Depreciation in intellectual disabilities

1. DEPRESSION IN
INTELLECTUAL DISABILITIES
Ehab elbaz, MD , MBA
Consultant psychiatrist
Military Medical Academy
Director of psychiatry hospital
Maadi Medical Military Compound

2. Objectives
Share
share our
experience for a
challenging case.
Highlight
Highlight the
presentation of
depressive
symptoms in people
with intellectual
disabilities.
Recognize
Recognize barriers
for diagnosis and
treatment of
depression in
people with
intellectual
disabilities.
Review
Review challenges
for ECT
administration
when a relative
contraindication is
present.

3. Case
presentation
• A 34 years old male patient was referred to our hospital from the neurology
department by the complaint of eating refusal and refusal to walk or stand.
Despite his neurological examination revealed no pathological
understanding of his condition.
• The patient has a history of cerebral palsy , brain cyst, hydrocephalus and
epilepsy since birth and he developed intellectual disability with the last
IQ= 55
• His epileptic activity was controlled with antiepileptic medication without
any recent changes in his disease activity.

4. • He was living with his parents and his younger brother in Cairo and used to be
attached to his brother who used to take care of him.
• 4 months ago, his brother travelled abroad for a job.
• After that the patient was gradually aggressive , withdrawn, uncooperative
with his parents, refusing any help from other family members
• He progressively refused eating , drinking and getting out of bed

5. • At the time of presentation to the ER he had multiple bed sores in his back
and buttocks , and was vitally stable
• His mental state examination revealed poor hygiene, stupor, mutism ,
negativism with gloomy facial expressions
• Patient was diagnosed as catatonia and treatment with benzodiazepine was
initiated with IV fluid
• A multidisciplinary team including psychiatry, neurology, neurosurgery ,clinical
nutrition , plastic surgery and anesthesia was formed to manage his condition

6. • After 3 days of admission , there was no improvement in his condition and
continued to be uncooperative with the nursing staff and continue to resist
eating, drinking and getting out of his bed.
• We started giving aripeprazole 10 mg IM twice daily with no progress
• We decided to start ECT, and we consulted our colleges in neurosurgery
department for the condition of his intracranial pressure and MRI CSF
flowmetry was requested and repeated twice, which revealed within average
intracranial pressure
• At the 7th day of admission, the patient had sudden cardiac arrest without any
warning signs with failed CPR.

10. How Common Are Intellectual Disabilities?
Approximately 6.5 million people in the United States have an intellectual disability.
Approximately 1 – 3 percent of the global population has an intellectual disability—as many as 200
million people.
Intellectual disability is significantly more common in low-income countries—16.41 in every 1,000
people. Disabilities overall are more common in low-income countries.
The United Nations Development Program estimates that 80 percent of all people with disabilities live
in low-income countries. While people with disabilities represent approximately one in 10 people
worldwide, they are one in every five of the world’s poorest people.
Sources: American Association of Intellectual and Developmental Disabilities; National Center on Birth Defects and Developmental Disabilities; the United
Nations Development Program; and the Centers for Disease Control and Prevention.

11. Barriers to good Health Care
among People with Intellectual
Disabilities and Depression
• Failure to recognize their symptoms
• failure to communicate their needs effectively and the people around them
may misinterpret what their need is.
• Family members may not realize the significance of symptoms or feel that
they are minor and do not require medical attention.
• People with depression can be challenging to live with at times, due to their
symptoms and unpredictability

12. • They may not be offered the same treatment as others with similar conditions due
to potential interactions with other medications, difficulty obtaining consent or
assumptions being made regarding how they might respond to some of the
treatments.
• A person who is receiving care, might not have the same people supporting them
for the duration of treatment, so they may fail to recognize that the person is
improving or deteriorating.
• Diagnostic overshadowing is a common occurrence among people with intellectual
disabilities. This is where the healthcare professional assessing the person,
misdiagnoses them on behalf of their intellectual disability e.g. where social
withdrawal is seen, this may be picked up as an element of their intellectual
disability, as opposed to a new symptom of potential depressive illness.

14. Behavioral
indicators of
depression
(13 studies)
Construct & Behavior
Number of studies in which
behavior indexes the depression
profile in severe ID
Psychomotor agitation 2
Little Appetite 2
Depressed affect 4
Irritability 3
Crying/tearfulness 2
Reduced interest and
pleasure/anhedonia
4
Fatigue/loss of energy/lethargy 2

15. Behavioral
correlates of
depression
(13 studies)
Construct &
Behavior
Number of studies in which
behavior indexes the
depression profile in severe ID
Self-injurious behavior 3
Aggression 4
Temper tantrums 2
Screaming 2
Disruptive behavior 2

16. Algorithm for acute treatment of catatonia
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17. Contraindications of
ECT
There are no absolute contraindications to ECT
Relative contraindications include:
• Space-occupying cerebral lesion with increased
intracranial pressure or mass effect
• Recent myocardial infarction (if <1 month ago)
• Recent stroke or cerebral hemorrhage (if <1 month ago)
• Unstable vascular aneurysms or malformations
• Pheochromocytoma
• Class 4 or 5 anaesthesia risk (ASA IV, ASA V)
• Recent orthopedic injury with unstable
fracture/dislocation (if <1 month ago)

22. Conclusion
Depression in patients with
intellectual disabilities may be
difficult to recognize
Early intervention may be life
Using multidisciplinary team in
managing challenging situation is
key in clinical practice

23. Thank you