Introduction
Active participation by psychiatrists in efforts to understand and care for persons with mental retardation is long-standing. In the mid-nineteenth century, many of the pioneers of educational efforts and humane treatment were psychiatrists.
The first medically oriented journal devoted to the subject, Observations on Cretinism, was published by a prominent psychiatrist, Wilhelm Greisinger, in 1850, while the precursor to the American Association on Mental Retardation was founded in 1876 by six psychiatrists. Lamentably, in the first half of this century, the role of psychiatrists was reduced to that of custodial gatekeeper of large residential institutions.
Mentally retarded patients were often tranquilized with neuroleptic medication with little regard for diagnosis or psychiatric indication. Educational-behavioral treatment models were ascendant, and psychiatrists and their medical model were increasingly unwelcome. However, the last decade has offered many reasons to believe that a renaissance of psychiatry’s involvement in the field of mental retardation is upon us.
The mainstreaming or normalization of individuals with mental retardation has proceeded steadily over the past three decades. The population of public institutions has fallen more than 65%. Even though no more than 10% were ever housed there, mentally retarded individuals were often unwelcome in most public and private health and recreational centers.
Today, many live in a variety of settings, family homes, residences, and supervised apartments, have daily jobs that range from competitive employment to sheltered workshops, and use most of the usual community facilities.
However, they are often traumatized by their institutional experiences or rejection from society at large. Unprepared for the stresses of modern-day life in a world unequipped to handle their special needs, they are presenting themselves in disproportionately higher numbers in, general hospitals, the criminal justice system, and substance abuse programs, as well as in psychiatric emergency rooms and inpatient units.
The psychiatrist can play a major, if not a leading, role in the care of this most underserved population. The value of psychiatric diagnostic skills, the appropriate use of psychotropic medications, and integration of various treatment modalities is now recognized. The need for psychiatric education of care providers and consultation to program developers and government representatives is pressing.
Although difficulties in the recruitment of psychiatrists and in obtaining training in the field remain, there is a growing interest and expertise. In this regard, both a curriculum guide and a task force report on psychiatric services to the mentally retarded/developmentally disabled (MR/DD) population are available from the APA.
The curriculum guide, which includes an annotated bibliography for more than twenty topic areas, is an excellent resource for psychiatrists interested in a basic education or a knowledge update. What follows is a snapshot of the field and, contained within, a glimpse of the challenges and opportunities for psychiatrists.
Diagnostic Issues
Until recently, mental retardation and mental illness were regarded as mutually exclusive, so that behaviors believed to be manifestations of mental retardation tended to overshadow the presence of mental disorders. Frank Menolascino’s 1970 Psychiatric Approaches to Mental Retardation was a landmark in the beginning recognition of psychiatric comorbidity in persons with mental retardation.
However, DSM-III listed mental retardation as an axis I clinical syndrome with irritability, aggressivity, and impulsiveness as possible behavioral concomitants. In DSM-III-R, on the other hand, mental retardation became an axis II disorder with no associated unique personality or behavioral features.
This change suggested that the presentation of behavioral or emotional difficulties should lead to a search beyond the mental retardation itself for a diagnostic explanation just as with a nonretarded patient.
Forming the necessary theoretical underpinning of this change was the demand for clinicians to conceptualize, in mild or borderline cases, a mentally healthy, mentally retarded person as a baseline and to make more use of a developmental perspective in more intellectually impaired cases. One might say that this represented psychiatry’s version of mainstreaming.
Nevertheless, impairments in cognitive and verbal skills may obscure the standard diagnostic indicators. These may need to be modified to include a greater emphasis on biological signs and behavioral equivalents of subjective states.
History gathering may involve interviewing of several caretakers or other health professionals who may need to be educated as to how to organize their observations so as to best participate in the diagnostic process. More than 70% of mentally retarded individuals who present for outpatient care have undiagnosed medical conditions that contribute to their mental health needs, most likely neurological or endocrinological in nature.
Coordination of care among health professionals is therefore crucial and has a demonstrable effect on outcome, including mortality.
Psychopathology
The full spectrum of psychiatric disorders can be identified in this population. It is estimated that between 30% and 70% of persons with mental retardation have psychiatric disorders. Psychotic disorders tend to be overdiagnosed, while mood, anxiety, and personality disorders are underrecognized.
Schizophrenia, mood disorders, and impulse disorders may be more prevalent than in the general population. Mental retardation alone clearly challenges the individual’s adaptive abilities as well as caretakers’ cabilities to provide an optimum environment. Additionally, a variety of risk factors for psychopathology have been identified.
Greater neurological abnormality, sometimes paralleling increased intellectual deficit, represents a significant risk factor as well as altering the symptom profile.
Psychosocial factors such as increased incidence of medical disorders combined with inadequate health care, neglect and understimulation, poverty, separation from family, physical abuse, and sexual abuse have also been documented.
