Developmental Disabilities

A collumn in Psychiatric News (the newspaper of the American Psychiatric Association) comments on the lack of training that psychiatry residents receive in treating adults with autism and mental retardation:

http://pn.psychiatryonline.org/cgi/content/full/39/22/4

Child Psychiatry fellows receive plenty of experience treating this population, but once they reach the age of approximately 18-21, the patients are transitioned to often ill-prepared general psychiatrists.

Once a week I see patients at Mississippi's institution for the mentally retarded/autistic. I also see more functional patients at group homes. The most frustrating part of this assignment is that I have to invent psychiatric diagnoses for many of the patients in order to treat them with medications. Some mentally retarded patients are impulsive, have mood swings, or are violent. They are like my 4-year old son, except that they are six feet tall, weight 200 pounds, and can do a lot of damage when they get out of control. However, due to a consent decree between the Justice Department and this state institution, I am not allowed to treat their mental retardation. Instead I must give them an axis 1 diagnosis such as "bipolar disorder". A mentally retarded person with "bipolar disorder" is very different from a person with a normal IQ who has bipolar disorder. I don't mean to imply that I arbitrarily give these patients a psychiatric diagnosis. The full-time psychologists at the state institution have ultimate control over the diagnosis given the patient, and make sure that DSM-IV criteria are strictly followed. Something just seems wrong about giving the same diagnosis of bipolar disorder to someone with an IQ of 40 who has increased energy most of the time and is constantly pacing and a person with IQ of 100 who has clearly alternating depressive and manic episodes.

On the other hand, my experience is that depression in the mentally retarded is very similary to depression in the normal-IQ population. Depression is common among institutionalized individuals with an IQ of 50-70; these individuals often express frustration about not being able to lead a "normal" life.

I don't want to give the impression that mentally retarded individuals at the state institution are all medicated to control their behavior. Medication is only tried after behavioral interventions fail. Less than half of the residents of this state facility are receiving psychotropics.

Gradually, through experience and reading, I feel that I have gained competence in treating the developmentally disabled. However, I wish that I would have received more training during residency.