NADD Bulletin Volume IV Number 1 Article 3

Complete listing

Creating a Continuum of Intensive Psychiatric Services for Individuals with Dual Diagnosis: A Perspective on the Massachusetts Experience III. Inpatient Psychiatric Care

Lauren Charlot, Ph.D.; Van R. Silka, M.D.

The neuropsychiatric disabilities unit (NDU) is a 10-bed short stay, locked inpatient psychiatric unit located within a general medical facility. The University of Massachusetts Memorial Health Center (UMMHC) has a number of hospital sites in its system, as well as a variety of outpatient programs. UMMHC is a private non profit organization with a close affiliation with the University of Massachusetts Medical School. UMMHC and its satellite programs primarily serve central and western Massachusetts residents. A wide range of clinical services are provided including medical and psychiatric services. Two other sites in the state were already designated as specializing in the inpatient psychiatric care of adults with a developmental disability (DD) when the NDU opened in January of 1999, but both of these units were located within private psychiatric hospitals. It was decided that there would be enough service need to open a third unit and that this unit could provide care primarily to residents of central and western Massachusetts, but might also be the designated site for patients with significant comorbid medical problems. Admission criteria are listed in Table 1. Mean length of stay on the NDU has been 12.29 days.

Table 1: NDU Admission Criteria

1.Age 16 or older

2.Has been identified to receive services from the Department of Mental Retardation

3.Axis I psychiatric disorder

4.Danger to self or others

5.In need of inpatient setting to safely manage psychopharmacologic interventions i.e. individual has comorbid medical problems that complicate the psychopharmacologic treatment plan or patient is at significant risk of becoming violent when medications are tapered.

Model

An important goal for the NDU has been to provide patients with holistic care. Behavioral, psychosocial, and milieu treatments are integrated with medical treatments, and the interdisciplinary team members work closely together. The NDU core team includes a clinical nurse specialist and psychologist who co - lead the unit, medical director/attending psychiatrist, medical consultant, behavioral specialist, clinical social worker, and occupational therapist. The unit is usually staffed with a minimum of five staff on the floor including at least one - two RNs with three - four mental health counselors. Staff are trained in behavioral treatment techniques as well as having a specialized course in the prevention and management of aggressive behavior (PMAB). A critical aim has been to use techniques that can be used when the patient is discharged. Efforts have been made to reduce the use of chemical and mechanical restraints to manage serious agitated episodes. Behavioral treatment plans are developed for each patient, including strategies for increasing adaptive behaviors, manipulating possible antecedents for problem behaviors, as well as developing a hierarchy of interventions to prevent and manage agitated or aggressive behaviors.

Having a structured and predictable routine is also part of the inpatient treatment. Groups are held on the unit daily from early morning until evening, and patients are expected to participate in the unit routines unless they are unable to due to a medical or behavioral concern. Most groups are task versus talk oriented, although opportunities to build social and coping skills are used throughout all of the groups. A sample of the daily unit group schedule is provided in Table 2.

Table 2: NDU Daily Schedule of Activities

7:00 am Wake - up / Personal Care/ Room Care

7:30 am Breakfast (dining room)

8:00 am Pass Time

8:15 - 9:00 Medications/ Complete ADLs/ Medical Treatments

9:00 - 9:30 am Goal Setting Group

9:45-10:30 am OT Task Group

10:45 - 11:15 am Social Skills Group

11:30 am Lunch (dining room)

11:30 am - 1:00 pm Visiting Hours

12:45 - 1:30 pm Physical Skills

1:45 -2:30 pm Sensory Motor Group

3:30 - 4:15 pm Recreation/ Gross Motor Group

4:30 pm Supper (dining room)

5:00 pm Pass Time

5:00 pm Medications

5:30 - 6:00 pm Mixed Media Group

Music Group

6:15 - 7:00 pm Leisure Skills Group

7:00 - 8:00 pm Wrap Up / Goals review

Snacks

8:00 pm Pass Time

8:15 - 9:00 pm Evening Personal care

9:00 pm Medications

10:00 pm Bedtime Sunday - Thursdays

12:00 mid Bedtime Friday and

Saturday

Behavioral treatment plans are an important aspect of the inpatient treatment (Hurley, 1994). As much as possible during the brief admission, an effort is made to assess the function of problem behaviors, and to teach and reinforce adaptive replacement behaviors. Preventative strategies are developed to control antecedent conditions associated with problem behaviors. Cues (symptoms or behaviors that are seen at a high frequency prior to problem behaviors) are identified and interventions designed to target these ( Hurley, 1996; Luiselli, Benner, Stoddard, Lisowski, & Weiss, 1999). Many times, patients appear to learn through modeling, as they see others gaining from their positive behaviors (as well as observing that limits are set consistently when someone’s behavior becomes unsafe). Symptoms and behaviors that are targeted for change are tracked using an hourly interval data collection system. When available, data collected prior to admission are also reviewed.

