Prevalence and patterns of psychotropic medication use by adults with mental retardation living in community settings

We examined the prevalence and patterns of psychotropic medication use among adults with mental retardation living in community settings. The sample included 97 adults who were receiving psychotrophic medication and for whom the use of psychotropic medication is not federally regulated or monitored. Variables included demographics, diagnoses psychotropic medications, and challenging behavior. Sixty two percent of the clients had no psychiatric diagnosis documented in the confidential folder and 31% had no psychiatric or psychological evaluation documented in the confidential folder. Neuroleptics were prescribed for 89% of the clients and continuous use ranged from 2 months to 28 years. Five percent of the clients were receiving interclass polypharmacy and 46% were receiving interclass polypharmacy (two to five medications excluding anticonvulsants). Medication reduction programs were reported for 5% of the clients and 9% participated in an interdisciplinary medication review and monitoring process. Eighteen percent of the prescribing physicians provided a written list of potential side effects to the client or an appropriate representative of the client, and 7% ensured that the written list was signed by the client or an appropriate representative of the client. While challenging behavior was reported for 85% of the clients, only 7% had a formal behavior management plan, and behaviors were measured systematically in terms of frequency or intensity for 17% of the clients. The results of the study revealed a notable absence of recognized guidelines for use of psychotropic medication for the 97 clients examined. Implications regarding Hawaii's system of care for persons with mental retardation, psychiatric diagnoses, and challenging behavior are addressed.     

Effects of drug changes and physician prescribing practices on the behavior of persons with mental retardation

Psychoactive drugs are often prescribed to control challenging behaviors of individuals with mental retardation. We examined the effects of drug changes and physician’s prescribing behavior on the aggressive and collateral behaviors of three individuals with severe and profound mental retardation. Despite repeated drug changes over the course of 2 years, no decrease in aggression was observed for any of the three subjects. In fact, with one of the clients (X.W.) aggression was more problematic after two years of attempted pharmaceutical control. Observed confounds to assessing behavior control included: the lack of withdrawal phases; unsystematic dosage manipulations; potential history and maturational effects; polypharmacy; and unreliable qualitative measures. Future psychopharmacological research should include the prescribing behavior of physicians as an ecobehavioral variable that may impact treatment outcome.     

Assessment of Schizophrenia in Persons with Severe and Profound Mental Retardation Using the Diagnostic Assessment for the Severely Handicapped-II (DASH-II)

The identification and diagnosis of schizophrenia in persons with severe and profound mental retardation has been a controversial issue. Although it has been established that schizophrenia occurs in this clinical population, persons with odd behaviors characteristic of mental retardation or severe behavior disturbances are often diagnosed with schizophrenia and treated with traditional or atypical antipsychotic medications. The present study assessed schizophrenia in a sample of persons with severe and profound mental retardation using the Diagnositic Assessment for the Severly Handicapped-II (DASH-II), a rating scale which contains purely behavioral criteria that are essential features of various DSM-IV disorders. Three groups of participants were compared; (a) those with an independent psychiatric diagnosis of schizophrenia and a significant elevation on the schizophrenia subscale of the DASH-II; (b) those with a significant elevation on this subscale, but no formal diagnosis of schizophrenia; and (c) controls without any elevation of the DASH-II subscales. Results indicated that the three groups were empirically distinguished across the frequency, duration, and severity dimensions of the DASH-II schizophrenia subscale. Item analyses demonstrated that individuals with a diagnosis of schizophrenia and an elevation of the subscale had higher scores on items containing verbal symptoms of the disorder. Implications of these findings are discussed with respect to the diagnosis of schizophrenia in persons with severe and profound mental retardation, with particular emphasis on the efficacy of the DASH-II for assessing the disorder.     

The Relationship Between Challenging Behavior and Symptoms of Depression in Intellectually Disabled Adults with and without Autism Spectrum Disorders

The presence of an intellectual disability (ID) is associated with the presence of co-occurring psychiatric diagnoses, and challenging behavior. Autism spectrum disorders (ASDs) and other comorbid psychopathologies are also commonly–observed in this population. Behavioral profiles of depression may help clinicians to detect depression in individuals with ID. In this study of 332 adults with intellectual disability, we found a significant association between symptoms of depression in those with ASD, PDD-NOS, and those with an ID and no ASD. Aggressive/destructive behavior and stereotyped behavior was significantly predictive in all conditions, but self-injurious behavior appears to be a useful predictor only in those with an ASD. Diagnosticians should consider the possibility of a depressive disorder when individuals with an ID present with challenging behavior.     

