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MENTAL HANDICAP VOL. 21 SEPTEMBER 1993 Recurrent Brief Depression and Mild Learning Disability: Successful Communitv Management David J. Clarke Marianne MacLeod A 58 year old woman with a 30 year history of mental illness, and numerous hospital admis- sions, was assessed by two members of a community team for people with learning dis- ability. A lOcm analogue scale (rated by her family) was used to record changes in her behaviour. A diagnosis of recurrent brief depression was made and appropriate pharma- cological treatment and support provided with- out admission to hospital. A marked increase in the intervals between episodes of depression, and a shortening of depressive episode length, have been observed over 18 months of follow- up. Recurrent brief depression is a recently recognised sub-type of depressive illness which may occur in association with learning dis- ability. It is treatable, and assessment and treatment may be possible without recourse to hospital admission. Introduction In the nineteenth century, the four major classes of psychiatric illness (organic disorders, such as dementia; psychoses, such as depressive psychoses and schizophrenia; neuroses, such as phobic anxiety states; and personality disorders) were delineated. The distinction between affective (mood) disorders such as bipolar (manic depressive) illness and schizophrenia has been supported by evidence regarding the genetics, symptomatlology and natural history of the two types of illness. Affective disorders are characterised by a change in mood and activity and are usually episodic with long disease-free intervals. Bipolar affective disorder is characterised by the occurrence of one or more episodes of elevated mood (hypomania or mania) which may in turn lead to abnormal behaviour or abnormal beliefs. Depressive disorders are distinguished from ‘ordinary’ unhappiness or misery by their degree and by their association with specific symptoms such as loss of appetite, weight loss, abnormal sleep pattern with early morning waking, loss of energy and interest, abnormal feelings of self-reproach or guilt, and recurrent thoughts of death or suicide. It is important that people working with clients with learning disability are familiar with the concept of depressive illness (Yapa & Roy, 1990). The condition interferes markedly with normal functioning, is associated with a significant morbidity and mortality (especially from suicide), and is about four times more common among people with learning disability than among the general population (Corbett, 1978; Lund, 1985). Angst et al. (1990) described a sub-type of depression; recurrent brief depression (RBD), which differed from the depressive illnesses familiar to psychiatrists and general practitioners in that the episodes of depression were both more frequent and of shorter duration than usual. Angst et al.’s criteria for RBD are listed in Table 1. We describe a 58 year old woman with mild learning disability and a 30 year history of mental health problems, who was successfully assessed and treated at home for a psychiatric disorder fulfilling criteria for RBD. DAVID J. CLARKE is a Senior Lecturer in Developmental Psychiatry at the University of Birmingham Department of Psychiatry. MARIANNE MACLEOD is a Community Nurse at Harris House Resource Centre, Birmingham. 92 0 1993 BlLD Publications

Recurrent Brief Depression and Mild Learning Disability: Successful Community Management

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MENTAL HANDICAP VOL. 21 SEPTEMBER 1993

Recurrent Brief Depression and Mild Learning Disability: Successful Communitv Management

David J. Clarke Marianne MacLeod

A 58 year old woman with a 30 year history of mental illness, and numerous hospital admis- sions, was assessed by two members of a community team for people with learning dis- ability. A lOcm analogue scale (rated by her family) was used to record changes in her behaviour. A diagnosis of recurrent brief depression was made and appropriate pharma- cological treatment and support provided with- out admission to hospital. A marked increase in the intervals between episodes of depression, and a shortening of depressive episode length, have been observed over 18 months of follow- up. Recurrent brief depression is a recently recognised sub-type of depressive illness which may occur in association with learning dis- ability. It is treatable, and assessment and treatment may be possible without recourse to hospital admission.

