You are on page 1of 7

The British Journal of Developmental Disabilities

Vol. 44, Part 2, JULY 1998, No. 87


Gabriele Masi, Pietro Pfanner and Mara Marcheschi

Mental retardation (MR) has often been
considered an intellectual impairment
principally requiring educational or social
interventions; hence, the psychiatric dimension of the problem has been neglected (Potter, 1971). This is particularly
true for children and adolescents with MR
(Masi et al., 1996).
The impact of MR on personality development is confirmed by psychopathological vulnerability of people with MR
(Masi, 1997). According to the DSM-IV
(American Psychiatric Association, 1994),
all the types of mental disorders can be
observed in these subjects, with a prevalence estimated to be at least 3 or 4 times
higher than in the general population.
Rutter et al. (1970) in their epidemiological
study in the isle of Wight examined psychiatric and behavioural problems in all 9
and 10 year old with IQ under 70,
screened by group IQ test, then assessed
with individual WISC (Weschler, 1974) (59
subjects). They used standardised parent

and teacher rating scales together with

child psychiatric interview. A parent questionnaire revealed psychiatric disorders in
30% of low IQ children and in 8% of control (children with normal intelligence levels), with a teacher questionnaire psychiatric problems were found in 42% of low IQ
children and in 10% of controls; using
child interview psychiatric disorders were
found in 24% of low IQ children and in
1.4% of controls. Incidence rates were similar among non institutionalised subjects in
Sweden (Gillberg et al., 1986).
People with MR can experience the full
range of affective disorders (Sovner and
Hurley, 1983; Dosen and Gielen, 1993). The
prevalence of depressive disorders is unclear, because cognitive impairment can
mask the emotional disturbance (the so
called diagnostic overshadowing) (Reiss,
A crucial problem in depressive disorders of children and adolescents with MR
has to do with the diagnostic criteria and
the clinical features. DSM IV criteria for
mood disorders (American Psychiatric

Gabriele Masi, M.D.

Pietro Pfanner, M.D.
Mara Marcheschi, M.D.
Institute of Developmental Neurology, Psychiatry and Educational Psychology, University of
Pisa, Italy - Stella Maris Scientific Institute, Pisa, Italy.
Gabriele Masi, M.D., Institute of Developmental Neurology, Psychiatry and Educational
Psychology, University of Pisa, Via dei Giacinti 2, 56018 Calambrone, Pisa, Italy.
Tel. 0039 50 886111 Fax: 0039 50 886247


Association, 1994) seems to consent reliable

diagnosis in subjects with mild MR
)Pawlarcyk and Beckwith, 1987). In severe
MR, modifications to the current diagnostic criteria are needed (Sovner, 1986). Furthermore, the use of rating scales (self-report or other-report rating scales) can yield
a more detailed identification of typical
symptoms of depressive disorder in people
with MR (Masi et al., 1997).
The clinical characteristics of depressive
disorders are strongly influenced by the
Menolascino, 1982). Clinical features are
often not well defined, symptoms are
more specific as the intellectual impairment becomes more severe. Hence, diagnosis can be particularly difficult. The longitudinal course of depressive disorders
often differs from that of corresponding
disorders in subjects with normal intelligence; for example, the remission of
symtomatology is less frequent in MR. The
role of traumatic life events is especially
important, as they have a triggering effect
more frequently in subjects with MR than
in subjects with normal intelligence levels.
Principal aim of this paper is to provide
some information about assessment and
clinical features of depressive disorder in a
group of adolescents with mild MR.

a) Sample
From the Outpatient Department
based at the Institute of Developmental
Neurology and Psychiatry and Educational Psychology of the University of Pisa,
a group of 60 adolescents with MR were
consecutively screened for psychiatric disorders; 15 adolescents fulfilled the DSM IV
criteria for depressive episode (American
Psychiatric Association, 1994).

The high percentage of depressed adolescents (25% on the whole sample) can be
justified because people with MR came for
consultation for emotional and/or behavioural problems and not for problems of
intellectual disability. Therefore, they are
not a representative sample of the general
population of people with MR (Masi et al.,
The age range of the subjects (10 males
and 5 females) was 14.0-19.2 (mean age
16.2) 4 subjects had Down syndrome, 1
had Prader-Willie syndrome, 2 had X-fragile syndrome, 3 subjects had brain lesions
(perinatal damage), 5 subjects had a socalled familiar MR without known etilogy.
No subject were on psychotropic drugs
during the assessment. No subject has
taken anti-depressants before this study.

b) Instruments
The 15 subjects were classified according to the DSM IV diagnostic criteria
(American Psychiatric Association, 1994) as
suffering from Major Depressive Disorder.
A rating scale for depression, the
Montgomery-Asberg Depression Scale
(MADRS) (Montgomery and Asberg, 1979;
Masi et al., 1997) was administered to all
the subjects.
The MADRS explores ten areas of the
depressive symptomatology:

Apparent sadness
Reported sadness
Inner tension
Reduced sleep
Reduced appetite
Concentration Difficulties
Inability to feel
Pessimistic thoughts
Suicidal thoughts


In each area the severity of the illness

can be rated on a seven point scales (from
0 to 6), on the basis of a clinical assessment
of the subject and/or descriptions by parents or informed others. The global severity of the depressive illness can be inferred
from the total score. The assessment can be
repeated for retests.
The same child psychiatrist administered the MADRS (Montgomery and
Asberg, 1979) to all the subjects.

