[ORIGINAL RESEARCH]
Toward Impacting Medical and Psychiatric Comorbidities in Persons with Intellectual/ Developmental Disabilities: FUNDING: No funding was provided. FINANCIAL DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article. ADDRESS CORRESPONDENCE TO: Paulette Marie Gillig, MD, PhD, Professor, Wright State University, Department of Psychiatry, 627 Edwin C. Moses Boulevard; Dayton, OH 45417; Email: [email protected] KEY WORDS: Intellectual disability, developmental disability, dual diagnosis, behavioral support, psychotherapy
An Initial Prospective Analysis by JULIE P. GENTILE, MD; PAULETTE MARIE GILLIG, MD, PhD; KELLY STINSON, MD; and JEREMY JENSEN, MD Dr. Gentile is Professor, Department of Psychiatry, Wright State University, Dayton, Ohio; Dr. Gillig is Professor, Department of Psychiatry, Wright State University, Dayton, Ohio; Dr. Stinson is Administrative Chief Resident, Department of Psychiatry, Wright State University, Dayton, Ohio; and Dr. Jensen is Staff Psychiatrist, Scott Air Force Base, 375 MDOS/SGOW. Innov Clin Neurosci. 2014;11(11–12):22–26
ABSTRACT Objective: The purpose of this study was to determine the effectiveness of psychiatric medical services, counseling, and behavioral treatments for adult patients with intellectual disabilities plus behavioral disorders and/or emotional distress. Methods: Behavioral and medical data were collected at six and 12 months for a consecutive series of 141 adult patients with mild, moderate, or severe/profound intellectual disabilities who had been referred to a dual diagnosis mental health clinic, and treatment outcomes were compared. Results: Most improvement in behavioral problem severity occurred at six months, then plateaued. Treatment improvement for subjects with anxiety disorders was statistically significant across all interventions. In this sample, as expected, patients with intellectual disability had higher incidences of medical illnesses than the general population. Conclusions: Subjects with more
22
Innovations in CLINICAL NEUROSCIENCE
behavioral (overt) symptoms tended to receive referrals for behavioral support, and subjects with less overt symptoms were referred to counseling. In a follow-up study, similar individuals with moderate intellectual disabilities will be seen psychiatrically, but then randomly assigned to either supportive counseling or behavior support, or both. They will be followed prospectively, to determine the relative benefits of supportive psychotherapy, behavior support, or a combination, and for what duration of time the treatment should be continued.
INTRODUCTION The purpose of this study was to determine the relative effectiveness at six and 12 months of psychopharmacologic, counseling, and behavioral interventions for a sample of 141 adult patients with mild, moderate, or severe/profound intellectual disability (ID), who had been referred to a dual diagnosis
[VOLUME 11, NUMBER 11–12, NOVEMBER–DECEMBER 2014]
mental health clinic (mental illness and/or behavioral disturbances persons with ID). In addition, the relative frequencies of selected medical disorders among this patient sample were compiled and contrasted with rates in the general population. The particular clinical population that was chosen for this study was selected because persons with ID often are referred for psychiatric evaluation due to behavioral disturbance, and these behaviors can occur for a number of medical and psychological reasons. One area of concern for the psychiatrist is that behavioral disturbances can be related to undiagnosed medical conditions,1,2 or to complications or side effects from medications. Appropriate diagnosis and treatment are important, because as medical care for individuals with ID has improved over the years, individuals who have more severe cognitive deficits and who require increased dependency on community supports still have shortened lifespans compared to persons with mild to moderate ID, who are more likely to live to adulthood.3–6 Individuals with ID experience the full range of psychiatric disorders at rates higher than the general population.7 Many psychiatric disorders are misdiagnosed, under-diagnosed, or undiagnosed in this population, often because the ID symptoms overshadow (“diagnostic overshadowing”) other mental health symptoms and the clinician cannot “see” the other aspects of the patient’s presentation. From the limited data available, it appears that depressive disorders and anxiety disorders are under-diagnosed, although psychotic disorders are overdiagnosed. The co-occurrence of ID and mental illness, referred to as a “dual diagnosis,” is common. It is estimated that as many as 30 to 40 percent of persons with ID are dually diagnosed.
