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Marquis S, Marquis NE, Lunsky Y, McGrail KM, Baumbusch J. Prescriptions for Antipsychotics: Youth with Intellectual/Developmental Disabilities Compared to Youth without Intellectual/Developmental Disabilities. J Autism Dev Disord 2024:10.1007/s10803-024-06344-z. [PMID: 38678514 DOI: 10.1007/s10803-024-06344-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE The purpose of this study was to compare antipsychotic use by youth with intellectual/developmental disabilities to youth without IDD as they transitioned from pediatric to adult health care services. In addition, antipsychotic use was compared between youth with different types of IDD (autism, Fetal Alcohol Syndrome, Down syndrome and 'other'). METHODS Population level administrative health data was used to compare the dispensing of antipsychotics for youth aged 15 to 24 years with and without IDD, between 2010 and 2019. Because antipsychotics are associated with metabolic syndrome and type 2 diabetes, we also examined the dispensing data for metformin. In addition, we examined dispensed antipsychotics between different types of IDD. For both dispensing of antipsychotics and metformin, we used multi-variable logistic regression to derive adjusted odds ratios. RESULTS There were 20,591 youth with IDD and 1,293,791 youth without IDD. Youth with IDD had significantly higher odds of being dispensed an antipsychotic (7.13 (6.82, 7.44)), even when a diagnosis of a psychotic illness was included in the regression. Higher odds were found in all age groups. Youth with IDD also had significantly higher odds of being dispensed metformin (3.739 (3.323, 4.208)) compared to youth without IDD. Youth with autism, FAS and 'other' types of IDD diagnoses all had higher odds of being dispensed an antipsychotic compared to youth with Down syndrome. CONCLUSION Compared to youth without IDD, youth with IDD were more frequently dispensed antipsychotics and metformin. These findings have important implications for the health of youth with IDD.
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Affiliation(s)
- Sandra Marquis
- School of Nursing, University of British Columbia, T201-2211, Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
| | - N Esmé Marquis
- School of Nursing, University of British Columbia, T201-2211, Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
| | - Yona Lunsky
- Azrieli Adult Neurodevelopmental Centre, Campbell Family Mental Health Research Institute, CAMH, 1025 Queen St West, Toronto, ONT, M6J 1H4, Canada.
| | - Kimberlyn M McGrail
- Centre for Health Services and Policy Research, The University of British Columbia, 201-2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Jennifer Baumbusch
- School of Nursing, University of British Columbia, T201-2211, Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
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Odalović M, Gorman A, Paul A, McCallion P, Burke É, MacLachlan M, McCarron M, Henman MC, Moran M, O'Connell J, Walsh M, Shankar R, Ryan C, O'Dwyer M. Psychotropic medicines' prevalence, patterns and effects on cognitive and physical function in older adults with intellectual disability in Ireland: longitudinal cohort study, 2009-2020. BJPsych Open 2024; 10:e39. [PMID: 38297892 PMCID: PMC10897684 DOI: 10.1192/bjo.2023.607] [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] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND The frequent prescribing of psychotropics and high prevalence of polypharmacy among older adults with intellectual disabilities require close monitoring. AIMS To describe change in prevalence, predictors and health outcomes of psychotropic use during the four waves (2009/2010, 2013/2014, 2016/2017, 2019/2020) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). METHOD Eligible participants were adults (≥40 years) with intellectual disabilities who participated in all four waves of IDS-TILDA and who reported medication use for the entire period. Differences between groups were tested using Cochran's Q test for binary variables and the McNemar-Bowker test for variables with more than two categories. Generalised estimating equation models were used to assess associations between psychotropic use, participants' characteristics and health outcomes. RESULTS Across waves (433 participants) there were no significant differences in prevalence of psychotropic use (61.2-64.2%) and psychotropic polypharmacy (42.7-38.3%). Antipsychotics were the most used subgroup, without significant change in prevalence between waves (47.6-44.6%). A significant decrease was observed for anxiolytics (26.8-17.6%; P < 0.001) and hypnotics/sedatives (14.1-9.0%; P < 0.05). A significant increase was recorded for antidepressants (28.6-35.8%; P < 0.001) and mood-stabilising agents (11.5-14.6%; P < 0.05). Psychotropic polypharmacy (≥2 psychotropics) was significantly associated with moderate to total dependence in performing activities of daily living over the 10-year period (OR = 1.80, 95% CI 1.21-2.69; P < 0.05). CONCLUSIONS The study indicates an increase in usage of some classes of psychotropic, a reduction in others and no change in the relatively high rate of antipsychotic use over 10 years in a cohort of older adults with intellectual disabilities and consequent risk of psychotropic polypharmacy and medication-related harm.
