5/7/2020 Nisonger Institute 2020: IDD Psychiatry Best Practices Pharmacologic and Non-Pharmacologic Treatment of Persons with IDD and Co-occurring Mental Illness and/or Behavioral Challenges Stephen Ruedrich M.D. L. Douglas Lenkoski Professor, and Vice Chair of Psychiatry Case Western Reserve University School of Medicine Cleveland Ohio May 8, 2020 • This webinar is being recorded; you must consent to view once the recording starts. • Presentation materials are available from the event webpage: http://go.osu.edu/ni2020 • For Zoom support, contact: lindsay.seidl@osumc.edu • For questions regarding Cont. Ed./certificate of attendance, please contact: tamara.hager@osumc.edu Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices Disclosures: Dr. Ruedrich has: Additional disclosures: Dr. Ruedrich: Previous research support from Pfizer and Cyberonics Will start out evidence-based, and then will likely drift into consensus-based treatment, and may ultimately veer off into wild speculation Current research support from the Alana Foundation and the Alzheimer’s Association Seems to love the Bolding Function a bit too much None will have any direct or indirect bearing on today’s presentation May have a serious counting obsession Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices Question: Question: What is the best psychotropic medication to treat a person with an intellectual disability? What is the best psychotropic Answer: medication to treat a person with an The one (or more) that is/are appropriate for his/her psychiatric diagnosis(es) intellectual disability? 5 6 1
5/7/2020 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices Outline: IMPORTANCE OF PSYCHIATRIC DIAGNOSIS Importance of psychiatric diagnosis Antipsychotic Medications are: Medical condition(s) vs. psychiatric illness? Used extensively to treat aggression in persons with ID Disease vs. Symptom Past/Present/Future of IDD psychopharm. 30-50% of all psychotropics used in persons with ID Treatment of behavioral disorders? However, prevalence of psychotic disorders only 3-5% WPA Guidelines A word or two about side effects (Tsiouris JA, JIDR 2009) Conclusion 7 8 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices IMPORTANCE OF PSYCHIATRIC DIAGNOSIS IMPORTANCE OF PSYCHIATRIC DIAGNOSIS Today, psychotropic treatment of persons with ID should start with making an accurate diagnosis In a Norwegian community sample of 116 adults with ID: Once a diagnosis is made, psychotropic treatment can usually proceed as it would for a person without ID: 43% were taking psychotropic medication Antipsychotics for psychosis Antidepressants for depression 32% were taking antipsychotic medication SSRI’s for OCD Mood stabilizers for bipolar illness Stimulants for ADHD, etc. Only 27% of those on psychotropics had a psychiatric diagnosis (Ruedrich, 2016) (Baasland & Engedal, Tidsskr Nor Laegeforen, 2009) 9 10 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices IMPORTANCE OF PSYCHIATRIC DIAGNOSIS IMPORTANCE OF PSYCHIATRIC DIAGNOSIS PubMed Search: However, almost no psychopharmacologic Drug treatment of persons with ID 4779 literature describes the treatment of specific psychiatric illnesses: Psychotropic drug treatment of persons with ID 1463 depression bipolar illness Psychotropic drug treatment OCD of psychiatric disorders in persons with ID 1316 ADHD Psychotropic drug treatment in persons with intellectual disabilities of specific psychiatric disorders in persons with ID 57 11 12 2
5/7/2020 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices DIAGNOSTIC SYSTEMS IN PSYCHIATRY IMPORTANCE OF PSYCHIATRIC DIAGNOSIS Most reports of psychiatric disorders in persons with ID have utilized one of two mainstream diagnostic systems available: The reason is, as we know: – Diagnostic and Statistical Manual of Mental Disorders (DSM) – International Classification of Diseases (ICD) – Most current versions: Accurate psychiatric diagnosis in persons • DSM-5 (2013) with intellectual and developmental disability • ICD-10 (1992) (APA, 2013; WHO, 1992) – However, neither system is universally applicable to individuals with ID, particularly those with limited verbal communication IS DIFFICULT abilities, and/or more severe/profound ID (Fletcher, et al., 2007). 13 14 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices Diagnostic Criteria for Psychiatric Disorders for use with Adults with DIAGNOSTIC SYSTEMS IN PSYCHIATRY Learning Disabilities/Mental Retardation (DC-LD) Two additional diagnostic manuals have been recently proffered to address this difficulty: – Diagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities/Mental Retardation (DC-LD) (RCP, 2001) – Diagnostic Manual for Intellectual Disabilities (DM-ID 2007; DM-ID-2, 2016, NADD Press) – The DC-LD has undergone significant field testing, (52 field investigators; over 700 patients), demonstrating acceptable validity and reliability (Cooper et al., 2003). – The DM-ID has not yet been field tested, although an initial clinician survey (63 clinicians, 845 patients) expressed significant satisfaction (Fletcher et al., 2009). 15 16 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices OP48. DC-LD: Diagnostic criteria for psychiatric disorders for use Diagnostic Manual for Intellectual Disabilities (DM-ID) with adults with learning disabilities/mental retardation Price: £20.00 Published: Apr 2001 DC-LD is a new classification system providing operationalised diagnostic criteria for psychiatric disorders, intended for use with adults with moderate to profound learning disabilities. It also be used in conjunction with the ICD-10 and DSM-IV manuals in a complementary way, when working with adults with mild learning disabilities. DC-LD was developed by a working party convened on behalf of the Faculty for the Psychiatry of Learning Disability of the Royal College of Psychiatrists and the Penrose Society. 17 18 3
5/7/2020 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices Diagnostic Manual – Intellectual Disability (DM-ID) Diagnostic Manual-Intellectual Disability-2 The NADD, in association with the APA, developed a Manual that is designed to be an adaptation of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Grounded in evidence based methods and supported by the expert- consensus model, the DM-ID offers a broad examination of the topic, including a description of each disorder, a summary of the DSM-IV-TR diagnostic criteria, a review of the literature and research, and an evaluation of the strength of evidence, a discussion of the etiology and pathogenesis of the disorders, and adaptations of the diagnostic criteria www.dmid.org 19 20 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices FULL STOP! The DM-ID-2 provides state-of-the-art information concerning mental disorders in persons with intellectual disabilities. Grounded in evidence Before we can proceed with discussion of based methods and supported by the expert- accurate psychiatric diagnosis, and consensus model, DM-ID-2 offers a broad examination of the issues involved in applying psychiatric treatment (both pharmacologic diagnostic criteria for psychiatric disorders to and non-pharmacologic), we need to persons with intellectual disabilities. The DM-ID-2 make sure that our patient’s symptoms is an essential resource for every clinician who works with individuals with a dual diagnosis and illness is psychiatric in nature (IDD/MI). 21 22 Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices Medical issues commonly presenting as behavioral problems: MEDICAL ISSUES can present as behavioral changes Pain from any source Persons with ID may have difficulty, or may be completely unable to report any kind of medical • Dental discomfort or distress . They may act out their • Arthritis • Headache (migraine) discomfort, so that the first person to observe or • Abdominal learn of some change in status may be a direct carer, • Menstrual-related family member, or behavioral specialist. 23 24 4
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