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Adams D, Hastings RP, Maidment I, Shah C, Langdon PE. Deprescribing psychotropic medicines for behaviours that challenge in people with intellectual disabilities: a systematic review. BMC Psychiatry 2023; 23:202. [PMID: 36978032 PMCID: PMC10044393 DOI: 10.1186/s12888-022-04479-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 12/15/2022] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Clear evidence of overprescribing of psychotropic medicines to manage behaviours that challenges in people with intellectual disabilities has led to national programmes within the U.K. such as NHS England's STOMP to address this. The focus of the intervention in our review was deprescribing of psychotropic medicines in children and adults with intellectual disabilities. Mental health symptomatology and quality of life were main outcomes. METHODS We reviewed the evidence using databases Medline, Embase, PsycINFO, Web of Science, CINAHL and Open Grey with an initial cut-off date of 22nd August 2020 and an update on 14th March 2022. The first reviewer (DA) extracted data using a bespoke form and appraised study quality using CASP and Murad tools. The second reviewer (CS) independently assessed a random 20% of papers. RESULTS Database searching identified 8675 records with 54 studies included in the final analysis. The narrative synthesis suggests that psychotropic medicines can sometimes be deprescribed. Positive and negative consequences were reported. Positive effects on behaviour, mental and physical health were associated with an interdisciplinary model. CONCLUSIONS This is the first systematic review of the effects of deprescribing psychotropic medicines in people with intellectual disabilities which is not limited to antipsychotics. Main risks of bias were underpowered studies, poor recruitment processes, not accounting for other concurrent interventions and short follow up periods. Further research is needed to understand how to address the negative effects of deprescribing interventions. TRIAL REGISTRATION The protocol was registered with PROSPERO (registration number CRD42019158079).
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Affiliation(s)
- Danielle Adams
- Centre for Educational Development, Appraisal and Research, University of Warwick, Coventry, CV4 8UW, UK.
| | - Richard P Hastings
- Centre for Educational Development, Appraisal and Research, University of Warwick, Coventry, CV4 8UW, UK
| | - Ian Maidment
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
| | - Chetan Shah
- Pharmacy Department, Hertfordshire Partnership University NHS Foundation Trust, Hertfordshire, WD7 9FB, UK
| | - Peter E Langdon
- Centre for Educational Development, Appraisal and Research, University of Warwick, Coventry, CV4 8UW, UK
- Coventry and Warwickshire Partnership NHS Trust, Coventry, CV6 6NY, UK
- Herefordshire and Worcestershire Health and Care NHS Trust, Worcester, WR5 1JR, UK
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Shoumi Deb S, Limbu B, Nancarrow T, Gerrard D, Shankar R. The UK psychiatrists' experience of rationalising antipsychotics in adults with intellectual disabilities: A qualitative data analysis of free-text questionnaire responses. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2023; 36:594-603. [PMID: 36808782 DOI: 10.1111/jar.13083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/13/2022] [Accepted: 01/19/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND Overprescribing of off-licence psychotropic medications, particularly antipsychotics, for challenging behaviours in people with intellectual disabilities without a psychiatric disorder is a significant public health concern. In the United Kingdom, the National Health Service England launched an initiative in 2016, 'STopping Over-Medication of People with learning disabilities, autism or both (STOMP)', to address this concern. STOMP is supposed to encourage psychiatrists in the United Kingdom and elsewhere to rationalise psychotropic medication use in people with intellectual disabilities. The current study aims to gather UK psychiatrists' views and experience of implementing the STOMP initiative. METHODS An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disabilities (estimated 225). Two open-ended questions allowed participants to write comments in response to these questions in the free text boxes. One question asked about the challenges psychiatrists faced locally to implement STOMP, and the other asked for examples of successes and positive experiences from the process. The free text data were analysed using a qualitative method with the help of the NVivo 12 plus software. RESULTS Eighty-eight (estimated 39%) psychiatrists returned the completed questionnaire. The qualitative analysis of free-text data has shown variation within services in the experience and views of the psychiatrists. In areas with good support for STOMP implementation provided through adequate resources, psychiatrists reported satisfaction in the process with successful antipsychotic rationalisation, better local multi-disciplinary and multi-agency working, and increased awareness of STOMP issues among the stakeholders such as people with intellectual disabilities and their caregivers and multidisciplinary teams, and improved quality of life caused by reduced medication-related adverse events in people with intellectual disabilities. However, where resource utilisation is not optimum, psychiatrists seemed dissatisfied with the process with little success in medication rationalisation. CONCLUSIONS Whereas some psychiatrists are successful and enthusiastic about rationalising antipsychotics, others still face barriers and challenges. Much work is needed to achieve a uniformly positive outcome throughout the United Kingdom.
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Affiliation(s)
- Shoumitro Shoumi Deb
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, Truro, Cornwall, UK
| | - Bharati Limbu
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, Truro, Cornwall, UK
| | - Tom Nancarrow
- University of Exeter Medical School, Truro, Cornwall, UK
| | | | - Rohit Shankar
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, Cornwall, UK
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Uso de psicofármacos en personas con discapacidad intelectual en Extremadura, España. ACTA COLOMBIANA DE PSICOLOGIA 2022. [DOI: 10.14718/acp.2023.26.1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
El uso de psicofármacos es frecuente en adultos con discapacidad intelectual, a menudo por conductas desafiantes en ausencia de diagnóstico de trastorno mental. Investigaciones previas cuestionan la eficacia de estos tratamientos a falta de una enfermedad psiquiátrica, y destacan sus efectos secundarios. El objetivo de esta investigación es analizar el uso de psicofármacos en función del diagnóstico de enfermedad mental y conducta desafiante, así como la distribución de la población según el uso de psicofármacos en 569 adultos con discapacidad intelectual que presentan enfermedad mental o conductas desafiantes. Los datos acerca de la elevada prescripción de psicofármacos y, especialmente, de antipsicóticos alertan sobre la necesidad de una profunda revisión de la práctica clínica que permita reducir el uso de esta medicación en el tratamiento de la conducta y los trastornos mentales en esta población, para garantizar una atención de calidad y el respeto de los derechos de estas personas.
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Costello A, Hudson E, Morrissey S, Sharma D, Kelly D, Doody O. Management of psychotropic medications in adults with intellectual disability: a scoping review. Ann Med 2022; 54:2486-2499. [PMID: 36120887 PMCID: PMC9518601 DOI: 10.1080/07853890.2022.2121853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND/OBJECTIVE(S) Psychotropic medications are commonly prescribed among adults with intellectual disability, often in the absence of a psychiatric diagnosis. The aim of this scoping review is to provide an overview of the extent, range, and nature of the available research on medication use and practices and medication management in people with intellectual disability taking psychotropic medications for behaviours that challenge. MATERIALS AND METHODS A scoping review of research studies (qualitative, quantitative, and mixed design) and Grey Literature (English) was carried out. Databases included: Ovid MEDLINE, Embase, CINAHL, JBI Evidence Synthesis, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Scopus. A three-step search strategy was followed, with results screened by two independent reviewers. Data was extracted independently by two reviewers using a data extraction tool with results mapped and presented using a narrative form supported by tables and diagrams to the research questions. RESULTS Following the removal of duplicates, records were screened, full texts assessed, and 49 studies were included. Medication outcomes included reduced repetitive, stereotypic, and/or aggressive behaviours. High dosing/prescribing in the setting of an absent/unclear clinical indication was associated with worsening of symptoms for which psychotropics were prescribed. While psychotropics had a role in managing behaviours that challenge, reducing or discontinuing psychotropics is sometimes warranted. Study designs were frequently pragmatic resulting in small sample sizes and heterogeneous cohorts receiving different doses and combinations of medications. Access to multidisciplinary teams, guidelines, medication reviews, staff training, and enhanced roles for carers in decision-making were warranted to optimize psychotropic use. CONCLUSIONS These findings can inform prescribing interventions and highlight the need for timely and comprehensive patient outcome data, especially on long-term use of high doses of psychotropics and what happens when reduce or stop prescribing these doses.KEY MESSAGESPsychotropic medications are frequently prescribed for people with intellectual disabilities, often at high doses and these medications are associated with both positive and negative patient outcomes.Work to rationalize psychotropic use has been reported with interventions aiming to reduce polypharmacy or deprescribe a single psychotropic medicine. These interventions had mixed success and risk of relapse was documented in some studies.Limitations in sample size and heterogenous patient cohorts make it challenging to understand the risks and benefits associated with reducing or stopping psychotropic medicines.Patient, carer, and clinician partnerships are critical to advance medication management.
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Affiliation(s)
- Ashley Costello
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Eithne Hudson
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Susan Morrissey
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Drona Sharma
- Intellectual Disabilities, Nua Healthcare Services, Naas, Ireland
| | - Dervla Kelly
- School of Medicine, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Owen Doody
- Health Research Institute, University of Limerick, Limerick, Ireland.,Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
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Limbu B, Deb SS. Support staff liaising effectively with professionals for the rational use of psychotropics for behaviours that challenge in adults with intellectual disabilities: Findings from a co-design event. Front Psychiatry 2022; 13:954522. [PMID: 36245886 PMCID: PMC9559865 DOI: 10.3389/fpsyt.2022.954522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022] Open
Abstract
Experience Based Co-Design (EBCD) and co-production are interdisciplinary collaborative approaches to improve health care services by involving all stakeholders. These approaches capture the experiences of all stakeholders who come in contact with services and use experiences as evidence to promote and implement service changes. The use of psychotropic medications for behaviours that challenge (BtC) in people with intellectual disabilities (ID) is a complex issue because of its off-licence use and use in combination with other medications for physical and psychiatric co-morbidities, which leads to overmedication of people with ID. As support staff plays a pivotal role in the prescribing for people with ID, we have developed a staff training programme, SPECTROM, to help reduce overmedication. A project team developed SPECTROM under the guidance of a Programme Development Group (PDG) consisting of 21 stakeholders. The PDG analysed data from a literature review, four focus groups and a co-design event day involving 26 stakeholders. In this paper, we have presented data based on the findings from the co-design event day, primarily on the issue of support staff effectively liaising with professionals such as doctors, nurses, and other community learning disability team members. In-depth information and recommendations were proposed at the co-design event, which helped develop the draft SPECTROM. The draft was finalised after receiving feedback from 56 stakeholders. Co-production and a modified EBCD can be successfully used to create training interventions and improve health care services. More research should utilise co-production and EBCD and use service users' experiences to develop interventions and improve health care services.