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Affiliation(s)
- Marina Odalović
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland; and Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Ireland
| | - Ashleigh Gorman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland; and Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Ireland
| | - Aviejay Paul
- School of Social Work, College of Public Health, Temple University, Philadelphia, USA
| | - Philip McCallion
- School of Social Work, College of Public Health, Temple University, Philadelphia, USA
| | - Éilish Burke
- School of Nursing and Midwifery, Trinity College Dublin, Ireland; and Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Ireland
| | - Malcolm MacLachlan
- National Clinical Programme for People with Disabilities, Health Service Executive, Dublin, Ireland; Assisting Living & Learning Institute, Maynooth University, Ireland; and Psychology Department, Maynooth University, Ireland
| | - Mary McCarron
- School of Nursing and Midwifery, Trinity College Dublin, Ireland; and Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Ireland
| | - Martin C Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland; and Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Ireland
| | - Maeve Moran
- Faculty of Learning Disability Psychiatry, College of Psychiatrists of Ireland, Dublin, Ireland
| | - Juliette O'Connell
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland; and Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Ireland
| | - Michael Walsh
- National Clinical Programme for People with Disabilities, Health Service Executive, Dublin, Ireland
| | - Rohit Shankar
- Peninsula Medical School, University of Plymouth, UK
| | - Caitriona Ryan
- School of Nursing and Midwifery, Trinity College Dublin, Ireland; and Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Ireland
| | - Máire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland; and Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Ireland
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Yoshida K, Lunsky Y, Müller DJ, Desarkar P. Prevalence of Psychotropic Medication Use and Psychotropic Polypharmacy in Autistic Adults With or Without Intellectual Disability. J Autism Dev Disord 2024:10.1007/s10803-023-06208-y. [PMID: 38219270 DOI: 10.1007/s10803-023-06208-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 01/16/2024]
Abstract
The aim of this study was to compare the rates of psychotropic medication use and psychotropic polypharmacy between autistic adults with and without intellectual disability (ID) and to examine factors associated with psychotropic medication use and psychotropic polypharmacy in autistic adults, stratified by the presence of ID. We conducted a retrospective medical chart review of outpatients with an autism diagnosis aged 18 years and older. The rates of psychotropic medication use and psychotropic polypharmacy were compared between autistic adults with and without ID. Subsequently, logistic regression analyses were performed to identify factors associated with psychotropic medication use and psychotropic polypharmacy in autistic adults with ID and those without ID, respectively. The rates of prevalence of psychotropic medication use and polypharmacy were significantly higher in participants with ID than those without ID (78.6% vs. 58.8% and 49.3% vs. 31.2%; p-values < 0.05). Age, gender, race, residence, presence of mood disorders, presence of schizophrenia, absence of anxiety disorder, number of psychiatric comorbidities, and presence of behaviors that challenge were significantly associated with these outcomes, depending on the presence/absence of ID. The need to optimize pharmacotherapy in autistic adults, stratifying by the presence of ID, is highlighted.