METHODS This study is a confidential review of data collected from a consecutive sample of 141 individuals with ID who attended an outpatient clinic over a
one-year period, and who had been referred for psychiatric consultation by other clinicians. Data were analyzed by frequency counts, means, standard deviations, chi-square comparisons where appropriate, and one-way analysis of variance (ANOVA) including a repeated-measures analysis for subject weight at beginning and the end of the one-year time period. The study design was reviewed and approved by a university institutional review board (full review), as well as the superintendent and board of directors of the county board of developmental disability services and by the board of directors of the agency. All of the individuals in the study were followed over a 12-month period by a psychiatrist and a nurse. Some also had been referred for behavioral support, others were referred for counseling, and some received both. In this initial study, individuals had not been referred to these behavioral treatments on a random basis, but instead on the basis of a needs assessment by the psychiatry service and treatment team. Data were collected on outcomes for these interventions in order to get information about relative effectiveness of the various interventions depending on level of ID and behavioral/emotional symptoms and signs. Psychiatry medication-somatic program (all patients). Psychiatric diagnoses were made by a boardcertified psychiatrist; medical diagnoses were collected from the medical charts and also on the basis of a medical screening by a registered nurse. At the time of intake to the Medication-Somatic Program each subject received the following measures: outpatient nursing assessment, including vital signs, allergies, medication side effects, mood, assessment of thought patterns, orientation, and other physical signs and symptoms; psychiatric diagnostic assessment, including reason for referral, living situation, social information, education, employment and legal history, medical history,
[VOLUME 11, NUMBER 11–12, NOVEMBER–DECEMBER 2014]
previous mental health treatment, current medications, current symptoms and problems, behavioral observations and mental status examination, and diagnoses; Abnormal Involuntary Movement scale (AIMS);8 list of current medications; and orders for any continued medications or medication changes. Patients were seen monthly or quarterly for 30 minute appointments by the nurse and/or the psychiatrist throughout the period of the study, depending on medical stability. Behavior support program (by referral). Initial behavioral “problem severity” was rated by the clinic director (master’s level social worker) on the basis of the psychiatric history and available chart material, and ranked accordingly on the Problem Severity Scale.9 Subjects who received the additional behavioral support were enrolled in a program that assessed and attempted to modify behavior using reinforcement and incentive principles. No aversive interventions were utilized in this program. The identified target behaviors were monitored daily and documented. An individualized design was created for each patient to fit specific needs and symptoms/behaviors. Supportive psychotherapy program (by referral). Subjects who received supportive psychotherapy were enrolled in a program that provided encouragement, ideas for decreasing mental health symptoms, and increased coping skills/strategies. These subjects were seen once or twice weekly. The main focus of this program was teaching patients better coping skills by using techniques such as better identification of feeling states, management of grief and loss, and coping skills to use when feeling angry or frustrated, as well as assignment to a clinical social worker for supportive psychotherapy.1
RESULTS All data analyses were completed using SPSS version 20 and SAS v 9.3. Where appropriate, analyses include one-way ANOVA (weight-change data); chi-square or Fisher’s exact test
Innovations in CLINICAL NEUROSCIENCE
23
(medical and psychiatric conditions within intellectual disability group); and Wilcoxin signed rank test (number of medications at beginning and end of study, AIMS scores beginning and end of study for bipolar, anxiety disorder and psychosis subgroups). Demographic information is summarized in Table 1. Co-occurring medical conditions. An analysis of cooccurring medical conditions among the three ID groups (mild, moderate, severe/profound) revealed the highest frequency of diagnosis of gastroesophageal reflux disease (GERD) among persons diagnosed with mild intellectual disability relative to those with more significant cognitive deficits, which was unexpected. Those with mild ID had a prevalence of 38.1 percent, compared to those with moderate ID (28.6%) or severe/profound ID (28.6%) group (p
