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Towards a best practice model

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

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Towards a best practice model

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  1. Developing Best Practice Guidelines for Treating People with Co-OccurringMental IllnessandMental RetardationIntellectual DisabilityThe Basis for Models of Treatment

  2. Lisa S. Hovermale, MDMaryland Department of Health and Mental HygieneLiaisonMental Hygiene AdministrationDevelopmental Disabilities Administrationlhovermale@dhmh.state.md.us

  3. Towards a best practice model of diagnosing mental illness and prescribing psychotropic medications in individuals with mental retardation /intellectual disability

  4. Overview • History Of Issues In Mental Retardation • Definitions of MR vs. DD • Diagnostic Issues • Treatment Strategies • Infrastructure Issues

  5. The History of Psychiatry and Mental Retardation A Story of Mutual Rejection

  6. The Tragic Interlude Frank Menolascino, MD

  7. There is a belief that individuals with mental retardation can not have mental illness.

  8. 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

  9. Developmental DisabilitiesDD Mental Retardation MR Pervasive Developmental Delay PDD

  10. 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

  11. 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

  12. 10 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

  13. Prevalence 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

  14. 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

  15. Intellectual Disability may be the term of the future

  16. American Association on Mental Retardation ClassificationsBased on supports needed • Intermittent • Limited • Extensive • Pervasive www.aamr.org

  17. 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) Mental Retardation (Intellectual Disability)is a big umbrella.It covers many sub-populations. Behavioral Phenotypes

  18. 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)

  19. 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.

  20. 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

  21. 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

  22. Axis V • Global assessment of functioning • Current • Highest within the last year Mental Health Aspects of Developmental Disabilities-2001, volume 4, number1

  23. General 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

  24. General Safety Precautions in Prescribing for individuals with MR/MI-cont.Safety Precautions for Persons with Developmental Disabilities-HCFA-1995 • Start low and go slow • Periodically consider gradual dose reduction • Maintain active treatment objectives • Maintain optimal functional status

  25. 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)

  26. Rule out other causes(medical, environmental, behavioral, other) • Check labs • Look at pattern • Brainstorm • Gallbladder • Menopause • Headache • Gynecologic issues

  27. Behavioral Assessment • Functional Analysis • Functional Assessment • Having a psychologist skilled in behavioral thinking on your multidisciplinary team is extremely important.

  28. 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

  29. State a Reasonable Hypothesis • Look for an identifiable pattern • Identify target signs and symptoms that you expect to change with medication

  30. 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

  31. Start low and go slow • Goal of achieving symptom resolution with the lowest effective dose. A different twist on least restrictive alternative

  32. Monitor for Adverse Drug Reactions (ADRs)Drug combinations risk increased side effects • Diarrhea • Headache • Unsteadiness • Anything different

  33. Collect outcome data If there is no demonstrable improvement with a particular medication, DON’T CONTINUE TO USE IT

  34. Periodically consider gradual dose reduction • Radical Concept

  35. Maintain active treatment objectives • Is the individual’s learning of new skills improving, deteriorating, or staying the same.

  36. Maintain optimal functional status • Use adaptive functioning scales as part of your monitoring process.

  37. Evidence Based Practice • Implies • Randomized-matched population • Placebo Controlled • Double-blinded Therefore Generalizable

  38. MI/ID populations tend to be: • Very heterogeneous • Very medically and behaviorally involved • Compromised when it comes to informed consent • Socially vulnerable-easily coerced

  39. Therefore, when it comes to psychiatric treatment in MI/ID: • Best Practice is very dependant on • Consensus opinion • Case Studies

  40. 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

  41. 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

  42. “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, MDhttp://www.sma.org/smj/96dec2.htm

  43. 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….

  44. 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.

  45. 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.)

  46. 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.

  47. 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.

  48. 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.

  49. 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

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