Admission

Whenever possible, planned admissions are encouraged. Although some insurers will insist that patients must be a current danger to self or others to be admitted, educating clinicians who perform the emergency screenings can be helpful. In our experience, people with DD often have spikes of agitation and may be calm briefly at an Emergency Department (ED), only to explode again as soon as they return home. Many patients have complicated psychopharmacologic regimens and comorbid medical conditions in addition to their psychiatric problems. When it is clear that some significant medication changes are needed, it may be safest to do this during an inpatient stay. Community teams are asked to participate in an admissions meeting within the first 24 hours after admission (or the following business day if the admission occurs on a weekend or holiday). Important clinical information is gathered but also expectations regarding the inpatient stay can be discussed. Goals for the admission are outlined and a tentative discharge date is set. Service needs that will assist the patient to successfully return home may be identified at this time.

Diagnostic Assessment Issues

Differential diagnosis of psychiatric disorders in adults with developmental delays can be challenging, and there are a number of key considerations. (Please see Hurley, 1996; Sovner & Hurley, 1986 ; Silka & Hauser,1997, and Charlot, 1998 for detailed reviews of these concerns.) At the time of admission, relevant clinical information is gathered. Often, the initial review of past treatment is critical, though time consuming, when patients have elaborate and extensive past treatment records. Consideration of a variety of factors that affect psychiatric diagnostic assessment is also important, including the impact of developmental delay on psychiatric symptoms and syndromes, the effects of reliance on informant reports, the impact of comorbid medical conditions, and the contribution of environmental stressors and other psychosocial variables to the presenting problem (Sovner & Hurley 1986).

During the NDU’s first year of operation, certain types of diagnostic problems seemed to arise frequently. There were many patients diagnosed with psychotic disorder NOS, schizophrenia, schizoaffective disorder, or delusional disorder who did not appear to present with any psychotic features. Also, some patients who had apparent autism spectrum disorders were not diagnosed with a pervasive developmental disorder; in some cases, commonly observed features in PDD such as obsessional anxiety and behavioral fixations were taken as evidence of psychosis. Often, these individuals displayed regressed, odd, or developmentally appropriate but primitive coping behaviors that were possibly mislabeled as psychotic (Hurley, 1996). In general, depression and anxiety problems seemed to be under diagnosed while disorders such as intermittent explosive disorder or psychotic disorder were over diagnosed (Charlot, 1998; Hurley, 1996; Khreim & Mikkelsen, 1997). Affective lability was sometimes described as representing mania without other symptoms of a bipolar illness being present (Pary, Levitas, & Hurley,1999). A high rate of comorbidity of medical problems has been found. Approximately 85% of admissions had a comorbid medical disorder that in some way affected the acute behavioral changes requiring a psychiatric hospitalization. In 30% of admissions, the resolution of an acute medical issue resulted in marked behavioral improvement and subsequent discharge. Common medical disorders that we have encountered are listed in Table 3.

Table 3 Common Medical Disorders

Occurring in Patients with Developmental Disabilities Constipation

Infection (respiratory, skin or urinary)

Sleep apnea

Pain

Broken bones

Thyroid disease

Hypogonadism

Hepatitis

Treatment Issues

The most critical aspect of successful inpatient treatment of adults with DD and psychiatric disorders is use of a holistic, integrated approach. Problems that bring individuals with DD into an inpatient setting are often complex and solutions are not likely to be simple. Most patients require a combination of psychoactive medication adjustments, medical treatments, behavioral treatment, and other supportive counseling as well as family support and systems interventions (Sovner , Beasley, & Hurley, 1995). In some cases, suggestions may be made regarding the need for a residential change, for example, when a patient shows a clear, rapid response to increased structure.

A number of patients have presented with suspected medication side effects (i.e. akathisia) or withdrawal effects (following a neuroleptic medication taper that occurred too rapidly) that appeared to have exacerbated psychiatric or behavioral problems and/or were misinterpreted as evidence for a psychiatric disorder. Many of the individuals admitted to the NDU were receiving treatments that were not clearly related to a diagnostic hypothesis, but appeared aimed at specific symptoms such as aggressive behavior. Given that agitated and aggressive behaviors are typically nonspecific surface features of a wide array of underlying problems, this kind of treatment approach may not be the most effective. Some patients were helped significantly by having their psychoactive medication regimen simplified, usually in combination with switching to less sedating medication treatment alternatives and combining this with increased use of behavioral treatments. Part of the patient’s treatment may include systems interventions such as working with the community care taking system to reduce risk factors and increase supports that will be provided to the patient post discharge (Sovner & Hurley, 1987).

