Treating Intellectually Disabled Patients

By Sherman, Carl | Clinical Psychiatry News, May 2008 | Go to article overview

Treating Intellectually Disabled Patients


Sherman, Carl, Clinical Psychiatry News


With increasing numbers of intellectually disabled individuals living in residential settings or with their families, psychiatrists in the community are becoming more involved in their care.

Many are unprepared. "Most psychiatric training programs don't include much experience in this area," said Dr. Mark H. Fleisher, director of the adult community psychiatry division at the University of Nebraska, Omaha.

These patients appear prone to the same spectrum of psychiatric disorders as the general population. "They have subaverage intelligence because their central nervous system has been damaged," Dr. Fleisher said. "Intellectual disability [one of several terms preferred by some for what is still called mental retardation] doesn't convey protection against disorders such as depression, anxiety, or schizophrenia."

The prevalence of some disorders--particularly those that can be related to stress--is in fact higher, said Dr. Edwin J. Mikkelsen of Harvard Medical School, Boston. "The intellectually disabled don't have the reserve that a lot of people in the general population do." An excess of obsessive-compulsive disorder probably "has to do with the desire to bring some control over their environment," he said.

Diagnosis poses challenges. "Even the mildly retarded aren't that verbal," said Dr. David S. Janowsky, professor of psychiatry at the University of North Carolina at Chapel Hill. "You may have to use a lot of inference and listen more carefully." DSM criteria might be difficult to apply or misleading. (A recent volume published by the National Association for the Dually Diagnosed in association with the American Psychiatric Association proposes modified criteria for this population. See box.)

When a psychiatric disorder can be diagnosed, the same drugs are usually indicated as for the general population. Dr. Janowsky generally prescribes a selective serotonin reuptake inhibitor (SSRI) for depression, but the risk of activation makes it particularly important to start at a low dosage and titrate up slowly. An initial 10-mg dose of paroxetine (Paxil), for example, could be increased by 5 mg after 2 weeks, he said. "One-fourth to one-fifth of these patients become much more agitated on an [SSRI]. Things like aggression and self-injurious behavior worsen, and it appears to be dose-related."

This might be the equivalent of a more subtle adverse response in other patients, Dr. Janowsky suggested. "A normally intelligent person may tell you that his thoughts are getting worse, that he's feeling suicidal. If he's autistic, he can't."

For this reason, Dr. Janowsky avoids agents with a long half-life, like fluoxetine. Dr. Mikkelsen also avoids fluoxetine because it seems to be more liable to activate patients. But he has had good experience with fluvoxamine. Citalopram (Celexa) and escitalopram (Lexapro) are less likely to interact with other drugs.

The same SSRI issues arise when treating anxiety. Beyond that, "I'd tend to stay away from benzodiazepines," Dr. Fleisher said. "They sometimes have an idiosyncratic effect, as they do with children."

Dr. Mikkelsen noted that intellectually disabled patients are more likely to be treatment-naive when presenting with anxiety, and more apt to respond to bus-pirone than are patients previously treated with benzodiazepines.

Psychotic patients often display fairly typical schizophrenic symptoms, but in more severely impaired individuals, hallucinations and paranoid delusions might need to be inferred from fearful behavior, irrational irritability, or physically striking out at invisible objects, Dr. Mikkelsen said.

In general, medication management should be tailored to the needs of this group. Issues surrounding education and consent might resemble those that come up when working with children, Dr. Fleisher said. …

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