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Affiliation(s)
- Bharati Limbu
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, United Kingdom
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Antipsychotics withdrawal in adults with intellectual disability and challenging behaviour: study protocol for a multicentre double-blind placebo-controlled randomised trial. BMC Psychiatry 2021; 21:439. [PMID: 34488701 PMCID: PMC8422779 DOI: 10.1186/s12888-021-03437-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In people with intellectual disability (ID) and challenging behaviour, antipsychotics (AP) are often used off-label and for a long period. Despite a lack of evidence for efficacy for challenging behaviour and concerns about common and clinically relevant side effects, complete withdrawal often fails. We postulate three possible hypotheses for withdrawal failure: 1. Influence of subjective interpretation of behavioural symptoms by caregivers and family; 2. Beneficial effects from AP treatment on undiagnosed psychiatric illness, through improvement in sleep or a direct effect on behaviour; and 3. Misinterpretation of withdrawal symptoms as a recurrence of challenging behaviour. METHODS To investigate our hypotheses, we have designed a multicentre double-blind, placebo-controlled randomised trial in which AP (pipamperone or risperidone) are withdrawn. In the withdrawal group, the AP dose is reduced by 25% every 4 weeks and in the control group the dose remains unaltered. Behaviour, sleep, psychiatric disorders, withdrawal symptoms and side effects will be measured and compared between the two groups. If drop-out from the protocol is similar in both groups (non-inferiority), the first hypothesis will be supported. If drop-out is higher in the withdrawal group and an increase is seen in psychiatric disorders, sleep problems and/or behavioural problems compared to the control group, this suggests effectiveness of AP, and indications for AP use should be reconsidered. If drop-out is higher in the withdrawal group and withdrawal symptoms and side effects are more common in the withdrawal group compared to the control group, this supports the hypothesis that withdrawal symptoms contribute to withdrawal failure. DISCUSSION In order to develop AP withdrawal guidelines for people with ID, we need to understand why withdrawal of AP is not successful in the majority of people with ID and challenging behaviour. With this study, we will bridge the gap between the lack of available evidence on AP use and withdrawal on the one hand and the international policy drive to reduce prescription of AP in people with ID and challenging behaviour on the other hand. TRIAL REGISTRATION This trial is registered in the Netherlands Trial Register (NTR 7232) on October 6, 2018 ( www.trialregister.nl ).
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McLaren JL, Lichtenstein JD, Metcalfe JD, Charlot LR, Drake RE, Beasley JB. Psychotropic Use Among Youths With Intellectual and Developmental Disabilities. Psychiatr Serv 2021; 72:988-997. [PMID: 33882691 DOI: 10.1176/appi.ps.201900465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined the prevalence and correlates of psychotropic medication prescribing among outpatient youths with intellectual and developmental disabilities. METHODS The authors reviewed cross-sectional data on medications for 1,333 youths (ages 5-21 years) with intellectual and developmental disabilities who were referred to a community-based mental health crisis service. Descriptive statistics and regression analysis were used to describe the study group and to identify correlates of psychotropic polypharmacy, antipsychotic use, and anticonvulsant use in the absence of a seizure disorder. RESULTS Most youths were taking psychotropic medications (N=1,139, 86%), often three or more medications (N=733, 55%) from two or more drug classes (N=919, 69%). Most youths received antipsychotics (N=863, 65%), and a third (N=432, 32%) were taking anticonvulsants in the absence of a seizure disorder. Greater severity (number of psychiatric diagnoses and recent psychiatric hospitalization), older age, and living in a group home were significantly correlated with these practices. CONCLUSIONS Polypharmacy, antipsychotic use, and anticonvulsant use in the absence of seizure disorders were common among youths with intellectual and developmental disabilities referred to the crisis service. Older age, number of psychiatric diagnoses, living in a group home, and psychiatric hospitalization correlate with these prescribing practices. These elevated prescribing rates in a very vulnerable population warrant further study.
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Affiliation(s)
- Jennifer L McLaren
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire (McLaren, Lichtenstein); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (McLaren, Lichtenstein); Lebanon Westat, Lebanon, New Hampshire (Metcalfe, Drake); Department of Psychiatry, University of Massachusetts Medical School, Worcester (Charlot); Center for START Services, University of New Hampshire Institute on Disabilities, Concord (McLaren, Beasley)
| | - Jonathan D Lichtenstein
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire (McLaren, Lichtenstein); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (McLaren, Lichtenstein); Lebanon Westat, Lebanon, New Hampshire (Metcalfe, Drake); Department of Psychiatry, University of Massachusetts Medical School, Worcester (Charlot); Center for START Services, University of New Hampshire Institute on Disabilities, Concord (McLaren, Beasley)
| | - Justin D Metcalfe
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire (McLaren, Lichtenstein); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (McLaren, Lichtenstein); Lebanon Westat, Lebanon, New Hampshire (Metcalfe, Drake); Department of Psychiatry, University of Massachusetts Medical School, Worcester (Charlot); Center for START Services, University of New Hampshire Institute on Disabilities, Concord (McLaren, Beasley)
| | - Lauren R Charlot
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire (McLaren, Lichtenstein); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (McLaren, Lichtenstein); Lebanon Westat, Lebanon, New Hampshire (Metcalfe, Drake); Department of Psychiatry, University of Massachusetts Medical School, Worcester (Charlot); Center for START Services, University of New Hampshire Institute on Disabilities, Concord (McLaren, Beasley)
| | - Robert E Drake
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire (McLaren, Lichtenstein); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (McLaren, Lichtenstein); Lebanon Westat, Lebanon, New Hampshire (Metcalfe, Drake); Department of Psychiatry, University of Massachusetts Medical School, Worcester (Charlot); Center for START Services, University of New Hampshire Institute on Disabilities, Concord (McLaren, Beasley)
| | - Joan B Beasley
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire (McLaren, Lichtenstein); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (McLaren, Lichtenstein); Lebanon Westat, Lebanon, New Hampshire (Metcalfe, Drake); Department of Psychiatry, University of Massachusetts Medical School, Worcester (Charlot); Center for START Services, University of New Hampshire Institute on Disabilities, Concord (McLaren, Beasley)
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Deb S, Nancarrow T, Limbu B, Sheehan R, Wilcock M, Branford D, Courtenay K, Perera B, Shankar R. UK psychiatrists' experience of withdrawal of antipsychotics prescribed for challenging behaviours in adults with intellectual disabilities and/or autism. BJPsych Open 2020; 6:e112. [PMID: 32938512 PMCID: PMC7576649 DOI: 10.1192/bjo.2020.97] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A high proportion of adults with intellectual disabilities are prescribed off-licence antipsychotics in the absence of a psychiatric illness. The National Health Service in England launched an initiative in 2016, 'Stopping over-medication of people with a learning disability [intellectual disability], autism or both' (STOMP), to address this major public health concern. AIMS To gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours. METHOD An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225). RESULTS Half of the 88 respondents stated that they started withdrawing antipsychotics over 5 years ago and 52.3% stated that they are less likely to initiate an antipsychotic since the launch of STOMP. However, since then, 46.6% are prescribing other classes of psychotropic medication instead of antipsychotics for challenging behaviours, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11.4% reported deterioration in challenging behaviours in over 50% of patients on withdrawal and the same proportion (11.4%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid carers' concern, lack of multi-agency and multidisciplinary input and unavailability of non-medical psychosocial intervention are key reported factors hampering the withdrawal attempt. CONCLUSIONS There is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.
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Affiliation(s)
- Shoumitro Deb
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, UK
| | | | - Bharati Limbu
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, UK
| | - Rory Sheehan
- Division of Psychiatry, University College London, UK
| | | | | | - Ken Courtenay
- Faculty of Intellectual Disabilities, Royal College of Psychiatrists, London, UK
| | - Bhathika Perera
- Haringey Learning Disability Partnership, Barnet, Enfield and Haringey Mental Health NHS Trust, London, UK
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Edwards N, King J, Williams K, Hair S. Chemical restraint of adults with intellectual disability and challenging behaviour in Queensland, Australia: Views of statutory decision makers. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2020; 24:194-211. [PMID: 29929418 DOI: 10.1177/1744629518782064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Psychotropic medication is widely prescribed to treat mental illness. However, it is controversial when used as a chemical restraint (CR) to manage challenging behaviours (CBs) of adults with intellectual disability (ID). CR has potentially negative consequences and affects human rights. METHOD Qualitative research conducted between 2014 and 2015 explored the views of 'guardian' decision makers appointed under unique Queensland legislation oversighting the use of CR. RESULTS Findings included (1) negative conceptualization of CR, (2) concerning relationships with prescribers and disability sector staff, (3) challenges to information seeking about people with ID prescribed CR and (4) problematic implementation of positive behaviour support plans. CONCLUSION According to guardians, CR may be used in lieu of community supports, and prescribers sometimes diagnose mental illness to avoid CR legislative requirements. Guardians, prescribers and professionals would benefit from training that addresses the intersection between physical and mental health, CB and CR.
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Affiliation(s)
| | - Julie King
- Queensland University of Technology, Australia
| | | | - Sara Hair
- Queensland University of Technology, Australia
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Cohen D, Recalt A. Withdrawal effects confounding in clinical trials: another sign of a needed paradigm shift in psychopharmacology research. Ther Adv Psychopharmacol 2020; 10:2045125320964097. [PMID: 33224467 PMCID: PMC7656873 DOI: 10.1177/2045125320964097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022] Open
Abstract
Randomized controlled trials' ability to produce evidence useful for people to decide whether to take, continue taking, or stop taking psychotropic drugs has been intensely critiqued, along with the trials' commercial, ideological, and regulatory contexts. This article applies the critique to the topic of withdrawal effects confounding the outcomes of relapse-prevention trials where prescribed psychotropic drugs are discontinued. Until recently, the complexity and reach of withdrawal and post-withdrawal effects were neglected by mainstream psychiatry, but not by lay users of prescribed psychotropics. This article discusses withdrawal effects as part of the pharmacology of psychotropic drugs but shaped by psychosocial factors, and possibly shaping the presentation of psychological distress generally. It outlines biases and misconceptions in assumptions, design, and reporting of general efficacy trials and findings from a recent review of 80 discontinuation trials. In theory, relapse-prevention trials are tautological and exaggerate efficacy. In publications, they pay little attention to the central feature of their design, favor abrupt or rapid discontinuations, do not attend to environmental factors, and provide insufficient data to allow re-analyses. Thus, relapse-prevention RCTs likely confound the detection of their main outcome of interest: "relapse." Using slower tapers, active placebo controls, and specific covariates in analyses would reduce the risk of withdrawal confounding, and better reporting would reduce the opaqueness of trials. The crisis in psychopharmacology is fueled partly by the disconnect between claims of therapeutic efficacy from so-called best-evidence methods despite unchanging population-level indicators of psychiatric sickness. Only by "stacking the deck" against trial sponsors' hoped-for outcomes can psychopharmacology trials regain scientific credibility.
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Affiliation(s)
- David Cohen
- UCLA Luskin School of Public Affairs, 3250 Public Affairs Building, Los Angeles, CA 90095-1656, USA
| | - Alexander Recalt
- Department of Social Welfare, Luskin School of Public Affairs, and Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
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Sheehan R, Strydom A, Marston L, Morant N, Fiori F, Santosh P, Hassiotis A. A structured medication review tool to promote psychotropic medication optimisation for adults with intellectual disability: feasibility study. BMJ Open 2019; 9:e033827. [PMID: 31843854 PMCID: PMC6924735 DOI: 10.1136/bmjopen-2019-033827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To investigate the feasibility of delivering structured psychotropic medication review in community services for adults with intellectual disability (ID). DESIGN Single-arm feasibility study conducted over a 6-month period. SETTING Specialist community ID teams in England. PARTICIPANTS Psychiatrists working with adults with ID and adults with ID who had been prescribed psychotropic medication. INTERVENTION A structured web-based psychotropic medication review tool (the HealthTracker-based structured medication review) comprising measures of therapeutic benefit and adverse side-effects was made available for use by psychiatrists in routine clinic appointments. A summary measure of medication effectiveness was graphically presented to aid discussion and decision-making. MAIN OUTCOME MEASURES Feasibility metrics including number of people with ID referred, eligible and recruited, and uptake of the medication review tool in naturalistic clinical settings. Psychiatrist and patient feedback was collected to assess acceptability of the intervention and suggestions for development. RESULTS Fifteen psychiatrists from five clinical teams took part. In total 94 potentially eligible people with ID were referred, of whom 79 (84%) were recruited and together underwent 97 medication reviews over the 6-month study period. Feedback from participants with ID was favourable. Psychiatrists indicated that the HealthTracker-based structured medication review was broadly acceptable and suggested adaptations to improve integration with existing information technology systems and to enhance patient involvement in the review. CONCLUSIONS Structured psychotropic medication review can be used in community services for adults with ID as part of a programme of medication optimisation. It would be feasible to test clinical and patient outcomes of the HealthTracker-based medication review in a randomised clinical trial.
