Reviewing the use of antipsychotic drugs in people with intellectual disability

Pharmacological treatment for challenging behavior in adults with intellectual disability: Systematic review and meta-analysis

INTRODUCTION

Few evidence on the use of antipsychotics in people with intellectual disabilities and challenging behaviors, generates the need to develop studies that contribute to collect, compare and synthesize the available information. The present systematic review and meta-analysis aims to determine the clinical efficacy of antipsychotic medication in reducing critical episodes in this population.

METHODS

We searched Web of Science, Scopus, EBSCO, Embase, and PubMed for randomized controlled trials of antipsychotic medication versus placebo. Preliminarily yielded 1354 abstracts and citations; six studies with 274 subjects met the inclusion criteria of studies with experimental design, longitudinal type, with pre- and post-intervention measurements.

RESULTS

There is evidence for the use of psychotropic drugs in the acute management of challenging behaviors in patients with intellectual disability (SMD=-0.85; 95% CI=-1.69 to -0.01; p=0.05).

CONCLUSIONS

Our results coincide with the recommendations on the efficacy of the use of antipsychotics. Although our study provides evidence, the limited number of studies included in this research does not allow us to obtain totally conclusive results, although it can be considered as a guide for future studies.

Etiology and Management of Behavioral Disorder in Adults With Intellectual and Developmental Disabilities

Intellectual disability (ID) encompasses a wide variety of disorders that can severely affect an individual’s cognitive, social, emotional, and physical development, even when identified early in life. Initially, individuals with such disorders had shorter life expectancies. However, medical advances have increased the life expectancy of individuals with ID similar to that of the general population. More attention must be paid to manage diseases affecting the intellectually disabled elderly, such as diabetes, cardiovascular disease, chronic constipation, and behavioral disorders.

Use of antipsychotics, benzodiazepine derivatives, and dementia medication among older people with intellectual disability and/or autism spectrum disorder and dementia

BACKGROUND

Although people with intellectual disability (ID) and people with dementia have high drug prescription rates, there is a lack of studies investigating drug use among those with concurrent diagnoses of ID and dementia.

AIM

To investigate the use of antipsychotics, benzodiazepine derivatives, and drugs recommended for dementia treatment (anticholinesterases [AChEIs] and memantine) among people with ID and dementia.

METHODS AND PROCEDURES

Having received support available for people with ID and/or autism spectrum disorder (ASD) was used as a proxy for ID. The ID cohort consisted of 7936 individuals, aged at least 55 years in 2012, and the referent cohort of age- and sex-matched people from the general population (gPop). People with a specialists' diagnosis of dementia during 2002-2012 were identified (ID, n=180; gPop, n=67), and data on prescription of the investigated drugs during the period 2006-2012 were collected.

OUTCOME AND RESULTS

People with ID/ASD and dementia were more likely than people with ID/ASD but without dementia to be prescribed antipsychotics (50% vs 39% over the study period; odds ratio (OR) 1.85, 95% confidence interval 1.13-30.3) and benzodiazepine derivatives (55% vs 36%; OR 2.42, 1.48-3.98). They were also more likely than people with dementia from the general population to be prescribed antipsychotics (50% vs 25%; OR 3.18, 1.59-6.34), but less likely to be prescribed AChEIs (28% vs 45%; OR 0.32, 0.16-0.64).

Clozapine for psychotic disorders in adults with intellectual disabilities

BACKGROUND

Psychosis is three times more common in people with an intellectual disability than in those without an intellectual disability. A low intelligence quotient (IQ) is a defining characteristic for intellectual disability and a risk factor for poor outcome in psychosis. Clozapine is recommended for treatment-resistant psychosis. The effect of psychotropic medication can be different in people with intellectual disability; for example, they may be more prone to side effects. People with an intellectual disability and psychosis form a special subgroup and we wanted to examine if there is randomised controlled trial (RCT) data in this population to support the use of clozapine.

OBJECTIVES

To determine the effects of clozapine for treating adults with a dual diagnosis of intellectual disability and psychosis.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Embase and eight other databases up to December 2014. We also searched two trials registers, the Cochrane Schizophrenia Group's Register of Trials, and contacted the manufacturers of clozapine.

SELECTION CRITERIA

RCTs that assessed the effects of clozapine, at any dose, for treating adults (aged 18 years and over) with a dual diagnosis of intellectual disability and psychotic disorder, compared with placebo or another antipsychotic medication.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened all titles, abstracts and any relevant full-text reports against the inclusion criteria.

