Peter Sturmey, Ph.D. Department of Psychology, Queens College and The Graduate Center, City University of New York
People with mental retardation experience a range of psychiatric and behavioral disorders, including mood disorders. Although extensive research has addressed assessment and diagnosis of mood disorders, less attention has been paid to treatment. This article reviews the evidence for the efficacy of psychotropic medication, other biological treatments, such as ECT, psychotherapy and counseling, cognitive therapy, and applied behavior analysis. Although several treatment options appear promising, there is an absence of convincing evidence testifying to the effectiveness for any treatment approach at this time. Future research should focus on conducting well-controlled randomized trials of promising treatments for mood disorders in people with mental retardation.
Mood disorders are often characterized as the "common cold" of mental health. They are some of the most frequently reported mental health problems that people may report, including people with mental retardation (Rojahn & Ebensen, 2005.). Hence treatment of mood disorders is a common aspect of work in dual diagnosis.
Evaluation of treatments of psychiatric and behavior disorders is of paramount importance. People with mental retardation already have disability and handicap-those who have an additional mood disorder may experience additional and potentially preventable disability and handicap. Not only do people with mental retardation experience negative consequences of untreated mood disorders, but others suffer too. Family members and staff have to manage the additional disability and society generally pays for lost productivity and the costs of additional services (Sturmey, 2005a).
The evaluation of psychiatric and psychological treatments is not straightforward. The design requirements of an apparently simple group design required random assignment of participants to groups. If the results are to be generalized to some population of interest, then that population must be defined and the sample drawn at random from that population. This is an extremely difficult requirement that is rarely met. Dependent variables must be selected that are reliable and valid. More subtly, a range of dependent variables must be selected that measure all the treatment outcomes. For example, a double-blind study that demonstrates reduction in a target maladaptive behavior may be criticized because it may be that all behavior was suppressed by the medication; a better design is to include measures of the target symptom and adaptive behaviors and learning (Singh, Matson, Cooper, Dixon, & Sturmey, 2005; Sturmey, 2005, b.) Changes following intervention must be not only statistically significant, but also clinically significant. For example, a modest and statistically significant decrease in the average number of symptoms of depression may still leave a significant number of participants with suicidal symptoms or great social impairment. Measures of change must also be shown in multiple settings. Change that occurs in one setting is no guarantee of meaningful change elsewhere. Finally, the evaluation of psychiatric and psychological treatments require meaningful follow-up to ensure that initial changes are maintained.
Psychiatric and psychological treatments are often subject to treatment fads and fashions (Jacobson, Mulick & Foxx, 2005.) These fads and fashions do harm to clients by denying them access to established effective treatments, and perhaps exposing them to ineffective and sometimes harmful therapy. Society generally is harmed by wasted resources and by preventable disability that was not prevented (Sturmey, 2005e). At the same time therapists accrue benefits to themselves such as fees and notoriety (Foxx, 2005a, 2005b)-sometimes faddish therapies do more for the therapists than for their clients.
Treatments also have strong and often articulate advocates. Some are motivated by true belief and others are motivated by less idealistic motives. Hence, practitioners often must interpret contradictory information from apparently authoritative sources. Unfortunately, many practitioners and service users are unable to discriminate between spurious and unsubstantiated claims that may well claim scientific status and those claims that do indeed have evidence to support them (Jacobson et al., 2005). Drug companies, motivated by profit, also may periodically suppress evidence that is unfavorable to their products, actively lobby the FDA, and promote their products under the guise of medical education. Hence evaluation of the effectiveness of psychiatric and psychological treatments is a truly difficult task.
A wide variety of treatment options are available for mood disorders in people with mental retardation. The most commonly used treatments include psychotropic medication, other biological treatments, cognitive therapy, psychotherapy and counseling, and applied behavior analysis. This paper reviews some of the evidence for the effectiveness of these most commonly used treatments.
