research design– Study the trajectory of the individualStudy the trajectory of the individual– Develop a theory of the caseDevelop a theory of the case– Define measurable target symptoms on Define measurable target symptoms on

which data can be collected (sleep, which data can be collected (sleep, weight, aggression, property destruction, weight, aggression, property destruction, disruption, disorganized behavior, threats)disruption, disorganized behavior, threats)

– Observe whether the target symptoms Observe whether the target symptoms change with medication intervention-change with medication intervention-measure outcomemeasure outcome

– Prove or disprove your theoryProve or disprove your theory

Unfortunately:Unfortunately:

• Community Medicaid pays for time Community Medicaid pays for time spent face to face with a patientspent face to face with a patient– Doesn’t allow for the extensive Doesn’t allow for the extensive

collateral information collection and collateral information collection and collaboration necessary to provide a collaboration necessary to provide a best practice model of care.best practice model of care.

DDA Administration Home and DDA Administration Home and Community Based Waiver may be Community Based Waiver may be

helpfulhelpful

““As neurochemistry continues to As neurochemistry continues to expand its base of understanding, it expand its base of understanding, it may be possible that in the future may be possible that in the future

there will be no such dual diagnosis. there will be no such dual diagnosis. Mental illness may be no more than Mental illness may be no more than a developmental disability in which a developmental disability in which 35 % of the patients are mentally 35 % of the patients are mentally

retarded and there is only one retarded and there is only one diagnosis with multiple diagnosis with multiple

manifestations.”manifestations.”

Frank P. Bongiorno, MDFrank P. Bongiorno, MDhttp://www.sma.org/smj/96dec2.htmhttp://www.sma.org/smj/96dec2.htm

A young, nonverbal man with severe to A young, nonverbal man with severe to profound mental retardation presents to the profound mental retardation presents to the emergency room with the new, self abusive emergency room with the new, self abusive

behavior of slapping his face on the left behavior of slapping his face on the left cheek area repeatedly with great intensity. cheek area repeatedly with great intensity. He is triaged to psychiatry because of his He is triaged to psychiatry because of his

aberrant behavior….aberrant behavior….

A visual exam of his mouth reveals A visual exam of his mouth reveals obvious dental caries. An X-ray is obvious dental caries. An X-ray is

obtained with great difficulty due to obtained with great difficulty due to the patientthe patient’’s agitation. Multiple s agitation. Multiple

abscesses are seen.abscesses are seen.

The behavior resolves completely The behavior resolves completely after the abscessed teeth are pulled after the abscessed teeth are pulled

and the patient is treated with and the patient is treated with antibiotics. (The psychiatrist suffers antibiotics. (The psychiatrist suffers vocal cord stress secondary to the vocal cord stress secondary to the “discussion“discussion”” required to get this required to get this patient seen by individuals who patient seen by individuals who

could diagnose and treat his could diagnose and treat his problem.)problem.)

A woman with mental retardation has A woman with mental retardation has spent most of her life in an institution. In spent most of her life in an institution. In

her late thirties, she is discharged to a her late thirties, she is discharged to a group home in the community where she group home in the community where she

lives with eleven other disabled lives with eleven other disabled individuals. Her discharge medications individuals. Her discharge medications include Phenobarbital and Dilantin for a include Phenobarbital and Dilantin for a seizure disorder. She has taken these seizure disorder. She has taken these

medications as long as anyone can medications as long as anyone can remember for seizures diagnosed in remember for seizures diagnosed in

childhood. Her behavior quickly becomes childhood. Her behavior quickly becomes problematic in the group home. problematic in the group home.

There are frequent pseudo seizures There are frequent pseudo seizures (documented by telemetry) that (documented by telemetry) that

appear to be attention seeking. She appear to be attention seeking. She exhibits low frustration tolerance exhibits low frustration tolerance being unable to tolerate minor being unable to tolerate minor

delays or disappointments without delays or disappointments without tantrums and/or becoming tantrums and/or becoming

aggressive toward staff and other aggressive toward staff and other clients. Her behavior escalates to clients. Her behavior escalates to

the point that hospitalization is the point that hospitalization is required. required.

While hospitalized, she is begun on While hospitalized, she is begun on Depakote and Phenobarbital is gradually Depakote and Phenobarbital is gradually

tapered. Her behavior improves tapered. Her behavior improves dramatically. Upon discharge, she is placed dramatically. Upon discharge, she is placed in a supervised apartment with a roommate in a supervised apartment with a roommate

and attends a day program as before. and attends a day program as before.

A year later, few staff remember that she A year later, few staff remember that she ever had a problem with aggressive ever had a problem with aggressive

outbursts. She is invited to speak at a outbursts. She is invited to speak at a program about community living for the program about community living for the developmentally disabled as a model of developmentally disabled as a model of

success.success.

http://www.mh.state.oh.us/index-dept.html

http://www.sma.org/smj/96dec2.htm

http://www.psychiatry.com/mr/assessment.html

http://psychiatry.com/mr/