MAIN RESULTS

Of the 1224 titles and abstracts screened, we shortlisted 38 full-text articles, which we subsequently excluded as they did not meet the inclusion criteria. These studies were not RCTs. Consequently, no studies are included in this Cochrane review.

AUTHORS' CONCLUSIONS

There are currently no RCTs that assess the efficacy and side effects of clozapine in people with intellectual disabilities and psychoses. Given the use of clozapine in this vulnerable population, there is an urgent need for a RCT of clozapine in people with a dual diagnosis of intellectual disability and psychosis to fill the evidence gap.

Trends in the use of psychotropic drugs in people with intellectual disability in Taiwan: a nationwide outpatient service study, 1997-2007

This study aims to examine trends in outpatient psychotropic drug use among people with intellectual disabilities in Taiwan. The NHI outpatient medication records between January 1, 1997 and December 31, 2007 for people with intellectual disabilities were analyzed to observe the percent change, prevalence and prescription trends in psychotropic drugs. The overall prevalence of psychotropic medication increased from 17.82% to 23.22% during the study period. Results from stepwise logistic analysis demonstrated that females, the elderly, and individuals suffering from catastrophic disease were more prone to receive psychotropic drugs and that those with mild intellectual disability were less likely to receive psychotropic drugs. The percentage change in prescription rates of antipsychotics, hypnotics/sedatives, and antidepressants were 85.30%, 127.25%, and 167.50%, respectively, and the trends were statistically significant (p<0.05). Taiwan's NHI program and off-label use of psychotropic drugs might have attributed to this trend.

A multilevel meta-analysis of single-case and small-n research on interventions for reducing challenging behavior in persons with intellectual disabilities

The effectiveness of different interventions for challenging behavior (CB) in persons with intellectual disabilities (ID) was reviewed by means of a two-phase study. First, a systematic review of 137 meta-analyses and reviews on group-study interventions for CB in persons with ID was conducted. Based on this review, hypotheses concerning the effectiveness of divergent interventions for CB and concerning the impact of variables moderating treatment effectiveness were systematically generated. Second, these hypotheses were tested by means of a multilevel meta-analysis of single-case and small-n research. Two hundred and eighty-five studies reporting on 598 individuals were examined. The average treatment effect was large and statistically significant. However, this effect varied significantly over the included studies and participants. Compared to the meta-analyses and reviews focusing on group-studies in this research domain, the results of the present multilevel meta-analysis of single-case and small-n intervention research provided more detailed knowledge on which specific CB and intervention components moderate the interventions' effectiveness.

Olanzapine vs. risperidone in treating aggressive behaviours in adults with intellectual disability: a single blind study

BACKGROUND

Aggressive behaviour represents a frequent symptom in people with intellectual disability (PWID). Despite uncertain evidence of effectiveness, the use of antipsychotics (APs) drugs to treat aggressive behaviour is very common. Antipsychotic medication of aggressivity in PWID has recently become one of the most debated issues in mental health and the need of further research is persistently stressed by most researchers.

AIM

The present study was firstly aimed at evaluating the effectiveness (efficacy on target behaviour, safety and persistence on treatment) of new generation APs, in particular, olanzapine and risperidone in treating aggressive behaviour in PWID for who previous medication with first generation APs (FGAs) were not effective.

METHODS

62 subjects with intellectual disability underwent to a 2-arm, parallel group pragmatic trial of olanzapine and risperidone with balanced randomisation and blind assessment of outcome at 4, 8, 12, 16, 20 and 24 weeks after a switch (cross-tapering) from a 24-week treatment with FGAs. Aggressive behaviours were assessed by Overt Aggression Scale (OAS) and clinical outcome by Clinical Global Impression Scale. Side effects were assessed with Dosage Record and Treatment Emergent Symptoms Scale, other symptom-specific scales, laboratory and instrumental tests.

RESULTS

Both risperidone and olanzapine resulted to be more effective than FGAs in reducing aggressive behaviour. Repeated-measures analysis of covariance revealed that treatment groups differed for cumulative number of aggressive episodes during the FGAs treatment, which was higher for olanzapine.

CONCLUSION

Our findings seem to confirm that olanzapine and risperidone can be effective in reducing aggressive behaviour in PWID. Both compounds resulted to be well tolerated, with side effects similar to those encountered in other patient populations.