Introduction In the nineteenth century, the four major classes

of psychiatric illness (organic disorders, such as dementia; psychoses, such as depressive psychoses and schizophrenia; neuroses, such as phobic anxiety states; and personality disorders) were delineated. The distinction between affective (mood) disorders such as bipolar (manic depressive) illness and schizophrenia has been supported by evidence regarding the genetics, symptomatlology and natural history of the two types of illness. Affective disorders are characterised by a change in mood and activity

and are usually episodic with long disease-free intervals. Bipolar affective disorder is characterised by the occurrence of one or more episodes of elevated mood (hypomania or mania) which may in turn lead to abnormal behaviour or abnormal beliefs. Depressive disorders are distinguished from ‘ordinary’ unhappiness or misery by their degree and by their association with specific symptoms such as loss of appetite, weight loss, abnormal sleep pattern with early morning waking, loss of energy and interest, abnormal feelings of self-reproach or guilt, and recurrent thoughts of death or suicide. It is important that people working with clients with learning disability are familiar with the concept of depressive illness (Yapa & Roy, 1990). The condition interferes markedly with normal functioning, is associated with a significant morbidity and mortality (especially from suicide), and is about four times more common among people with learning disability than among the general population (Corbett, 1978; Lund, 1985).

Angst et al. (1990) described a sub-type of depression; recurrent brief depression (RBD), which differed from the depressive illnesses familiar to psychiatrists and general practitioners in that the episodes of depression were both more frequent and of shorter duration than usual. Angst et al.’s criteria for RBD are listed in Table 1.

We describe a 58 year old woman with mild learning disability and a 30 year history of mental health problems, who was successfully assessed and treated at home for a psychiatric disorder fulfilling criteria for RBD.

DAVID J. CLARKE is a Senior Lecturer in Developmental Psychiatry at the University of Birmingham Department of Psychiatry. MARIANNE MACLEOD is a Community Nurse at Harris House Resource Centre, Birmingham.

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Dysphoric mood or loss of interest or pleasure. Duration less than two weeks. Four of the following symptoms: 0 Poor appetite or significant weight loss (when not dieting) or increased appetite or

significant weight gain Insomnia or hypersomnia Psychomotor agitation or retardation

Loss of energy; fatigue

0

Impairment in usual activities. At least 1-2 episodes per month over one year.

Loss of interest or pleasure in usual activities, or decrease in sexual drive

Feelings of worthlessness, self-reproach, or excessive or inappropriate guilt Diminished ability to think or concentrate, slowed thinking, or indecisiveness Recurrent thoughts of death, suicidal ideation, wishes to be dead, or suicide attempt

TABLE 1 Diagnostic criteria for recurrent brief depression (RBD) proposed by Angst e t d . (1990).

Case report M. was born in Birmingham in 1933, the fifth of

six siblings, two of whom subsequently received care in hospitals for people with learning disability, as had her maternal uncle. She is believed to have walked, talked, etc, around the .usual times, but on entering school was found to be ‘slow’, and transferred to a school for pupils with learning difficulties which she attended to the age of 19. She met her husband at the age of 20, and married at 22. She spent some time working as a packer, press operator and chambermaid. She left work when she had her family; three boys (one of whom died at the age of three months) and two girls. One pregnancy, when M. was 43, ended in miscarriage.

M.’s first documented episode of psychiatric illness was in 1962 after the birth of her second daughter, when she was treated in hospital for a puerperal psychotic illness. Between 1962 and 1982 she had many (at least 18) admissions to several psychiatric hospitals, with behaviours or symptoms including restlessness, argumentativeness, tear- fulness and depression, difficulty in sleeping and complaints of abnormal bodily sensations for which no physical cause could be found. She was some- times detained using mental health legislation, and received diagnoses including depressive illness and chronic schizophrenia (the latter possibly because her mild learning disability was not recognised).

In 1982 she started to receive services from the learning disability team. Her behaviour continued to fluctuate episodically, with repeated tearfulness, complaints of sickness and headaches, and occasional aggressive behaviour. She was suspended from her day placement in an adult training centre in 1985 because of aggressive behaviour, and was admitted to the local mental handicap hospital twice between 1985 and 1989. Her husband and daughters

tried to cope with M.’s behaviour as best they could, but her repeated episodes of illness left them feeling resentful to M. and to the learning disability services.

