Download Depression Anxiety in people with ID

Prozac on the Couch – Depression and
Anxiety in People with an Intellectual Disability
PsychDD
November 2013
Jack Dikian
Georgina 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 5 th ed. (DSM-V). American Psychiatric Publishing 2013.
References throughout the presentation are to Major Depressive Disorder and Generalised Anxiety Disorder
Prozac on
on the
the Couch
Couch
Prozac
A Biological Basis
Pop-culture
The interplay between neurotransmitters & symptomology
Serotonin (5-HT)
• Sex
• Appetite
• Aggression
Noradrenaline (NA)
• Mood
• Anxiety
• Irritability
• Concentration
• Interest
• Motivation
• Thought process
Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications: 2 nd ed. Cambridge University Press 2000.
Antidepressants (normal population)
People just recovered from depression
100
No (%) of people still well
People on an antidepressant
80
60
No antidepressants
used
Stopped antidepressant
use after 3 years
40
20
0
0
1
2
3
4
5
Years after recovery
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
94% of depressed
patients who
experienced lingering
symptoms had mild to
moderate physical
symptoms1
1. Adapted from: Paykel ES, et al. Psychol Med. 1995;25:1171-1180.
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

Sadness

Vague aches and pains

Loss of interest or pleasure

Headache

Overwhelmed

Sleep disturbances

Diminished ability to think or
concentrate, indecisiveness

Fatigue

Excessive or inappropriate guilt

Back pain

Weight loss/gain
 Medical problems
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

A pervasive feeling of apprehension
or dread

Feeling tense; having muscle
tightness or body aches

Can do nothing to stop worrying

Sleep disturbances

An inability to tolerate uncertainty

Feeling edgy, restless, or
jumpy

Intrusive thoughts

Stomach problems, nausea,
diarrhoea

Constant worries

Poor problem solving
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
Fourth Edition, Text Revision. American Psychiatric Association.
People report physical symptoms
 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
N = 1146 Primary care patients with
major depression (normal population)
1.
2.
Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.
Torr, J et al,2008, JIDR, Checklists for general practitioner diagnosis of depression adults
with intellectual disability
Important Classification Symptoms
Standard diagnostic criteria
(Normal population)
Cognitive
symptoms
DC-LD
 Sleep
 Appetite  Increase in irritability
 Agitation  Increase in aggression
 Other
Intellectual Disability - equivalents of depression
DSM-V Criteria for MDD
Equivalent observable behaviours*
1. Depressed or irritable
mood



Apathetic, sad or angry facial expression
Lack of emotional reactivity; upset; crying
Verbal and physical aggression



Withdrawal; lack of reinforcers
Refusal to participate in leisure activities or work
Change in ability to watch TV or listen to music

Tantrums at meals; stealing food; refusing activities,
hoarding food in room.
2. Markedly diminished
interest or pleasure
in most activities
nearly every day
3. Significant weight loss
or weight gain;
decrease or increase
in appetite nearly daily

4. Insomnia/
Hypersomnia
nearly every day
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
* Mental Health First Aid – Intellectual Disability Manual 2nd Edition 2010
Intellectual Disability - equivalents of depression
DSM-V Criteria for MDD
Equivalent behaviours*
5. Psychomotor agitation
or retardation nearly
every day


Pacing, hyperactivity; decreased energy, passivity
Slowness in activities of daily living; muteness
whispering; monosyllables
 Increase in self-injurious behaviour or aggression
6. Fatigue or loss of energy  Appears tired; refuses leisure activities or work
nearly every day
 Withdraws to room; loss of daily living skills


Refusal to perform personal care tasks
Incontinence due to lack of energy or motivation.
7. Feelings of worthlessness;
excessive/ inappropriate  Statements such as "I'm stupid" or “I’m bad” or “I’m
not normal”
guilt nearly daily
8. Diminished ability to
think/concentrate; or
indecisiveness



Poor performance at work
Change in leisure habits and hobbies
Appearing distracted
9. Recurrent thoughts
of death, suicidal
behaviour/ideation/
statements/ attempts


Perseveration on the deaths of family members & friends
preoccupation with funerals
* Mental Health First Aid – Intellectual Disability Manual 2nd Edition 2010
Intellectual Disability - equivalents of anxiety
DSM-V Criteria for GAD
1.
Excessive anxiety
& worry
(apprehensive
expectation)
2.
The individual
finds it difficult to
control the worry
Equivalent behaviours*

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
* Mental Health First Aid – Intellectual Disability Manual 2nd Edition 2010
Intellectual Disability - equivalents of anxiety
DSM-V Criteria for GAD
3. Physical Symptoms
including:
-
-
Restlessness of
feeling keyed up or on
edge
Being easily fatigued
Difficulty
concentrating or mind
going blank
-
Irritability
-
Muscle tension
Equivalent behaviours*







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
- Sleep disturbances
* 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.
Some Screening tools
The Glasgow Depression Scale – 20 items self report & parallel 16 it
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.
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 Dikian
Statewide Behaviour Intervention Services || Clinical Innovation and Governance
Ageing Disability and Home Care || Department of Family and Community Services
[email protected]
T 02 9407 1900 || F 02 9407 1990
Georgina Kenaghan
Behaviour Support Practitioner | Specialist Support Team 1
Ageing Disability and Home Care | Department of Family and Community Services
[email protected]
T 02 9407 1855 | F 02 9407 1677