Toward Impacting Medical and Psychiatric Comorbidities in Persons with Intellectual/ Developmental Disabilities: FUNDING: No funding was provided. FINANCIAL DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article. ADDRESS CORRESPONDENCE TO: Paulette Marie Gillig, MD, PhD, Professor, Wright State University, Department of Psychiatry, 627 Edwin C. Moses Boulevard; Dayton, OH 45417; Email: [email protected] KEY WORDS: Intellectual disability, developmental disability, dual diagnosis, behavioral support, psychotherapy
An Initial Prospective Analysis by JULIE P. GENTILE, MD; PAULETTE MARIE GILLIG, MD, PhD; KELLY STINSON, MD; and JEREMY JENSEN, MD Dr. Gentile is Professor, Department of Psychiatry, Wright State University, Dayton, Ohio; Dr. Gillig is Professor, Department of Psychiatry, Wright State University, Dayton, Ohio; Dr. Stinson is Administrative Chief Resident, Department of Psychiatry, Wright State University, Dayton, Ohio; and Dr. Jensen is Staff Psychiatrist, Scott Air Force Base, 375 MDOS/SGOW. Innov Clin Neurosci. 2014;11(11–12):22–26
ABSTRACT Objective: The purpose of this study was to determine the effectiveness of psychiatric medical services, counseling, and behavioral treatments for adult patients with intellectual disabilities plus behavioral disorders and/or emotional distress. Methods: Behavioral and medical data were collected at six and 12 months for a consecutive series of 141 adult patients with mild, moderate, or severe/profound intellectual disabilities who had been referred to a dual diagnosis mental health clinic, and treatment outcomes were compared. Results: Most improvement in behavioral problem severity occurred at six months, then plateaued. Treatment improvement for subjects with anxiety disorders was statistically significant across all interventions. In this sample, as expected, patients with intellectual disability had higher incidences of medical illnesses than the general population. Conclusions: Subjects with more
22
Innovations in CLINICAL NEUROSCIENCE
behavioral (overt) symptoms tended to receive referrals for behavioral support, and subjects with less overt symptoms were referred to counseling. In a follow-up study, similar individuals with moderate intellectual disabilities will be seen psychiatrically, but then randomly assigned to either supportive counseling or behavior support, or both. They will be followed prospectively, to determine the relative benefits of supportive psychotherapy, behavior support, or a combination, and for what duration of time the treatment should be continued.
INTRODUCTION The purpose of this study was to determine the relative effectiveness at six and 12 months of psychopharmacologic, counseling, and behavioral interventions for a sample of 141 adult patients with mild, moderate, or severe/profound intellectual disability (ID), who had been referred to a dual diagnosis
[VOLUME 11, NUMBER 11–12, NOVEMBER–DECEMBER 2014]
mental health clinic (mental illness and/or behavioral disturbances persons with ID). In addition, the relative frequencies of selected medical disorders among this patient sample were compiled and contrasted with rates in the general population. The particular clinical population that was chosen for this study was selected because persons with ID often are referred for psychiatric evaluation due to behavioral disturbance, and these behaviors can occur for a number of medical and psychological reasons. One area of concern for the psychiatrist is that behavioral disturbances can be related to undiagnosed medical conditions,1,2 or to complications or side effects from medications. Appropriate diagnosis and treatment are important, because as medical care for individuals with ID has improved over the years, individuals who have more severe cognitive deficits and who require increased dependency on community supports still have shortened lifespans compared to persons with mild to moderate ID, who are more likely to live to adulthood.3–6 Individuals with ID experience the full range of psychiatric disorders at rates higher than the general population.7 Many psychiatric disorders are misdiagnosed, under-diagnosed, or undiagnosed in this population, often because the ID symptoms overshadow (“diagnostic overshadowing”) other mental health symptoms and the clinician cannot “see” the other aspects of the patient’s presentation. From the limited data available, it appears that depressive disorders and anxiety disorders are under-diagnosed, although psychotic disorders are overdiagnosed. The co-occurrence of ID and mental illness, referred to as a “dual diagnosis,” is common. It is estimated that as many as 30 to 40 percent of persons with ID are dually diagnosed.
