Psychopharmacotherapy in children and adults with intellectual disability

Drug Burden Index in Older Adults with Psychiatric Illnesses: A Cross-Sectional Study

BACKGROUND

Medications with anticholinergic and/or sedative properties are commonly used in the management of psychiatric illnesses. The burden of anticholinergic and sedative medication use has been measured by the Drug Burden Index (DBI) score tool. A higher DBI score has been associated with increased risk of falls, bone and hip fractures, and functional and cognitive impairment, among other serious health outcomes, especially in older adults.

OBJECTIVES

We aimed to describe the drug burden in older adults with psychiatric illnesses using DBI, determine the factors that are associated with the drug burden measured by DBI, and examine the association between DBI score and Katz for activities of daily living (ADL) index.

METHODS

A cross-sectional study was conducted in the psychogeriatric division of an aged-care home. The study sample comprised all inpatients, aged ≥ 65 years, diagnosed with psychiatric illness. The data obtained included demographic characteristics, duration of hospital stay, primary psychiatric diagnosis and comorbidities, functional status using the Katz ADL index, and cognitive status using the Mini-Mental State Examination (MMSE) score. DBI score was calculated for each anticholinergic and sedative medication used.

RESULTS

Of the 200 patients eligible for analysis, 106 (53.1%) were females and the mean age was 76 ± 9 years. The most commonly encountered chronic disorders were hypertension 102 (51%) and schizophrenia 94 (47%). The use of drugs with anticholinergic and/or sedative effects was seen in 163 (81.5%) patients; the mean DBI score was 1.25 ± 1. The results of the multinomial logistic regression showed that schizophrenia (odds ratio (OR) = 2.1 (95% confidence interval (CI) 1.57-4.45), p = 0.01), level of dependency (OR = 3.50 (95% CI 1.38-5.70), p = 0.001), and polypharmacy (OR = 2.99 (95% CI 2.15-4.29), p = 0.003) were significantly associated with DBI score ≥ 1 compared to DBI score 0.

CONCLUSIONS

The study showed that anticholinergic and sedative medication exposure measured by DBI was associated with higher levels of dependency on the Katz ADL index in a sample of older adults with psychiatric illnesses from an aged-care home.

Medication use and potentially inappropriate prescribing in older adults with intellectual disabilities: a neglected area of research

It is known that for all adults, prevalence of potentially inappropriate prescribing (PIP) and polypharmacy increases with advancing age and morbidity. This has been associated with adverse drug reactions and poor outcomes. As a result, screening tools have been developed to identify PIP and to improve prescribing and health outcomes. A growing body of evidence supports the fact that there are even greater concerns among older adults with intellectual disability (ID) who are living longer than before but still have premature mortality and poorer health outcomes compared with the general population. They have different patterns of multimorbidity, with higher rates of epilepsy and mental health conditions. Polypharmacy is prevalent and some prescribing practices may be inappropriate. High exposure to anticholinergic and sedative medicines has additional adverse effects on quality of life. There may also be underutilization of clinically needed therapies. There has been substantial controversy internationally relating to extensive use of psychotropic medicines, particularly off-label use for challenging behaviours. Despite the mounting evidence and concerns about the impact of PIP on quality of life, health and safety for people with ID, appropriate methods to measure PIP are lacking, which represents an important gap in the research literature. Differences in morbidity and medicines use patterns in this population mean instruments used to identify inappropriate medicines in the older population are not suitable. In this perspective article we outline the specific health and medicinal needs for people with ID, the prevalence of polypharmacy and presentation of chronic health conditions in older adults with ID. We provide an overview of the psychotropic medicine classes most frequently used in people with ID which carry substantial risk. We highlight studies to date that have attempted to assess PIP and present research priorities to improve prescribing, health outcomes and quality of life for people with ID.

Drug burden index to define the burden of medicines in older adults with intellectual disabilities: An observational cross-sectional study

AIMS

The drug burden index (DBI) is a dose-related measure of anticholinergic and sedative drug exposure. This cross-sectional study described DBI in older adults with intellectual disabilities (ID) and the most frequently reported therapeutic classes contributing to DBI and examined associations between higher DBI scores and potential adverse effects as well as physical function.

METHODS

This study analysed data from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA), a representative study on the ageing of people with ID in Ireland. Self- and objectively-reported data were collected on medication use and physical health, including health conditions. The Barthel index was the physical function measure.

RESULTS

The study examined 677 individuals with ID, of whom 644 (95.1%) reported taking medication and 78.6% (n = 532) were exposed to medication with anticholinergic and/or sedative activity. 54.2% (n = 367) were exposed to high DBI score (≥1). Adjusted multivariate regression analysis revealed no significant association between DBI score and daytime dozing, constipation or falls. After adjusting for confounders (sex, age, level of ID, comorbidities, behaviours that challenge, history of falls), DBI was associated with significantly higher dependence in the Barthel index (P = 0.002).