A Comparison of Social and Adaptive Functioning in Persons with Psychosis, Autism, and Severe or Profound Mental Retardation

Despite the findings that persons with mental retardation are several times more likely to experience mental health disorders than are persons of normal intelligence, relatively little is known about the nature of these disorders and related social and adaptive deficits. This situation is especially true for persons with severe and profound impairment who experience psychotic disorders. The purpose of this research was to examine the adaptive and social behavior of individuals with severe and profound mental retardation (MR) who are diagnosed with a psychotic disorder. Scores on measures of adaptive and social behavior for these individuals were compared to those of 2 other groups, both of whom had severe or profound MR, and who experienced mental health conditions commonly confused with psychotic disorders (e.g., autism/PDD, nondiagnostic behavior problems). Individuals in the psychotic disorders group displayed significantly higher levels of some social and many adaptive skills than did individuals in both control groups, with the most striking differences appearing between the psychotic disorders and autism/PDD groups. Results underscore the need to consider social and adaptive variables during the diagnostic and treatment planning process.     

Psychopathology in Adults with Mental Retardation Before and After Deinstitutionalization

In a pilot study, the presence of psychopathology in 47 individuals with co-occurring mental retardation and psychiatric disturbance was examined before and after their move from the last remaining state institution for persons with mental retardation in Vermont. These persons, identified in previous literature as the least likely to succeed in community placements, experienced reduced psychopathological symptomatology and appeared to be served equally well in a variety of small-scale community residences irrespective of their care providers' prior experience. Individuals under 50 years of age showed significant psychiatric improvement while those older tended to remain unchanged. These preliminary findings appear to support the viability of a community-based service model using small residences for all persons with mental retardation regardless of their need for mental health care.     

误诊为精神障碍的抗N-甲基-D-天冬氨酸受体脑炎43例分析

目的:探讨误诊为精神障碍的抗N-甲基-D-天冬氨酸受体（N-methyl-D-aspartate-receptor;NMDAR）脑炎患者的临床特征,提高早期诊断率,减少误诊。方法:收集2012年至2018年在郑州大学第一附属医院确诊的抗NMDA受体脑炎患者的临床资料,筛选出误诊为精神障碍疾病的患者,回顾性分析其精神症状特征、病程特点、影像学及实验室检查结果,治疗及预后情况。结果:共收集121例确诊为抗NMDA受体脑炎患者,筛选出误诊为精神障碍的43例。43例患者中,16例（37.2％）存在前驱症状,所有患者均有精神行为异常（100％）,其中癫痫发作32例（74.4％）、意识水平下降13例（30.2％）、不自主运动21例（48.8％）、记忆力下降15例（34.9％）、言语功能障碍8例（18.6％）、其他神经系统症状（中枢性低通气、自主神经功能障碍）8例（18.6％）,各种不同症状可能在同一患者身上同时或相继出现,症状完全缓解或只留下轻微肢体障碍者38例,遗留精神异常和癫痫发作反复入院者5例,复发率占11.6%（5/43）。结论:抗NMDA受体脑炎临床表现复杂多样,多数以精神行为异常为首发症状,极易误诊为精神障碍,延迟治疗会导致病程延长,预后不良。     

A Descriptive Study of Pica Behavior in Persons with Mental Retardation

Individual variables of 45 persons residing in an institutional setting who displayed pica behavior were studied. Included in the analysis were the demographics of the sample, the types of materials being ingested, the sample's psychiatric diagnoses, and social skills deficits in persons with pica. Pica was prevalent in all age ranges of lower functioning clients with mental retardation. Furthermore, subjects in the study engaged in pica for predominantly nonsocial reasons (automatic reinforcement). Persons who displayed the mental disorders of pica, autism, and stereotypic movement disorder were more likely to exhibit pica. Implications of these results are discussed.     

Dual diagnosis screening: preliminary findings on the comparison of 50 clients attending community mental health services and 50 clients attending community substance misuse services

While dual diagnosis research has often focussed on substance misuse disorders among mental health clients, relatively little is known about comparable rates of dual diagnosis in community mental health and substance misuse settings because of, inter alia, limitations and lack of consistency in screening. In the current study clinicians administered a brief screening tool, which detects problematic alcohol, drug use, psychosis and common mental health symptoms, to 50 substance misuse and 50 mental health treatment attenders. Sixty-four per cent of the total sample screened positive for dual diagnosis (positive for any psychiatric disorder and either a drug or alcohol problem). Highest rates were observed in the alcohol sample (92.3%), followed by the drug sample (87.5%), and lowest in the community mental health (CMHT) sample (38%). Current depression and social phobia were most prevalent in alcohol clients compared to psychosis, mania and suicidal ideation in CMHT clients. Around one-third of CMHT clients reported using drugs (mainly cannabis) and around a fifth reported problematic alcohol use. The study demonstrates the feasibility of incorporating a dual diagnosis screen into routine clinical practice. The screen can be used in both mental health and substance misuse treatment settings, which are evidently managing complex client caseloads.     