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Affiliation(s)
- Kazunari Yoshida
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, 1025 Queen Street West, Toronto, ON, M6J 1H1, Canada
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Yona Lunsky
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, 1025 Queen Street West, Toronto, ON, M6J 1H1, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Daniel J Müller
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Pushpal Desarkar
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, 1025 Queen Street West, Toronto, ON, M6J 1H1, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Adult Neurodevelopmental Services, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Groves L, Jones C, Welham A, Hamilton A, Liew A, Richards C. Non-pharmacological and pharmacological interventions for the reduction or prevention of topographies of behaviours that challenge in people with intellectual disabilities: a systematic review and meta-analysis of randomised controlled trials. Lancet Psychiatry 2023; 10:682-692. [PMID: 37595996 DOI: 10.1016/s2215-0366(23)00197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND People with intellectual disability show a high prevalence of behaviours that challenge. Clinical guidelines recommend that such behaviour should first be treated with non-pharmacological interventions, but research suggests off-label pharmaceuticals are commonly used. We aimed to evaluate the efficacy of non-pharmacological and pharmacological interventions for topographies of behaviours that challenge drawn from randomised controlled trials (RCTs). METHODS In this systematic review and meta-analysis, we searched PsycINFO, MEDLINE, Embase, CINAHL, and CENTRAL databases for RCT studies assessing an intervention (pharmacological or non-pharmacological) for behaviours that challenge (self-injury behaviour, aggression, destruction of property, irritability, and a composite overall measure) in participants with intellectual disability. The primary aim was to assess the efficacy of non-pharmacological and pharmacological interventions on behaviours that challenge. Secondary aims were to evaluate how effects varied over time and whether intervention, methodological, and participant characteristics moderate efficacy. We extracted standard mean difference (SMD) effect sizes (Cohen's d) from eligible studies and meta-analysed the data using a series of random effects models and subgroup analyses. This study was registered with PROSPERO 2021, CRD4202124997. FINDINGS Of 11 912 reports identified, 82 studies were included. 42 (51%) studies assessed non-pharmacological interventions and 40 (49%) assessed pharmacological interventions. Across all studies, 4637 people with intellectual disability aged 1-84 years (mean age 17·2 years) were included. 2873 (68·2%) were male, 1339 (28·9%) were female, and for 425 (9·2%) individuals, data on gender were not available. Data on ethnicity were unavailable. Small intervention effects were found for overall behaviours that challenge at post-intervention (SMD -0·422, 95% CI -0·565 to -0·279), overall behaviours that challenge at follow-up (-0·324, -0·551 to -0·097), self-injury behaviour at post-intervention (-0·238, -0·453 to -0·023), aggression at post-intervention (-0·438, -0·566 to -0·309), and irritability at post-intervention (-0·255, -0·484 to -0·026). No significant differences between non-pharmacological and pharmacological interventions were found for any topography of behaviours that challenge (all p>0·05). INTERPRETATION A broad range of interventions for behaviours that challenge are efficacious with small effect sizes for people with intellectual disability. These findings highlight the importance of precision in the measurement of behaviours that challenge, and when operationalising intervention components and dosages. FUNDING Cerebra.
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Affiliation(s)
- Laura Groves
- School of Psychology, University of Birmingham, Birmingham, UK; Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK; Birmingham Community Healthcare NHS Foundation Trust, Birmingham, UK.
| | - Chris Jones
- School of Psychology, University of Birmingham, Birmingham, UK
| | - Alice Welham
- School of Psychology, University of Birmingham, Birmingham, UK; Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
| | - Anna Hamilton
- School of Psychology, University of Birmingham, Birmingham, UK
| | - Ashley Liew
- School of Psychology, University of Birmingham, Birmingham, UK; Paediatric Neurosciences, Evelina London Children's Hospital, London, UK; Institute for Mental Health, University of Birmingham, Birmingham, UK; CEDAR, University of Warwick, Warwick, UK
| | - Caroline Richards
- School of Psychology, University of Birmingham, Birmingham, UK; Cerebra Network, University of Birmingham, Birmingham, UK
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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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Laermans P, Morisse F, Lombardi M, Gérard S, Vandevelde S, de Kuijper G, Audenaert K, Claes C. Aligning quality of life and guidelines for off-label psychotropic drugs in adults with intellectual disabilities and challenging behaviour. INTERNATIONAL JOURNAL OF DEVELOPMENTAL DISABILITIES 2023; 69:398-413. [PMID: 37213586 PMCID: PMC10197992 DOI: 10.1080/20473869.2023.2195721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 05/23/2023]
Abstract
Introduction Adults with intellectual disabilities have an increased vulnerability to mental health problems and challenging behaviour. In addition to psychotherapeutic or psychoeducational methods, off-label pharmacotherapy, is a commonly used treatment modality. Objective The aim of this study was to establish evidence-based guideline recommendations for the responsible prescription of off-label psychotropic drugs, in relation to Quality of Life (QoL). Method A list of guidelines was selected, and principles were established based on international literature, guideline review and expert evaluation. The Delphi method was used to achieve consensus about guideline recommendations among a 58-member international multidisciplinary expert Delphi panel. Thirty-three statements were rated on a 5-point Likert-scale, ranging from totally disagree to totally agree, in consecutive Delphi rounds. When at least 70% of the participants agreed (score equal or higher than 4), a statement was accepted . Statements without a consensus were adjusted between consecutive Delphi rounds based on feedback from the Delphi panel. Results Consensus was reached on 4 general:the importance of non-pharmaceutical treatments, comprehensive diagnostics and multidisciplinary treatment. Consensus was reached in 4 rounds on 29 statements. No consensus was reached on 4 statements concerning: freedom-restricting measures, the treatment plan, the evaluation of the treatment plan, and the informed consent. Conclusion The study led to recommendations and principles for the responsible prescription - aligned with the QoL perspective - of off-label psychotropic drugs for adults with intellectual disabilities and challenging behaviour. Extensive discussion is needed regarding the issues on which there was no consensus to furthering the ongoing development of this guideline.