Psychotropic medications are some of the most widely used interventions with people with mental retardation; perhaps one third to a half of people with mental retardation take psychotropic medication (Singh et al., 2005.) Approximately six percent of adults with mental retardation (Spreat, Conroy & Jones, 1997) and one in five children and people with autism take antidepressants (Aman, Lam & Collier-Crespin, 2003; Langworthy-Lam, Aman & Van Bourgondien, 2002.)
There are a wide variety of psychotropic medications which are organized into a number of classes such as tricyclic anti-depressants and selective serotonin reuptake inhibitors, which are usually used for depression, and other mood stabilizers, which are usually used for mania and related mood disorders. There is a very large literature on the efficacy of psychotropic medication in the general population, showing that many psychotropic medications are superior to placebo in treating symptoms of many mood disorders (Janciak, Dabis, Preskorn, & Ayd, 1997a; Janciak et al., 1997b.) However, significant questions remain regarding superiority of one psychotropic medication over another in terms of symptom reduction. Further, the short- and long-term side-effects of psychotropic medications, especially in children and adolescents, the costs of psychotropic medications, the frequent absence of adjunctive therapies, and the lack of attention to measures of outcome other than symptom reduction, such as lifestyle and adaptive behavior are often ignored. Outcome research on the efficacy of psychotropic medication uses group designs and hence emphasizes statistical over clinical significance of change' and changes in the average score of the group, rather than the actual score of the individual client being seen.
The research literature on the effectiveness of psychotropic medication is much more circumscribed in people with mental retardation, although a very modest number of double-blind trials exists (Stigler, Posey, & McDougle, 2005.) Clinicians are therefore largely guided by research conducted with the general population. The use of psychotropic medication for mood disorders in people with mental retardation faces additional challenges. Monitoring negative side-effects in people with limited or no verbal skills can be problematic. Although antidepressants are probably the most commonly used treatment, the evidence for their effectiveness is more limited than is desirable.
Other Biological Treatments
There are a range of other biological treatments for mood disorders. These include phototherapy, dietary modifications and herbal supplements, and electro-convulsive therapy (ECT) (Sturmey & Ghazzuiddin, 2005). Some forms of mood disorders appear to be seasonal and some have hypothesized that light deprivation may be a relevant factor in the onset of Seasonal Affective Disorder. Hence, phototherapy attempts to remedy this by providing additional light. Although there have been one or two publications on phototherapy, those with people with mental retardation have been poorly controlled.
Dietary modifications and herbal supplements are appealing and popular for many problems, including mood disorders, but are largely unevaluated. The one exception to that is the use of St. John's Wart used for Major Depressive Disorder and Dysthymia. There are an extensive number of well controlled, double-blind placebo controlled trials of St. Johns Wart demonstrating that it is superior to placebo, comparable to conventional anti-depressant medication and may have a better side effect profile (Whisky, Werneke, &Taylor, 2001) although it is not entirely free of side effects. Clinicians should be aware that a few clients might take St. John's Wart from family members or by themselves, without informing the clinician.
A well evaluated but controversial treatment for mood disorders is electro-convulsive therapy (ECT). Several authorities have noted that ECT is well evaluated and effective and may even have benefits over psychotropic medication, such as faster initial response, and hence should be considered as a first line treatment for depression (Wheeler Vega, Mortimar, & Tyson, 2000). The use of ECT has been reported in a large number of uncontrolled case studies in people with mental retardation (Van Warde, Stolker, & Van der Mast, 2001.) Although reports in the literature have been relatively positive, this may merely reflect publication bias rather than any true effect. Controlled trials of ECT for people with mental retardation have not yet been conducted. The use of ECT for behavior problems-even those presumed to reflect an underlying mood disorder-remains controversial and has little evidence to support its use.
Psychotherapy and Counseling
Mental retardation has traditionally been a contraindication for psychotherapy, yet from the 1950's occasional reports of psychotherapy have been reported regularly. Indeed since the 1980's there has been an increased professional interest in psychotherapy with people with mental retardation in the United Kingdom (Beail & Newman, 2005.)
