Prozac on the Couch – Depression and Anxiety in People with an Intellectual Disability

PsychDD November 2013

Jack DikianGeorgina Kenaghan

Presentation objectives

Depression and anxiety in a historical and cultural context – psychoanalysis to pharmacology

The high prevalence and reasons for depression and anxiety in people with Intellectual Disability (ID)

Recognizing the symptoms and behaviours associated with depression and anxiety in people with ID

Discuss the emerging screening tools and acknowledgement of the difficulties of diagnosis in this population group

Opportunities to increase the awareness of and screening for depression and anxiety when supporting people with ID

Depression and Anxiety

Depression – The common features of depressive disorders are the presence of sad, empty or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.

Anxiety Disorders – Include disturbances that share features of excessive fear, worry, behavioural disturbances; that are out of proportion to the actual likelihood or impact of the anticipated event.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th ed. (DSM-V). American Psychiatric Publishing 2013. References throughout the presentation are to Major Depressive Disorder and Generalised Anxiety Disorder

Prozac on the CouchProzac on the Couch

A Biological Basis

Pop-culture

The interplay between neurotransmitters & symptomology

• Sex• Appetite• Aggression

• Concentration• Interest• Motivation

• Mood

• Anxiety

• Irritability

• Thought process

Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications: 2nd ed. Cambridge University Press 2000.

Noradrenaline (NA)Serotonin (5-HT)

Antidepressants (normal population)

0 1 2 3 4 5

100

80

60

40

20

0

No

(%) o

f peo

ple

still

wel

l

Years after recovery

People just recovered from depression

People on an antidepressant

Stopped antidepressantuse after 3 years

No antidepressantsused

Frank & Kupfer studies, Archives of General Psychiatry 1990

High rates of relapse (normal population)

• 76% of patients with lingering symptoms of depression relapsed within 10 months1

1. Adapted from: Paykel ES, et al. Psychol Med. 1995;25:1171-1180.

94% of depressed patients who experienced lingering symptoms had mild to moderate physical symptoms1

Prevalence rates of Depression and Anxiety for people with ID vary greatly

Holt et al., 2008 10% - 74%

Lacono et al., 1997 25% - 40%

Gillberg et el., 1986 10% - 37%

Rai., et 2010 Antidepressant use in adults with intellectual disability as high as 62% “Co-occurring mental health in Intellectual Disability is 3 to 4 times higher than in the normal population” (APA, 2013)

• Holt G, Hardy S, Bouras N (2008) Mental Health in Learning Disabilities. A Reader. Brighton, UK. Pavilion Publishing• Lacono I, Torr J, Galea J and Graham J (1997) Centre for Developmental Disability Health Victoria, Australia• Gillberg C, Presson E, Grufman M, Themner U (1986) Psychiatric disorders in mildly and severely mentally retarded urban children and adolescents: epidemiological aspects. British Journal of Psychiatry.• Rai P, Kerr M (2010) Antidepressant use in adults with Intellectual Disability. The Psychiatrist, The Royal College of Psychiatrists • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th ed. (DSM-V). American Psychiatric Publishing 2013.

High rates of mental illness in people with ID

1. Diagnostic difficulties ie. overshadowing

2. Biologically-driven arousal regulation

3. Psychosocial

Diminished communication abilities leading to inadequate coping skills and coping statements

Social rejection & social support links with life stresses

References: Victorian Dual Disability Service (Aust data)

Symptoms of Depression - normal population

Cognitive/emotional Physical

Excessive or inappropriate guilt

Diminished ability to think or concentrate, indecisiveness

Overwhelmed

Loss of interest or pleasure

Sadness

Back pain Weight loss/gain

Medical problems

Fatigue

Sleep disturbances

Headache

Vague aches and pains

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. American Psychiatric Association.

Symptoms of Generalized Anxiety - normal population

Cognitive/emotional Physical

Constant worries

Poor problem solving

An inability to tolerate uncertainty

Can do nothing to stop worrying

A pervasive feeling of apprehension or dread

Stomach problems, nausea, diarrhoea

Feeling edgy, restless, or jumpy

Sleep disturbances

Feeling tense; having muscle tightness or body aches

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. American Psychiatric Association.