The subjects were evaluated according
to both DSM IV criteria (American Psychiatric Association, 1994) and MADRS
(Montgomery and Asberg, 1979). All the

subjects with major depressive episodes,

according to the DSM IV criteria, had a
high score on the MADRS, 28 or more, a
value that is strongly indicative of depressive disorder.
A descriptive analysis of the depressive
symptoms in our sample, as they were assessed according to the diagnostic criteria
of DSM IV (American Psychiatric Association, 1994), showed some recurrent patterns (FIGURE 2).
All the subjects presented depressed
mood (in four subjects irritability was also
present), psychomotor agitation or retardation, loss of energy. 11 subjects showed a
diminished interest for almost all the activities. 7 had disturbed sleep, 5 reduced
appetite, 5 diminished ability to think or
concentrate, 5 had feelings of worthless-

MADRS Total Score in the Whole Sample


Depressive Symptoms, According to DMS IV Criteria

Mean Score of MADRS Items


ness or guilt, 3 had recurrent thoughts of

A descriptive analysis of the MADRS
protocol (Montgomery and Asberg, 1979)
showed similar features (FIGURE 3). The
means of the scores for each area are evident in the Figure:

Apparent sadness: 4.5

Reported sadness: 3.2
Inner tension: 4.2
Reduced sleep: 2.7
Reduced appetite: 2.2
Concentration difficulties: 2.5
Lassitude: 4.1
Inability to feel: 3.5
Pessimistic thoughts: 2.5
Suicidal thoughts: 1.5

Children and adolescents with MR are
considered particularly vulnerable to depression (Reynolds and Miller, 1985). Diagnosis of major depressive disorder in these
special populations is often difficult, because of deficit of language expression and
comprehension and insight, and the peculiarity of clinical expression of depressive
disorder in this population. This issue is
related to the essence of psychopathology
in people with MR: do psychopathological
phenomena in people with MR correspond to similar phenomena in normal IQ
subjects? Are there peculiar emotional-behavioural disturbances in people with MR?
Can main nosological categories of DSM
IV (American Psychiatric Association, 1994)
be applied to MR? Are these clinical pictures present for all levels of severity of
MR? How does the level of MR affect the
expression of these clinical pictures (Aman,
These aspects must be kept in mind
when we evaluate reliable assessing


instruments for psychiatric disorders in

people with MR. Some of these instruments were specifically created for
developmentally delayed persons; other
diagnostic tests were originally developed
for normal IQ subjects, and then used for
people with MR. Some instruments were
mainly developed for evaluating and describing maladaptive behaviours, others
aimed to obtain diagnosis according to the
most important nosographioc systems.
Any diagnostic procedure should explore a broad range of affects and emotions, behaviourally defined whenever it is
possible, together with an other-report
completion by caretakers (Feinstein et al.,
1988). In children and adolescents with
MR careful exploration of the course of
developmental process is needed.
Several studies reported low correlations between self-report and other report
depression rating scales in people with
MR. Subjects and informants probably report different aspects of depressive
symtomatology, more cognitive for the
subjects (guilt, hopelessness), more behavioural (crying, irritability) for the informants (Kazdin et al., 1983). The importance
of using both self-report and other report
measures in person with MR is crucial, as
these subjects may have difficulty in reporting depressive states.
Our preliminary data on a small sample of adolescents with mild MR with depression seem to indicate that DSM IV criteria (American Psychiatric Association,
1994) and MADRS (Montgomery and
Asberg, 1979) are coherent and reliable diagnostic instruments. A descriptive analysis of these protocol suggests that some
depressive symptoms are more frequent
than others, specifically depressed mood,
psychomotor agitation or retardation and
loss of energy and interest. Our data indicate that cognitive symptoms (depressive
ideation) and functional symptoms

(disturbed sleep, appetite, etc.) are less

frequent than emotional symptoms (sadness, inner tension) and psychomotor
Apparent sadness is significantly more
represented than referred sadness. Inner
tension is a form of anxiety expressed by
discomfort, edginess, internal turmoil that
the subject cannot conceptualise or verbalise. Psychomotor symptoms are often
mixed: lassitude and loss of energy can coexit with episodic psychomotor agitation.
The reduced interest in surroundings and/
or activities is expressed by a reduction in
emotional reaction to circumstances.
This configuration of symptoms, although in themselves non specific, must
be kept in mind; they can represent a risk
factor for more serious psychopathology
and/or for maladaptation in social and interpersonal functioning.