In 1990 M. was re-assessed by a community nurse and psychiatrist from the Health Authority Learning Disability Team, following a brief admission to hospital for respite care after a further episode of aggressive behaviour directed at her husband. She was thought to be suffering from a depressive illness, and had been prescribed an antidepressant (lofepramine) in addition to chlorpromazine and procyclidine which she had been taking for many years.

Assessment

by M. and her husband to be:

Not sleeping at night.

0

Assessment showed the problems as perceived

Sometimes aggressive to her husband and other members of the family.

Sometimes withdrawn, quiet, and unable to do things.

Sometimes not eating or drinking.

Sometimes very sad and tearful.

0

0

0

M. and her husband and family agreed to a period of observation in which M. and her husband (if M. was well) or her husband and family would rate her behaviour on a specially designed form, and also fill in a diary describing how she had seemed each day. A form with lOcm analogue scales was prepared using the behaviours identified as problems for M., and constructed so that the ‘problem’ behaviour appeared at one end of the lOcm line, and the ‘opposite’ behaviour at the other end (see Figure I): This allows behaviours to be scored 1 to

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Name ............................................................... Date ............................................................... Time.. ................................

m: ++-------I +-.-.-------

Sleeping normally Not sleeping

Flace an 'x' on the l i n e to indicate how .... M? ...... has been today.

Please t r y to complete the chart a t the same time each day.

.....................................................................

.....

Calm, t 1 Aggressive relaxed

HaPDY t t Sad

overactive 1 W I thdravn

Eating NO t eating normally 1 1 0 , n o t

drlnking

Sleeping 1 4 Not sleeping normally

c("Ts: ...................................................................... ...................................................................... ...................................................................... .....................................................................

FIGURE 1 Rathg sheet used to quantify aspects of behaviour

10 by measuring where on the line the cross is placed each day, and thus monitor changes in behaviour.

Outcome M. and her husband completed the behaviour-

rating forms as agreed, and continue to do so. Figures2 and 3 show two of the charts obtained by plotting the resulting figures. M.'s recurrent episodes of depression occurred at the same time as her aggressive behaviour (implying that the aggression was probably a result of her mood change) and not eating/drinking and withdrawal were also found to occur in tandem with the episodes of low mood. M.'s sleep had returned to normal, and continued to be rated as normal throughout the episodes of depression. In view of the frequency of M.'s episodes of depression, a diagnosis of recurrent brief depression was made and treatment with carbamazepine was started. Carbamazepine is an antiepileptic drug which also has a mood-stabilising effect and is used prophylac- tically to treat rapid cycling affective disorders (Kishimoto et aZ., 1983; Post et aZ., 1986). The introduction of carbamazepine resulted in an increase in depression-free intervals and a reduction

Chloropromane IOOmg BD nuoxetinc 2Omg at Night

Procyclidinc 5mg in Morning mamawpine Chlorpromadnc Lactulosc loml at Night Increased to Reduced to

I 2OOmg ai Night loomg Carbamazepine

Lnuoduced IOOmg BD

I

Chlorpromdne and Procyclidine both rtoppcd

SO

40

30

20 > $ 10 e

0

-10

-20 i vI -30

40

-50 Nov Dec Jan Feb Mar Aor May Jun Jul AUC Sep Oc: Nov

1990 I 1991

FIGURE2 Chart of mood derived from 10cm analogue ratings

Chloropromzine l a g BD Fluoxednc 2 b g at Night Procyciidme 5mg in Morning ~ a m w c p i n e Chlorpromadnc Lactulosc loml at Night Increased to Reduced to

I 2Wmg at Night l m g

I Carbamazepine I n U d U C e d lOOmg BD

Chlorpromadnc and Procyclidine

tmlh stoppcd

I I I I t

1990 I 1991

FIGURE3 Chart of severity of aggressive be- haviour, derived from 10 cm analogue ratings

in the duration of depressive episodes, as shown on Figures 2 and 3.