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Affiliation(s)
- Rory Sheehan
- Division of Psychiatry, University College London, London, UK
| | - André Strydom
- Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nicola Morant
- Division of Psychiatry, University College London, London, UK
| | - Federico Fiori
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, King's College London, London, UK
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Shankar R, Wilcock M, Deb S, Goodey R, Corson E, Pretorius C, Praed G, Pell A, Vujkovic D, Wilkinson E, Laugharne R, Axby S, Sheehan R, Alexander R. A structured programme to withdraw antipsychotics among adults with intellectual disabilities: The Cornwall experience. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2019; 32:1389-1400. [PMID: 31192534 DOI: 10.1111/jar.12635] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/18/2019] [Accepted: 05/15/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antipsychotic medications are used among 19%-58% of adults with intellectual disabilities to manage challenging behaviour against the NICE guideline recommendations. Studies show that it is possible to completely withdraw antipsychotics in about one third of adults with intellectual disabilities and a dose reduction of 50% or more in another third. METHOD In Cornwall, over three years the present authors developed a structured pathway to withdraw antipsychotics among adults with intellectual disabilities which involved people with intellectual disabilities and their carers, GPs, community learning disability team members and pharmacists. RESULTS The present authors managed to withdraw antipsychotics totally among 46.5% (33/71) and reduced over 50% of dosage in another 11.3% (8/71) of adults with intellectual disabilities. At three months follow-up no one required hospital admission or change in placement. CONCLUSION It is possible to withdraw/reduce antipsychotics in a high proportion of adults with intellectual disabilities if a concerted effort is made involving all stakeholders from the outset.
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Affiliation(s)
- Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Truro, UK.,University of Exeter Medical School, Exeter, UK
| | - Mike Wilcock
- Kernow Clinical Commissioning Group, Saint Austell, UK
| | | | | | - Eve Corson
- Cornwall Partnership NHS Foundation Trust, Truro, UK
| | | | | | - Amanda Pell
- Kernow Clinical Commissioning Group, Saint Austell, UK
| | - Dee Vujkovic
- Cornwall Partnership NHS Foundation Trust, Truro, UK
| | | | | | - Sharon Axby
- Cornwall Partnership NHS Foundation Trust, Truro, UK
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13
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Cohen D, Recalt A. Discontinuing Psychotropic Drugs from Participants in Randomized Controlled Trials: A Systematic Review. PSYCHOTHERAPY AND PSYCHOSOMATICS 2019; 88:96-104. [PMID: 30923288 DOI: 10.1159/000496733] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/08/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Methods and justifications for discontinuing psychotropic drugs in randomized controlled trials (RCTs), and RCTs' acknowledgement of possible withdrawal symptoms following discontinuation, have not been examined systematically, which this review aims to do. Study Eligibility, Data Extraction, and Synthesis: Publications in MEDLINE, EMBASE, and PsycINFO (2000-2017) randomly assigning participants diagnosed with mental disorders to discontinue antipsychotic, antidepressant, anticonvulsant, antimanic, mood-stabilizing, benzodiazepine, or stimulant drugs. Authors independently extracted data, devised a typology of trials, and assessed trials' recognition of with-drawal symptoms. RESULTS Eighty RCTs (70% with industry participation) discontinued drugs from 5,757 participants to investigate relapse prevention (44%), successful dis-continuation (26%), architecture of withdrawal (14%), and practicality of discontinuation (10%). RCTs of stimulants, antidepressants, and antipsychotics mostly aimed to reach conclusions about relapse prevention by testing abrupt or rapid discontinuations; RCTs of benzodiazepines mostly aimed to reduce drug use by testing longer-lasting, supportive discontinuations. In 67% of RCTs, no justification was given for the specific discontinuation strategy, which lasted under 2 weeks in 60% of RCTs. Possible withdrawal confounding of trial outcomes was addressed in 14% of eligible RCTs. LIMITATIONS Only the published literature was searched. CONCLUSIONS AND IMPLICATIONS RCTs use drug discontinuation to study several key issues in psychopharmacology but infrequently justify how they implement it or acknowledge that possible withdrawal symptoms may threaten internal validity. Reappraising the use of drug discontinuation and the recognition of withdrawal symptoms in RCTs is required.
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Affiliation(s)
- David Cohen
- Department of Social Welfare, Luskin School of Public Affairs, University of California, Los Angeles, California, USA,
| | - Alexander Recalt
- Department of Social Welfare, Luskin School of Public Affairs, University of California, Los Angeles, California, USA.,Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California, USA
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14
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Ramerman L, de Kuijper G, Scheers T, Vink M, Vrijmoeth P, Hoekstra PJ. Is risperidone effective in reducing challenging behaviours in individuals with intellectual disabilities after 1 year or longer use? A placebo-controlled, randomised, double-blind discontinuation study. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2019; 63:418-428. [PMID: 30609152 DOI: 10.1111/jir.12584] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 09/21/2018] [Accepted: 12/01/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Many people with intellectual disabilities use risperidone long term for the management of challenging behaviours, despite its limited proof of effectiveness and its clear association with adverse events. Therefore, this study aimed to investigate the effectiveness of ongoing treatment with risperidone in reducing challenging behaviours versus controlled discontinuation on behaviour and health parameters. METHOD This was a placebo-controlled, double-blind, randomised discontinuation trial of risperidone. In the discontinuation group, risperidone was gradually replaced by a placebo over 14 weeks, while the control group maintained their existing dosage. Eight weeks after discontinuation, behaviour (as measured by the 'Aberrant Behavior Checklist') and health parameters (dyskinesia, akathisia, parkinsonism, weight, waist circumference, sedation and laboratory outcomes) were compared in both groups. RESULTS A total of 25 participants were included in the trial, of which 11 were randomised into the discontinuation group and 14 were randomised into the continued treatment group. In the discontinuation group, 82% completely withdrew from risperidone. There was no significant change in irritability, compared with the continuation group, although there was a Group*Time effects on stereotypical behaviour in favour of the continuation group. Significant Group*Time effects were also found for weight, waist, body mass index, prolactin levels and testosterone levels, with beneficial effects for the discontinuation group. CONCLUSION Discontinuation of long-term risperidone for reducing challenging behaviours is possible, without an increase in irritability. Discontinuation of risperidone may have beneficial effects on weight, waist circumference, prolactin levels and testosterone levels. The study suffered from difficulties in achieving the required sample size, which affected study power and generalizability.
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Affiliation(s)
- L Ramerman
- Centre for Intellectual Disability and Mental Health, GGZ Drenthe, Assen, The Netherlands
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - G de Kuijper
- Centre for Intellectual Disability and Mental Health, GGZ Drenthe, Assen, The Netherlands
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - T Scheers
- Accare Child and Adolescent Psychiatry, Groningen, The Netherlands
| | - M Vink
- Cosis, Assen, The Netherlands
| | - P Vrijmoeth
- De Baalderborg Groep, Hardenberg, The Netherlands
| | - P J Hoekstra
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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15
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Kleijwegt B, Pruijssers A, de Jong-Bakker L, de Haan K, van Os-Medendorp H, van Meijel B. Support staff's perceptions of discontinuing antipsychotics in people with intellectual disabilities in residential care: A mixed-method study. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2019; 32:861-870. [PMID: 30790388 PMCID: PMC6850344 DOI: 10.1111/jar.12577] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 01/11/2019] [Accepted: 01/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although there is little evidence on their efficacy regarding challenging behaviour, antipsychotics are the most used psychotropic drugs in residential intellectually disabled people. Discontinuation is possible for some residential clients with intellectual disabilities. This study aimed to gain insight into support staff's perceptions of discontinuing antipsychotics in residential clients with intellectual disabilities. METHOD Four focus groups were conducted in this mixed-methods study, followed by a survey. RESULTS A large majority of support staff perceive antipsychotics to be effective in controlling challenging behaviour. Support staff regarded themselves as willing to contribute to the discontinuation of antipsychotics, but were more confident about achieving reductions. CONCLUSIONS The attitude of the majority of support staff towards discontinuation provides a good basis for regularly reviewing antipsychotics use. A reduction plan should include preliminary steps, methods of monitoring and evaluating the process, and establishing measures for dealing with possible crises.
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Affiliation(s)
- Bas Kleijwegt
- Esdégé-Reigersdaal, Heerhugowaard, The Netherlands.,Department of Nursing Science, University Medical Centre Utrecht, Utrecht, The Netherlands.,Inholland University of Applied Sciences, Amsterdam, The Netherlands
| | - Addy Pruijssers
- Inholland University of Applied Sciences, Amsterdam, The Netherlands.,De Rotonde, Centre of Expertise ID-MH, Heerhugowaard, The Netherlands
| | - Lydie de Jong-Bakker
- Department of Nursing Science, University Medical Centre Utrecht, Utrecht, The Netherlands.,School of Health Care, Zwolle, The Netherlands
| | - Koos de Haan
- Inholland University of Applied Sciences, Amsterdam, The Netherlands
| | - Harmieke van Os-Medendorp
- Department of Dermatology and Allergology, University Medical Centre, Utrecht, The Netherlands.,Clinical Health Sciences, University Medical Centre, Utrecht, The Netherlands
| | - Berno van Meijel
- Inholland University of Applied Sciences, Amsterdam, The Netherlands.,Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.,Parnassia Psychiatric Centre, The Hague, The Netherlands.,GGZ-VS Academy for Masters in Advanced Nursing Practice, Utrecht, The Netherlands
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16
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Shankar R, Wilcock M, Oak K, McGowan P, Sheehan R. Stopping, rationalising or optimising antipsychotic drug treatment in people with intellectual disability and/or autism. Drug Ther Bull 2019; 57:10-13. [PMID: 30567853 DOI: 10.1136/dtb.2018.000009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Truro, UK
- University of Exeter Medical School, Exeter, UK
| | | | - Katy Oak
- Royal Cornwall Hospitals Trust, Truro, UK
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17
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Dills H, Shah K, Messinger-Rapport B, Bradford K, Syed Q. Deprescribing Medications for Chronic Diseases Management in Primary Care Settings: A Systematic Review of Randomized Controlled Trials. J Am Med Dir Assoc 2018; 19:923-935.e2. [DOI: 10.1016/j.jamda.2018.06.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 02/07/2023]
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18
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de Kuijper GM, Hoekstra PJ. An open label discontinuation trial of long-term used off-label antipsychotic drugs in people with intellectual disability: The influence of staff-related factors. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2018; 32:313-322. [PMID: 30264420 DOI: 10.1111/jar.12528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 07/12/2018] [Accepted: 08/28/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Results of discontinuation of antipsychotics in people with intellectual disability are variable and may depend on staff factors. METHOD We attempted to taper off antipsychotics in 14 weeks after which participants were free to restart. We investigated the influence of support professionals' feelings towards challenging behaviour, their knowledge of psychotropic drugs and clinicians' judgements of participants' behavioural functioning on whether or not antipsychotics were completely discontinued after 16, 28 and 40 weeks. RESULTS Of the 129 participants, 61% achieved discontinuation at 16 weeks; at 28 and 40 weeks, 46% and 40% were completely discontinued. Staff's feelings of Depression/Anger towards their client's behaviour, less knowledge about psychotropic medication and clinicians' judgements of behavioural worsening were negatively associated with achievement of discontinuation. CONCLUSIONS To enhance discontinuation off-label drug use, staff's feelings should be explored, their knowledge of psychotropic drugs improved and reasons for clinicians' judgements of participants' behavioural worsening investigated.