CONCLUSIONS

This is the first time DBI has been described in older adults with ID. Scores were much higher than those observed in the general population and higher scores were associated with higher dependence in Barthel index activities of daily living.

Psychopharmacology in children with intellectual disability

Children and adolescents with intellectual disability have high rates of psychiatric morbidity, the most common presentation being behavioural difficulties, especially in the context of autism. This clinical review describes the applicability of the full range of current psychopharmacological agents to the mental health difficulties commonly encountered in clinical practice in this field, with an emphasis on informing the choice of an initial ‘best fit’ single agent for the various clusters of symptoms and signs presented by individual patients. It is emphasised that the evidence base for most practice parameters in this area is extremely modest and that a high level of caution is recommended when applying this information in everyday practice. The article also discusses some of the specific difficulties and challenges encountered within the field and makes some practical suggestions for good practice.

Systematic management approach to pharmacotherapy for people with learning disabilities

With progressive deinstitutionalisation in many countries, the general psychiatrist is now more frequently requested to provide assistance with behavioural problems in people with learning disabilities. There are a range of challenges in providing quality care for these people. There are challenges in assessment and diagnosis, in coordinating behavioural and social interventions with pharmacotherapy, and in the lack of psychopharmacological research in this population, which results in a diminished evidence base. In addition, there are numerous factors beyond the patient. These include legal consent requirements and the complex system of carers surrounding those with disabilities with whom the practitioner may need to interact.

Developmental progression of intellectual disability, autism, and epilepsy in a child with an IQSEC2 gene mutation

The neurodevelopmental progression of a school‐aged child with a spontaneous IQSEC2 mutation has demonstrated apparent regression of milestones and language. Seizures associated with the disorder have been refractory to medical treatment. Late treatment of autism in this child has led to improved social skills.

Practical Paediatric Psychopharmacological Prescribing in Autism

Claims of ‘miracle cures’ for autism in the press and on the Internet bring new pressures to bear on parents of children with autism, and the professionals who care for them. Between a third and a half of people with autism in America are receiving some psychotropic medication. Despite recent advances in paediatric psychopharmacology, there is no proof that any medication can target the primary social impairments that characterize autism. The article discusses the evidence behind two approaches to psychopharmacological management in children with autism. The first approach selects certain target symptoms such as resistance to change, ritualistic/compulsive behaviours, hyperactivity, aggressive behaviours and sleep problems. The evidence for the effectiveness of agents including stimulants, anti- depressants, and melatonin when used to treat these symptoms is appraised. The second approach attempts to treat or cure the primary social impairment underlying autism. The evidence for the effectiveness of agents including naltrexone, fenfluramine and secretin is appraised. Early reports in this field have generated false hope, and the need for well-designed larger multicentre trials is emphasized.

Central nervous system medication use in older adults with intellectual disability: Results from the successful ageing in intellectual disability study

OBJECTIVE

Information on the rates and predictors of polypharmacy of central nervous system medication in older people with intellectual disability is limited, despite the increased life expectancy of this group. This study examined central nervous system medication use in an older sample of people with intellectual disability.

METHODS

Data regarding demographics, psychiatric diagnoses and current medications were collected as part of a larger survey completed by carers of people with intellectual disability over the age of 40 years. Recruitment occurred predominantly via disability services across different urban and rural locations in New South Wales and Victoria. Medications were coded according to the Monthly Index of Medical Specialties central nervous system medication categories, including sedatives/hypnotics, anti-anxiety agents, antipsychotics, antidepressants, central nervous system stimulants, movement disorder medications and anticonvulsants. The Developmental Behaviour Checklist for Adults was used to assess behaviour.

RESULTS

Data were available for 114 people with intellectual disability. In all, 62.3% of the sample was prescribed a central nervous system medication, with 47.4% taking more than one. Of those who were medicated, 46.5% had a neurological diagnosis (a seizure disorder or Parkinson's disease) and 45.1% had a psychiatric diagnosis (an affective or psychotic disorder). Linear regression revealed that polypharmacy was predicted by the presence of neurological and psychiatric diagnosis, higher Developmental Behaviour Checklist for Adults scores and male gender.

CONCLUSION

This study is the first to focus on central nervous system medication in an older sample with intellectual disability. The findings are in line with the wider literature in younger people, showing a high degree of prescription and polypharmacy. Within the sample, there seems to be adequate rationale for central nervous system medication prescription. Although these data do not indicate non-adherence to guidelines for prescribing in intellectual disability, the high rate of polypharmacy and its relationship to Developmental Behaviour Checklist for Adults scores reiterate the importance of continued medication review in older people with intellectual disability.

Using venlafaxine to treat behavioral disorders in patients with autism spectrum disorder

OBJECTIVE

To test the efficacy of venlafaxine at a dose of 18.75 mg/day on the reduction of behavioral problems such as irritability and hyperactivity/noncompliance in patients with intellectual disabilities and autism spectrum disorder (ASD). Our secondary hypothesis was that the usual doses of zuclopenthixol and/or clonazepam would decrease in the venlafaxine-treated group.