Psychotherapy aims to bring about improved personal functioning. It does so in the context of a special, confidential relationship between the psychotherapist. The putative mechanism of change is to make links between the current problems and the person's history and how these current problems reflect previous historical problems. The therapist is relatively neutral and reflects the client's speech and behavior, only occasionally making interpretations that link current issues with past issues. Whereas counseling is time-limited, goal-directed, and problem-focused, psychotherapy is open-ended, could involve several sessions per week, and does not focus on specific problems. The psychotherapist uses counter-transference-the psychotherapist's own emotional reactions to the client's behavior-as an important source of information of the emotional reactions of people in general to the client's behavior. The therapist also uses reflections to let the client know that they are accurately listening and observing their behavior. The psychotherapist uses linking responses to interpret current material and tentatively to link it to its unconscious content. Transference refers to the client transferring the positive and emotional reactions from previous significant relationships to the therapist (Beail & Newman, 2005.)
In the past there has been little research evaluating the effectiveness of psychotherapy with people with mental retardation. Over the last ten years there has been a gradual accumulation of uncontrolled case series (Beail, 1995; 2003), but well-controlled studies have not yet been conducted (Prout & Norwick-Drabik, 2003; Sturmey, 2005c). The necessity for good verbal skills to participate in many forms of psychotherapy and the high cost of many treatment sessions also limits is applicability of psychotherapy.
Cognitive therapy has become immensely popular with clinicians for a wide range of problems, including mood disorders. Indeed there is a large evidence base for the effectiveness of cognitive therapy for many disorders. A cognitive model of depression posits that mood disorders are caused by faulty cognitive processes such as incorrect attributions, incorrect perceptions, and biased memory processes. The job of cognitive therapy is to correct these faulty cognitive processes in order to change depression. Cognitive therapy involves recognizing harmful cognitive processes, challenging the evidence for the faulty belief or attribution through logical consideration of the evidence and behavioral experiments, and making more accurate realistic interpretation of events.
Applications of cognitive therapy to people with mental retardation has become an active field over the last ten years (Stenfert-Krose, 1997) and has included modification of assessment measures including questionnaires to assess mood, modified methods of questioning, and assessments in which people with mental retardation can link emotions to events (Lindsay, Stenfert-Kroese, & Drew, 2005.) There are a number of uncontrolled case studies on cognitive therapy (Lindsay, Howells, & Pitcaithly, 1993) and a number of promising case series combining cognitive with behavior therapy (Lindsay, Marshall, Neilson, Quinn, & Smith, 1998). Although these approaches are promising, Sturmey (2004) noted that controlled studies had not yet been conducted. Further, many accounts of cognitive therapy also included behavioral interventions mis-labeled as cognitive interventions, and behavioral interventions such as skills training and reinforcement procedures.
Applied Behavior Analysis
Applied Behavior Analysis (ABA) is one of the most widely and extensively evaluated forms of therapy. It has been used extensively with people with mental retardation and has a very substantial quantity of evidence supporting its use for a wide range of applications such as skills training, enhancing independence and choice, and reducing maladaptive behaviors and mental health disorders (Didden, Duker, & Korzilius, 1997). ABA involves operationalizing the behavior of interest, identifying the environmental variables that the therapist, client or others can modify to improve behavior. Environmental variables are classified as antecedents, if they occur before the behavior, consequences if they occur after the behavior. Establishing operations, such as stimulus deprivation and satiation, affect the later value of a stimulus as a consequence and are also included in the analysis.
ABA begins with a functional assessment of the target behavior. This involves an analysis of the relationship between environmental event and the target behavior of interest in order to determine variables that can be manipulated that have a large and reliable effect on the target behavior. If the experimenter / clinician systematically manipulated environmental variables to observe the effect on behavior it is called a functional analysis. Once the functional assessment is completed a treatment plan is developed based on the functional assessment. For example, if certain activities were correlated with being happy and other activities were associated with being sad, an intervention plan might include increasing the availability of preferred activities, removing non-preferred activities, teaching the client to discriminate when they were happy and sad, and also teaching them how to ask for preferred materials.