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Affiliation(s)
- Gerda M de Kuijper
- Centre for Intellectual Disabilities and Mental Health/GGZ Drenthe, Assen, The Netherlands.,Department of Psychiatry, University of Groningen, University Medical Center Groningen, University Centre Child and Adolescent Psychiatry, Groningen, The Netherlands
| | - Pieter J Hoekstra
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, University Centre Child and Adolescent Psychiatry, Groningen, The Netherlands
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19
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Ramerman L, Hoekstra PJ, de Kuijper G. Changes in Health-Related Quality of Life in People With Intellectual Disabilities Who Discontinue Long-Term Used Antipsychotic Drugs for Challenging Behaviors. J Clin Pharmacol 2018; 59:280-287. [PMID: 30161270 DOI: 10.1002/jcph.1311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/08/2018] [Indexed: 01/21/2023]
Abstract
Health-related quality of life in people with intellectual disabilities can be affected by challenging behaviors and side effects of antipsychotics. The aim of this study was to evaluate the effect of discontinuation antipsychotic drugs on health-related quality of life, including data from 2 discontinuation trials: an open-label trial of various antipsychotic drugs and a double-blind trial of risperidone. In both studies, antipsychotics were discontinued in 14 weeks, with steps of 12.5% of the baseline dosage every 2 weeks. Health-related quality of life was measured at baseline and at 16 weeks, and 40 weeks after baseline, by means of the RAND-36 (domains on physical well-being, role limitations caused by physical or emotional problems, vitality, pain, mental well-being, social functioning, general health, and changes in health). Participants who had completely discontinued antipsychotics according to the scheduled discontinuation and were still free of use at 40 weeks were compared with those who had incompletely discontinued. Physical well-being showed an increase in the group that had achieved complete discontinuation. Social functioning showed a decrease in the group that incompletely discontinued, which recovered at follow-up. Mental well-being decreased at 16 weeks but recovered at follow-up, regardless of complete or incomplete discontinuation. To conclude, discontinuation of antipsychotics had a positive effect on physical well-being when complete discontinuation was possible. When complete discontinuation was not possible, there was a negative effect on health-related quality-of-life domains. However, none of the unfavorable effects were irreversible.
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Affiliation(s)
- Lotte Ramerman
- Centre for Intellectual Disability and Mental Health/GGZ Drenthe, Assen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department of Child and Adolescent Psychiatry, Groningen, The Netherlands
| | - Pieter J Hoekstra
- University of Groningen, University Medical Center Groningen, Department of Child and Adolescent Psychiatry, Groningen, The Netherlands
| | - Gerda de Kuijper
- Centre for Intellectual Disability and Mental Health/GGZ Drenthe, Assen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department of Child and Adolescent Psychiatry, Groningen, The Netherlands
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20
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McNamara R, Randell E, Gillespie D, Wood F, Felce D, Romeo R, Angel L, Espinasse A, Hood K, Davies A, Meek A, Addison K, Jones G, Deslandes P, Allen D, Knapp M, Thapar A, Kerr M. A pilot randomised controlled trial of community-led ANtipsychotic Drug REduction for Adults with Learning Disabilities. Health Technol Assess 2018; 21:1-92. [PMID: 28857740 DOI: 10.3310/hta21470] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Data suggest that approximately 50,000 adults with learning disabilities (LDs) in England and Wales are currently prescribed antipsychotic medication. Illness in this population is common, including significant rates of challenging behaviour and mental illness, but there is particular concern over the use of antipsychotics prescribed for reasons other than the treatment of psychosis. Control of challenging behaviour is the primary reason why such medications are prescribed despite the absence of good evidence for any therapeutic effect for this purpose. OBJECTIVES To assess the feasibility of recruitment and retention and to explore non-efficacy-based barriers to a blinded antipsychotic medication withdrawal programme for adults with LDs without psychosis compared with treatment as usual. A secondary objective was to compare trial arms regarding clinical outcomes. DESIGN A two-arm individually randomised double-blind placebo-controlled drug reduction trial. SETTING Recruitment was through community learning disability teams (CLDTs) in south Wales and south-west England. PARTICIPANTS Adults with LDs who are prescribed risperidone for treatment of challenging behaviour with no known current psychosis or previous recurrence of psychosis following prior drug reduction. INTERVENTION A double-blind drug reduction programme leading to full withdrawal within 6 months. Treatment in the intervention group was gradually reduced over a 6-month period and then maintained at the same level for a further 3 months, still under blind conditions. In the control group, the baseline level of medication was maintained throughout the 9-month period. The blind was broken at 9 months, following final data collection. MAIN OUTCOME MEASURES Feasibility outcomes were (1) the number and proportion of general practices/CLDTs that progressed from initial approach to recruitment of participants and (2) the number and proportion of recruited participants who progressed through the various stages of the study. Trial arms were also compared regarding clinical outcomes, the Modified Overt Aggression Scale, the Aberrant Behaviour Checklist, the Psychiatric Assessment Schedule for Adults with Developmental Disability checklist, the Antipsychotic Side-effect Checklist, the Dyskinesia Identification System Condensed User Scale, the Client Service Receipt Inventory, use of other interventions to manage challenging behaviour, use of as-required (pro re nata) medication and level of psychotropic medication use. RESULTS Of the 22 participants randomised (intervention, n = 11; control, n = 11), 13 (59%) achieved progression through all four stages of reduction. Follow-up data at 6 and 9 months were obtained for 17 participants (intervention, n = 10; and control, n = 7; 77% of those randomised). There were no clinically important changes in participants' levels of aggression or challenging behaviour at the end of the study. There were no expedited safety reports. Four adverse events and one serious adverse event were reported during the trial. LIMITATIONS Recruitment was challenging, which was largely a result of difficulty in identifying appropriate persons to consent and carer concerns regarding re-emergence of challenging behaviour. Reduced recruitment meant that the full trial became an exploratory pilot study. CONCLUSIONS The results indicate that drug reduction is possible and safe. However, concerns about taking part were probably exacerbated by limited availability of alternative (behavioural) interventions to manage behaviour; therefore, focused support and alternative interventions are required. The results of the qualitative study provide important insights into the experiences of people taking part in drug reduction studies that should influence future trial development. FUTURE WORK We recommend that further work focuses on support for practitioners, carers and patients in reducing antipsychotic medication. TRIAL REGISTRATION Current Controlled Trials ISRCTN38126962. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 47. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | | | | | - Fiona Wood
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - David Felce
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Renee Romeo
- Centre for the Economics of Mental Health, Institute of Psychiatry, King's College London, London, UK
| | - Lianna Angel
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Aude Espinasse
- National Institute for Health Research Biomedical Research Centre - Clinical Trials Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Kerry Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Amy Davies
- Community Learning Disability Team, 2gether NHS Foundation Trust, Rotherwas, UK
| | - Andrea Meek
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Katy Addison
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Glyn Jones
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Paul Deslandes
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - David Allen
- The Tizard Centre, University of Kent, Canterbury, UK.,Positive Response Training & Consultancy, Penryn, UK
| | - Martin Knapp
- Personal Social Services Research Unit, London School of Economics, London, UK
| | - Ajay Thapar
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Michael Kerr
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
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21
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Lunsky Y, Khuu W, Tadrous M, Vigod S, Cobigo V, Gomes T. Antipsychotic Use With and Without Comorbid Psychiatric Diagnosis Among Adults with Intellectual and Developmental Disabilities. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:361-369. [PMID: 28830241 PMCID: PMC5971404 DOI: 10.1177/0706743717727240] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Antipsychotic use is controversial in the management of adults with intellectual and developmental disabilities (IDD) because of inconclusive evidence for efficacy in the absence of a comorbid psychiatric condition, and substantial concerns about adverse effects. We aimed to characterize antipsychotic use among Ontario adults with IDD and compare profiles of those with and without a documented psychiatric diagnosis. METHOD This population-based study included 51,881 adults with IDD under 65 y as of April 2010 receiving provincial drug benefits in Ontario who were followed until March 2016 to identify those dispensed at least one antipsychotic medication. Profiles of those with and without a psychiatric diagnosis were compared. RESULTS Overall, 39.2% of adults ( n = 20,316) were dispensed an antipsychotic medication, which increased to 56.4% in a subcohort residing in group homes. Almost one-third (28.91%) of people prescribed an antipsychotic medication did not have a documented psychiatric diagnosis. Those without a psychiatric diagnosis differed considerably from those with a diagnosis. In particular, those without a psychiatric diagnosis were older, less likely to have used antidepressants or benzodiazepines in the year before, and less likely to have used ambulatory and acute care. CONCLUSIONS Antipsychotic use in IDD is common, and occurs frequently without a psychiatric diagnosis. Attention toward how antipsychotics are prescribed and monitored for people with IDD in Canada is warranted to ensure appropriate prescribing.
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Affiliation(s)
- Yona Lunsky
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Psychiatry at the University of Toronto, Toronto, Ontario, Canada
| | - Wayne Khuu
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Mina Tadrous
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada
| | - Simone Vigod
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Psychiatry at the University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation at the University of Toronto, Toronto, Ontario, Canada
| | - Virginie Cobigo
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Tara Gomes
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation at the University of Toronto, Toronto, Ontario, Canada
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22
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Brophy S, Kennedy J, Fernandez-Gutierrez F, John A, Potter R, Linehan C, Kerr M. Characteristics of Children Prescribed Antipsychotics: Analysis of Routinely Collected Data. J Child Adolesc Psychopharmacol 2018; 28:180-191. [PMID: 29486137 PMCID: PMC5905863 DOI: 10.1089/cap.2017.0003] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Antipsychotics are licensed for psychosis and are also prescribed for behavior control. This study aims to examine characteristics and outcomes of children prescribed antipsychotics. METHODS A cohort study using general practice and hospital records linked with education records for 1,488,936 children living in Wales between 1999 and 2015. The characteristics of the children who were prescribed antipsychotics are presented using descriptive statistics and outcomes such as respiratory illness, diabetes, and injury were analyzed using multilevel logistic regression and the prior event rate ratio (PERR). RESULTS Children with intellectual difficulty/autism were more likely to be prescribed antipsychotics (2.8% have been prescribed an antipsychotic [75% with autism] compared with 0.15% of children without intellectual difficulty). Those with intellectual disabilities/autism were prescribed antipsychotics at a younger age and for a longer period. Antipsychotic use was associated with a higher rate of respiratory illness for all (PERR of hospital admission: 1.55 [95% CI: 1.51-1.598] or increase in rate of 2 per 100 per year in those treated), and for those with intellectual difficulty/autism, there was a higher rate of injury and hospitalized depression. However, among those without intellectual difficulty/autism, there were lower rates of depression (PERR: 0.55 [95% CI: 0.51-0.59]). CONCLUSIONS This work shows real-world use of antipsychotics and provides information on the rate of possible adverse events in children treated. Antipsychotics are predominantly used for those with intellectual difficulty/autism rather than those with a psychotic diagnosis. There is evidence that rates of respiratory disease, epilepsy, and diabetes are also higher postantipsychotic use for all. In those with intellectual difficulty/autism, hospital-admitted depression and injury are higher postantipsychotic use. The use of antipsychotics for behavioral management is likely to have increased cost implications to the healthcare system.