METHODS

In a randomized double-blind study, we compared six patients who received venlafaxine along with their usual treatment (zuclopenthixol and/or clonazepam) with seven patients who received placebo plus usual care. Irritability, hyperactivity/noncompliance, and overall clinical improvement were measured after 2 and 8 weeks, using validated clinical scales.

RESULTS

Univariate analyses showed that the symptom of irritability improved in the entire sample (p = 0.023 after 2 weeks, p = 0.061 at study endpoint), although no difference was observed between the venlafaxine and placebo groups. No significant decrease in hyperactivity/noncompliance was observed during the study. At the end of the study, global improvement was observed in 33% of participants treated with venlafaxine and in 71% of participants in the placebo group (p = 0.29). The study found that decreased cumulative doses of clonazepam and zuclopenthixol were required for the venlafaxine group. Multivariate analyses (principal component analyses) with at least three combinations of variables showed that the two populations could be clearly separated (p b 0.05). Moreover, in all cases, the venlafaxine population had lower values for the Aberrant Behavior Checklist (ABC), Behavior Problems Inventory (BPI), and levels of urea with respect to the placebo group. In one case, a reduction in the dosage of clonazepam was also suggested. For an additional set of variables (ABC factor 2, BPI frequency of aggressive behaviors, hematic ammonia at Day 28, and zuclopenthixol and clonazepam intake), the separation between the two samples was statistically significant as was the Bartlett's test, but the Kaiser–Meyer–Olkin Measure of Sampling Adequacy was below the accepted threshold. This set of variables showed a reduction in the cumulative intake of both zuclopenthixol and clonazepam.

CONCLUSION

Despite the small sample sizes, this study documented a statistically significant effect of venlafaxine. Moreover, we showed that lower doses of zuclopenthixol and clonazepam were needed in the venlafaxine group, although this difference was not statistically significant. This was confirmed by multivariate analyses, where this difference reached statistical significance when using a combination of variables involving zuclopenthixol. Larger-scale studies are recommended to better investigate the effectiveness of venlafaxine treatment in patients with intellectual disabilities and ASD.

Treatments for the challenging behaviours of adults with intellectual disabilities

OBJECTIVE

To provide an overview and critical assessment of common problems and best evidence practice in treatments for the challenging behaviours (CBs) of adults with intellectual disabilities (IDs).

METHOD

Commonly observed problems that present obstacles to successful treatment plans are discussed, followed by an analysis of available research on the efficacy of behavioural and pharmacological therapies.

RESULTS

Behavioural and pharmacological interventions are most commonly used when addressing CBs in people with IDs. However, within each of these techniques, there are methods that have support in the literature for efficacy and those that do not. As clinicians, it is important to follow research so that we are engaging in best practices when developing treatment plans for CBs.

CONCLUSIONS

One of the most consuming issues for psychiatrists and other mental health professionals who work with people who evince developmental disabilities, such as IDs, are CBs. These problems are very dangerous and are a major impediment to independent, less restrictive living. However, there is a major gap between what researchers show is effective and much of what occurs in real-world settings.

Pharmacotherapy of disruptive behavior in mentally retarded subjects: A review of the current literature

The review presented here describes the state of the art of pharmacological treatment of aggression in subjects with mental retardation (MR) summing up results for both, children and adults. In general, psychopharmacological treatment of disruptive behavior in individuals with MR is similar to the treatment in subjects without MR. Compared to individuals without MR medication should "start lower and go slower." For children and adults results were similar but were obtained by somewhat different medications. There is evidence for the conventional antipsychotic zuclopenthixol having positive effects on disruptive behavior. Most studies described the atypical antipsychotic risperidone to control severe self-injurious behavior and other behavior problems in a variety of diagnoses. Anticonvulsants, antidepressants, and anxiolytic medications are reported as effective as well for the treatment of individuals with disruptive behavior. Aggression-related behavior often gets treated with stimulants or with stimulants combined with atypical neuroleptics.

Incidence and trends in psychopathology symptoms over time in adults with severe to profound intellectual disability

Individuals with intellectual disability (ID) have a high risk for developing comorbid psychopathology. While researchers have shown that symptoms of psychopathology remain relatively stable in children with ID over time, little research has been conducted to demonstrate symptom stability for adults with ID. Incidence of psychopathology symptoms was examined in 124 adults with severe to profound ID. Then, trends in symptoms of psychopathology over time were studied in 74 of those individuals who had data collected quarterly over the span of one year. Data from the Diagnostic Assessment for the Severely Handicapped-Second Edition (DASH-II) were evaluated for each of the 13 subscales, as well as the total DASH-II score. For all of the scales except PDD/Autism, symptoms did not fluctuate significantly over the one year period. The PDD/Autism scale revealed a significant change in symptoms from Time 1 to Time 3. The implications of these results are discussed.

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.

Antipsychotic drug side effects for persons with intellectual disability

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.