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Affiliation(s)
- P. Laermans
- EQUALITY//ResearchCollective, University College Ghent, Ghent, Belgium
- Correspondence to: Pauline Laermans, EQUALITY//ResearchCollective, University College Ghent.
| | - F. Morisse
- Department of Special Needs Education, Ghent University, Ghent, Belgium
| | - M. Lombardi
- EQUALITY//ResearchCollective, University College Ghent, Ghent, Belgium
| | - S. Gérard
- Superior Health Council, Brussels, Belgium
| | - S. Vandevelde
- Department of Special Needs Education, Ghent University, Ghent, Belgium
| | - G. de Kuijper
- Centre for Intellectual Disabilities & Mental Health, Mental Healthcare Drenthe, the Netherlands
| | - K. Audenaert
- Department of Psychiatry, Ghent University, Ghent, Belgium
| | - C. Claes
- EQUALITY//ResearchCollective, University College Ghent, Ghent, Belgium
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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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de Kuijper G, de Haan J, Deb S, Shankar R. Withdrawing Antipsychotics for Challenging Behaviours in Adults with Intellectual Disabilities: Experiences and Views of Prescribers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:17095. [PMID: 36554973 PMCID: PMC9779134 DOI: 10.3390/ijerph192417095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 06/17/2023]
Abstract
International current best practice recommends the discontinuation of antipsychotics for challenging behaviours in people with intellectual disabilities (ID), due to lack of evidence of efficacy and risks of harmful side-effects. In clinical practice, discontinuation may be difficult. The aim of this study was to gain insight into prescribers' practice by investigating their experiences with the discontinuation of long-term antipsychotics for challenging behaviour. From professionals' associations thirty-four registered ID physicians, psychiatrists and specialist mental healthcare nurses were recruited who completed an online questionnaire in this survey-study. Almost all participants had attempted to deprescribe antipsychotics for their patients with ID. Sixty-five percent of participants achieved complete discontinuation in 0-25% of their patients, but none in over 50%. Barriers were a lack of non-pharmaceutical treatments for challenging behaviours and caregivers' and/or family concern. Seventy percent of participants indicated that their institutions had encouraged implementing their discontinuation policies in line with the new Dutch Act on Involuntary care and a new Dutch multidisciplinary guideline on problem behaviour in adults with ID. Support and facilitation of clinicians from institutions' managers and political and professional bodies may be helpful in further implementation of best practice in the treatment of challenging behaviour in people with ID.
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Affiliation(s)
- Gerda de Kuijper
- GGZ-Drenthe/Centre for ID and Mental Health, Middenweg 19, 9404 LL Assen, The Netherlands
- Academic Collaboration ID and Mental Health, Department Psychiatry and Department Family Practice, University Medical Centre Groningen, 9713 GZ Hanzeplein, The Netherlands
| | - Joke de Haan
- GGZ-Drenthe/Centre for ID and Mental Health, Middenweg 19, 9404 LL Assen, The Netherlands
| | - Shoumitro Deb
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - Rohit Shankar
- Peninsula School of Medicine, University of Plymouth and Cornwall Partnership NHS Foundation Trust, Plymouth PL4 8AA, UK
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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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11
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Hefner G, Wolff J, Toto S, Reißner P, Klimke A. Off-label use of antidepressants, antipsychotics, and mood-stabilizers in psychiatry. J Neural Transm (Vienna) 2022; 129:1353-1365. [PMID: 36070009 DOI: 10.1007/s00702-022-02542-0] [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: 08/08/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
Off-label drug prescribing in psychiatry is increasing. Many psychotropic drugs are approved for psychopathologic syndromes rather than based on international standard diagnostic classification systems which might facilitate the clinical decision for off-label prescriptions. The objective of this study was to analyze the prevalence and category of off-label use of psychotropic drugs. The study was conducted in 10 psychiatric hospitals in Germany over a period of 2 years. Prescription data of all patients were retrospectively analyzed after identification of antidepressants, antipsychotics, and mood-stabilizers, which were classified as off-label according to the German prescribing information and diagnostic classification according to ICD-10. In total, 53,909 patient cases (46% female) with a mean age of 46.8 (SD: 18) years were included in the study. 30.2% of the cases received at least one off-label prescription of a psychotropic drug during hospital stay. Off-label prevalence rates differed markedly between different diagnostic groups (ICD-10 F0/G3: 47%, F1: 33%, F2: 25%, F3: 21%, F4: 27%, F6: 46%, F7: 84%). The most often off-label prescribed drugs were quetiapine and mirtazapine for organic mental disorders (F0/G3), valproate and quetiapine in patients with disorders due to psychoactive substance use (F1), valproate in patients with psychotic disorders (F2), and risperidone and olanzapine in patients with affective disorders (F3). The prevalence rate of psychotropic off-label prescriptions is high if restricted to product description and ICD-10 diagnosis. Therefore, current psychiatric guidelines should drug-specifically issue this problem by defining psychiatric off-label indications based on a clear benefit-risk assessment.