Intrusive thoughts

People report physical symptoms

1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.2. Torr, J et al,2008, JIDR, Checklists for general practitioner diagnosis of depression adults

with intellectual disability

N = 1146 Primary care patients with major depression (normal population)

69% of diagnosed depressed patients reported unexplained physical symptoms as their chief complaint 1

Carers identified features of depression within people with ID that GPs failed to recognise; even with the carers present. 2

Important Classification Symptoms

Cognitive symptoms

Standard diagnostic criteria(Normal population)

Increase in irritability Increase in aggression

Sleep Appetite Agitation Other

DC-LD

Intellectual Disability - equivalents of depression

May report being up at night; others may note going to bed quite late. Any change in sleeping habits; tantrums or activity during sleeping hours Sleeping or napping during the day

4. Insomnia/ Hypersomnia nearly

every day

Tantrums at meals; stealing food; refusing activities, hoarding food in room.

3. Significant weight loss or weight gain; decrease or increase in appetite nearly daily

Withdrawal; lack of reinforcers Refusal to participate in leisure activities or work Change in ability to watch TV or listen to music

2. Markedly diminished interest or pleasure in most activities nearly every day

Apathetic, sad or angry facial expression Lack of emotional reactivity; upset; crying Verbal and physical aggression

1. Depressed or irritable mood

Equivalent observable behaviours*DSM-V Criteria for MDD

* Mental Health First Aid – Intellectual Disability Manual 2nd Edition 2010

Intellectual Disability - equivalents of depression

Perseveration on the deaths of family members & friends preoccupation with funerals

9. Recurrent thoughts of death, suicidal behaviour/ideation/ statements/ attempts

Poor performance at work Change in leisure habits and hobbies Appearing distracted

8. Diminished ability to think/concentrate; or indecisiveness

Statements such as "I'm stupid" or “I’m bad” or “I’m not normal” 7. Feelings of worthlessness; excessive/ inappropriate guilt nearly daily

Appears tired; refuses leisure activities or work Withdraws to room; loss of daily living skills Refusal to perform personal care tasks Incontinence due to lack of energy or motivation.

6. Fatigue or loss of energy nearly every day

Pacing, hyperactivity; decreased energy, passivity Slowness in activities of daily living; muteness whispering; monosyllables Increase in self-injurious behaviour or aggression

5. Psychomotor agitation or retardation nearly every day

Equivalent behaviours*DSM-V Criteria for MDD

* Mental Health First Aid – Intellectual Disability Manual 2nd Edition 2010

Intellectual Disability - equivalents of anxiety

Self-reports of feeling nervous, anxious, panicked or scared & excessive worry about health, family relationship with friends/carers/staff, work/day program, change or uncertainty; expecting the worst to happen Avoidance of certain stimuli, people or environments A person with an ID is more likely to report the physical sensations rather than their emotional state

Expression through:

Self injurious behaviour, Aggressive behaviour, Disruptive or defiant behaviour, Self-soothing behaviours Seeking reassurance, ‘clingy’ or over-demanding behaviour Withdrawal (avoidance) refusal to participate in activities Seeming to ‘freeze’ Overactivity or increased agitation Repetitive questioning

1. Excessive anxiety & worry (apprehensive expectation)

2. The individual finds it difficult to control the worry

Equivalent behaviours*DSM-V Criteria for GAD

* Mental Health First Aid – Intellectual Disability Manual 2nd Edition 2010

Intellectual Disability - equivalents of anxiety

Physical symptoms are often not reported in medical terms & lack specific information about location of symptoms Irritability, increased arousal, restlessness ie. pacing Appears tired; refuses leisure activities Changes in attention to tasks normally completed Muscle trembling/ twitching, feeling shaky, muscle aches/ soreness reported Difficulty falling asleep or staying asleep or restless unsatisfying sleep Associated physical symptom features including somatic symptoms of sweating, nausea, diarrhoea; and exaggerated startle response

3. Physical Symptoms including:

- Restlessness of feeling keyed up or on edge

- Being easily fatigued

- Difficulty concentrating or mind going blank

- Irritability

- Muscle tension

- Sleep disturbances

Equivalent behaviours*DSM-V Criteria for GAD

* Mental Health First Aid – Intellectual Disability Manual 2nd Edition 2010

Screening tools and associated difficulties

DSM-V acknowledges that “Assessment procedures may require modifications for a number of reasons or disabilities”.