Pharmacological management in children and adolescents with pervasive developmental disorder

OBJECTIVE

Pervasive developmental disorder (PDD) is associated with emotional and behavioural problems. There is no pharmacological cure for PDD, but some comorbidities and dysfunctional behaviours in PDD can be managed pharmacologically. The aim of the present study was to provide a better understanding of the efficacy and limitations in the currently available agents.

METHODS

Electronic literature searches were conducted from the following sources: MEDLINE, Cochrane Library, PSYARTICLES and PsycINFO. Search terms included, but were not limited to, 'autism', 'PDD', 'autism spectrum disorder' ('ASD'), and 'pharmacological management'.

RESULTS

A range of pharmacological agents are available for the management of various dysfunctional symptoms in PDD. Broadly speaking, these agents help in the management of repetitive stereotyped behaviours, anxiety, aggression/irritability/self-injurious behaviour, hyperactivity/inattention and in sleep.

CONCLUSIONS

There is a paucity of systemic, well-conducted trials on the use of pharmacological agents in the management of PDD, and more research in this area is warranted.

Determinants of prescription drug use by adolescents with intellectual disabilities in Taiwan

Direct family caregivers of population-based adolescents with intellectual disabilities in Taiwan were surveyed regarding their perceptions of the use of prescribed medication and its relationship with health-related behaviors, medical care and preventive health utilization of people with intellectual disabilities. Cross-sectional data on 1419 adolescents 12-17 years of age was collected from the 2007 National Survey on Healthy Behaviors and Preventive Health Utilizations of People with Intellectual Disabilities in Taiwan. Multiple logistic regression models were used to examine risk profiles in relation to the use of prescribed medication and other relevant variables: participant characteristics, health-related behaviors, medical care and preventive health utilization. The results indicate that 47.1% of subjects were accompanied by other impairments, the morbidity prevalence was 16.5% and 23.8% of subjects were reported to have used prescribed medication regularly in the past 6 months. The main reasons for medication use were epilepsy (36.9%), psychiatric problems (24.2%) and gastrointestinal problems (6.3%). A large majority of caregivers reported that the subject's health status was excellent (15.4%), good (38%) or fair (38%), and only 6.5% were reported to be in bad health. Finally, data were analyzed using a logistic regression model to identify possible reasons for drug use. The following factors correlate with the regular use of prescribed medication by adolescents with intellectual disabilities: Down syndrome, possession of a Major Illness Card, a history of smoking, an additional impairment, reported health status, outpatient care and acceptance of other specific medical examinations. Our principal conclusion was that these data indicate a need for more education on a variety of issues, including predisposition, healthy behavior, medical care and preventive health utilization issues as they relate to prescribed medication use, and assessment of the long-term effects of drug use on people with intellectual disabilities.

Polypharmacy and the lack of oculo-visual complaints from those with mental illness and dual diagnosis

BACKGROUND

Individuals with mental illness (MI) and intellectual disability (ID) are characterized as dually diagnosed (DD). These individuals are known to have numerous systemic and oculo-visual anomalies. This comorbidity of conditions should elicit frequent oculo-visual complaints from these patients during the initial review of systems. A search of MedLine yielded one article that was published on oculo-visual symptomology/pain associated with MI and DD. This report appears to be the first to assess the frequency of these symptoms within these 2 unique populations.

METHODS

A retrospective analysis of all medical records for patients (N = 202) evaluated at the Neumann Association (NA) Developmental Disabilities Service of the Illinois Eye Institute was completed. Only the records of patients who had either MI or DD and who were prescribed antipsychotics, antidepressants, anticonvulsants, or tranquilizers/anxiolytics were used for our analysis. Upon record review, 89.9% of MI and 59.4% of DD individuals met the above subject criteria. We determined the frequency of ocular anomalies, drugs taken, and complaints reported by patients during the initial review of systems.

RESULTS

The most common documented side effects for the targeted drug types were decreased or blurred vision (near or far), visual hallucinations, decreased accommodation, and eyelid/conjunctiva irregularities. In our sample, the most frequent ocular anomalies encountered were astigmatism (50% MI and 37.84% DD), myopia (60.71% MI and 62.16% DD), presbyopia (35.71% MI and 37.84%DD), and blepharitis (32.14% MI and 32.43%DD). Additionally, the most frequently encountered complaints were no complaints (45.16% MI and 46.84% DD), blurry vision (17.74% MI and 17.72% DD), and need new glasses (11.29% MI and 17.72% DD).

CONCLUSIONS

It has been established that MI and DD populations exhibit a higher incidence of oculo-visual anomalies (uncorrected refractive error, binocular vision anomalies, ocular pathology) than noted in the general population. They are also typically taking 1 or more neuropsychotropic medications that are frequently associated with undesirable visual side effects. Individuals with MI and DD should report numerous complaints associated with the medications they take and the oculo-visual anomalies they exhibit during the initial case history and the review of systems. The data from this study suggest that this is not the case and that only about 50% of those who should have complaints actually report them.