Discharge Issues

A discharge meeting is held just before the actual discharge. The inpatient team typically reviews diagnostic, treatment, and discharge planning issues providing a rationale for diagnostic changes and for treatment recommendations. This can include recommendations for further medication changes such as continuing a medication taper or what other options to consider if the current treatment is not effective. Also, if further medical follow-up is indicated, this can sometimes be scheduled before discharge. In some cases, the inpatient team will assist the community team in developing a crisis plan and often, there will be considerable attention paid to identifying strategies for prevention of future decompensations that might lead to a need for readmission. One problem area has been cases becoming “stuck” on the unit. These are individuals who are in need of a new disposition but an appropriate setting is not available when the patient is ready for discharge (Sovner, Beasley, & Hurley, 1995). The NDU administration has worked closely with the Massachusetts Department of Mental Retardation (DMR) and have found them to be very supportive, understanding that patients who are not discharged when ready can and often do suffer setbacks. Also, access to a limited resource for other individuals in need may be denied when a disposition problem occurs.

References

Charlot, L. R. (1998). Developmental effects on mental health disorders in persons with developmental disabilities. Mental Health Aspects of Developmental Disabilities, 1, 29-38.

Hurley, A. D. (1994). The effective use of positive reinforcement techniques for persons with developmental and psychiatric disabilities. The Habilitative Mental Healthcare Newsletter, 13, 91-95.

Hurley, A. D. (1996). The misdiagnosis of hallucinations and delusions in persons with mental retardation : A neurodevelopmental perspective. Seminars in Clinical Neuropsychiatry, 1, 122-133.

Khreim, I. & Mikkelsen, E. (1997). Anxiety disorders in adults with mental retardation. Psychiatric Annals, 98, 175-181.

Luiselli, J. K., Benner, S., Stoddard, T., Lisowski, K., & Weiss, R. (2000). Behavior support intervention in psychiatric partial hospitalization for adults with mental retardation: Two case studies. Mental Health Aspects of Developmental Disabilities, 3, 1-7.

Pary, R. J., Levitas, A. S., & Hurley, A. D. (1999). Diagnosis of bipolar disorder in persons with developmental disabilities. Mental Health Aspects of Developmental Disabilities, 2, 37-49.

Sovner, R. & Hurley, A. D. (1987). Guidelines for the treatment of mentally retarded persons on psychiatric inpatient units. Psychiatric Aspects of Mental Retardation Reviews, 6, 7-14.

Sovner, R. & Hurley, A. D. (1986). Four factors affecting the diagnosis of psychiatric disorders in mentally retarded persons. The Habilitative Mental Healthcare Newsletter, 5, 45-49.

Sovner, R., Beasley, J., & Hurley, A. D. (1995). How long should a psychiatric inpatient stay be for a person with developmental disabilities? The Habilitative Mental Healthcare Newsletter, 14, 1-6.

Silka, V. R. & Hauser, M. J. (1997). Psychiatric assessment of the person with mental retardation. Psychiatric Annals, 98, 162-169.

Other Suggested Reading

Abend, S. & Silka, V. R. (1999). Medical care of patients with developmental disabilities. Mental Health Aspects of Developmental Disabilities, 2, 2.

Charlot, L. R. (1997). Irritability, aggression, and depression in adults with mental retardation: A developmental perspective. Psychiatric Annals, 98, 190-197.

Gold, I. M., Wolfson, E. S., Lester, C. M., Ratey, J. J., & Chmielinski, H. E. (1989). Developing a unit for mentally retarded-mentally ill patients on the grounds of a state hospital. Hospital and Community Psychiatry 40, 836-840.

Lowry, M. A. (1997). Unmasking mood disorders: Recognizing and measuring symptomatic behaviors. The Habilitative Mental Healthcare Newsletter, 16, 1-6.

Pary, R. J., Silka, V. R., & Blaha, S. J. (1995). Individuals with mental retardation and psychiatric disorders admitted to inpatient units. In O. J. Thienhaus (Ed.), Manual of Clinical Hospital Psychiatry, Washington, DC. American Psychiatric Press.

Sovner, R. & Hurley, A. D. (1990). Seven questions to ask when considering an acute psychiatric inpatient admission for a developmentally disabled adult. The Habilitative Mental Healthcare Newsletter, 9, 91-98.

Sovner, R. & Hurley, A. D. (1983). Do the mentally retarded suffer from affective illness? Archives of General Psychiatry, 40, 61-67.

Silka, V. R. & Hurley, A. D. (2000). Admissions to psychiatric inpatient hospitals. Mental Health Aspects of Developmental Disabilities, 3, 36-40.

Stack, L. S., Haldipur, C. V., & Thompson, M. (1987). Stressful life events and psychiatric hospitalization of mentally retarded patients. American Journal of Psychiatry, 144, 661-663.

Xenitidis, K. I., Henry, J., Russell, A. J., Ward, A., & Murphy, D. G. M. (1999). An inpatient treatment model for adults with mild intellectual disability and challenging behaviour. Journal of Intellectual Disability Research, 43, 128-134.

For further information:

Lauren Charlot, Ph.D.
P. O. Box 784
Wrentham, MA 02093
E-mail: tillynic@aol.com