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Affiliation(s)
- Gudrun Hefner
- Psychiatric Hospital, Vitos Clinic for Forensic Psychiatry, Kloster-Eberbach-Straße 4, 65346, Eltville, Germany.
| | - Jan Wolff
- Peter L. Reichertz Institute for Medical Informatics, Hannover Medical School, Hannover, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Pamela Reißner
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany
| | - Ansgar Klimke
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany.,Heinrich-Heine-University, Duesseldorf, Germany
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12
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Patterns and Predictors of Off-Label Drug Prescribing in Psychiatric Practice: A Qualitative Study. PHARMACY 2021; 9:pharmacy9040203. [PMID: 34941635 PMCID: PMC8703660 DOI: 10.3390/pharmacy9040203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022] Open
Abstract
Off-label drug prescribing (OLDP) must be based on strong scientific evidence to make sure that patients get the optimum therapeutic outcomes. Adherence to the prerequisites is determined by the physicians’ attitude and knowledge. In this context, the present study was conducted with the goal of investigating psychiatrists’ perceptions of the use of OLDP in their clinical practice. A total of 14 psychiatrists were interviewed using a semi-structured interview guide. Thematic content analysis was performed. Data saturation was achieved at the 12th interview. Six major themes and fifteen subthemes emerged from qualitative interviews. Among the major themes were knowledge and concepts about the off-label drugs, attitude and current practice of prescribing off-label drugs, and rationale of prescribing and suggestions for reducing the use of off-label drugs. Almost all of the respondents interviewed provided detailed comments concerning the OLDP concept, depicted an optimistic approach and deemed that OLDP is quite common in psychiatry. Off-label usage of benzodiazepines such as clonazepam, diazepam and lorazepam in mania, depression, and obsessive–compulsive disorder were commonly reported. It was observed that the majority of the respondents did not inform the patients before prescribing off-label drugs. The present findings revealed that respondents had awareness; however, they depicted diverse attitudes towards prescribing off-label drugs. Further education and sensitization in regions with impoverished knowledge would certainly assist in preventing the risks associated with the use of OLDP.
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13
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Yoshida K, Koyama E, Zai CC, Beitchman JH, Kennedy JL, Lunsky Y, Desarkar P, Müller DJ. Pharmacogenomic Studies in Intellectual Disabilities and Autism Spectrum Disorder: A Systematic Review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:1019-1041. [PMID: 33222504 PMCID: PMC8689451 DOI: 10.1177/0706743720971950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Individuals with intellectual disability (ID) and autism spectrum disorder (ASD) often receive psychotropic medications such as antipsychotics and antidepressants to treat aberrant behaviors and mood symptoms, frequently resulting in polypharmacy and drug-related adverse effects. Pharmacogenomic (PGx) studies with ASD and/or ID (ASD/ID) have been scarce despite the promise of optimizing treatment outcomes. We reviewed the literature on PGx studies with antipsychotics and antidepressants (e.g., treatment response and adverse effects) in ASD/ID. METHODS We performed a systematic review using MEDLINE, Embase, and PsycINFO, including peer-reviewed original articles in English referring to PGx in the treatment of ASD/ID in any age groups (e.g., treatment response and adverse effects). RESULTS A total of 28 PGx studies using mostly candidate gene approaches were identified across age groups. Notably, only 3 studies included adults with ASD/ID while the other 25 studies focused specifically on children/adolescents with ASD/ID. Twelve studies primarily investigated treatment response, of which 5 and 6 studies included patients treated with antipsychotics and antidepressants, respectively. Most interesting results for response were reported for 2 sets of candidate gene studies, namely: (1) The DRD3 Ser9Gly (rs6280) polymorphism was examined in patients treated with risperidone in 3 studies, 2 of which reported an association with risperidone treatment response and (2) the SLC6A4 5-HTTLPR polymorphism and treatment response to antidepressants which was investigated in 4 studies, 3 of which reported significant associations. In regard to side effects, 9 of 15 studies focused on hyperprolactinemia in patients treated with risperidone. Among them, 7 and 5 studies examined the impact of CYP2D6 and DRD2 Taq1A polymorphisms, respectively, yielding mostly negative study findings. CONCLUSIONS There is limited data available on PGx in individuals with ASD/ID and in particular in adults. Given the potential for PGx testing in improving treatment outcomes, additional PGx studies for psychotropic treatment in ASD/ID across age groups are warranted.