Psychotropic medication use for challenging behaviors in persons with intellectual disabilities: an overview

Challenging behaviors in persons with intellectual disabilities are primary target for treatment in mental health clinics and institutions. Furthermore, an increasing number of people are receiving psychotropic medications for the management of their challenging behaviors. Many people are often treated with high doses of multiple psychotropic medications for extended periods of time with little or no data collected to determine treatment efficacy. Similarly, data demonstrating treatment effectiveness is at best questionable at this time. It is for these reasons that controversy exists regarding the use of psychotropic medication for challenging behaviors. The purpose of this paper was to summarize past and current studies of drug related interventions for challenging behaviors for persons with intellectual disabilities. Based on the results of this review, the effectiveness of psychotropic medications in managing challenging behaviors is best described as minimal and a need exists for controlled studies of higher scientific quality in this area. Considering alternative psychologically based interventions and careful functional assessments appear to be advisable.

Psychotropic drug prescribing in child and adolescent learning disability psychiatry

This postal questionnaire study investigated the prescribing practices of a group of senior British psychiatrists who have responsibilities for children and adolescents with learning disabilities (mental retardation). The study revealed that all of the clinicians surveyed (n = 16) were prescribing psychotropic medication; psychostimulants and major tranquillizers represented the most frequently prescribed classes and, respectively, methylphenidate, risperidone, melatonin, sodium valproate and carbamazepine were the most frequently employed specific agents. Most patients were receiving monotherapy. Many (14/16) clinicians reported difficulties in shared-care prescribing arrangements with General Practitioners. The study concludes that psychopharmacology is an established part of the psychiatric management of learning disabled children but acknowledges the need for the elaboration of clinical governance standards to this area of practice.

Practitioner review: Psychopharmacology in children and adolescents with mental retardation

BACKGROUND

The use of psychotropic medication to treat children and adults with mental retardation (MR) has a long and extensive history. There are no identified medications to address specific cognitive deficits among persons with MR. Instead, psychotropic medications are used to treat specific behavioral symptoms and/or psychiatric syndromes. The purpose of this review is to provide an overview of the recent literature regarding the use of psychotropic medications in this population, focusing primarily on children and adolescents.

METHODS

The paper is divided into five general drug categories: psychostimulants, antipsychotics, antidepressants, mood stabilizers, and other drugs. Each section offers an overview of the research supporting the use of that class of medications in children and adolescents with MR as well as cautions regarding potential side effects. Finally, specific clinical recommendations are offered.

RESULTS

The majority of studies in MR tend to be open trials, case reports, or controlled studies with small samples. The available data suggests that persons with MR respond to various psychotropic medications in ways similar to the typically developing population. However, rates of response tend to be poorer and the occurrence of side effects tends to be more frequent.

CONCLUSIONS

The use of psychotropic medications in children and adolescents with MR requires even greater monitoring and the use of lower doses and slower dosage increases than in the general population.

Development of an Internet-based real-time system for monitoring pharmacological interventions in children with neurodevelopmental and neuropsychiatric disorders

Few children have a 'pure' diagnosis of neuropsychiatric disorders such as attention deficit hyperactivity disorder or autism. Most have complex, overlapping symptoms, and it is often these associated and common comorbidities that cause as much, if not more impairments, than the core symptoms. Prescribing decisions are therefore complex and made on the basis of eliciting a range of agreed 'target symptoms'. At present, however, there are no agreed systems that allow monitoring of all areas of potential change, and few services are able to monitor symptoms, side effects, impact on family life and individual children's quality of life systematically. At best many clinics use a plethora of paper-based standardized questionnaires, based on individual diagnoses. This article describes the development of a novel biomedical informatics system that has been designed to allow parents, professionals and children to use a web-based, real-time symptom monitoring system to enable more effective treatments, better pathways of shared care, and more equitable and efficient service delivery for this group of vulnerable children.

Short- and long-term efficacy and safety of risperidone in adults with disruptive behavior disorders

RATIONALE

Function in society can be severely affected by disruptive behaviors in adults.

OBJECTIVES

To examine the efficacy and safety of risperidone in the treatment of disruptive behavior disorders in intellectually disabled adults.

METHODS

Intellectually disabled patients with disruptive behavior disorder were randomly assigned to receive risperidone (n = 39) in a flexible dosage ranging from 1 to 4 mg/day (mean dosage, 1.45+/-0.08 mg/day) or placebo (n = 38) for 4 weeks of double-blind treatment. Efficacy at endpoint was measured primarily by using the Aberrant Behavior Checklist (ABC); secondary efficacy measures included the Behavior Problems Inventory and Clinical Global Impressions scales. After this 4-week period, patients could enter open-label treatment with risperidone for 48 weeks.

RESULTS

Risperidone was well tolerated, and patients treated with risperidone demonstrated significantly greater improvement at endpoint on the ABC than those who received placebo [-27.3 points (52.8% improvement) versus -14.9 points (31.3% improvement); P = 0.036] and also improved on Behavior Problems Inventory and Clinical Global Impressions ratings. Over the 48-week, open-label follow-up period, there was a further decrease of 6.3 points (P < or = 0.05) on the ABC for patients who initially received risperidone and a decrease of 11.3 points (P < or = 0.05) for patients who initially received placebo and were switched to open-label risperidone. These results were achieved with a mean modal dosage of 1.8 mg/day.