M. has now been receiving treatment for nearly two years. She, and her husband, are very pleased with the medication and support from the com- munity team. Episodes of illness do still occur (and some of them are still associated with aggressive behaviour directed at family members). M., however, now has much greater self-esteem, and her family are more tolerant of the episodes of abnormal behaviour (because the cause has been explained, the episodes are less frequent, and there is an obvious improvement in M.'s quality of life in

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between episodes). One recent episode (with promi nent persecutory delusions) necessitated the re- prescription of chlorpromazine on a temporary basis.

Discussion Many people with learnnig disability aid dep

we illness are admitted to ktospital for treatment, especially if their behaviour has changed in a way which presents difficulties for their carer(sj. This may be appropriate in some circumstances (e.g. where there is a significant danger of self-harm, where the person has become physically frail as a result of not eating or drinking, or where admission is essential to provide respite for relatives). Hospital admission does, however, mean that the potential to monitor behaviour in the setting in which it usually occurs has been lost. There will also be a discontinuity in behavioural observation following discharge from hospital. Affective disorders are characteristically associated with a relapsing course, and admission to hospital does not affect the long- term course of the disorder, other than by preventing additional morbidity. Admission may also have other adverse consequences, such as loss of rule and the risk of ‘institutionalisation’. Home treatment is associated with other benefits, such as earlier detection of symptoms (in part because symptoms are disclosed more readily if hospitaiisation is unlikely to result from disclosure) and greater patient satisfaction (Reynolds & Houit, 1984; Dean & Gadd, 1990). Some studies of home treatment have also found improvements in outconie, with a greater reduction in symptoms and improved social functioning (Stein & Test, 1980). One study of people with schizophrenia also found a reduction in family burden at the six month follow-up for people treated at home (Pai & Kapur, 1982).

We suggest that assessment and treatment of relatively severe affective disorder associated with learning disability is also feasible at home, and has several advantages. One additional benefit in the case described above was that the patient’s husband became more involved in monitoring her behaviour and observing changes; as a result he became more aware of the origin of her aggressive behaviour, and more able to cope with it when it occurred. It may be that part of the beneficial effect observed was due to increased attention or better family understanding promoted by the assessment pro- cedure. It seems likely that much of the observed improvement was due to the prescription of carbamazepirie. (An alternative hypothesis, that the improvement wds due to withdrawing the chlorpromazine and procy clidirte, was rend,red unlikely by the reiiitroduction of these medications during a recent episode of illness, with a beneficial effect.)

The instrument used (a lOcm analogue scale of items identified by the patient and her family as the biggest ‘problems’) proved easy for the family to use, and a very useful method of quantifying behaviour over a lengthy period of observation. The ratings made by staff at the day centre were similar to those made by her husband, implying that the instrument was reasonably reliable, but no statistical assessment of reliability was made (in part because the ratings at the day centre were not made consistently each day, and were discontinued after several weeks). M.’s husband assumed that all the scales were organised so that ‘normal’ behaviour was rated at the extreme left of the scale, in spite of one scale (withdrawdoveractive) being designed to detect possible pathological over-activity. Because he used his interpretation of the scale consistently, the behavioural ratings remain comparable through- out the assessment period.

The use of simple assessment instruments (individually tailored to the behaviours seen) may enable psychiatric and behavioural disorders to be assessed and treated at home, and may facilitate recognition of unusual episodic clusters of behav- iours.

The appropriate response to someone with a learning disability who has a consistently low mood will vary according to the cause. Depressive states may be related to environmental changes (such as bereavement), to physical illness, or to a syndrome of depressive illness. Careful assessment is needed to decide on the likely cause, and the most appropriate intervention (such as bereavement counselling or other psychotherapeutic inter- ventions, alteration of the environment, or the use of specific antidepressant medication). Advice and information can then be given to the person affected and their carer(s), and the most appropriate course of action agreed. This may involve a combination of interventions rather than just one. For example, where the depression appears to have been precipi- tated by an en\*onmental change, but has become so severe that it is associated with appetite and sleep charges, an antidepressant may be indicated, along with changes to the environment to reduce the likelihood of future episodes of illness.

