Intellectual disability and inpatient psychiatry

[heyjack70]

In your experience with inpatient psych units do you find that patients with intellectual disability and behavioral disturbance (typically violence towards group home staff or property) end up getting admitted? I've seen this handled differently at different places. In my residency in a bigger city there were good DD services that essentially managed these patients and they were not admitted to psych. At a moonlighting job in a busy hospital in a smaller town the main psychiatrist admitted almost everyone if he had beds open and seemed more than happy to generate RVUs even if he wasn't really offering much in the way of treatment.

Ultimately the inpatient units I've worked on don't have near the services needed to treat this population and end up just serving as a place they can be locked up until they calm down on their own or get tranquilized with antipsychotics to the point they stop having outbursts of violence. In reality they need high staff numbers to implement consistent behavioral treatments, but I've only seen these types of units in state hospitals serving a habilitation role.

A frequent issue is many patients live in group homes with 24 hour staffing who should be able to handle these types of behavioral problems but often do not want to and think the psych unit is the de facto solution. And once admitted they decline to accept the patients back. It seems like it is more appropriate to not admit and send these patients back to the group homes which are supposedly set up to manage them. Also, many patients seem to know they are behaving inappropriately but choose to continue acting out, which seems like a matter better handled by law enforcement. What are your thoughts?

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[wolfvgang22]

Yes.

 

[whopper]

You touched on something that's long been a problem in every area I've seen. Intellectual disability will not improve with medications. Further some other problems make it worse such as staff members freaking out over issues where medication isn't the answer and expecting us to medicate the intellectually disabled patient.

It's only appropriate the hospitalize such a patient if the home is in a situation where they can't inject the patient and an injection is needed, but like I said above, for intellectual disability this isn't a good solution unless the person has an actual Axis I disorder where it's warranted such as psychosis. Very good behavioral approaches instead should be implemented but most homes do not or cannot implement these due to lack of staff members or training.

 

[wolfvgang22]

You touched on something that's long been a problem in every area I've seen. Intellectual disability will not improve with medications. Further some other problems make it worse such as staff members freaking out over issues where medication isn't the answer and expecting us to medicate the intellectually disabled patient.

It's only appropriate the hospitalize such a patient if the home is in a situation where they can't inject the patient and an injection is needed, but like I said above, for intellectual disability this isn't a good solution unless the person has an actual Axis I disorder where it's warranted such as psychosis. Very good behavioral approaches instead should be implemented but most homes do not or cannot implement these due to lack of staff members or training.

Yep, behavioral management is mostly what they need. Lifelong sedation is not a solution.

Similar, but separate situation: A lot of times I get consulted by inpatient doctors on elderly, dying patients that are headed to hospice to "evaluate and treat for depression". They usually have at most about a couple of weeks to live. Patient is already up to his or her eyeballs in morphine, what do they think I'm going do?

 

[heyjack70]

Yep, behavioral management is mostly what they need. Lifelong sedation is not a solution.

Similar, but separate situation: A lot of times I get consulted by inpatient doctors on elderly, dying patients that are headed to hospice to "evaluate and treat for depression". They usually have at most about a couple of weeks to live. Patient is already up to his or her eyeballs in morphine, what do they think I'm going do?

Ketamine?

 

[ferning]

I worked in a group home before med school. Staffing is a revolving door and they paid 2 bucks more then minimum wage. Its too much responsibility and work for those labor standards. They give medications, drive to doc appts, prepare meals, clean the house, and keep the residents from killing each other at times. Some are pretty old and can be very physically disabled as well.

Upper management has no problem dumping residents in a hospital if they get low staffed. Insurance pays for meals and meds when inpatient which keeps gives them a little extra money.

What I saw was a great improvement over institutions and hospitals, but there should be some state laws on minimum staffing requirements per resident. controlled for physical and behavioral issues. And limits on non-direct care workers in these organizations who divert the mission

 

[whopper]

Ketamine?

The potential hope of Ketamine to aid in treatment has a big pitfall attached to it. It only helps for a few days. It also doesn't address the real issue. E.g. if someone is depressed to the point of being suicidal, what do we do if we give them Ketamine, now they're fine but they will likely drop back to where they were in about a week? Do we discharge them knowing that in a week, outside the hospital they could kill themself?

Or do we keep them in the hospital against their will despite that at the present moment and for the next few days they'll be fine?

Aside that it only temporarily helps, what then after the few days are up?

The above will be a major issue to tackle both ethically and legally. Many states do not allow one to hold a patient against their will even if there is an imminent future risk if at the present they are not at risk.

I too used to work in a group home. The care I saw there was pathetic. The previous psychiatrist had everyone doped up on benzos. Being that I was only going to see these patients once a month I could only lower their benzos very slowly. I'm talking about 8 mg a day of Ativan and unnecessary polypharmacy. After about a year I got a lot of these patients completely off of benzos, and the staff members told me the patients looked dramatically better with them not being zombies to actually being able to interact.

Very few psychiatrists are willing to work at a group home and the few I saw did were usually bottom of the barrel.

 

[notdeadyet]

The potential hope of Ketamine to aid in treatment has a big pitfall attached to it. It only helps for a few days. It also doesn't address the real issue. E.g. if someone is depressed to the point of being suicidal, what do we do if we give them Ketamine, now they're fine but they will likely drop back to where they were in about a week? Do we discharge them knowing that in a week, outside the hospital they could kill themself?

I'd disagree with this characterization of Ketamine. The literature seems to suggest otherwise. I know of one study that showed a 50% reduction in MADRS was sustained through day 10 post-infusion. Another done with patients in the ED for suicide found it effective and only 6% showed return of SI 10 days later. I don't agree with folks who think it's a panacea, but for something like SI, where our typical medical interventions are limited to medications that take weeks to take effect (if they take effect at all)? I wouldn't dismiss it so easily.

 

[heyjack70]

Especially for depression in hospice patients. At that point why not use ketamine.

 

[whopper]

Agree with the Ketamine comments with hospice.

As for your comments Notdeadyet, so be it. I'm not against revising my view especially with a potential treatment that is still in progress with the research. If anything I should be thanking you for inserting this knowledge into my brain.

 

[notdeadyet]

No worries, whopper. It will be interesting to see how it holds up in bigger n studies. I'm just cautiously optimistic at this point. Time will tell...


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[Armadillos]

As an aside, anyone ever seen IV ketamine for migraine? Saw it once or twice for people who had failed literally everything else and it was a pretty profound response.