There continues to be reliability concerns around diagnosis, validation or eliciting symptoms; particularly in moderate or severe ID

Growing literature validating mental health symptomology in mild ID

Difficulties including diagnostic overshadowing etc

Examples of emerging or existing screening tools

Ref: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th ed. (DSM-V). American Psychiatric Publishing 2013.

The Glasgow Depression Scale – 20 items self report & parallel 16 items informant version. Using DC-LD, DSM, & ICD-10 & extensive scale development renders it a promising tool.

The Anxiety, Depression & Mood Scale [Esbensen AJ] targets depression & severe ID. This is an informant, empirically derived scale. Able to assess co-morbid anxiety.

The Mood, Interest & Pleasure Questionnaire developed for caregivers of individuals with severe ID. Specific focus is placed on level of interest/pleasure.

Mini PAS-ADD Psychiatric Assessment Schedule for Adults with a Developmental Disability (PAS-ADD) used to screen a population for mental Health problems, or to monitor the symptoms of at-risk individuals.

Some Screening tools

Going forward

The ongoing need for increased awareness. Increasing the awareness of depression and anxiety for carers supporting people with an ID.

We are reviewing/investigating this need and how we might address it.

Proposal to develop further awareness and reconination of depression and anxiety

Output and Outcomes

• A guide used by support workers & Mangers to better understand depression & anxiety, so they are better prepared when discussing client behaviours/issues with practitioners and other health professionals.

• Able to be more proactive and timely in raising concerns around possible emergence of depression and anxiety. • Identification of behaviours that may be suggestive of depression and anxiety.

• An augmented screening tool to help gauge the possibility of depression and anxiety and facilitate relevant data gathering and analysis.

Resources Intellectual Disability Mental Health First Aid Manual 2nd Edition http://www.mhfa.com.au/cms/wp-content/uploads/2011/02/2nd_edition_id_manual_dec10.pdf

The Royal Collage of Psychiatrists. Depression in people with learning disabilities. http://www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthproblems/depression/learningdisability.aspx

Mental Health First Aid Training and Research Program. Suicidal Thoughts and behaviours: First Aid Guidelines. Melbourne: ORYGEN Youth health Research Centre, University of Melbourne http://www.mhfa.com.au/Guidelines.shtml

Intellectual Disability Mental Health e-Learning. 3DN (Department of Developmental Disability Neuropsychiatry) at the University of New South Wales (UNSW). http://www.idhealtheducation.edu.au/

Depression in Adults with an Intellectual Disability: Checklist for Carers & General Information. Centre for Developmental Disability Health Victoria. http://www.cddh.monash.org/research/depression/

Children’s Hospital Westmead (CHW) School Link Initiative: Supporting the Mental Health of Children and Adolescents with an Intellectual Disability. http://www.schoollink.chw.edu.au/

Prozac on the Couch – Depression and Anxiety in People with an Intellectual Disability

Jack DikianStatewide Behaviour Intervention Services || Clinical Innovation and Governance

Ageing Disability and Home Care  ||  Department of Family and Community ServicesJack.Dikian@facs.nsw.gov.au

T 02 9407 1900 ||  F 02 9407 1990

Georgina Kenaghan

Behaviour Support Practitioner | Specialist Support Team 1Ageing Disability and Home Care | Department of Family and Community Services

Georgina.Kenaghan@facs.nsw.gov.auT 02 9407 1855 | F 02 9407 1677