METHODS This study is a confidential review of data collected from a consecutive sample of 141 individuals with ID who attended an outpatient clinic over a
one-year period, and who had been referred for psychiatric consultation by other clinicians. Data were analyzed by frequency counts, means, standard deviations, chi-square comparisons where appropriate, and one-way analysis of variance (ANOVA) including a repeated-measures analysis for subject weight at beginning and the end of the one-year time period. The study design was reviewed and approved by a university institutional review board (full review), as well as the superintendent and board of directors of the county board of developmental disability services and by the board of directors of the agency. All of the individuals in the study were followed over a 12-month period by a psychiatrist and a nurse. Some also had been referred for behavioral support, others were referred for counseling, and some received both. In this initial study, individuals had not been referred to these behavioral treatments on a random basis, but instead on the basis of a needs assessment by the psychiatry service and treatment team. Data were collected on outcomes for these interventions in order to get information about relative effectiveness of the various interventions depending on level of ID and behavioral/emotional symptoms and signs. Psychiatry medication-somatic program (all patients). Psychiatric diagnoses were made by a boardcertified psychiatrist; medical diagnoses were collected from the medical charts and also on the basis of a medical screening by a registered nurse. At the time of intake to the Medication-Somatic Program each subject received the following measures: outpatient nursing assessment, including vital signs, allergies, medication side effects, mood, assessment of thought patterns, orientation, and other physical signs and symptoms; psychiatric diagnostic assessment, including reason for referral, living situation, social information, education, employment and legal history, medical history,
[VOLUME 11, NUMBER 11–12, NOVEMBER–DECEMBER 2014]
previous mental health treatment, current medications, current symptoms and problems, behavioral observations and mental status examination, and diagnoses; Abnormal Involuntary Movement scale (AIMS);8 list of current medications; and orders for any continued medications or medication changes. Patients were seen monthly or quarterly for 30 minute appointments by the nurse and/or the psychiatrist throughout the period of the study, depending on medical stability. Behavior support program (by referral). Initial behavioral “problem severity” was rated by the clinic director (master’s level social worker) on the basis of the psychiatric history and available chart material, and ranked accordingly on the Problem Severity Scale.9 Subjects who received the additional behavioral support were enrolled in a program that assessed and attempted to modify behavior using reinforcement and incentive principles. No aversive interventions were utilized in this program. The identified target behaviors were monitored daily and documented. An individualized design was created for each patient to fit specific needs and symptoms/behaviors. Supportive psychotherapy program (by referral). Subjects who received supportive psychotherapy were enrolled in a program that provided encouragement, ideas for decreasing mental health symptoms, and increased coping skills/strategies. These subjects were seen once or twice weekly. The main focus of this program was teaching patients better coping skills by using techniques such as better identification of feeling states, management of grief and loss, and coping skills to use when feeling angry or frustrated, as well as assignment to a clinical social worker for supportive psychotherapy.1
RESULTS All data analyses were completed using SPSS version 20 and SAS v 9.3. Where appropriate, analyses include one-way ANOVA (weight-change data); chi-square or Fisher’s exact test
Innovations in CLINICAL NEUROSCIENCE
23
(medical and psychiatric conditions within intellectual disability group); and Wilcoxin signed rank test (number of medications at beginning and end of study, AIMS scores beginning and end of study for bipolar, anxiety disorder and psychosis subgroups). Demographic information is summarized in Table 1. Co-occurring medical conditions. An analysis of cooccurring medical conditions among the three ID groups (mild, moderate, severe/profound) revealed the highest frequency of diagnosis of gastroesophageal reflux disease (GERD) among persons diagnosed with mild intellectual disability relative to those with more significant cognitive deficits, which was unexpected. Those with mild ID had a prevalence of 38.1 percent, compared to those with moderate ID (28.6%) or severe/profound ID (28.6%) group (p