One might think that ABA might be especially unsuitable for treatment of what might be regarded as an essentially private experience, but this perception comes from a misunderstanding of behavior analysis. Behavior analysis does not deny the existence of private events, but does avoid elevating them to causes of behavior. The causes of behavior lie in the environment, not within the person. Private events can only be observed by one person-the person doing the thinking and feeling-and hence can never be subject to scientific analysis (Skinner, 1953). A behavioral account of depression emphasizes the analysis of observable depressed behaviors, such as complaining, lack of activity, and crying and their relationship to the environment. Behavioral treatment of depression focuses on constructional tactics such as teaching effective skills, such as social, problem solving, work and self-management skills, and progressively engaging in preferred activities over time. In this way healthy behaviors are encouraged to compete with depressed behaviors. Behavioral treatment of depression received considerable attention in the 1970's, but as cognitive therapy became more popular less attention was given to behavioral treatment of depression. More recently there has been a revival of behavioral treatment of depression (Lejuez, Hopko, Hopko, & McNeil, 2001).
Several studies have applied ABA to treat depression in people with mental retardation. Matson, Dettling, and Senatore (1979) and Matson (1982) used modeling, self-monitoring, positive reinforcement, and prompting of positive self-statements to increase healthy speech in an adult and child with depression respectively. A number of studies with people with severe and profound mental retardation have shown that happy and unhappy behaviors can be reliably observed. These affective behaviors can be systematically modified by changing the ongoing activities associated with mood states. Hence, behavioral procedures can effective in promoting happiness in people with mental retardation without diagnosed mood disorders (Ivancic, Barret, Simonow, & Kimberly, 1997; Lancioni, O'Reilly, Singh, Oliva, & Groenbeweg, 2002) and with mood disorders (Lindauer, DeLeon, & Fisher, 1999.) The literature on ABA approaches to depression in people with mental retardation is modest in size, but does indicate that such interventions are possible and may be effective (Sturmey, 2005d).
Summary and Future Directions
The evidence base for the treatment of mood disorders in people with mental retardation is surprisingly weak. Although there have been some double-blind trials of some psychotropic medications with people with mental retardation, many anti-depressants and mood stabilizers have not been evaluated with this population. Those double-blind trials that have been conducted are still limited because they focused only on reduction in the target symptom, did not evaluate the impact on other desirable behaviors, focused on statistical rather than clinical significance, and lacked data from more than one setting and follow-up data. Future research should conduct double blind trials on medications that have not been evaluated with this population, should include multiple outcome measures, social validity data, and long-term follow-up, including safety data. The evidence for other biological treatments with this population is notably weaker.
Cognitive therapy, psychotherapy, counseling, and applied behavior analysis all lack well-conducted trials. Cognitive therapy, most forms of psychotherapy and counseling all depend on verbal skills and sometimes rather sophisticated verbal skills. This may be a significant limiting factor in their applicability to this population. There are far fewer publications on ABA interventions for mood disorders than for other applications of ABA. Although there is good evidence that mood can be modified by ABA these studies have been limited in number and most have not intervened with people with clinical diagnoses. Behavioral activation treatment for depression seems promising and applicable to this population, but has not yet been evaluated with this population. Future research into the effectiveness of psychosocial treatments for mood disorders should focus on using participants with bona fide diagnoses of mood disorders, including novelty and attention placebo conditions and well designed group or single subject experimental designs.
Aman, M. G., Lam, K. S., & Collier-Crespin, A. (2003). Prevalence and patterns of use of psychoactive medicines among individuals with autism in the Autism Society of Ohio. Journal of Autism and Developmental Disorders, 33, 527-534.
Beail, N. (1995). Outcome of psychoanalysis, psychoanalytic and psychodynamic psychotherapy with people with intellectual disabilities. Changes, 13, 186-191.