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Affiliation(s)
- Sinead Brophy
- FARR Institute (CIPHER), Swansea University Medical School, Swansea, United Kingdom
| | - Jonathan Kennedy
- FARR Institute (CIPHER), Swansea University Medical School, Swansea, United Kingdom
| | | | - Ann John
- Population Psychiatry, Suicide and Informatics, FARR Institute (CIPHER), Swansea University Medical School, Swansea, United Kingdom
| | - Robert Potter
- Cwm Taf Health University Health Board and Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, Wales
| | - Christine Linehan
- UCD Centre for Disability Studies, University College Dublin, Dublin, Ireland
| | - Michael Kerr
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, Wales
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23
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Mulhall P, Taggart L, Coates V, McAloon T, Hassiotis A. A systematic review of the methodological and practical challenges of undertaking randomised-controlled trials with cognitive disability populations. Soc Sci Med 2018; 200:114-128. [PMID: 29421458 DOI: 10.1016/j.socscimed.2018.01.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 11/28/2022]
Abstract
Approximately 10% of the world's population have a cognitive disability. Cognitive disabilities can have a profound impact on a person's social, cognitive or mental functioning, requiring high levels of costly health and social support. Therefore, it is imperative that interventions and services received are based upon a sound evidence-base. For many interventions for this population, this evidence-base does not yet exist and there is a need for more Randomised Controlled Trials (RCTs). The process of conducting RCTs with disabled populations is fraught with methodological challenges. We need a better understanding of these methodological barriers if the evidence-bases are to be developed. The purpose of this study was to explore the methodological and practical barriers to conducting trials with adults with cognitive disabilities. As a case example, the literature regarding RCTs for people with intellectual disabilities (ID) was used to highlight these pertinent issues. A systematic literature review was conducted of RCTs with adults with ID, published from 2000 to 2017. A total of 53 papers met the inclusion criteria and were reviewed. Some of the barriers reported were specific to the RCT methodology and others specific to people with disabilities. Notable barriers included; difficulties recruiting; obtaining consent; resistance to the use of control groups; engaging with carers, staff and stakeholders; the need to adapt interventions and resources to be disability-accessible; and staff turnover. Conducting RCTs with people with cognitive disabilities can be challenging, however with reasonable adjustments, many of these barriers can be overcome. Researchers are not maximising the sharing of their experience-base. As a result, the development of evidence-bases remains slow and the health inequities of people with disabilities will continue to grow. The importance of the MRC guidelines on process evaluations, together with implications for the dissemination of 'evidence-base' and 'experience-base' are discussed.
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Affiliation(s)
- Peter Mulhall
- School of Nursing, Ulster University, Shore Rd, Newtownabbey, BT37 0QB, Northern Ireland, United Kingdom.
| | - Laurence Taggart
- School of Nursing, Ulster University, Shore Rd, Newtownabbey, BT37 0QB, Northern Ireland, United Kingdom
| | - Vivien Coates
- School of Nursing, Ulster University, Shore Rd, Newtownabbey, BT37 0QB, Northern Ireland, United Kingdom
| | - Toni McAloon
- School of Nursing, Ulster University, Shore Rd, Newtownabbey, BT37 0QB, Northern Ireland, United Kingdom
| | - Angela Hassiotis
- University College London, Division of Psychiatry, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, United Kingdom
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Marshall T. Audit of the use of psychotropic medication for challenging behaviour in a community learning disability service. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.28.12.447] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodThe aims of the study were to identify patients in a community learning disability service receiving psychotropic medication for challenging behaviour, to examine prescribing practice and to compare this against local consensus standards. Local consensus standards were agreed by the consultants and the notes were reviewed by the author.ResultsA total of 102 patients were identified as receiving psychotropic medication for challenging behaviour (26.7% of notes examined). The most common additional diagnoses were autism (29%) and epilepsy (28%). The average duration of treatment was 5.3 years, and multiple drugs were used in 34% of these patients. Antipsychotics were the most commonly used drugs (96% of patients). There was rarely a detailed description of the challenging behaviour. There was little regular monitoring of side-effects or warning about potential side-effects when the medication was started.Clinical ImplicationsChallenging behaviour is a common cause of multiple prescribing in learning disability patients, and is often long-term in the absence of a strong evidence base. Other specialties use medication to control disturbed behaviour, particularly in people with dementia or personality disorder, so this audit may also be of interest to old age, adult and forensic psychiatrists.
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Matthews T, Weston SN. Experience of thioridazine use before and after the Committee on Safety of Medicines warning. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.27.3.87] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodTo describe the use of thioridazine in a population of adults with learning disabilities at the time of the warning issued by the Committee on Safety of Medicines (CSM). Also, to observe the result of discontinuation of thioridazine and to examine factors that were associated with adverse events. Retrospective case note analysis was carried out for a sample of individuals with a learning disability.ResultsOver 50% of those on regular thioridazine experienced adverse events during or following drug withdrawal. Adverse events were significantly associated with the duration of previous thioridazine prescription. Higher drug dosage and a more severe degree of learning disability may also be factors linked to poorer outcomes.Clinical ImplicationsMore caution may be required when reducing or withdrawing antipsychotic medication in this patient group.
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de Kuijper GM, Hoekstra PJ. Physicians' reasons not to discontinue long-term used off-label antipsychotic drugs in people with intellectual disability. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2017; 61:899-908. [PMID: 28560761 DOI: 10.1111/jir.12385] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 03/30/2017] [Accepted: 04/26/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND People with intellectual disability (ID) frequently use antipsychotic drugs on an off-label base, often for many years. Physicians' decisions to discontinue these drugs not only depend on patient characteristics, like the presence of mental or behavioural disorders, but also on environmental factors, such as inappropriate living circumstances, and on attitudes, knowledge and beliefs of staff, clients and their representatives towards the effects of antipsychotic drug use. In this study, we therefore investigated the influence of participant and setting-related factors on decisions of physicians not to discontinue off-label prescribed antipsychotics. METHODS The study took place in living facilities of six service providers for people with ID spread over the Netherlands and staffed with support professionals, nurses, behavioural scientist and physicians and was part of an antipsychotics discontinuation trial. ID physicians had to decide whether the off-label use of antipsychotics could be discontinued. Medical and pharmaceutical records were used to establish the prevalence of antipsychotic drug use in the study population, along with duration of use and whether the use was off-label. Reasons of physicians not to discontinue the prescription of antipsychotics in those participants who used off-label antipsychotics for more than a year were collected and categorised as related to participant or setting characteristics, including lack of consent to discontinue, and staff members, participants or their legal representatives. RESULTS Of the 3299 clients of the service providers, 977 used one or more antipsychotic drugs. The prevalence of antipsychotic drug use was 30%. Reasons for use were in 5% of cases, a chronic psychotic disorder classified according to Diagnostic System Mental Disorders, Fourth Edition, criteria, in 25%, present or past (suspected) non-schizophrenia-related psychotic symptoms and in 69%, challenging behaviours. Overall, physicians were willing to discontinue their prescriptions in 51% of cases, varying from 22% to 87% per service provider. The odds for decisions of physicians to discontinue off-label prescriptions varied from 0.19 to 13.95 per service provider. The variables 'a living situation with care and support' and 'challenging behaviour' were associated with a higher chance of discontinuation. The main reasons for decisions not to discontinue were concerns for symptoms of restlessness, the presence of an autism spectrum disorder, previously unsuccessful attempts to discontinue and objections against discontinuation of legal representatives. Reasons for physicians' decisions not to discontinue the off-label use of antipsychotics varied largely between the service providers. CONCLUSIONS The prevalence of antipsychotic drug use for off-label indications in people with ID remains high. The results of this study indicate that there is a large variation in clinical practice of physicians regarding discontinuation of long-term antipsychotic drug prescriptions, which may be partially related to environmental factors as setting culture and attitudes of staff towards off-label antipsychotic drug use in persons with ID.
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Affiliation(s)
- G M de Kuijper
- Assen, GGZ Drenthe/Department Centre for Intellectual Disability and Mental Health, the Netherlands
- University Medical Centre Groningen/Department Psychiatry, the Netherlands
| | - P J Hoekstra
- University Medical Centre Groningen/Department University Centre Child and Adolescent Psychiatry, the Netherlands
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Bowring DL, Totsika V, Hastings RP, Toogood S, McMahon M. Prevalence of psychotropic medication use and association with challenging behaviour in adults with an intellectual disability. A total population study. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2017; 61:604-617. [PMID: 28090687 DOI: 10.1111/jir.12359] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 11/15/2016] [Accepted: 11/30/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND There is a high prevalence of psychotropic medication use in adults with Intellectual Disabilities (ID), often in the absence of psychiatric disorder, also associated with challenging behaviour. Previous research has focused on specific sample frames or data from primary care providers. There is also a lack of consistency in the definition of challenging behaviour used. METHODS We adopted a total population sampling method. Medication data on 265 adults with ID were classified according to the Anatomical Therapeutic Chemical classification system. The Behaviour Problems Inventory - short form classified challenging behaviours. We examined the association between challenging behaviour and the use of psychotropic medication, and whether any association would still be present after accounting for socio-demographic and clinical characteristics. RESULTS 70.57% of adults with ID were prescribed at least one class of any medication (mean per person =2.62; range 0-14). Psychotropic medications were used by 37.73% of participants with antipsychotics the commonest type used by 21.89% of individuals. Polypharmacy and high dosages were common. Generalised Linear Models indicated significant associations between psychotropic medication and the presence of a psychiatric diagnosis, challenging behaviour, older age and type of residence. Male gender was additionally associated with antipsychotic medication. CONCLUSIONS The use of a total population sample identified via multiple routes is less likely to overestimate prevalence rates of medication use. Current challenging behaviour was a predictor of medication use after controlling for other variables. Data indicate that there may be differences in prescribing patterns associated with different topographies of challenging behaviours.
