‘Back to the Future’: Caring for Mentally Retarded, Psychiatrically Ill Patients

Although mentally retarded, developmentally disabled patients are frequently encountered in psychiatric practice, there appears to be a paucity of targeted preparatory training available to the average psychiatry resident. I have often wondered about the reason for this imbalance. Could it be due to physicians’ attitudes toward this challenging field or the public’s perception of these patients? Might the present trend against institutionalization have influenced our commitment to train residents? Whatever the cause, this training gap helps to perpetuate a cycle wherein psychiatrists lack experience in this area, resulting in few psychiatrists working with these patients. Since I have had the opportunity to work on an inpatient mental retardation unit in my residency program, I view such specialized training from a somewhat different perspective. I feel that this experience provides residents with a fulfilling educational adventure in a field with many challenges and rewards.

Training on a 20-bed, dedicated inpatient unit for mentally retarded (MR) mentally ill patients at Hillside Hospital in New York was a rich learning experience for me. This ward is one of the few acute “short-term” stay psychiatric units in the state of New York devoted to such specialized care, as well as to educating future psychiatrists.

I faced many challenges while working on this special unit, including difficulties communicating with many of the more severely impaired patients. Obtaining a collateral history took on increased significance when evaluating MR patients, analogous to working with geriatric patients with dementia. For instance, a patient with a very low IQ may provide a history with less clarity or fewer details. In contrast, verbal communication by other patients was clear to attuned evaluators and highlighted the need to assess each person individually. In this way, psychiatry residents modified their interviewing skills to obtain an accurate evaluation. We learned to approach MR patients with a somewhat different interviewing technique, looking at cases from “outside the box.”

In addition, residents learn firsthand that teamwork with other mental health professionals is of paramount importance. Collaborating with outside agencies provides residents with experience that helps develop their clinical skills regardless of their future psychiatric career goals. In this vein, communicating with family members and the patient’s caregivers takes on added importance.

These mentally ill MR patients often illustrate a complex overlay of medical, neurologic, and psychiatric illnesses to the resident psychiatrist. Moreover, a multitude of medical illnesses can be observed while working with this patient population segment. These medical comorbidities may influence both the patient’s behavior and the mental illness itself. House staff must keep medical and organic etiologies in mind as part of their differential diagnosis when the patient decompensates.

This rotation provided me with several tools to evaluate developmentally disabled, psychiatrically ill patients, which complemented my preexisting skills. I learned much about safety issues while treating agitated patients, which also served me well when working in other psychiatric settings. I developed teaching abilities to educate the team, families, and patients within such a therapeutic milieu. Lastly, I learned several nonpsychopharmacologic management skills such as cognitive-behavioral strategies to model behavior (such as actually closing a door rather than telling the patient to do so).

While some physicians may view the diagnosis of mentally retarded patients as being time consuming and difficult, I perceive it as an intellectual challenge. For instance, I find it fascinating to differentiate whether a developmentally disabled patient who hears voices is indeed hallucinating or whether this may simply be appropriate to the patient’s developmental stage (such as having an imaginary friend). So not only is it more difficult to get patients to report specific symptoms, but patients often don’t seem to fit neatly into DSM-IV categories. By extension, this can lead to certain difficulties treating and studying these patients as well, when the diagnosis remains somewhat unclear. In this way, psychiatrists learn to cope with the double hurdle of making a somewhat uncertain diagnosis and subsequently choosing the most appropriate therapeutic option.

Due to these dilemmas, there is a dearth of research pertaining specifically to mentally retarded, psychiatrically ill patients. This deficiency of hard evidence leads to myriad challenges in treating this population. As such, the standards of psychopharmacology established on non-MR patients are extended without knowing whether the conclusions are applicable and generalizable to mentally retarded patients. Where else can residents better learn the interaction of environment and behavior with pharmacological methods of treatment? This experience has fostered my interest in such issues. While residents may become frustrated with this lack of specific data, they learn how to be flexible in their approach. As a result they use the art of medicine to complement the science by relying more on clinical skills and intuition. This is reminiscent of the bygone days of psychiatry when psychiatrists were perhaps guided more by the art than the science of medicine.

I feel strongly that this educational experience in the field of mental retardation has been invaluable to my psychiatric training. I also feel better prepared and willing to care for mentally retarded patients. This experience has fostered my interest in doing so, one that I may not have developed if I had not completed this rotation.

As in the adage, “see one, do one, teach one,” I hope to impart this training to others as I develop my career. I hope that as time marches on, we will go “back to the future” by offering more residents training specifically in the art (while developing the science) of working with mentally retarded patients. ▪

Dr. Reinblatt is chief resident at Long Island Jewish-Hillside Hospital in New York City and the Area 1 member-in-training representative to the APA Assembly.