Beail, N. (2003). What works for people with mental retardation? Critical commentary on cognitive behavioral and psychodynamic psychotherapy. Mental Retardation, 41, 468-472.
Beail, N., & Newman, D. (2005). Psychodynamic counseling and psychotherapy for mood disorders. In P. Sturmey (Ed.), Mood disorders in individuals with mental retardation. Kingston, NY:NADD Press.
Didden, R., Duker, P. C., & Korzilius, H. (1997). Meta-analytic study on treatment effectiveness for problem behaviors with individuals who have mental retardation. American Journal on Mental Retardation, 101, 387-399.
Foxx, R. M. (2005a). Severe aggressive and self-destructive behavior: The myth of non-aversive treatment of severe behavior. In: J. Jacobson, J. A, Mulick, & R. M. Foxx (Eds.), Fads: Dubious and improbable treatments for developmental disabilities (pp. 295-311). Hillsdale, NJ: Lawrence Erlbaum Assoc.
Foxx, R. M. (2005b). The National Institute of Health Consensus Development Conference on the Treatment of Destructive Behaviors: A study in professional politics. Severe aggressive and self-destructive behavior: The myth of non-aversive treatment of severe behavior. In J. Jacobson, J. A, Mulick, & R. M. Foxx (Eds.), Fads: Dubious and improbable treatments for developmental disabilities (pp. 461-475). Hillsdale, NJ: Lawrence Erlbaum Assoc.
Ivancic, M. T., Barret, G. T., Simonow, A., & Kimberly, A. (1997). A replication to increase happiness indices among some people with profound multiple disabilities. Research in Developmental Disabilities, 18, 79-89.
Jacobson, J., Mulick, J. A., & R. M. Foxx (Eds.) (2005). Fads: Dubious and improbable treatments for developmental disabilities. Hillsdale, NJ: Lawrence Erlbaum Assoc.
Janicak, P. G., Davis, J. M., Preskorn, S. H., & Ayd, F. J. (1997a). Treatment with antidepressants. In P. G. Janicak, J. M. Davis, S. H. Preskorn, & F. J. Ayd (Eds.), Principles and practice of psychopharmacotherapy (2nd. Ed.), 2nded.) (pp. 243-321). Philadelphia: Lippincott Williams & Wilkins.
Janicak, P. G., Davis, J. M., Preskorn, S. H., & Ayd, F. J. (1997b). Treatment with mood stabilizers. In P. G. Janicak, J. M. Davis, S. H. Preskorn, & F. J. Ayd (Eds.), Principles and practice of psychopharmacotherapy (2nd ed.) (pp. 403-470). Philadelphia: Lippincott Williams & Wilkins.
Lancioni, G. E., O'Reilly, M. F., Singh, N. N., Oliva, D., & Groenweg, J. (2002). Impact of stimulation versus microswitch-based programs on indices of happiness of people with profound multiple disabilities. Research in Developmental Disabilities, 23, 149-160.
Langworthy-Lam, K. S., Aman, M. G., & Van Bourgondien, M. E. (2002). Prevalence and patterns of use of psychoactive medicines in individuals with autism in the Autism Society of North Carolina. Journal of Child & Adolescent Psychopharmacology, 12, 311-321.
LeJuez, C. W., Hopko, D. R., Hopko, S. D. & McNeill, D. W. (2001). A brief behavioral activation treatment for depression treatment manual. Behavior Modification, 25, 225-286.
Lindauer, S. E., DeLeon, I. G., & Fisher, W. W. (1999). Decreasing signs of negative affect and correlated self-injury with mental retardation and mood disturbances. Journal of Applied Behavior Analysis, 32, 103-106.
Lindsay, W. R., Howells, L., & Pitcaithly, D. (1993). Cognitive therapy for depression with individuals with intellectual disability. British Journal of Medical Psychology, 66, 135-141.