CONCLUSION

Risperidone is efficacious and well tolerated in managing disruptive behavior disorders in adults with intellectual disability.

Psychotropic medication use among Kansas Medicaid youths with disabilities

Knowledge of current patterns of psychotropic medication use by disabled youths is an important starting point for targeting future efforts to improve prescribing practices. This study provides a retrospective, descriptive analysis of the prevalence and patterns of psychotropic medication among 1022 Kansas Medicaid youths in 2001 who were enrolled with either Supplemental Security Income (SSI) or Medically Needy benefits and who were having clearly defined mental and neurological disabilities. Rates of psychotropic medication use were generally higher for the Medically Needy than for the SSI youths: Central nervous system (CNS) stimulants (24.6% versus 20.0%), antidepressants (30.9% versus 13.7%), anticonvulsants (22.0% versus 13.9%), and antipsychotics (23.3% versus 11.5%). Use of the four major drug classes varied among children with attention-deficit/hyperactivity disorder (ADHD) and disruptive disorders, pervasive developmental disabilities, mental retardation (MR) and learning disabilities, mood and anxiety disorders, and adjustment disorders. Future work should explore the appropriateness and effectiveness of these medications within specifically targeted subgroups.

Risperidone in children with disruptive behavior disorders and subaverage intelligence: a 1-year, open-label study of 504 patients

OBJECTIVE

To determine the long-term safety and effectiveness of risperidone for severe disruptive behaviors in children.

METHOD

A multisite, 1-year, open-label study of patients aged 5 to 14 years with disruptive behaviors and subaverage intelligence was conducted.

RESULTS

Seventy-three percent of the 504 patients enrolled completed the study. The mean +/- SE dose of risperidone was 1.6 +/- 0.0 mg/day. The most common adverse events were somnolence (30%), rhinitis (27%), and headache (22%). The incidence of movement disorders was low, and mean Extrapyramidal Symptom Rating Scale scores decreased during risperidone treatment. No clinically significant changes in mean laboratory values were noted, except for a transient increase in serum prolactin levels. Scores on the Nisonger Child Behavior Rating Form Conduct Problem Scale improved significantly as early as week 1, and improvement was maintained throughout the trial (p < .001 at each time point). Significant improvements were noted on positive social behavior and other Nisonger Child Behavior Rating Form subscales, Aberrant Behavior Checklist, Clinical Global Impressions scale, and tests of patients' cognitive function (each p < .001).

CONCLUSIONS

Risperidone was well tolerated and effective in the long-term treatment of disruptive behavior disorders in children with subaverage intelligence.

Health, healthcare utilization and psychiatric disorder in people with intellectual disability in Taiwan

OBJECTIVES

The aims of the present study were to examine health characteristics and healthcare utilization in relation to people with intellectual disability (ID) having psychiatric disorders in Taiwan.

METHODS

A cross-sectional study was employed; study subjects were recruited from the National Disability Registration Database. Taiwan, stratified by administrative geographical area for the study. Statistical analysis of 1026 carers for people with ID was made to examine the health status and healthcare utilization of individuals with ID having psychiatric disorders.

RESULTS

Approximately 12.1% of people with ID had psychiatric disorders. These individuals were more likely to be poorer in health condition and consuming more medical services (in the outpatient, inpatient and emergency care areas), than those individuals without psychiatric disorders. These individuals with psychiatric disorders were also taking medicines regularly at a far greater percentage than did those without psychiatric disorders.

CONCLUSIONS

Given the high prevalence of psychiatric disorders among individuals with ID, the healthcare system should take further steps to develop an appropriate health status monitoring system and community-based and easily accessible mental health services for them.

Integration of a psychiatric service in a long-term charitable facility for people with intellectual disabilities: a 5-year medication survey

Since the implementation of a psychiatric service in a long-term facility for people with intellectual disability, the usage of psychotropic and anti-convulsant drugs has been surveyed over the 5-year period 1994-1999. At that time, although the overall prevalence rate of residents on medication was not declining significantly, a decrease in number, dosage and polypharmacy of those receiving neuroleptic drugs occurred than 1994. A reduction also resulted among the in-patients prescribed anxiolytic preparations, despite a relative increase in their mean daily intake. Anti-convulsant drugs climbed slightly during the same interval with a parallel increase in the mean daily dosage. A retrospective comparison of current findings to prevalence, dosage and type of psychoactive medications dispensed 10 years previously in 1989 revealed no trend towards drug rationalisation. Until interdisciplinary training programmes as well as effective community services combining disability and mental health needs are forthcoming, a therapeutic approach involving early psychiatric inputs may contribute to ensure a more rational prescribing practice for long-stay adults with intellectual disability who are referred for neuro-psychiatric consultation.

