Treating intellectual disabilities in patients who can’t talk

Psychiatrists treating patients who can’t talk. Sounds fishy, doesn’t it?

Well, I do it 2-3 days per week, and as strange as it may sound, it makes perfect sense.

Let me explain.

I provide psychiatric consultation services in a facility for people with intellectual and developmental disabilities. (Intellectual disability is the newer term for mental retardation). Some of my patients are short-term admissions from the community, and others are long-term residents of the facility. Over the past couple of decades as community living has become the norm, many long-term residents have moved to the community. Those who are left are quite fragile and very medically complex. About 70% have seizure disorders. Most have severe or profound intellectual disabilities and are completely non-verbal. Being dependent on others for assistance with activities of daily living is the norm.

One of the old myths about persons with intellectual disabilities (ID’s) is that they cannot develop mental illnesses. You may have heard the term “dual diagnosis.” Usually that term refers to persons who have both mental illness and substance dependence. However, in the field of developmental disabilities it also refers to persons who have both an intellectual disability and mental illness. Patients with any level of ID, including those with no expressive communication skills, can develop mental illness.

Since these severely intellectually disabled individuals who can’t talk can develop mental illness, how does one determine whether mental illness is present and which diagnosis is most likely?

Not the traditional way that medicine is practiced in the U.S.

It takes a multidisciplinary team approach and careful data collection. Our team is comprised of primary care, psychiatry, nursing, psychology, occupational therapy, physical therapy, speech and language pathology, dietary, pharmacy, social work, Qualified Mental Retardation Professionals, recreational therapy, vocational services, and direct care staff (CNA’s).

The good news is that not only do we have access to all of these disciplines, but every team member is experienced in evaluating and treating intellectually disabled patients who have minimal communication skills.

One of the advantages of being in a system without fee-for-service medicine is that we can seamlessly involve as many disciplines as necessary without having to deal with administrative or reimbursement barriers. For example, as a psychiatrist, I can contribute my expertise (and learn a great deal as well) to cases that do not strictly involve mental illness. And my involvement transcends prescribing psychiatric medications.

When evaluating a new patient, our team will review outside records and then meet with the patient’s stakeholders from the community: parents/guardians, case managers, group home staff, etc. We will all sit around a table together and have an admission staffing meeting, a rare entity in health care these days.

The various disciplines will perform their assessments. If there are problem behaviors identified, then psychology will perform a functional assessment of the behavior. They will collect objective data of the relevant behaviors throughout the patient’s stay.

As a psychiatrist, I rely a great deal on the patient’s history as reported both in outside medical records and at the admission meeting. Then I consider the results of the assessments of the other disciplines with significant attention to the primary care physician’s and psychologist’s workup.

Many behavioral problems in this patient population are caused or exacerbated by non-psychiatric medical issues. Constipation and pain are a couple of common examples. Patients with such issues may begin to exhibit or show an increase in already-present behaviors such as agitation, yelling, aggression, or self-injurious behavior.

It is crucial not to be too quick to make a psychiatric diagnosis–one does not want to make the mistake of treating pain with psychiatric medication, for example.

Once I am able to consider the patient’s history and clinical signs in the context of the other team members’ assessments and objective behavioral data, I determine whether the clinical picture resembles established psychiatric diagnoses. This is where understanding “the art” of psychiatry and having previous experience treating verbal, developmentally normal patients is vital.

The longer I have to work with a patient, the better I am able to make an accurate diagnosis. Sometimes the diagnosis is fairly clear on the day of admission, but in some cases (such as with some of the long-term residents), it may take a couple of years or more.

When I do make a diagnosis, if I believe medication is warranted, then I typically prescribe very cautiously, starting only one medication at a time, using low doses, and making only one change at a time. If psychology wants to try a behavioral intervention, then that is considered a change. If primary care wants to start a medication for pain or reflux, then that is considered a change. Working collaboratively it is usually possible to stick to the “one change at a time” approach.

We all rely on the objective data that psychology tracks combined with each other’s observations of the patient to track the patient’s progress and to guide our treatment. This integrated approach allows me to provide much higher quality psychiatric care than I could in the traditional outpatient setting of the fragmented U.S. health care system.

Jeffrey Knuppel is a psychiatrist who blogs at Lockup Doc, where this post originally appeared.

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  • http://blogs.vnsny.org/ Jeffrey Jue

    It is great to hear that your patients receive their care through a multidisciplinary approach. Often communication or proper treatment can be lacking under a traditional referral or consultation system within many of our health care facilities.

    Based on my current experience working for a long term managed home care company I am in agreement with your views on the benefits of having a multidisciplinary approach.

  • http://www.channahthailand.com Wade

    That must be very challenging and rewarding work when you can make a break through.

  • http://lockupdoc.com Jeffrey Knuppel, MD

    Thanks for your comments thus far.

    Yes–a multidisciplinary approach makes possible much better care. I’ve worked in the office in the community where I’ve had to do it on my own, and with complicated non-verbal patients, it’s a real challenge. And, yes, it is rewarding when we’re able to help. But the work requires lots of patience and comfort with a lot of diagnostic and prognostic ambiguity. Progress can be slow, and one does not see the positive results of his work every day.