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Affiliation(s)
- Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Emiko Koyama
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Clement C Zai
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
| | - Joseph H Beitchman
- Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada
| | - James L Kennedy
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Yona Lunsky
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Pushpal Desarkar
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada.,Adult Neurodevelopmental Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Daniel J Müller
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
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14
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Abstract
INTRODUCTION Ireland has an ageing population of persons with intellectual disability (ID), autism spectrum disorder (ASD) and both (ID/ASD). Despite this, little is known about the prevalence of ASD and its effect on functional outcomes, psychiatric comorbidity or diagnostic issues in an older population with ID. This article reviews the literature on older adults with ID/ASD and identifies opportunities for future research in this population. METHOD The authors searched the Medline, Pubmed, Embase, CINAHL and PsychInfo databases using the search terms using key words: (older adults) AND (ID OR mental retardation OR learning disability) AND (autism OR ASD). After excluding articles for relevance, a scoping review was carried out on the results retrieved. RESULTS Of the 1227 articles retrieved from the literature on ID and autism/ASD in older adults, 85 articles were relevant to an adult population with ID/ASD. The data were collated and are presented covering domains of diagnosis, prevalence, psychiatric comorbidities and functional outcomes. CONCLUSIONS Despite increased prevalence in childhood ASD in the last 20 years, there is a lack of research regarding adults, especially older adults, with ASD, up to half of whom will have some level of ID. The existing literature suggests that older adults with ID/ASD may have reduced functional independence, increased psychiatric comorbidity and psychotropic prescribing and more behavioural presentations than the older population generally or those with ID only. There is a need for longitudinal data to be collected on this ageing population so that care and management needs can be met in the future.
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15
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An Exploratory Study among Intellectual Disability Physicians on the Care and Coercion Act and the Use of Psychotropic Drugs for Challenging Behaviour. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910240. [PMID: 34639540 PMCID: PMC8547136 DOI: 10.3390/ijerph181910240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
The new Dutch Care and Coercion Act aims to better regulate the use of psychotropic drugs for challenging behaviour in people with an intellectual disability. This study explores experiences of intellectual disability physicians (IDPs) in prescribing psychotropic drugs and investigates how the Act and the new multidisciplinary guideline on challenging behaviour affects their practice. A qualitative study was conducted, consisting of nine semi-structured in-depth interviews with IDPs, followed by a thematic analysis. It was found that IDPs experienced the new Act and guideline as supportive of their work as guardians of the appropriate use of psychotropic drugs. The multidisciplinary character of the guideline was experienced positively. However, IDPs are faced with organisational barriers and time constraints, as such, they question the feasibility of implementing the Act. Based on these findings, it can be concluded that the Care and Coercion Act may support the existing shift towards the appropriate use of psychotropic drugs if required conditions can be met.