The aim of this paper is to provide
some information about assessment and
clinical features of depressive disorder in a
group of mildly mentally retarded depressed adolescents. 15 mildly mentally
retarded adolescents (10 males and 5 female, age range 14.0-19.2, mean age 16.2)
fulfilled the DSM IV criteria for depressive
episode. An other-report rating scale for
depression, the Montgomery Asberg Depression Rating Scale (MADRS) was administered to all the subjects of the sample.
All the subjects that met DSM IV diagnostic criteria had at the MADRS a score
strongly indicative of depressive disorder.
A descriptive analysis of the DSM IV diagnostic criteria and MADRS protocol seems
to indicate that some depressive symptoms
are particularly frequent; cognitive symptoms (depressive ideation) and functional
symptoms (disturbed sleep, appetite, etc.)

are less frequent than emotional symptoms (sadness, inner tension) and
psychomotor symptoms.

Aman, M. G. (1991). Assessing psychopathology
and behavior problems in persons with mental
retardation: a review of available instruments.
Rockville, MD: Department of Health and
Human Services.
American Psychiatric Association (1994).
Diagnostic and Statistical Manual of mental
disorders. IV Edition. Washington, DC:
American Psychiatric Association.
Dosen, A. and Gielen, J. J. M. (1993).
Depression in person with mental
retardation: assessment and diagnosis. In:
Dosen, A. and Menolascino, F. J. (Eds.).
Depression in mentally retarded children and
adults. Leiden: Logon.
Eaton, L. F. and Menolascino, F. J. (1982).
Psychiatric disorders in the mentally
retarded: types problems and challenges.
American Journal of Psychiatry, 139, 1297-1303.
Feinstein, C., Kaminer, Y., Barrett, R. P. and
Tylenda, B. (1988). The assessment of mood
and affect in developmentally disabled
children and adolescents. The Emotional
Disorders Rating Scale. Research in
Developmental Disabilities, 9, 109-121.
Gillberg, C., Persson, E., Grufman, N. and
Themmer, V. (1986). Psychiatric disorders in
mildly and severely mentally retarded
Epidemiological aspects. British Journal of
Psychiatry, 149, 68-74.
Kazdin, A. E., Matson, J. L. and Senatore, V.
(1983). Assessment of depression in
mentally retarded adults. American Journal of
Psychiatry, 140, 1040-1043.
Masi, G. (1997). Psychiatric illness in mentally
retarded adolescents: clinical features.
Adolescence (in press).
Masi, G., Marcheschi, M., and Pfanner, P.
(1996). Troubles de lapprentissage dans la


dbilit mentale. La Psychiatrie de LEnfant,

39, 411-446.
Masi, G., Marcheschi, M. and Pfanner, P. (1997).
Paroxetine in depressed mentally retarded
adolescents: an open label study. Journal of
Intellectual Disability Research, 41, 268-272.
Montgomery, S. A. and Asberg, M. (1979). A
new depression scale designed to be
sensitive to change. British Journal of
Psychiatry, 39, 41-45.
Pawlarcyzk, D. and Beckwith, B. (1987).
Depressive symptoms displayed by persons
with mental retardation. Mental Retardation,
25, 325-330.
Potter, H. W. (1971). Mental retardation: the
Cinderella of psychiatry. In: Menolascino, F.
J. (Ed.). Psychiatric aspects of diagnosis and
treatment of mental retardation. Seattle: Special
Child Publications.
Reiss, S. (1990). Prevalence of dual diagnosis in
community-based day programs in the
Chicago metropolitan area. American Journal
of Mental Retardation, 94, 578-585.
Reynolds, W. M. and Miller, K. L. (1985).
Depression and learned helplessness in
mentally retarded and non mentally
investigation. Applied Research in Mental
Retardation, 6 295-306.
Rutter, M., Graham, P. and Yule, (1970). A
neuropsychiatric study in childhood. Spastics
London: Heinemann.
Sover, R. (1986). Limiting factors in the use of
DSM III criteria with mentally ill/mentally
retarded persons. Psychopharmacological
Bulletin, 22, 1055-1060.
Sovner, R. and Hurley, A. D. (1983). Do the
mentally retarded suffer from affective
illness? Archives of General Psychiatry, 40, 6167.
Weschler, O. (1974). Manual for the Weschler
Intelligence Scale for Children - Revised.
New York: Psychological Corporation.