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Affiliation(s)
- D L Bowring
- School of Psychology, Bangor University, Bangor, Gwynedd, UK
- Community and Social Services, Health and Social Services, Jersey
| | - V Totsika
- CEDAR, University of Warwick, Coventry, UK
| | | | - S Toogood
- School of Psychology, Bangor University, Bangor, Gwynedd, UK
| | - M McMahon
- Community and Social Services, Health and Social Services, Jersey
- Centre for Disability Research, Lancaster University, Lancaster, UK
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de Kuijper G, van der Putten AAJ. Knowledge and expectations of direct support professionals towards effects of psychotropic drug use in people with intellectual disabilities. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2017; 30 Suppl 1:1-9. [PMID: 28467003 DOI: 10.1111/jar.12357] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND/INTRODUCTION In this study, we investigated intellectual disability support professionals' knowledge and expectations towards effects of psychotropic drug use on behaviour and drug use in their clients, because shortcomings may lead to misinterpretations of behavioural symptoms and inappropriate drug use. METHODS Two self-designed questionnaires were used to measure the knowledge and expectations of 194 support professionals in 14 residential facilities regarding psychotropic drug use and effects of antipsychotics on behavioural, cognitive and mental functioning of people with intellectual disability. The psychometric properties of both questionnaires were adequate. RESULTS A majority of the professionals had unrealistic expectations regarding the positive effects of antipsychotics on cognitive and behavioural functioning, and 94% scored below the cut-off scores regarding knowledge; 60% indicated they needed education and training. CONCLUSIONS To achieve sufficient collaboration of intellectual disability support professionals in reducing inappropriate psychotropic drug use of clients, vocational educational training is needed.
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Affiliation(s)
- Gerda de Kuijper
- Centre for Intellectual Disability and Mental Health/GGZ Drenthe, Assen, The Netherlands.,Department Psychiatry, University Medical Centre Groningen, Groningen, The Netherlands
| | - Annette A J van der Putten
- Department of Special Needs Education and Youth Care, University of Groningen, Groningen, The Netherlands
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Sheehan R, Hassiotis A. Reduction or discontinuation of antipsychotics for challenging behaviour in adults with intellectual disability: a systematic review. Lancet Psychiatry 2017; 4:238-256. [PMID: 27838214 DOI: 10.1016/s2215-0366(16)30191-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 01/20/2023]
Abstract
The use of antipsychotics to manage challenging behaviour in adults with intellectual disability is widespread but controversial, and evidence is scarce. There is a perception that antipsychotics used in this context can be reduced or discontinued, and this has been a major focus of recent national policy. However, such an intervention risks harm as well as having potential benefits. We reviewed the available evidence and found that antipsychotics can be reduced or discontinued in a substantial proportion of adults who use them for challenging behaviour, although not always without adverse effects. There is a group which displays behavioural deterioration on antipsychotic reduction that prevents discontinuation; predictors of poor response could not be reliably identified. In view of the relatively scarce data and methodological limitations of the available studies, we cannot draw firm conclusions to inform a population level approach to this issue. Antipsychotic medication used for behaviour should be reviewed regularly and an individualised approach taken to treatment.
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Affiliation(s)
- Rory Sheehan
- Division of Psychiatry, University College London, London, UK.
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Beumer S, Anne Maria Maes-Festen D. Reduction or discontinuation of antipsychotics for challenging behaviour in adults with intellectual disability: why does it fail? Lancet Psychiatry 2017; 4:e2. [PMID: 28236957 DOI: 10.1016/s2215-0366(17)30041-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Sylvie Beumer
- Department of General Practice, University Medical Centre Rotterdam, 3000 CA Rotterdam, Netherlands.
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O'Dwyer M, Peklar J, McCallion P, McCarron M, Henman MC. Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study. BMJ Open 2016; 6:e010505. [PMID: 27044582 PMCID: PMC4823458 DOI: 10.1136/bmjopen-2015-010505] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/03/2016] [Accepted: 03/07/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES (1) To evaluate the prevalence of polypharmacy (5-9 medicines) and excessive polypharmacy (10+ medicines) and (2) to determine associated demographic and clinical characteristics in an ageing population with intellectual disabilities (IDs). DESIGN Observational cross-sectional study. SETTING Wave One (2009/2010) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). PARTICIPANTS A nationally representative sample of 753 persons with ID, aged between 41 and 90 years. Participants/proxy reported medicines (prescription and over the counter) taken on a regular basis; medication data was available for 736 participants (98%). MAIN OUTCOME MEASURES/INTERVENTIONS Participants were divided into those with no polypharmacy (0-4 medicines), polypharmacy (5-9 medicines) and excessive polypharmacy (10+ medicines). Medication use patterns were analysed according to demographic variables and reported chronic conditions. A multinomial logistic regression model identified factors associated with polypharmacy (5-9 medicines) and excessive polypharmacy (≥10 medicines). RESULTS Overall, 90% of participants reported use of medicines. Polypharmacy was observed in 31.5% of participants and excessive polypharmacy in 20.1%. Living in a residential institution, and reporting a mental health or neurological condition were strongly associated with polypharmacy and excessive polypharmacy after adjusting for confounders, but age or gender had no significant effect. CONCLUSIONS Polypharmacy was commonplace for older adults with ID and may be partly explained by the high prevalence of multimorbidity reported. Review of appropriateness of medication use is essential, as polypharmacy places ageing people with ID at risk of adverse effects.
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Affiliation(s)
- Máire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
- IDS-TILDA School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Jure Peklar
- School of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Philip McCallion
- Center for Excellence in Aging and Community Wellness, University At Albany, New York, USA
| | - Mary McCarron
- Dean of the Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Martin C Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
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Scheifes A, Egberts TCG, Stolker JJ, Nijman HLI, Heerdink ER. Structured Medication Review to Improve Pharmacotherapy in People with Intellectual Disability and Behavioural Problems. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2015; 29:346-55. [PMID: 25882186 DOI: 10.1111/jar.12183] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Polypharmacy and chronic drug use are common in people with intellectual disability and behavioural problems, although evidence of effectiveness and safety in this population is lacking. This study examined the effects of a structured medication review and aimed to improve pharmacotherapy in inpatients with intellectual disability. METHODS In a treatment facility for people with mild to borderline intellectual disability and severe behavioural problems, a structured medication review was performed. Prevalence and type of drug-related problems (DRPs) and of the recommended and executed actions were calculated. RESULTS In a total of 55 patients with intellectual disability and behavioural problems, 284 medications were prescribed, in which a DRP was seen in 106 (34%). No indication/unclear indication was the most prevalent DRP (70). Almost 60% of the recommended actions were also executed. CONCLUSIONS This high prevalence of DRPs is worrying. The structured medication review is a valuable instrument to optimize pharmacotherapy and to support psychiatrists in adequate prescribing of both psychotropic and somatic drugs.
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Affiliation(s)
- Arlette Scheifes
- Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands.,Altrecht Institute for Mental Health Care, Den Dolder, The Netherlands
| | - Toine C G Egberts
- Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Joost Jan Stolker
- Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands.,Licht-Zorg, Psychiatric Care, Maarssen, The Netherlands
| | - Henk L I Nijman
- Altrecht Institute for Mental Health Care, Den Dolder, The Netherlands.,Faculty of Social Sciences, Behavioural Science Institute (BSI), Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Eibert R Heerdink
- Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands.,Altrecht Institute for Mental Health Care, Den Dolder, The Netherlands.,Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
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Deb S, Unwin G, Deb T. Characteristics and the trajectory of psychotropic medication use in general and antipsychotics in particular among adults with an intellectual disability who exhibit aggressive behaviour. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2015; 59:11-25. [PMID: 24450426 DOI: 10.1111/jir.12119] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 06/03/2023]
Abstract
BACKGROUND A high proportion of adults with an intellectual disability (ID) are known to receive psychotropic medications for the management of aggressive behaviour in the absence of any psychiatric diagnosis. Despite this widespread use of psychotropic medication in general and antipsychotic medication in particular, no study has reported the trajectory of psychotropic medication use using a prospective design. METHOD We have prospectively studied a community, clinic-based sample of 100 adults with ID and aggressive behaviour over a 6-month period for use of psychotropic medication in general and antipsychotics in particular, and compared them with demographic, psychiatric and behavioural variables. RESULTS Psychotropic medications were used for 89% of patients at baseline (T1) and 90% at 6 months' (T2) follow-up. Risperidone was the most commonly used antipsychotic medication followed by chlorpromazine, haloperidol, olanzapine, zuclopenthixol and quetiapine. Other commonly used medications were SSRI antidepressants such as citalopram, paroxetine and fluoxetine followed by mood stabilisers such as carbamazepine and sodium valproate. Although in a high proportion of cases carbamazepine and sodium valproate were used to treat epilepsy per se. A high proportion (45%) received more than one (polypharmacy) psychotropic medication at T1; however, this proportion decreased slightly to 41% at T2. As for antipsychotic prescribing specifically, a similar proportion received them at T1 (75%) and T2 (73%), with polypharmacy of antipsychotics remaining similar at T1 (10%) and at T2 (9%). Twenty-three per cent and 20% of patients received over 300 mg/day of chlorpromazine equivalent dose of antipsychotics at T1 and T2 respectively. However, there was an overall significant reduction in the severity of aggressive behaviour between T1 and T2. Higher doses of antipsychotic prescribing were positively correlated with more severe aggressive behaviour, physical aggression towards objects, self-injurious behaviour and increasing age. There was no significant association with other demographic variables, physical health conditions or psychiatric diagnosis. Neither was there any significant correlation between mean aggression severity score change and antipsychotic daily dose change between T1 and T2. CONCLUSIONS To our knowledge, this is the first ever comprehensive follow-up study of use of psychotropic medications in general but antipsychotics in particular over a 6-month period in adults with ID and aggressive behaviour, in a clinic-based community setting which also compared the trajectory of severity of aggressive behaviour with that of antipsychotic medication dose. Our study shows that not only the use of psychotropic medication is common among adults with ID who attend psychiatric clinics for aggressive behaviour, the use of polypharmacy of psychotropic medications in general and high dose of antipsychotics in particular are equally prevalent. However, in some cases two antipsychotics may have been prescribed simultaneously as the psychiatrist is in the process of switching from one to another.
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Affiliation(s)
- S Deb
- Imperial College London, Department of Medicine, Division of Brain Sciences, Charing Cross Hospital, London, UK
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Abstract
AbstractObjectives: There is a view that antipsychotic drugs can be successfully withdrawn from people with intellectual disabilities with resultant health gain. This study critically examines whether antipsychotic drug withdrawal is beneficial.Methods: 119 adults with intellectual disabilities were included in a programme of antipsychotic drug withdrawal.Results: The clinical outcomes of this programme are poor. Only 7.6% completely withdrew from antipsychotic drugs, and 48.7% experienced onset/deterioration in problem behaviours or mental ill-health. Significant drug side effects with the introduction of new drugs were experienced by 23.3%. Resultant mean antipsychotic drug doses were higher compared with those at the start of the programme. The cost to the intellectual disabilities psychiatric service (over and above that of routine psychiatric care) was £258,050 (€391,693), and the human cost was considered high. Primary care, social care and family costs were not calculated. The only specific factors found to be associated with poor outcome were increased severity of intellectual disabilities and female gender.Conclusions: The successful role of antipsychotic drugs in the management of problem behaviours in people who do not have verbal communication skills may relate to the pathoplastic effect of intellectual disabilities on clinical presentation, with problem behaviours being markers of eg. psychosis and anxiety disorders. Our original findings challenge the view that routine withdrawal of antipsychotic drugs is good practice; we reinterpret the existing literature, and recommend caution and vigilance in pharmacotherapy.