Because severe depressive illness is more common among people with learning disability, it is important that people working with this client group are aware of its nature. It is an extremely unpleasant disorder for the sufferer. It adversely affects many aspects of life, may lead to self-harm, and is treatable. Antidepressant drugs do not cause dependence, and most of the more modern compounds are relatively free of side effects, such as sedation.

Recurrent brief depression is a sub-type of depression which is characterised by brief changes in mood and behaviour, which may be very severe.

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(British Journal of Learning Disabilities from 1994)

when answering advertisements

It should be considered when assessing people whose ‘challenging’ behaviour fluctuates markedly and appears to be associated with other features suggestive of severe depression. It can be managed without recourse to hospital admission, given adequate community services.

Registered with Birmingham Social Services.

Contact: Tracey, 56 Cambridge Road, Birmingham B 13 9UD.

Tel:(021) 441 4417. Fax: (021) 449 4488.

REFERENCES Angst, J., Merikangas, K., Scheidegger, P., Wicki, W.

(1990) Recurrent brief depression: A new subtype of affective disorder. Journal of Affective Dis- orders 19, 87-98.

Corbett, J. A. (1978) Psychiatric morbidity and mental retardation. In P. Snaith and F. E. James (eds) Psychiatric Illness and Mental Handicap. Ashford: Headley.

Dean, C. and Gadd, E. M. (1990) Home treatment for acute psychiatric illness. British Medical Journal 301, 10213.

Kishimoto, A., Ogura, C., Hazama, H. and Inoue, K. (1983) Long-term prophylactic effects of carbama- zepine in affective disorder. British Journal of Psychiatry 143, 32731.

Lund, J. (1985) The prevalence of psychiatric morbidity in mentally retarded adults. Acta Psychiatrica Scundinavica 72, 563-70.

Pai, S. and Kapur, R. L. (1982) Impact of treatment intervention on the relationship between dimen- sions of clinical psychopathology, social dysfunc- tion and burden on the family of psychiatric patients. Psychological Medicine 12, 651-58.

Post, R. M., Uhde, T. W., Roy-Burne, P. P. and Joffe, R. T. (1986) Antidepressant effects of carbamazepine. American Journal of Psychiatry 143, 2934.

Reynolds, I. and Hoult, J. E. (1984) The relatives of the mentally ill: A comparative trial of community- orientated and hospital orientated psychiatric care. Journal of Nervous and Mental Disease 172, 480-9.

Stein, L. I. and Test, M. A. (1980) Alternative to mental hospital treatment. I. Conceptual model, treatment programme and clinical evaluation. Archives of General Psychiatry 37, 392-7.

Yapa, P. and Roy, A. (1990) Depressive illness and mental handicap: Two case reports. Mental Handicap 18, 19-21.

Correspondence should be directed to Dr David Clarke, University of Birmingham, Department of Psychiatry, Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Birmingham B15 2QZ.

Please mention 1 Mental Handicap

INSTITUTE FOR HEALTH POLICY STUDIES

UNIVERSITY OF SOUTHAMPTON

CONFERENCE

CREATING OPPORTUNITIES FOR CHOICE FOR PEOPLE WITH LEARNING DISABILITIES

1 Oth-1 1 th November 1993, Novotel, Southampton

Chair: Ray Robinson Speakers will include:

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The conference is intended for those who commission, )Ian, provide and manage services for people with earning disabilities, as well as researchers and xademics. It will examine the concept of choice, policy ssues and practical examples. Special attention will be )aid to the needs of people with learning disabilities who are visually disabled and those who have iignificant challenging behaviours.

Iees: €1 90 residential, €1 30 non-residential Iurther details can be obtained from:

Mrs Jan Baker, Conference Secretary, Institute for Health Policy Studies, Faculty of Social Sciences, The University, Southampton SO9 5NH

relephone: (0703) 592698 or 593394 (ansaphone). Iacsimile: (0703) 5931 77.

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AUTISTIC ADULTS: Cambridge House offers a Home for life with a structured day care package for adults (17+) with Autism or associated traits, Learning Difficulties, Challenging Behaviour.

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