Effectiveness of antipsychotic medication in people with intellectual disability and schizophrenia: a systematic review

Psychopharmacology and people with learning disability

“These medications (antipsychotic drugs) were originally developed to treat not the mentally handicapped but the mentally ill; those, for example, with schizophrenia, paranoia and other specific conditions, but now the far wider use of these drugs has been challenged because there is evidence that they can produce serious side-effects in addition to the distress already suffered. Future changes in the use of antipsychotic drugs in the UK may come from the Royal College of Psychiatrists or from action in the Law Courts” (Public Eye, BBC2, 1.5.92).

Interventions for adults with mild intellectual disabilities and mental ill-health: a systematic review

BACKGROUND

People with intellectual disabilities have very high rates of mental ill health. Standard psychosocial interventions designed for the general population may not be accessible for people with mild intellectual disabilities, and drug usage tends to be modified - 'start low and go slow'. This systematic review aims to synthesise the evidence on psychological, pharmacological and electroconvulsive therapy (ECT) interventions for adults with mild intellectual disabilities and mental ill health.

METHOD

PRISMA guidelines were followed. Medline, Embase, PsycINFO and CINAHL were searched, as was grey literature and reference lists of selected papers. Papers were selected based on pre-defined inclusion and exclusion criteria. A proportion of papers were double reviewed. Data was extracted using a structured table.

STUDY REGISTRATION

PROSPERO 2015:CRD42015015218.

RESULTS

Initially, 18 949 records were identified. Sixteen studies were finally selected for inclusion; seven on psychological therapies, two on group exercise, five on antipsychotics and two on antidepressants. They do not provide definitive evidence for effectiveness of psychosocial interventions, nor address whether starting low and going slow is wise, or causes sub-optimum therapy.

CONCLUSIONS

There are few evidence-based interventions for people with mild intellectual disabilities and mental ill-health; existing literature is limited in quantity and quality. Group cognitive-behavioural therapies have some supporting evidence - however, further randomised control trials are required, with longer-term follow-up, and larger sample sizes.

Psychotropic treatments in Prader-Willi syndrome: a critical review of published literature

Prader-Willi syndrome (PWS) is a rare genetic syndrome. The phenotype includes moderate to intellectual disability, dysmorphia, obesity, and behavioral disturbances (e.g., hetero and self-injurious behaviors, hyperphagia, psychosis). Psychotropic medications are widely prescribed in PWS for symptomatic control. We conducted a systematic review of published literature to examine psychotropic medications used in PWS. MEDLINE was searched to identify articles published between January 1967 and December 2014 using key words related to pharmacological treatments and PWS. Articles with original data were included based on a standardized four-step selection process. The identification of studies led to 241 records. All selected articles were evaluated for case descriptions (PWS and behavioral signs) and treatment (type, titration, efficiency, and side effects). Overall, 102 patients were included in these studies. Treatment involved risperidone (three reports, n = 11 patients), fluoxetine (five/n = 6), naltrexone (two/n = 2), topiramate (two/n = 16), fluvoxamine (one/n = 1), mazindol (one/n = 2), N-acetyl cysteine (one/n = 35), rimonabant (one/n = 15), and fenfluramine (one/n = 15).

CONCLUSION

We identified promising treatment effects with topiramate for self-injury and impulsive/aggressive behaviors, risperidone for psychotic symptoms associated with uniparental disomy (UPD), and N-acetyl cysteine for skin picking. The pharmacological approach of behavioral impairment in PWS has been poorly investigated to date. Further randomized controlled studies are warranted.

WHAT IS KNOWN

Behavioral disturbances in Prader-Willi syndrome including aggressive reactions, skin picking, and hyperphagia might be very difficult to manage. Antipsychotic drugs are widely prescribed, but weight gain and increased appetite are their major side effects.

WHAT IS NEW

Topiramate might be efficient for self-injury and impulsive/aggressive behaviors, N-acetyl cysteine is apromising treatment for skin picking and Antidepressants are indicated for OCD symptoms. Risperidone is indicated in case of psychotic symptoms mainly associated with uniparental disomy.

Understanding systemic problems in providing mental health services to people with an intellectual disability and co-morbid mental disorders in Victoria

OBJECTIVE

This paper explores the difficulties the services system in Victoria has in responding to people with intellectual disability (ID) and mental health problems and identifies the underlying assumptions that have led to these. These issues are discussed and where possible put into a Victorian context with the intention of informing service development in the area of Dual Disability (co-morbid mental disorders in people with intellectual disability).

CONCLUSIONS

People with ID have high levels of mental health need. Generic services have difficulty responding to these needs due to a range of patient, professional and service system factors as well as some of the conceptual issues underpinning policy and legislation.

Prevalence of psychotropic drug use in adults with intellectual disability: positive and negative findings from a large scale study

The use of psychotropics by categories and the reason for their prescription was investigated in a large scale study of 4,069 adults with ID, including those with autism spectrum disorder, in New York State. Similar to other studies it was found that 58 % (2,361/4,069) received one or more psychotropics. Six percent received typical, while 39 % received atypical antipsychotics [corrected]. There was greater use of antidepressants (23 %), mood stabilizers (19 %), and antianxiety agents (16 %) relative to other studies. The use of anti-impulsives, stimulants and hypnotics was rare (1-2 %). Half of the psychotropics were prescribed for treatment of major psychiatric disorders, 13 % for control of challenging behaviors, and 38 % for both. Results indicated that the major psychiatric disorders, except anxiety disorder and autism, influenced the use of psychotropics and the number of medication used. These findings imply that although practitioners still rely too heavily on the use of antipsychotics in this population, there is a welcome shift in the prescription patterns relative to other studies. The practitioners appeared to use psychotropics primarily to treat diagnosed psychiatric disorders and not just to control aggressive behavior which suggests that evidence-based practice of psychiatry is playing an increasing role in the ID population.