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16
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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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17
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Falligant JM, Bednar MK. Further analysis of psychotropic medication and severe problem behavior. BEHAVIORAL INTERVENTIONS 2021. [DOI: 10.1002/bin.1823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- John M. Falligant
- Department of Behavioral Psychology Kennedy Krieger Institute Baltimore Maryland USA
- Department of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Molly K. Bednar
- Department of Behavioral Psychology Kennedy Krieger Institute Baltimore Maryland USA
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18
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Cox AD, Pritchard D, Penney H, Eiri L, Dyer TJ. Demonstrating an Analyses of Clinical Data Evaluating Psychotropic Medication Reductions and the ACHIEVE! Program in Adolescents with Severe Problem Behavior. Perspect Behav Sci 2021; 45:125-151. [DOI: 10.1007/s40614-020-00279-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 12/01/2022] Open
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Song M, Ware RS, Doan TN, McPherson L, Trollor JN, Harley D. Appropriateness of psychotropic medication use in a cohort of adolescents with intellectual disability in Queensland, Australia. BJPsych Open 2020; 6:e142. [PMID: 33198847 PMCID: PMC7745239 DOI: 10.1192/bjo.2020.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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 Psychotropic medications are sometimes used off-label and inappropriately. This may cause harm to adolescents with intellectual disability. However, few studies have analysed off-label or inappropriate prescribing to this group. AIMS To examine the appropriateness of psychotropic prescribing to adolescents with intellectual disability living in the community in south-east Queensland, Australia. METHOD Off-label medication use was determined based on whether the recorded medical condition treated was approved by the Australian Therapeutic Goods Administration. Clinical appropriateness of medication use was determined based on published guidelines and clinical opinion of two authors who specialise in developmental disability medicine (J.N.T. and D.H.). RESULTS We followed 429 adolescents for a median of 4.2 years. A total of 107 participants (24.9%) were prescribed psychotropic medications on at least one occasion. Of these, 88 (82.2%) were prescribed their medication off-label or inappropriately at least once. Off-label or inappropriate use were most commonly associated with challenging behaviours. CONCLUSIONS Off-label or inappropriate use of psychotropic medications was common, especially for the management of challenging behaviours. Clinical decision-making accounts for individual patient factors and is made based on clinical experience as well as scientific evidence, whereas label indications are developed for regulatory purposes and, although appropriate at a population level, cannot encompass the foregoing considerations. Education for clinicians and other staff caring for people with intellectual disability, and a patient-centred approach to prescribing with involvement of families should encourage appropriate prescribing. The effect of the National Disability Insurance Scheme on the appropriateness of psychotropic medication prescribing should be investigated.
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Affiliation(s)
- Menghuan Song
- Queensland Centre for Intellectual and Developmental Disability, Mater Research Institute-University of Queensland, Mater Hospitals, Queensland, Australia
| | - Robert S Ware
- Queensland Centre for Intellectual and Developmental Disability, Mater Research Institute-University of Queensland, Mater Hospitals; and Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Tan N Doan
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Victoria, Australia
| | - Lyn McPherson
- Queensland Centre for Intellectual and Developmental Disability, Mater Research Institute-University of Queensland, Mater Hospitals; and Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Julian N Trollor
- Department of Developmental Disability Neuropsychiatry, Faculty of Medicine, University of New South Wales, New South Wales, Australia
| | - David Harley
- Queensland Centre for Intellectual and Developmental Disability, Mater Research Institute-University of Queensland, Mater Hospitals, Queensland, Australia
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20
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Maas S, Festen DAM, Hilgenkamp TIM, Oppewal A. The association between medication use and gait in adults with intellectual disabilities. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2020; 64:793-803. [PMID: 32885545 PMCID: PMC7540034 DOI: 10.1111/jir.12773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/24/2020] [Accepted: 08/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Adults with intellectual disabilities (ID) often have polypharmacy and often use antipsychotics. Both polypharmacy and antipsychotics have a negative effect on gait in the general population, but this has not been studied in adults with ID. These negative effects may add to pre-existing gait disturbances in adults with ID and increase the risk for adverse health outcomes in this population. Therefore, the aim of this study is to investigate the difference in gait parameters between adults with ID with and without polypharmacy and between adults with ID using and not using antipsychotics. METHOD The gait parameters of 31 participants were collected with the GAITRite walkway, a pressure sensitive walkway measuring spatial and temporal gait parameters, in addition to information about personal characteristics, prescribed medication and presence of polypharmacy. RESULTS After adjustment for sex and body mass index, participants with polypharmacy had a significantly shorter step length [polypharmacy B (SE) = -0.079 (0.034), P = 0.03], shorter stride length [polypharmacy B (SE) = -0.157 (0.069), P = 0.03] and longer double support time [polypharmacy B (SE) = 0.0004 (0.0001), P = 0.047]. Participants using antipsychotics had a significantly longer double support time [antipsychotic use B (SE) = 0.0003 (0.0002), P = 0.019]. CONCLUSION This study showed for the first time that both polypharmacy and using antipsychotics are associated with gait in adults with ID. The differences seem to resemble a more cautious gait. Further investigation with larger study samples, additional medication types and dosages are needed to acquire more insight in this important topic.