Lindsay, W. R., Marshall, I., Neilson, C. Q., Quinn, K., & Smith, A. H. W. (1998.) The treatment of men with learning disability convicted of exhibitionism. Research in Developmental Disorders, 19, 295-316.
Lindsay, W. R., Stenfert-Kroese, B. & Drew, P. (2005). Cognitive-behavioral approaches to depression in people with learning disabilities. In P. Sturmey (Ed.), Mood Disorders and people with mental retardation. Kingston, NY: NADD Press.
Matson, J. L. (1982). The treatment of behavioral characteristics of depression in the mentally retarded. Behavior Therapy, 13, 209-218.
Matson, J. L., Dettling, J., & Senatore, V. (1979). Treating depression of a mentally retarded adult. British Journal of Mental Subnormality, 26, 86-89.
Prout, H. T., & Nowak-Drabik, K. M. (2003). Psychotherapy with persons who have mental retardation: An evaluation of effectiveness. American Journal of Mental Retardation, 108, 82-93.
Rojahn, J. & Esbensen, A. J. (2005). Epidemiology of mood disorders in people with mental retardation. In P. Sturmey (Ed.), Mood disorders in individuals with mental retardation. Kingston, NY: NADD Press.
Singh, A. N., Matson, J. L., Cooper, C. L., Dixon, D., & Sturmey, P. (2005). The use of risperidone among individuals with mental retardation: Clinically supported or not? Research in Developmental Disabilities, 26, 203-218.
Skinner, B. F. (1953). Science and human behavior. London: MacMillan.
Spreat, S., Conroy, J. W., & Jones, J. C. (1997). Use of psychotropic medication in Oklahoma: A statewide survey. American Journal of Mental Retardation, 102, 80-85.
Stenfert-Kroese, B. (1997). Cognitive behaviour therapy for people with learning disabilities: Conceptual and contextual issues. In B. Stenfert-Kroese, D. Dagnan, K. Loumidis (Eds.), Cognitive behaviour therapy for people with learning disabilities. London: Routledge.
Stigler, K. A., Posey, D. J., & McDougle, C. J. (2005). Psychotropic medications for mood disorders in persons with mental retardation. In P. Sturmey (Ed.),Mood disorders in individuals with mental retardation. Kingston, NY: NADD Press.
Sturmey, P. (2004). Cognitive therapy with people with intellectual disabilities: A selective review and critique. Clinical Psychology and Psychotherapy, 11, 223-232.
Sturmey, P. (2005a). Ethical dilemmas. In J. Jacobson, J. A. Mulick, & R. M. Foxx (Eds.), Fads: Dubious and improbable treatments for developmental disabilities (pp. 45-450). Hillsdale, NJ: Lawrence Erlbaum Assoc.
Sturmey, P. (2005b). Secretin is a robustly ineffective treatment for autism: A review of 15 double-blind randomized controlled trials. Research in Developmental Disabilities, 26, 87-97.
Sturmey, P. (2005c). Against psychotherapy with people with mental retardation. Mental Retardation, 43, 55-57.
Sturmey, P. (2005d). Behavioural formulation and treatment of depression in people with mental retardation: Formulation and interventions. In P. Sturmey (Ed.), Mood disorders in people with mental retardation. Kingston, NY: NADD Press.
Sturmey, P. & Ghazzuidin, M. (2005). Other biological treatments. In P. Sturmey (Ed.), Mood disorders in people with mental retardation. Kingston, NY: NADD Press.
Van Waarde, J. A., Stolker, J. J., & Van der Mast, R. C. (2001). ECT in mental retardation: A review. Journal of ECT, 17, 233-235.
Wheeler-Vega, J. A., Mortimer, A. M., & Tyson, P. J. (2000). Somatic treatment of psychotic depression: Review and recommendations for practice. Journal ofClinical Psychopharmacology, 20, 504-519.
Whiskey, E., Werneke, U., & Taylor, D. (2001). A systematic review and meta-analysis of Hypericum perforatum in depression: A comprehensive clinical review. International Clinical Psychopharmacology, 16, 239-52.