Treatment
Psychiatric disorders in mentally retarded persons respond to pharmacological intervention just as they do in the nonretarded population. Some psychotropic agents may even have some efficacy in reducing symptoms associated with particular developmental disorders, such as the effect of the SSRI agents on symptoms of autism, a disorder associated with mental retardation in 75% of cases.
Mentally retarded patients in need of antipsychotic medication have particularly benefited from the more favorable side effect profiles of newer drugs such as risperidone, which also has shown efficacy in reducing a variety of behavioral disturbances in this population.
Anxiety and depressive disorders and disorders characterized by impulsive or compulsive symptoms have also responded well to the SSRI drugs. Because of an increased frequency of seizure disorders in this population, the rapid acceptance of the use of anticonvulsants for bipolar illness is particularly fortunate and makes for a natural alliance between psychiatrist and neurologist.
Moreover, a large body of literature has accumulated describing the effectiveness of behavior therapy and group and individual therapy, including psychoanalytic psychotherapy. Cognitive therapy has also been found useful for the treatment of depression and sex.
The psychiatrist learns to translate psychiatric, psychodynamic, or developmental understanding into treatment recommendations or refinements for the other members of the treatment team who encounter the patient in a variety of settings throughout the day.
The need for psychotherapeutic intervention or consultation with the family or other caretakers, day treatment staff, or behavioral specialists is commonplace. The need to understand the inner life of the mentally retarded individual is not only a clinical issue but a human rights issue. The biopsychosocial model has a comfortable home in the field of mental retardation.
The Interdisciplinary Team
A wide array of service providers may be involved in the care of a mentally retarded person, possibly including a psychologist, behavioral specialist, nurse, day treatment and group home staff, and case manager as well as speech, physical, and occupational therapists.
In addition, communication among physicians, especially psychiatrist, primary care physician, and neurologist, is crucial. The potential to learn from all these people about the patient and about the many aspects of the field is limitless.
Often the psychiatrist is in the best position to synthesize and coordinate the many perspectives that contribute to the patient’s care. The psychiatrist’s many areas of expertise may be called upon, exercised, and enriched, and some areas will be newly created.
Hauser lists the following as potential roles for the psychiatrist consultant: consultant to emergency teams and inpatient units, coordinator between staff and other physician specialists, treatment advocate, empirical experimenter, mediator, ombudsman, educator, and consultant to the dynamics of the care system.
Research
In every area and at every level of investigation there are opportunities for research in this field. Biological etiologies for ever-increasing numbers of mental retardation syndromes are being discovered, and with this comes the potential for prevention and more effective treatment.
Also, the increased incidence of psychiatric disorders or particular behavioral disturbances in patients with specific genetic abnormalities always raises the intriguing possibility of research that crosses mind-brain bridges.
There remain relatively few methodologically sound psychopharmacological studies in the field. Beyond the need to scientifically demonstrate efficacy, answers to questions about treatment duration, different dosaging strategies, and side effect profiles are sorely needed.
The creation of better diagnostic instruments (questionnaires and rating scales), outcome measures, and even some revamped diagnostic criteria for disorders in this population is an ongoing process. Mentally retarded patients have traditionally been excluded from experimental drug trials, in part because of the expectation of untoward and/or unusual reactions to drugs.
That such expectations are in fact not unwarranted makes such research even more important so as to safeguard this group of patients. Of course, problems of consent are of a particularly sensitive nature and necessarily complex.
System Challenges
Considering the limited knowledge and experience most psychiatrists have in the field and the complex demands of many cases, dealing with uncertainty may be considered an occupational hazard. Anxiety and frustration in the treatment team can reduce interdisciplinary communication, create adversarial positions, and make thoughtful decision making difficult.
Both self-knowledge and awareness of group processes can be antidotes to such maladies. For the most part, however, the support of other members of the treatment team is a reliable resource.
Psychiatrists treating this population may encounter a variety of standards and procedures for care that appear to impede their freedom to treat. Many of these were promulgated by legislatures and courts as safeguards against inappropriate psychotropic drug prescribing and unnecessary restraint.
They may take the form of human rights committee reviews, consent procedures, and a stream of paperwork that seem to demand a justification for all clinical decision making. Knowledge of the history of these standards and the dynamics of the care systems can be a mitigating factor.
If adroitly addressed, encounters with these regulations can be converted to opportunities to educate and be educated. Over time, there is the opportunity as well to transform them into guidelines that conform more closely to clinical realities.
The new economics of health care may place particular pressures on the diagnostic and treatment process with mentally retarded persons because of its requirement of time, communication, and thoughtfulness.
The psychiatrist today may be in the position of having to resist being returned to a role as the overseer of vast numbers of medicated patients, producing billable units rather than broad involvement and deep understanding.
Nevertheless, there remains much unsettled as to what systems of service delivery will survive the current belt-tightening. Amid this uncertainty there lie opportunities for the psychiatrist to help shape the future of the field.