Longitudinal prescribing patterns for psychoactive medications in community-based individuals with developmental disabilities: utilization of pharmacy records

BACKGROUND

Little is known about longitudinal prescribing practices for psychoactive medications for individuals with intellectual disabilities and developmental disabilities (IDDD) who are living in community settings.

METHODS

Computerized pharmacy records were accessed for 2344 community-based individuals with IDDD for whom a total of 3421 prescriptions were written during a 17-month period of study. Forty-two psychoactive medications were rank ordered in terms of prescription frequency.

RESULTS

Fifty-two per cent (52%) of all prescriptions written during the study period were for psychoactive medications. Anticonvulsant, antipsychotic and antidepressant medications were the most commonly filled prescriptions among psychoactive medications. Sixty per cent (62%) of the study population was given prescriptions for more than one psychoactive medication and 36% received three or more psychoactive medications. During the study period there was a statistically significant increase in prescriptions filled for olanzapine, risperidone, valproic acid, and clonazepam whereas prescriptions filled for thioridazine, haloperidol, and benzotropine showed a significant decline (P < 0.05-0.001). Distribution of psychoactive drug class by age showed that the majority of prescriptions were filled for individuals between 20 and 50 years with the exception of prescriptions for psychostimulants which peaked for individuals prior to 20 years.

CONCLUSIONS

(1) Analysis of pharmacy billing records provides a method for assessing prescribing patterns of psychoactive medications in community-based individuals with IDDD. (2) Polypharmacy for psychoactive medications is prevalent in this setting. (3) The second-generation antipsychotic medications are prominently represented by an increasing number of filled prescriptions during the study period.

Risperidone and olanzapine in adults with intellectual disability: a clinical naturalistic study

Atypical antipsychotics are the first-line treatment for psychosis and are commonly used for behavioural problems in people with intellectual disabilities (ID), but a comprehensive evidence base for this approach is lacking. We studied prescription trends and the clinical effectiveness of risperidone and olanzapine in people with ID in a clinical, naturalistic setting. The results suggest that both drugs are well tolerated and effective in treating target symptoms across a range of diagnoses and ID. Both risperidone and olanzapine appear to reach full efficacy within 3 months, after which improvement reaches a plateau, as reflected in the Clinical Global Impression-Improvement scale. Compliance with both drugs is high. Olanzapine tended to be prescribed mostly for psychotic disorders, and showed good rates of response, whereas risperidone was prescribed mostly for people with behavioural disturbance associated with a psychiatric diagnosis. Furthermore, approximately one-quarter of the risperidone group were prescribed the medication for a behavioural disorder associated with a pervasive developmental disorder. Again, the medication was broadly effective in treatment. Both medications were also used to effectively treat affective disorders in a small percentage of patients. This study appears to indicate that both medications could be of significant clinical benefit for people with ID across a wide range of diagnoses and level of ID, although further controlled trials are required.

Beyond the disability: recognizing mental health issues among persons with intellectual and developmental disabilities

Current societal changes mean increased possibilities for individuals with I/DD to participate in work, family, and community life. However, as individuals with I/DD have at least the same prevalence of mental health disorders as the general population and possibly an increased susceptibility to some mental health disorders, their ability to participate in work, housing, and social opportunities is hampered. It is important to improve nursing education about the specific issues of mental health care of individuals with I/DD. An important area for nursing research and education are improved clinical and practice guidelines. Research on medications and other therapies in mental health care of individuals with I/DD is limited and has methodological limitations. Nursing education and training are holistic, and nursing has the potential of positive impact on practice, education, and research that will improve the mental health care of individuals with I/DD.

Psychopharmacological treatments in persons with dual diagnosis of psychiatric disorders and developmental disabilities

People with developmental disabilities are at considerable risk for the development of comorbid psychiatric conditions. Psychopharmacological treatments may have a crucial role in a multidisciplinary and multimodal approach to the management of psychopathology in this population. Psychiatric illnesses that are particularly amenable include mood disorders, anxiety disorders, schizophrenia, and attention deficit hyperactivity disorders (ADHDs) and antidepressants, mood stabilisers, anxiolytics, antipsychotics, and stimulants should be considered, respectively. ADHD may also respond to alpha(2)-agonists. Psychotropic agents such as beta-antagonists can target aggressive, self injurious, and stereotypical behaviours and opioid antagonists may be helpful in treating self injurious behaviour and stereotypy. Selective serotonin reuptake inhibitors, newer anticonvulsants, and atypical neuroleptics are preferred when treating psychiatric disorders among people with developmental disabilities. This paper will review the major studies of pharmacological treatment of mental illness in individuals with developmental disabilities.

Annotation: The use of psychotropic medications in children: a British view

BACKGROUND

Prescribing practices relating to the use of psychotropic medication with mentally disordered children have changed significantly in Britain over recent years.