Use of antipsychotic drugs in individuals with intellectual disability (ID) in the Netherlands: prevalence and reasons for prescription

BACKGROUND

We investigated antipsychotic drug prescription practice of Dutch ID physicians, studying prevalence of antipsychotic drug use, reasons for prescription and the relationship between these reasons and patient characteristics.

METHODS

A cross-sectional study of medical and pharmaceutical records in a population living in residential settings of three care providers for persons with IDs in the Netherlands (n = 2373).

RESULTS

Prevalence of antipsychotic drug use was 32.2% (95% CI 30.1-33.9). Behavioural problems were the reason for prescription of antipsychotic drugs in 58% of cases and psychotic disorder or psychotic symptoms in 22.5%. In 11.7% the diagnosis of psychotic disorder was specified according to DSM-IV criteria. In 18.5% the reason for prescription was not noted in the medical record. Behavioural problems as reason for prescription was associated with profound and severe ID, living in a central location and male sex. Psychotic disorder specified according to DSM-IV as indication for prescription was negatively associated with profound and severe ID and with presence of an additional mental disorder. Absence of a noted reason for prescription was associated with female sex and with the presence of an additional mental disorder.

DISCUSSION

Current prevalence and reason for prescription of antipsychotic drugs are similar with outcomes of previous studies. Our results show the continuing lack of evidence-based psychopharmacological treatment in mental health care for persons with IDs.

A meta-analysis of intervention effects on challenging behaviour among persons with intellectual disabilities

BACKGROUND

Persons with intellectual disabilities (ID) often show challenging behaviour. We review distinct interventions that are applied to treat these challenging behaviours, and analyse intervention effects and moderating variables.

METHODS

A literature search was conducted using the databases ERIC, PsycINFO, Web of Science and Medline. A random-effects meta-analysis was carried out, supplemented with sensitivity, subgroup, meta-regression and publication bias analyses.

RESULTS

Eighty potential articles were identified, from which 30 contained sufficient data to enable statistical meta-analysis. From these 30 studies, 18 described a biological, 13 a psychotherapeutic and nine a contextual intervention, either applied alone or combined. The overall standardised mean difference was 0.671 (SD = 0.051). As shown by sensitivity analysis, this summary effect size is robust. Assessed through subgroup and meta-regression analysis, all tested moderators showed no statistically significant association with the treatment effects. After applying a funnel plot-, a fail-safe N-, and Duval's and Tweedie's trim and fill-analysis, we conclude that our meta-analysis does not suffer much from publication bias effects.

CONCLUSIONS

Several biological, psychotherapeutic and contextual interventions effectively reduce challenging behaviours among persons with ID.

Aggressive behaviour in adults with intellectual disability: defining the role of drug treatment

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.

Prevalence, correlates, and disease patterns of antipsychotic use in Taiwan

AIM

The population-based National Health Insurance database was used to investigate the prevalence, correlates, and disease patterns of antipsychotic use in Taiwan.

METHODS

The National Health Research Institutes provided a database of 200,000 random subjects for study. A random sample of 145 304 subjects was obtained, aged > or =18 years in 2004. Study subjects who had been given at least two antipsychotic drug prescriptions during this year were identified. The factors associated with any antipsychotic use were identified. The proportion of antipsychotic use for psychiatric and non-psychiatric disorders was also examined.

RESULTS

The 1-year prevalence of antipsychotic use was 3.5%. Antipsychotic use was found to be more prevalent by age; for women; for individuals with a lower insurance amount; for individuals with disability; and among those subjects who lived in the central or southern area. Among subjects with antipsychotic use, higher proportions of psychiatric disorders were found for schizophrenia, anxiety state, major depressive disorder, neurotic depression, dementia, and bipolar disorder. With respect to medical disorder, higher proportions of antipsychotic use were found for diseases of the digestive system; symptoms, signs, and ill-defined conditions; diseases of the respiratory system, musculoskeletal system and connective tissue, circulatory system, nervous system and sense organs, and genitourinary system.

CONCLUSIONS

Higher proportions of antipsychotic use were found for schizophrenia, depressive disorder, anxiety disorder, dementia, and bipolar disorder. More than 60% of subjects used antipsychotics for non-psychiatric disorders in Taiwan, which deserves further study for the sake of patient safety.