Dual diagnosis in primary care: Urgent situations​

The primary care provider role

The primary care provider is often the first person that individuals with developmental disabilities and those who care for them go to when a crisis is building.

Consider the crisis behaviour as a symptom, not a disorder. Behaviour changes are often the only way taht a person with a developmental disability expresses that something is wrong and communicates a need.

Assess risk

Use risk assessments applicable to the general population, but also take into account how the patient's developmental disability affects risks and protective factors.

Determine capacity to consent

As part of the patient's care team, the primary care provider is responsible for assessing whether the patient with a developmental disability is capable of consenting to treatment.

Tools

Initial Management of Behavioural Crises in Family Medicine (Developmental Disabilities Primary Care Initiative) 

Risk Assessment Tool for Adults with DD in Behavioural Crisis (Developmental Disabilities Primary Care Initiative)

Emergency and crisis response

If there is a risk of harm to your patient or to those around them, you will need to involve emergency or crisis services.

Visits to the hospital emergency department can be particularly stressful – even traumatizing – for people with developmental disabilities, so pursue less intimidating options such as mobile crisis services when possible.

Crisis response services

Crisis response services include: 

• police–mental health services partnerships,
• mobile teams staffed by health care professionals
• services based in hospital emergency departments.

Crisis services have been developed to fit the characteristics of the communities they serve (e.g., size of service area, population density).

Tip list: Reduce stress to the patient

If possible, call or fax the hospital or crisis service and provide background information about the patient:

• Essential Information for the Emergency Department (Developmental Disabilities Primary Care Initiative) is a template you can use to summarize information and warn the emergency department about certain triggers for the patient (e.g., need a quieter space, fear of restraints). Advise and support caregivers. 
• Guidance about Emergencies for Caregivers (Developmental Disabilities Primary Care Initiative) is a tip list for families and caregivers.
• Guidelines for Managing the Client with Intellectual Disability in the Emergency Room gives an overview of ER treatment and flags issues that people with developmental disabilities my experience.

Emergency medication management

Emergency medications

Medications may be needed on an emergency basis.

The primary care provider is responsible for assessing whether the person with a developmental disability has the capacity to consent to medication or any other form of treatment  If the person does not have the capacity to provide consent, the primary care provider should consult the substitute decision-maker.

Rapid Tranquillization of Adults with Crisis Behaviours (Developmental Disabilities Primary Care Initiative) discusses risks, precautions, interventions to avoid and ways to manage complications in community and emergency department settings.

Physicians considering medication as part of the immediate or longer-term management of concerning behaviours in patients with developmental disabilities should follow appropriate clinical guidelines.

People with developmental disabilities can be very sensitive to changes in medications. Medications given to calm the person can have paradoxical effects. Be aware of this possibility, as well as potential medication interactions if you are choosing emergency medication management. Explain to caregivers what to monitor, the effect the medication should have and how quickly a response should be evident.

Medications and developmental disability

In general, psychotropic medications should only be prescribed after a robust assessment has been conducted and a psychiatric diagnosis is highly suspected. Antipsychotic medications are often overprescribed in people with developmental disabilities and have not been shown to be effective for managing aggressive behaviour (Tyrer et al., 2008).

Short-term stabilization

If your patient's situation is stable, but the patient needs support to prevent an escalation or return to an emergency situation, use these strategies:

• Continue to assess the level of risk.
• Work with the patient and caregivers to indentify signs that indicate a shift from an urgent to an emergency situation.
• Investigate how medical issues, supports and expectations of others, emotional concerns or life events and mental health issues have contributed to the situation. The Diagnostic Formulation of Behaviour Problems algorithm in Initial Management of Behavioral Crisies in Family Medicine (Developmental Disabilities Primary Care Initiative) outlines a process for evaluating the causes of behavioural problems. Sometimes this work cannot begin until after the crisis has resolved, but often it can at least be started.

Connect with specialized clinical services

In addition to contacting emergency or crisis services, consider starting the referral process to specialized clinical services. Although these services may not be able to respond right away, contacting the agency may lead to the case being prioritized for an initial consultation or other services. Specialized assessment and consultation services may be needed if:

• the situation is clinically complex (e.g., history of difficulty clarifying a diagnosis or determining an effective intervention)
• several services are already involved
• the person's unsafe behaviours result in unstable housing or community living situations.

Crisis prevention and management

After a crisis, work with the patient, family and paid caregivers to plan how to prevent or prepare for emergencies. Crisis Prevention/Management Plan for Adults with DD (Developmental Disabilities Primary Care Initiative) provides step-by-step guidelines for creating a plan. It includes a template for recording patient-specific information about:

• stage-specific signs of behaviour escalation and recommended responses
• when to use "as needed" (PRN) medication
• the circumstances in which the person should go to the emergency department.

Review and update this plan after each crisis. The plan should also be reviewed at regular intervals to reflect changes in the patient's health status (physical, emotional, psychiatric) and in the available supports and expectations in their environment.

Evidence summary

Tyrer, P., Oliver-Africano, P.C., Ahmed, Z., Bouras, N., Cooray, S., Deb, S.,... Crawford, M. (2008). Risperidone, haloperidol, and placebo in the treatment of aggressive challenging behaviour in patients with intellectual disability: A randomised controlled trial. The Lancet, 371, 57–63.