Classification and Diagnosis of Psychiatric Disorders in Persons with Developmental Disabilities

This article presents a brief historical overview of psychiatric diagnosis in persons with developmental disabilities, including a review of the relationship between applied behavior analysis and dual diagnosis. The purposes of diagnosis are then outlined. The definitions of developmental disabilities, mental disorder, and dual diagnosis are reviewed and some of the problems when making a psychiatric diagnosis in persons with developmental disabilities are discussed. Special attention is given to the problem of diagnosing mental retardation in persons with mild through borderline mental retardation and to the problem of diagnosing psychiatric disorders in persons with severe and profound mental retardation. Finally, an overview of common issues in the process of collecting and combining information to make a psychiatric diagnosis in persons with developmental disabilities is given.     

Mental health services for persons with mental retardation: role of the advanced practice psychiatric nurse

The term dual diagnosis is frequently used by mental health professionals to refer to people who have mental illness complicated by substance abuse. A less commonly recognized population are those individuals who have the dual diagnosis of mental retardation and mental illness. In this paper the author discusses (1) the mental health needs of persons with mental retardation and (2) the current state of services for them. There is a significant lack of appropriately trained professionals to help address the needs of this population. Traditionally, nurses have primarily been identified as providers of physical care. Advanced practice psychiatric nurses, however, are an underutilized group of professionals who have the capacity to assume a leadership role in clinical care, service coordination, and advocacy for individuals and families affected by mental illness and mental retardation.     

MENTAL HEALTH SERVICES FOR PERSONS WITH MENTAL RETARDATION: ROLE OF THE ADVANCED PRACTICE PSYCHIATRIC NURSE

The term dual diagnosis is frequently used by mental health professionals to refer to people who have mental illness complicated by substance abuse. A less commonly recognized population are those individuals who have the dual diagnosis of mental retardation and mental illness. In this paper the author discusses (1) the mental health needs of persons with mental retardation and (2) the current state of services for them. There is a significant lack of appropriately trained professionals to help address the needs of this population. Traditionally, nurses have primarily been identified as providers of physical care. Advanced practice psychiatric nurses, however, are an underutilized group of professionals who have the capacity to assume a leadership role in clinical care, service coordination, and advocacy for individuals and families affected by mental illness and mental retardation.     

Community Habilitation and Integration of Adults with Psychiatric Disorders and Mental Retardation: Development of a Clinically Responsive Environment

Ten individuals with mental retardation and psychiatric disorders who failed in their community placements due to aggression, property destruction, and suicidal ideation were provided an environment emphasizing a network of mental health and developmental disabilities services. The focus of programing was the application of psychiatric rehabilitation principles and environmental behavior support strategies. Components of the treatment model included goal-setting, comprehensive case management, social skills training, positive reinforcement, crisis intervention, competency-based skills teaching, medication monitoring, data-based outcome measurement, and community-living arrangements. Results indicated that in contrast to their preintervention status, all individuals demonstrated significant reductions in targeted behaviors, maintained extended placement within the community without emergency hospitalizations, developed effective and adaptive social skills, secured job placement, and reported satisfaction with their quality of life.     

Dual Diagnosis: Examination of Service Use and Length of Stay During Psychiatric Hospitalization

Anecdotal reports suggest that persons with a dual diagnosis (mental retardation and psychiatric illness) admitted to acute psychiatric hospitals stay longer and require more services than individuals without mental retardation. To test these hypotheses, a questionnaire was completed for 64 people with dual diagnosis admitted to 10 psychiatric hospitals over 3 months. Multivariate analysis revealed that a diagnosis of mental retardation was not a predictor of length of stay. Use of 1-to-1 staffing was more likely, while arrangement of different community placement at discharge was less likely for persons with than without dual diagnosis. Additionally, age, diagnosis, symtomatology, living arrangement, insurance status, and service use distinguished the patient groups. Implications are discussed in the context of a need for further examination and training focused toward this population.     

