People with mental retardation and developmental disabilities (MRDD) sometimes display agitation, aggression, or other disruptive behaviors. To calm such patients down, psychiatrists traditionally have relied on sedating medications.
Targeting underlying causes, not merely the troublesome behaviors, however, improves both patients’ conduct and quality of life, specialists in MRDD asserted in a workshop at APA’s annual meeting in New Orleans in May.
An estimated 1 percent of the U.S. population—2.5 million Americans—have an IQ of about 70 or below, noted Susan Stabinsky, M.D., cochair of the workshop and chair of the department of psychiatry at Lincoln Hospital in the Bronx, N.Y. Genetic factors or birth trauma are the primary causes of the disorder. According to DSM-IV-TR, 85 percent of people with MRDD, those whose IQ ranges from about 50 to 70, usually can live and work successfully in the community, either independently or in supervised settings.
Psychiatrists have both pharmacological and psychosocial tools to help people with MRDD, Stabinsky said, but they "need to learn more about MRDD and not shy away from it."
Until recently most psychiatrists felt they had nothing to offer people with MRDD, said Harvey Stabinsky, M.D., J.D., director of education at St. Vincent’s Hospital and Medical Center, Westchester Division, in Harrison, N.Y., and cochair of the workshop with his wife.
Psychiatrists have typically viewed problems in people with MRDD as exclusively behavioral. If people with MRDD were admitted to psychiatric hospitals, they usually received antipsychotic medications to calm them down. Most of these hospitalized individuals were labeled as having schizophrenia. Probably few actually did, Stabinsky said. "It’s almost impossible to diagnose schizophrenia in someone whose MRDD hinders their ability to provide meaningful information," he said.
Until three years ago, St. Vincent’s rarely treated people with MRDD, Stabinsky said. Now it provides both inpatient and outpatient services for them.
Before prescribing medication, psychiatrists need to know what’s going on in the patient’s life, Stabinsky noted. Since few MRDD patients are able to provide good histories, he said, a well-trained caregiver who has known the patient for some time likely will be the best source of information.
"You need to ask caregivers or family members about recent changes, such as lack of appetite, insomnia, increased irritability, new stereotypic behaviors, and other symptoms," he said. While stereotypic behavior increases as intelligence decreases, Stabinsky said, "the aim is to distinguish baseline MRDD behavior from specific targetable psychiatric syndromes."
People with MRDD may become depressed, he said. Some have pronounced mood swings, and some have true obsessive-compulsive disorders. Some, most often those with only mild mental impairment, also use street drugs. "If you can address the new problems and make the depression or obsessions go away," Stabinsky said, "behavior most likely will improve."
The medical comorbidity in the MRDD population also is acute, Stabinsky said, but physicians often give it short shrift.
"We see patients because of their bad behavior," said Michael M. Scimeca, M.D., an associate clinical professor of psychiatry at Mount Sinai School of Medicine. "Our task is to interpret their behavior in terms of what we know about psychiatric illness and to treat it appropriately."
It’s important to find out what prompted the current request for psychiatric evaluation, he said. By visiting the patient’s residence and meeting with staff or family, the psychiatrist can learn which people, places, and circumstances induce troublesome behavior. Staff and family may be able to eliminate or reduce some of these triggers. Some MRDD patients can be taught better ways to manage their own behavior.
If the patient’s words or actions suggest an underlying mood disorder, selective serotonin reuptake inhibitors (SSRIs) often prove helpful. "You generally won’t hear about side effects from the patient," Scimeca said.
Starting with half the usual SSRI dose for a few days and increasing it slowly, he said, often quickly produces a calming effect. Frequently patients who can talk report they feel much better.
Mood stabilizers also may be useful, provided the patient is in a setting where one can readily obtain blood levels to monitor treatment. For patients who can’t swallow pills, lithium carbonate and valproic acid (Depakene) are available as liquids, and divalproex sodium (Depakote) as sprinkles to mix into food. "Many of us fight against the overuse and misuse of antipsychotics," Scimeca said, "but the medications we call antipsychotics, in lower doses, often are very effective in treating mood disorders."
Beta blockers may be useful for patients in whom the line between sel- injurious and destructive behavior is hard to define, he added. Use of beta blockers requires regular monitoring of the patient’s blood pressure.
Primary care physicians who request a psychiatric consultation for someone with MRDD may not know much about psychiatric comorbidity, stated David Preven, M.D., chief of psychiatry at Einstein-Weiler Hospital in the Bronx, N.Y.
Hospitalization of people with MRDD for any reason, Preven said, often prompts disruptive behavior. Sometimes people whose mental age is lower than their chronological age simply feel frightened by being in a strange place or by being ill. Everyone who is sick, he asserted, regresses in the hospital. One needs to adapt the environment to reduce the stress on MRDD patients and have a familiar caretaker stay with them, if possible.
Hospital staff often regard passivity in MRDD patients as good behavior, he said, but passivity may not be in patients’ best interest. If it stems from an underlying mood disorder, patients may hamper their own recovery.
Internet resources can help boost primary care physicians’ knowledge, Preven noted. California’s developmental disabilities Web site, www.ddhealthinfo.org, for example, describes more than 30 conditions associated with developmental disabilities. It also surveys related issues such as early identification of delay and disability, and dealing with nonverbal patients, noncompliance, and sexuality and reproductive health. Other information at the site includes steps to follow in the diagnosis and treatment of a psychiatric disorder in people with MRDD. The site also reports medical conditions that may cause psychiatric symptoms and offers links to resources for families and references for further reading.
Families of MRDD patients living at home often press psychiatrists to prescribe sedating medication to quell disturbing behavior. Not infrequently, patients already are taking high doses of medications such as thioridazine (Mellaril) or haloperidol (Haldol), said Sheldon Travin, M.D., associate director of psychiatry at Lincoln Hospital in the Bronx, N.Y. Lowering doses or using different medications, and getting patients into programs where they can learn better coping behavior, he maintained, often make patients more cooperative and happier than taking more of the highly sedating medications would have done.
One father insisted thioridazine was the only medication that calmed his son, who had been taking this drug for 10 years. After the son switched to divalproex sodium and risperidone, Travin said, the father agreed his son’s behavior improved.
Precision in diagnosis and treatment benefits people with MRDD, Travin said, just as it does everyone else with a psychiatric disorder. ▪