METHODS

I conducted a review of the modest body of empirical data available relating to the prescribing practices of child psychiatrists, paediatricians and general practitioners (primary care physicians). The data were obtained primarily from postal questionnaire studies but also from British drug studies and a government-sponsored evaluation of the efficacy of stimulant medication. Postgraduate training guidelines for the three principal clinical disciplines are also discussed.

RESULTS

Systematic evaluation of prescribing practices has a relatively short history. All the studies reviewed demonstrated consistent methodological weaknesses, the most important of which was reliance upon retrospective reports of prescribing practices from clinicians with no analysis of actual prescription data. No studies relating to the general use of psychotropic medication by paediatricians were found. Child psychiatrists and general practitioners appear to be using a range of drugs for a range of conditions; however, there was evidence of intra- and interdisciplinary variations in practice. It was also evident from the general practitioner data that drug treatments were frequently used for conditions best managed with behavioural methods (e.g., common sleep problems and enuresis). Government prescription data relating to methylphenidate use in ADHD reveal a dramatic rise over the past ten years. Currently, most child psychiatrists use this treatment compared to approximately half the profession only seven years ago. The use of newer antipsychotic agents as well as the SSRI antidepressants appears to be growing in child psychiatric practice. A majority of clinicians surveyed believed that medication was an important treatment modality but also felt that they were relatively unskilled in the field and requested further training.

CONCLUSIONS

Overall, a picture of both a growing and better informed use of psychotropic medication is emerging in Britain despite shortcomings in postgraduate training. Future research needs to evaluate prescribing practice in a more objective manner in order to improve training and also service developments in the field.

ECT in mental retardation: a review

The use of electroconvulsive therapy (ECT) in patients with mental retardation and a psychiatric disorder seems to be infrequent, and controlled studies are not available. We reviewed the literature on the use of ECT in mental retardation, using Medline, Embase, and the Cochrane Library. References were checked and ECT experts consulted. The reported case studies were examined on patients' characteristics and illness, treatment, and outcome variables. Forty-four patients, mostly with a diagnosis of psychotic depression, were found. In 84% (n = 37) of them, ECT was effective and without important side effects. However, relapse occurred frequently, in 48% (n = 21) of the patients. In 16% (n = 7), side effects and/or no improvement were noted. The reported case studies suggest that ECT may be of value in treating severe psychiatric disorders in mentally retarded patients, with similar indications as in general psychiatry. However, the lack of strong scientific evidence, besides complicated psychiatric assessment as well as ethical and legal issues, probably cause an unnecessarily limited use of ECT in these patients. Further controlled trails are needed to firmly establish the efficacy and safety of ECT in mental retardation.

Clinical considerations in the diagnosis of autism spectrum disorders

The diagnosis of autistic spectrum disorders (ASD) is being made more frequently in children and at younger ages. This paper discusses various factors to be considered in the screening of autism, early features of presentation, relevant to assessment and diagnosis, subtypes or different syndromes within the spectrum of autistic conditions including Asperger syndrome, the differential diagnosis from learning and language disorders and the medical and behavioural commonly associated disorders.

Pharmacotherapy of target symptoms in autistic spectrum disorders

There are no aetiologically-based treatments available to cure autism. Though psychotropics have a role in the management of some symptoms of autism, clinical trial evidence for the use of psychotropics is in its infancy and needs close monitoring. About half of the subjects with high functioning pervasive developmental disorders (PDDs) are currently reported to be on psychotropics (anti-depressants, stimulants and antipsychotics), with many of them being on anti-epileptic medication simultaneously. Despite this high level of psychotropic use, few studies exist investigating the pharmacokinetics, pharmacodynamics or side-effect profiles in this population. Multiprofessional and parent partnership is essential in managing autism and psychopharmacology should be used in conjunction with environmental manipulation, educational modification and/or behavioral management strategies. A symptomatic approach to managing the difficult behaviours associated with autism is recommended. Some symptoms of autism may be medication responsive (hyperactivity, obsessions, rituals, inattention, tics, etc), while other symptoms may be responsive to behavioural interventions, but may require medication (aggression, anxiety, depression, impulsivity, sleep difficulties, etc), and symptoms which need specific skill remediation are usually non-responsive to medication (deficits in academic, social or sport domains). The new atypical antipsychotics (such as risperidone, olanzapine, amisulpiride, quetiapine) and SSRIs are increasingly being used in autism, with encouraging results, but a risk-benefit ratio of pharmacotherapy is essential with due weight being given to the side-effects of medication. Despite symptomatic improvement with medication, one should remain cautious about long-term use of psychotropics. It is also important to recognize that psychotropics can sometimes worsen behaviour, and can produce iatrogenic symptoms. Certain anti-epileptic medication and psychotropic drugs are metabolized by the same cytochrome P450 isoenzymes in the liver. In such circumstances, the addition of a psychotropic agent may drastically alter the levels of the anti-epileptic medication and vice versa. It is suggested that specialist clinics should be involved when one is considering complex medication regimes, experimental drugs, polypharmacy, or if patients show unusual side-effects or is drug resistant.