A preliminary investigation into the experience of symptoms of psychosis in mental health professionals: implications for the psychiatric classification model of schizophrenia

The psychiatric classification system regarding the discrete category of schizophrenia remains controversial. Key concerns regarding the legitimacy of the classification system for this presentation focus on issues of study design, the relevance and inter-relationship between symptom clusters and the lack of a coherent model of aetiology. A defining summary feature of the psychiatric model is the distinctiveness of psychotic symptoms in those with a diagnosis of schizophrenia compared with non-clinical samples. The current study sought to challenge the prevailing psychiatric system by exploring the occurrence and experience of psychotic symptoms in mental health practitioners who routinely engage in therapeutic work with clients with a primary diagnosis of schizophrenia. A total of 16% ( n  = 19) of the sample indicated that they experienced voice hearing while 21% ( n  = 26) indicated they experienced delusions as assessed by validated assessment tools. The findings are indicative of a continuum model of psychotic symptom experience and run counter to the contemporary model of psychiatric classification of this disorder. The direction of future research is indicated.     

山东省聊城市第三次精神疾病流行病学调查

目的:了解聊城市≥18岁人群各类精神疾病的患病水平、分布特征、致残情况,掌握近三十年来精神疾病流行的动态资料。方法:采用多阶段分层整群随机抽样方法,对聊城市≥18岁的人群进行入户调查。使用一般健康问卷将调查对象分为患精神疾病高、中、低危险组,以DSM-IV轴Ⅰ障碍用临床定式检查量表、美国精神学会诊断手册第四版和精神发育迟滞/痴呆诊断量表为诊断工具,依次对高危组中的100%,中危组中的40%,低危组中的10%为调查对象进行定式检查,对各类精神障碍进行诊断。结果:4788人完成筛选,1568例完成诊断。精神疾病终生患病率为15.10%,现患病率为14.20%,最常见的疾病为心境障碍、酒精使用障碍和焦虑障碍。男性高于女性,且以40～55岁年龄组发病率最高。结论:聊城市精神疾病患病率明显上升,已成为常见病和迫切需要解决的重大公共卫生问题。     

The impact of nurses' opinion of client behaviour and level of social functioning on the amount of time they spend with clients

The impact of nurses' opinion of client behaviour and level of social functioning on the amount of time they spend with clients For people afflicted with different kinds of psychiatric disorder, suffering is a common denominator. The time the nurses spend with psychiatric clients may mirror their attitudes towards and feelings for these clients. The aim of this study was to investigate the connections between the time spent together and the nurses' opinion of client behaviour and social functioning in community-based psychiatry. In this quantitative study, 29 clients were assessed by 30 nurses, who answered the Global Assessment of Functioning Scale (GAF) and the Positive and Negative Syndrome Scale (PANSS). At the same time, 11,200 non-participant observations of clients were registered using the Patient Activity Classification (PAC) to investigate how they spent their time at two psychiatric group dwellings. The PAC instrument revealed that clients spent an average of 60.8% of time alone, while only 20% of their daily time was spent with the nurses. Based on a factor analysis, indices were made by setting cut-off points for the PANSS and the GAF scores, and four small groups of clients were generated: a relatively high level of social functioning and a low degree of psychiatric symptoms (A); a relatively high level of social functioning and a high degree of psychiatric symptoms (B); a low level of social functioning and a low degree of psychiatric symptoms (C); and, finally, a low level of social functioning and a high degree of psychiatric symptoms (D). The clients judged as having a low level of social functioning in combination with high degrees of psychiatric symptoms, that is, the most vulnerable and dependent individuals, receive less staff attention (18%) and are the clients who spend the most time alone (71.4%). It might be possible to interpret the results of this study in the light of a process of dehumanization.     

Social competence and maladaptive behavior of people with dual diagnosis

This study describes the social competence and maladaptive behavior of mentally retarded individuals with psychiatric impairments and examines the validity of five major psychiatric diagnoses as applied to the mentally retarded population: schizophrenia, personality disorders, autism, adjustment disorders, and conduct disorders. The adaptive and maladaptive behavior of individuals with a dual diagnosis (N=3,975) have been compared with the behavior of control samples who were selected by a pair-wise matching procedure on age, sex, IQ, and type of residence (i.e., own home or independent living, community care facilities, and state institutions). Among the dual diagnosis population, schizophrenic adults and autistic children have shown disturbances in many areas of adaptive and maladaptive behavior in comparison to their nonpsychiatric counterparts. Conduct disturbances, personality disorders, and adjustment disorders have shown significantly higher maladaptive behavior than their non- psychiatric counterparts. The results indicate a strong need for refined diagnostic techniques for identifying personality disorders and adjustment disorders in the mentally retarded population.