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Campbell M, Robertson A, Jahoda A. Psychological therapies for people with intellectual disabilities: comments on a matrix of evidence for interventions in challenging behaviour. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2014; 58:172-188. [PMID: 23106865 DOI: 10.1111/j.1365-2788.2012.01646.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/15/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Psychological therapies with a proven efficacy in the general population are being adapted for use with people who have intellectual disabilities in community settings. METHODS A systematic review of peer-reviewed literature published between 1980 and 2010 was carried out, to identify the evidence base for effective psychological interventions in challenging behaviour. Relevant databases were searched using applied key terms. Evidence was graded, according to the quality of the research. A best-evidence Matrix was produced to improve guidance for service providers and practitioners in the range, volume and quality of psychological interventions. RESULTS There is a limited amount of efficacy research that meets the most stringent standards of empirical evidence. CONCLUSIONS It is important to broaden the evidence base and consider the context of psychological interventions, alongside the values underpinning care and treatment.
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Affiliation(s)
- M Campbell
- School of Psychology & Neuroscience, University of St. Andrews, St. Andrews, Fife, UK
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Effects of discontinuation of long-term used antipsychotics on prolactin and bone turnover markers in patients with intellectual disability. J Clin Psychopharmacol 2014; 34:157-9. [PMID: 24135841 DOI: 10.1097/jcp.0b013e3182a60848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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de Kuijper G, Evenhuis H, Minderaa RB, Hoekstra PJ. Effects of controlled discontinuation of long-term used antipsychotics for behavioural symptoms in individuals with intellectual disability. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2014; 58:71-83. [PMID: 23046144 DOI: 10.1111/j.1365-2788.2012.01631.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/30/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Antipsychotics are frequently and often long-term used for challenging behaviour in persons with intellectual disability (ID), but the evidence base for this is meagre. As these agents may cause harmful side effects, discontinuation should be considered. Previous studies regarding discontinuation of long-term used antipsychotics mostly were uncontrolled and involved small numbers. The primary objective was to investigate the effects of controlled discontinuation of antipsychotics prescribed for challenging behaviour. Secondary objectives were to compare the results of two discontinuation time schedules, to compare groups of participants who had and had not achieved complete discontinuation, and to identify patient and medication characteristics that might predict the outcomes. Our hypothesis was that discontinuation of antipsychotics used for behavioural symptoms would not lead to worsening in behaviour. METHODS This was a multi-centre parallel-group study comparing two discontinuation schedules of 14 and 28 weeks. Allocation to the two discontinuation schedules took place in a 1:1 ratio. Antipsychotics were tapered off every 2 or 4 weeks with approximately 12.5% of the initial dosage. Follow-up was 12 weeks after the scheduled complete discontinuation, that is, 26 or 40 weeks after the first dose reduction, respectively. Discontinuation was stopped in case of significant behavioural worsening. Participants were 98 residents with ID of three care providing organisations in the Netherlands, aged 15-66 year, who had used for more than 1 year one or more of the six most frequently prescribed antipsychotics for challenging behaviour. Main outcome measure was the total score of the Aberrant Behaviour Checklist (ABC); also ABC sub-scales were used. RESULTS Of 98 participants, 43 achieved complete discontinuation; at follow-up 7 had resumed use of antipsychotics. Mean ABC ratings improved significantly for those who achieved complete discontinuation (directly after discontinuation, P < 0.01 and at follow-up, P = 0.03), and at follow-up (P = 0.03) for those who had not achieved complete discontinuation. Similar results were found with respect to most ABC sub-scales, including the 'irritability' sub-scale. There were no significant differences in improvement of ABC ratings between both discontinuation schedules. Higher ratings of extrapyramidal and autonomic symptoms at baseline were associated with less improvement of behavioural symptoms after discontinuation; higher baseline ABC rating predicted higher odds of incomplete discontinuation. CONCLUSIONS Discontinuation of antipsychotics prescribed for challenging behaviour in patients with ID is associated with improved behavioural functioning. There is no need to taper off in a time frame longer than 14 weeks.
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Affiliation(s)
- G de Kuijper
- Vanboeijen, Intellectual Disability Centre, Assen, The Netherlands
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Hastings RP. Running to catch up: rapid generation of evidence for interventions in learning disability services. Br J Psychiatry 2013; 203:245-6. [PMID: 24085735 DOI: 10.1192/bjp.bp.113.127605] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Few high-quality trials have been conducted in intellectual disability mental health. Trials such as Willner et al's have a 'close-to-market' focus. I argue that rapid generation of evidence for individuals with intellectual disability is the priority, alongside a new research focus on mental health in those with severe intellectual disability.
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Affiliation(s)
- Richard P Hastings
- Richard P. Hastings, PhD, School of Psychology, Bangor University, Bangor, Gwynedd LL57 2AS, UK.
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Doan TN, Lennox NG, Taylor-Gomez M, Ware RS. Medication use among Australian adults with intellectual disability in primary healthcare settings: a cross-sectional study. JOURNAL OF INTELLECTUAL & DEVELOPMENTAL DISABILITY 2013; 38:177-181. [PMID: 23550741 DOI: 10.3109/13668250.2013.778968] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND There is concern about widespread medication use by people with intellectual disability (ID), especially psychotropic and anticonvulsant agents. However, there is sparse information on prescribing patterns in Australia. METHOD This cross-sectional study was conducted between 2000 and 2002 among adults with ID who live in the community in Brisbane, Australia. Medication data were extracted from a health screening tool. Demographic and medical data were collected from telephone interviews and medical records. RESULTS Of 117 participants, 35% were prescribed psychotropic medications, most commonly antipsychotics, and 26% anticonvulsants. Complementary medications (vitamins, minerals, amino acids, fish oil, and herbal products) were used by 29% of participants. After adjusting for potentially confounding variables, psychotropic medication use was significantly associated with having a psychiatric illness (adjusted odds ratio = 4.6, 95% CI [1.0, 20.6]) and challenging behaviours (4.4, [1.1, 17.3]). CONCLUSIONS People with ID use a broad range of medications. Psychotropic medications continue to be the most predominant agents prescribed for this population. Psychotropic medication use is positively associated with having a psychiatric illness and challenging behaviours.
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Affiliation(s)
- Tan N Doan
- Queensland Centre for Intellectual and Developmental Disability, School of Medicine, The University of Queensland, Brisbane, Australia
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Bezuidenhout H, Wiysonge CS, Bentley JM. Risperidone for disruptive behaviour disorders in children with intellectual disabilities. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Heidre Bezuidenhout
- Red Cross Hospital, University of Cape Town; Western Cape Provincial Administration; 201 Bayviews Clifford Road, Seapoint Cape Town Western South Africa 8500
| | - Charles Shey Wiysonge
- University of Cape Town; Institute of Infectious Disease and Molecular Medicine & Division of Medical Microbiology; Anzio Road Observatory South Africa 7925
| | - Judith M Bentley
- University of Cape Town; Department of Psychiatry and Mental Health; 51 Washington Road Claremont Cape Town Western Cape South Africa 7708
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Frighi V, Stephenson MT, Morovat A, Jolley IE, Trivella M, Dudley CA, Anand E, White SJ, Hammond CV, Hockney RA, Barrow B, Shakir R, Goodwin GM. Safety of antipsychotics in people with intellectual disability. Br J Psychiatry 2011; 199:289-95. [PMID: 21816867 DOI: 10.1192/bjp.bp.110.085670] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite frequent use, little is known about the metabolic and endocrine side-effects of antipsychotics in individuals with intellectual disability. AIMS To compare indices of obesity, glucose, lipids and prolactin between antipsychotic-treated and antipsychotic-naive individuals with intellectual disability and also between participants with intellectual disability and controls from the general population. METHOD Observational study comparing 138 antipsychotic-treated and 64 antipsychotic-naive participants with intellectual disability in one National Health Service trust with general population controls. RESULTS Antipsychotic treatment comprised: risperidone 48%,olanzapine 18%, thioxanthenes 10%, other 24%; monotherapy 95% of participants; mean treatment duration 8 years;median daily chlorpromazine equivalent dose 108 mg(range 16–667). Metabolic indices were the same or more favourable in the intellectual disability group than the general population control group but overweight/obesity and type 2 diabetes were more prevalent in the women in the intellectual disability group than the control group. Metabolic indices were similar, statistically or clinically, between the antipsychotic-treated and the antipsychotic-naive groups but there was a non-significant trend towards a higher rate of type 2 diabetes in the antipsychotic group. A total of 100%and 70% of participants on amisulpride/sulpiride and risperidone respectively had hyperprolactinaemia, with secondary hypogonadism in 77% and 4% of affected women and men. CONCLUSIONS Antipsychotics, on average, did not increase metabolic risk,although the existence of a susceptible subgroup at risk of diabetes cannot be excluded. Some antipsychotics induced hyperprolactinaemic hypogonadism, requiring active management. However, our findings suggest that antipsychotics at the low doses routinely prescribed for people with intellectual disability are generally safe in relation to metabolic adverse effects, even if efficacy remains poorly defined.
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Affiliation(s)
- Valeria Frighi
- Department of Psychiatry, University of Oxford and Ridgeway Partnership (Oxfordshire Learning Disability NHS Trust), Oxford, UK.
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Paton C, Flynn A, Shingleton-Smith A, McIntyre S, Bhaumik S, Rasmussen J, Hardy S, Barnes T. Nature and quality of antipsychotic prescribing practice in UK psychiatry of intellectual disability services. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2011; 55:665-74. [PMID: 21507097 DOI: 10.1111/j.1365-2788.2011.01421.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Antipsychotics are perceived to be over-used in the management of behavioural problems in people with an intellectual disability (ID). Published guidelines have set good practice standards for the use of these drugs for behavioural indications. We sought to identify the range of indications for which antipsychotic drugs are prescribed in people with ID and to audit clinical practice against the standards. METHOD Data were collected from the clinical records of individuals with ID who were under the care of mental health services in the UK, and prescribed an antipsychotic drug. RESULTS The sample comprised 2319 patients from 39 clinical services. Twenty-seven per cent of the patients had a diagnosis of a psychotic illness (ICD-10 F20-29) and 27% an affective illness (ICD-10 F30-39). The proportion who did not have a psychiatric diagnosis ranged from 6% of those with borderline/mild ID to 21% of those with severe/profound ID. Overall, the most common indications for prescribing an antipsychotic drug were comorbid psychotic illness, anxiety and agitation, and a range of behavioural disturbances. The prevalence of use of antipsychotic drugs to manage challenging behaviour in the absence of concomitant mental illness increased with the severity of ID and accounted for almost half of prescriptions in those with severe/profound ID. Adherence to the audit standards related to documentation of clinical indications and review of efficacy was high. Side effect monitoring was less assiduous. CONCLUSIONS In clinical practice, most prescriptions for antipsychotic drugs in people with ID are consistent with the evidence base and the overall quality of prescribing practice, as measured against recognised standards, is good, although in some patients potentially remedial side effects may not be detected and treated.
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Affiliation(s)
- C Paton
- Pharmacy, Oxleas NHS Trust, Dartford, UK.
