essors and patterns of reinforcement or consequences; mental disorders, consequences of complex gene-environmental interactions. On closer analysis, gene-environmental interactions also bias the individual toward specific behavioral reactions to specific circumstances and the risk for psychiatric disorders. Sorting out these complex relationships and matching them with current evidence-based treatment or best practices are some of our greatest challenges.
Mental health professionals entering the world of IDD and dual diagnosis must be open to learning from other disciplines while thinking through problems both systemically and systematically. The time-consuming, multidisciplinary nature of assessment, diagnosis and treatment planning requires understanding of many bodies of knowledge. For psychiatrists, the challenge is to view psychopharmacological interventions as but one component of a complex toolkit (Table 1).
Table 1.Psychopharmacology Pearls for Patients with IDD
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|1. Most consultation patients present with multiple psychiatric diagnoses. Occam’s Razor should be applied prior to prescribing. Syndrome diagnoses are not based on single symptoms.|
|2. Challenging behaviors are heterogeneous states, before prescribing carefully review the functional behavioral analysis, previous diagnoses, previous behavioral and medication treatments and your differential diagnosis. The idea of single drug/ neurotransmitter per challenging behavior can get you into trouble.|
|3. Keep up with what is on the Internet. Families do and some are trying things and may not tell you. The National Institutes of Health has a website on Complementary and Alternative Medicine that can help you keep current. Have caregivers bring all medications, especially OTC or alternative meds.|
|4. Evidenced based treatments for neurotypical patients are essential BUT these studies may not have included patients with IDD or Autism Spectrum Disorders. Pharmacokinetic and pharmacodynamic differences can have a significant impact. The old saw “medications are poisons with positive side effects” can be useful. So is “start low and go slow but don’t forget to go” if there are no positive effects and side effects.|
|5. Use behavioral data, rating scales, measures of drug side effects to monitor treatment response. Many behavioral monitoring systems can be adapted to incorporate dose changes, serum drug levels, improvement on psychiatric rating scales into graphic data representations.|
|6. Serum drug levels can be very useful for patients with no response to high doses or severe side effects at low doses; monitor drug-drug interactions and adapting treatments. Free drug fractions measurements can be useful for valproic acid; 10-11 epoxide levels for carbamazepine. Serum drug and metabolite levels and can provide clues about CYT P450 polymorphisms|
|7. In psychopharmacology remember that more is not always better and a rush to polypharmacy may complicate rather than simplify treatment.|
|8. If you find yourself in a quandary about too many drugs, carefully review each, why they were added, what side effects they might have that complicates the clinical presentation, and carefully reduce, if possible beginning with the first ineffective drug and decrease slowly. An increase in target behaviors may not represent a relapse, if possible wait 1-2 weeks before increasing the old drug or jumping to new one.|
|9. Maintenance treatments are critical for many chronic mental disorders, but maintenance doses may be lower than those required for initial responses. Many increases in challenging behaviors are state related and may not require long term, high dose medication management. Reductions should also “start with small decrements and go slow”. Transient withdrawal states are not uncommon- they resemble extinction surges noted by behavioral therapists when reinforcers are removed.|
|10. Define your comfort zone: when you feel outside it or things don’t make sense, consult. Many IDD syndromes have associated co-occurring metabolic and neurological conditions. 