A retrospective population-based data analyses of inpatient care use and medical expenditure in people with intellectual disability co-occurring schizophrenia

The paper aims to analyze the hospital inpatient care use and medical fee of people with ID co-occurring with schizophrenia in Taiwan. A nationwide data were collected concerning hospital admission and medical expenditure of people with ID (n = 2565) among national health insurance beneficiaries in Taiwan. Multiple regression analyses were undertaken to determine the role of the explanatory variables to hospital psychiatric inpatient care and medical expenditure. We found that there were 2565 individuals with ID used hospital psychiatric inpatient care among people with ID in 2005, and 686 cases (26.7%) co-occurring with schizophrenia according to hospital discharge claims. Those ID patients co-occurring with schizophrenia consumed more annual inpatient fee than those without schizophrenia (251,346 vs. 126,666 NTD) (p < 0.001). We found factors of female cases, longer hospital stay in chronic ward and general ward users among ID patients co-occurring with schizophrenia used more hospital inpatient care (R(2) = 0.417). Annual hospital inpatient days were significantly affected by factors of severe illness card holder, annual inpatient care fee, longer hospital stay in acute or chronic ward (R(2) = 0.746). Those factors of female cases, high inpatient care users, longer hospital stay in acute ward and general ward were consuming more medical care fee than their counterparts (R(2) = 0.620). The study highlights the future study should examine the efficacy of hospital inpatient care for people with ID and schizophrenia.

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.

Psychiatric morbidity with focus on obsessive-compulsive disorder in an Israeli cohort of adolescents with mild to moderate mental retardation

The study evaluated the prevalence of DSM-IV-TR-defined psychiatric disorders in adolescents with mental retardation, with a focus on obsessive-compulsive disorder (OCD), for which data at present are sparse. Eighty-seven adolescents with mild to moderate mental retardation attending the Israeli special-education system were screened for psychiatric disorders in general and obsessive-compulsive symptoms in particular. Sixty-one percent had at least one psychiatric disorder. Of the 13 participants receiving antipsychotic medication, none had an underlying psychotic disorder and most had anxiety or depressive disorders. OCD was detected in 11% of participants and was characterized by high rates of psychiatric comorbidities. The severity of autistic symptoms predicted 39% of the variance in the severity of OCD symptoms. Adolescents with mild to moderate mental retardation have high rates of psychiatric morbidities that are often inappropriately treated. OCD is prevalent in this population and is strongly associated with autistic symptoms. Further studies are required in adolescents with mental retardation to better delineate psychiatric morbidities and their appropriate treatment in this at-risk population.

Reviewing the use of antipsychotic drugs in people with intellectual disability

INTRODUCTION

Antipsychotics are the most widely prescribed drugs in people with intellectual disability even if schizophrenia and other psychotic disorders do not affect more than 3% of such population. Many authors outline the lack of studies on the efficacy of antipsychotics on schizophrenia or other psychotic disorders in people with intellectual disability.

MATERIALS AND METHODS

The aim of the present study is to review all evidences resulting from international trials selected by Medline, and compare efficacy and side effects of different antipsychotics in people with both intellectual disability and psychotic disorders and/or behavioural disorders.

RESULTS

195 studies were identified; 117 concern traditional antipychotics while 78 new generation ones. If we consider the type of studies, it results that only the 12.8% of all production is represented by meta-analyses, systematic reviews, and randomised and not controlled trials.

CONCLUSIONS

Randomised controlled trials and systematic reviews would be the golden standard for therapeutical studies; unfortunately they are really few in this field. It is anyway significative that all the studies reported focus on the use of antipsychotics in people with intellectual disability presenting behavioural problems. To increase the validity of these studies it is recommendable to proceed only with well-designed studies, possibly double-blind versus placebo or other medications. There is need to define precise inclusion criteria, precise symptomatological or behavioural targets and adaptative ability assessment, using valid and reliable diagnostic instruments.

Neuropsychiatric syndromes in adults with intellectual disability: issues in assessment and treatment

The purpose of this article is to present a survey of important neuropsychiatric issues and recent findings regarding the evaluation and treatment of neuropsychiatric symptoms and syndromes in patients with intellectual disability (ID). The cause of ID, environmental or genetic, can be determined in few patients. Etiology is idiopathic in most patients. ID and psychiatric illness are not mutually exclusive; individuals with ID have increased rates of psychiatric illness. Although recognition of significant axis I psychopathology is important, not all challenging behaviors in persons with ID will have a clear axis I diagnosis. Psychologic, behavioral, and environmental treatments are appropriate measures, but pharmacotherapy often is needed. Our experience has shown us that the more severe, disruptive, and dangerous the behavior, the stronger the indication for empirical drug treatment trials. Community-based models of support with neuropsychiatric intervention can be a potent therapeutic combination in the management of challenging behaviors in individuals with ID.

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.