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Scheifes A, Stolker JJ, Egberts ACG, Nijman HLI, Heerdink ER. Representation of people with intellectual disabilities in randomised controlled trials on antipsychotic treatment for behavioural problems. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2011; 55:650-664. [PMID: 21155914 DOI: 10.1111/j.1365-2788.2010.01353.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Behavioural problems are common in people with intellectual disability (ID) and are often treated with antipsychotics. AIM To establish the frequency and characteristics of people with ID included in randomised controlled trials (RCTs) on antipsychotic treatment for behavioural problems, and to investigate the quality of these RCTs. METHODS A literature search in EMBASE, PubMed and Cochrane was performed and reviewed. RESULTS People with ID participated in 27 of the 100 included RCTs. The RCTs were of good quality but smaller compared with trials in patients with dementia or schizophrenia (average sample sizes = 55, 124 and 374). In 13/27 trials no clear definition of ID was given. Over 25 different outcome measures were used to assess behavioural problems. CONCLUSIONS Studies in which people with ID are included are of a sufficient quality, but of a small size. The heterogeneity in the characteristics of the ID population included as well as in the applied assessment instruments makes performing meta-analyses unfeasible.
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Affiliation(s)
- A Scheifes
- Altrecht Institute for Mental Health Care, Den Dolder, the Netherlands
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Matson JL, Mahan S. Antipsychotic drug side effects for persons with intellectual disability. RESEARCH IN DEVELOPMENTAL DISABILITIES 2010; 31:1570-1576. [PMID: 20580203 DOI: 10.1016/j.ridd.2010.05.005] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 05/10/2010] [Indexed: 05/29/2023]
Abstract
Antipsychotic drugs are the most frequently prescribed of the psychotropic drugs among the intellectually disabled (ID) population. Given their widespread use, efforts to systematically assess and report side effects are warranted. Specific scaling methods such as the Matson Evaluation of Side Effects (MEDS), the Abnormal Inventory Movement Scale (AIMS), and Dyskinesia Identification System Condensed User Scale (DISCUS) are reviewed. Symptom patterns and a focus on additional research are discussed. While progress has been made, more and more systematic methods to research these problems are necessary.
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Affiliation(s)
- Johnny L Matson
- Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, USA.
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Oliver-Africano P, Dickens S, Ahmed Z, Bouras N, Cooray S, Deb S, Knapp M, Hare M, Meade M, Reece B, Bhaumik S, Harley D, Piachaud J, Regan A, Ade Thomas D, Karatela S, Rao B, Dzendrowskyj T, Lenôtre L, Watson J, Tyrer P. Overcoming the barriers experienced in conducting a medication trial in adults with aggressive challenging behaviour and intellectual disabilities. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2010; 54:17-25. [PMID: 19627427 DOI: 10.1111/j.1365-2788.2009.01195.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Aggressive challenging behaviour in people with intellectual disability (ID) is frequently treated with antipsychotic drugs, despite a limited evidence base. METHOD A multi-centre randomised controlled trial was undertaken to investigate the efficacy, adverse effects and costs of two commonly prescribed antipsychotic drugs (risperidone and haloperidol) and placebo. RESULTS The trial faced significant problems in recruitment. The intent was to recruit 120 patients over 2 years in three centres and to use a validated aggression scale (Modified Overt Aggression Scale) score as the primary outcome. Despite doubling the period of recruitment, only 86 patients were ultimately recruited. CONCLUSIONS Variation in beliefs over the efficacy of drug treatment, difficulties within multidisciplinary teams and perceived ethical concerns over medication trials in this population all contributed to poor recruitment. Where appropriate to the research question cluster randomised trials represent an ethically and logistically feasible alternative to individually randomised trials.
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Mansell J, Beadle-Brown J. Dispersed or clustered housing for adults with intellectual disability: a systematic review. JOURNAL OF INTELLECTUAL & DEVELOPMENTAL DISABILITY 2009; 34:313-323. [PMID: 19860598 DOI: 10.3109/13668250903310701] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND The purpose of this review was to evaluate the available research on the quality and costs of dispersed community-based housing when compared with clustered housing. METHODS Searches against specified criteria yielded 19 papers based on 10 studies presenting data comparing dispersed housing with some kind of clustered housing (village communities, residential campuses, or clusters of houses). The studies reported the experience of nearly 2,500 people from four different countries. RESULTS In five of eight quality of life domains there were no studies reporting benefits of clustered settings. In respect of interpersonal relations, emotional, and physical well-being, clustered settings had some advantages. However, in many of these cases the better results refer only to village communities and not to campus housing or clustered housing. In terms of costs, clustered housing was usually less expensive because of lower staffing levels. In two of the three studies that examined costs controlling for user characteristics, there was no statistically significant difference. CONCLUSION Dispersed housing appears to be superior to clustered housing on the majority of quality indicators studied. The only exception to this is that village communities for people with less severe disabilities have some benefits; this is not, however, a model which can be feasibly provided for everyone. Clustered housing is usually less expensive than dispersed housing but this is because it provides fewer staff hours per person. There is no evidence that clustered housing can deliver the same quality of life as dispersed housing at a lower cost.
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Affiliation(s)
- Jim Mansell
- University of Kent at Canterbury, Canterbury, Kent CT2 7LZ, UK.
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Oliver-Africano P, Murphy D, Tyrer P. Aggressive behaviour in adults with intellectual disability: defining the role of drug treatment. CNS Drugs 2009; 23:903-13. [PMID: 19845412 DOI: 10.2165/11310930-000000000-00000] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
A complex form of aggression, commonly expanded as 'aggressive challenging behaviour', is reported in one in four adults with intellectual disability and is often treated with antipsychotics, mood stabilizers and antidepressants. Psychological treatments, including anger and behavioural management, person-centred planning and manipulation of the environment (nidotherapy), have also been used when available but to a lesser extent. In this article, the evidence for efficacy for each intervention is examined, with data from randomized controlled trials given primacy. Very little evidence, based on limited data, can be found for the interventions of anger and behavioural management and also for the atypical antipsychotic drug, risperidone; the data available on these interventions come primarily from studies conducted in children in whom the behaviour is part of the autistic spectrum. Antipsychotic drugs, particularly the atypical group, have been the most commonly used interventions in recent years, but a recent independent randomized trial showed no benefits for either risperidone or haloperidol compared with placebo, with some evidence of a better response to placebo than either active drug in the reduction of aggression. In the light of this uncertainty, the clinician must return to the task of collecting a careful history and mental state examination, including awareness of the setting in which the behaviour is shown, which will help with diagnosis and appropriate intervention. The choice of intervention should not be a casual one and is not likely to be chosen well if the clinician relies only on standard guidelines. The paucity of randomized trial evidence is preventing progress in the treatment of persistent aggressive behaviour. On present evidence, the use of drug treatment should be much more sparing and reserved for those patients who are putting themselves and others at particular risk as a consequence of their behaviour; such treatment should be regarded as temporary and as adjunctive to other forms of management. There is an urgent need for larger, randomized studies of psychological interventions, which at present appear to have a higher benefit-risk ratio than drug treatment but that also have a poor evidence base. More care should be taken to avoid the term 'aggressive challenging behaviour' being used as a portmanteau diagnostic pseudonym when it merely represents a diverse oppositional repertoire of many aetiologies.
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DEB SHOUMITRO, KWOK HENRY, BERTELLI MARCO, SALVADOR-CARULLA LUIS, BRADLEY ELSPETH, TORR JENNIFER, BARNHILL JARRET. International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities. World Psychiatry 2009; 8:181-6. [PMID: 19812757 PMCID: PMC2758582 DOI: 10.1002/j.2051-5545.2009.tb00248.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Psychotropic medications are used regularly to manage problem behaviours among people with intellectual disabilities. This causes concern because often these medications are used out of their licensed indications in this context. The WPA Section on Psychiatry of Intellectual Disability has recently developed an evidence and consensus-based international guide for practitioners for the use of psychotropic medications for problem behaviours among adults with intellectual disabilities. This guide advises on assessment of behaviours, producing a formulation, initiation of treatment, assessment of out-come and adverse effects, follow-up arrangements, and possibility of discontinuation of treatment.
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Affiliation(s)
- SHOUMITRO DEB
- WPA Section on Psychiatry of Intellectual Disability,Department of Psychiatry, University of Birmingham, 25 Vincent Drive, Birmingham B15 2FG, UK
| | - HENRY KWOK
- WPA Section on Psychiatry of Intellectual Disability,Kwai Chung Hospital, Hong Kong, China
| | - MARCO BERTELLI
- WPA Section on Psychiatry of Intellectual Disability,Italian Society for the Study of Mental Retardation, Florence, Italy
| | | | - ELSPETH BRADLEY
- WPA Section on Psychiatry of Intellectual Disability,Department of Psychiatry, University of Toronto, Canada
| | - JENNIFER TORR
- WPA Section on Psychiatry of Intellectual Disability,Monash University, Melbourne, Australia
| | - JARRET BARNHILL
- WPA Section on Psychiatry of Intellectual Disability,University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Romeo R, Knapp M, Tyrer P, Crawford M, Oliver-Africano P. The treatment of challenging behaviour in intellectual disabilities: cost-effectiveness analysis. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2009; 53:633-643. [PMID: 19460067 DOI: 10.1111/j.1365-2788.2009.01180.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Antipsychotic drugs are used in the routine treatment of adults with intellectual disabilities (ID) and challenging behaviour in the UK despite limited evidence of their effectiveness. There is no evidence on their cost-effectiveness. METHODS The relative cost-effectiveness of risperidone, haloperidol and placebo in treating individuals with an ID and challenging behaviour was compared from a societal perspective in a 26-week, double-blind, randomised controlled trial. Outcomes were changes in aggression and quality of life. Costs measured all service impacts and unpaid caregiver inputs. RESULTS After 26 weeks, patients randomised to placebo had lower costs compared with those in the risperidone and haloperidol treatment groups. Aggression was highest for patients treated with risperidone and lowest for patients treated with haloperidol; however, quality of life was lowest for patients treated with haloperidol and highest for patients treated with risperidone. CONCLUSION The treatment of challenging behaviour in ID with antipsychotic drugs is not a cost-effective option.
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Affiliation(s)
- R Romeo
- Centre for the Economics of Mental Health, King's College London, Institute of Psychiatry, London, UK.
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50
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Kozma A, Mansell J, Beadle-Brown J. Outcomes in different residential settings for people with intellectual disability: a systematic review. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2009; 114:193-222. [PMID: 19374466 DOI: 10.1352/1944-7558-114.3.193] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Large-scale reviews of research in deinstitutionalization and community living were last conducted about 10 years ago. Here we surveyed research from 1997 to 2007. Articles were included if the researchers based the study on original research, provided information on the participants and methodology, compared residential arrangements for adults with intellectual disability, and were published in English-language peer-reviewed journals. Sixty-eight articles were found. In 7 of 10 domains, the majority of studies show that community-based services are superior to congregate arrangements. These studies provide more evidence of the benefits of deinstitutionalization and community living and continue to indicate variability in results, suggesting that factors other than the basic model of care are important in determining outcomes.
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Affiliation(s)
- Agnes Kozma
- University of Kent, Tizard Centre, Canterbury, Kent, UK.
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