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Affiliation(s)
- S. Maas
- Intellectual Disability Medicine, Department of General PracticeErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
| | - D. A. M. Festen
- Intellectual Disability Medicine, Department of General PracticeErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
| | - T. I. M. Hilgenkamp
- Intellectual Disability Medicine, Department of General PracticeErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
- Department of Physical TherapyUniversity of NevadaLas VegasNVUSA
| | - A. Oppewal
- Intellectual Disability Medicine, Department of General PracticeErasmus MC University Medical Center RotterdamRotterdamThe Netherlands
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21
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Jakobs KM, Posthuma A, de Grauw WJC, Schalk BWM, Akkermans RP, Lucassen P, Schermer T, Assendelft WJJ, Biermans MJC. Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice. BMC FAMILY PRACTICE 2020; 21:153. [PMID: 32727372 PMCID: PMC7391510 DOI: 10.1186/s12875-020-01225-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/19/2020] [Indexed: 12/02/2022]
Abstract
Background Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice. Methods We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands. From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression. Results We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI. Conclusion CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.
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Affiliation(s)
- Kirsti M Jakobs
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Anne Posthuma
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Wim J C de Grauw
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Bianca W M Schalk
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Reinier P Akkermans
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Tjard Schermer
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Marion J C Biermans
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
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22
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Song M, Ware R, Doan TN, Harley D. Psychotropic medication use in adults with intellectual disability in Queensland, Australia, from 1999 to 2015: a cohort study. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2020; 64:45-56. [PMID: 31478300 DOI: 10.1111/jir.12685] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/03/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Longitudinal data on medication use in adults with intellectual disability (ID) are scarce. We describe the longitudinal use of and factors associated with psychotropic medication prescribing in adults with ID living in the Australian community. METHODS Longitudinal data were obtained from adults with ID in the community in Queensland, Australia, between 1999 and 2015. Participant characteristics and medication use information were extracted from baseline questionnaires and health check booklets. Logistic regression was used to investigate the associations between participant characteristics and psychotropic medication use, commencement or cessation. RESULTS Longitudinal data were available for 138 participants on 697 reviews. The proportion of participants prescribed psychotropic medications increased from 43% to 54% between 1999 and 2015. The rates of commencement and cessation of psychotropic medications between consecutive time periods ranged from 9% to 18% and 7% to 15%, respectively. Challenging behaviour was associated with psychotropic medication use (adjusted odds ratio = 4.1; 95% confidence interval: 2.1-7.9). Presence of challenging behaviour, either consistent or newly identified, was positively associated with ongoing use or commencement of psychotropic medications. CONCLUSIONS Psychotropic medications are commonly prescribed to adults with ID. Challenging behaviour is positively associated with ongoing use and commencement.
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Affiliation(s)
- M Song
- Queensland Centre for Intellectual and Developmental Disability (QCIDD), Mater Research Institute-University of Queensland (MRI-UQ), QLD, Australia
| | - R Ware
- Menzies Health Institute Queensland, Griffith University, QLD, Australia
| | - T N Doan
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, VIC, Australia
| | - D Harley
- Queensland Centre for Intellectual and Developmental Disability (QCIDD), Mater Research Institute-University of Queensland (MRI-UQ), QLD, Australia
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Psychotropic Medication in Intellectual and Developmental Disabilities: Patterns of Use and Recommendations for Monitoring Effects. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2019. [DOI: 10.1007/s40474-019-00179-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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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: 14] [Impact Index Per Article: 2.8] [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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25
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26
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De Vreese LP, Mantesso U, De Bastiani E, Marangoni A, Weger E, Gomiero T. Anticholinergic burden in adult and elderly people with intellectual disabilities: Results from an Italian multicenter cross-sectional study. PLoS One 2018; 13:e0205897. [PMID: 30379948 PMCID: PMC6209221 DOI: 10.1371/journal.pone.0205897] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 10/03/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Adults and older people with intellectual disabilities (ID) frequently receive anti-cholinergic drugs in chronic use, but no studies in Italy to date have investigated cumulative anticholinergic exposure and factors associated with high anticholinergic burden in this frail population. AIM To probe the cumulative exposure to anticholinergics and the demographic, social and clinical factors associated with high exposure. METHODS The 2012 updated version of the Anticholinergic Burden Score (ACB) was calculated for a multicentre sample of 276 adult and older people over 40 years with ID and associations with factors assessed. RESULTS Overall, antipsychotics, antiepileptics, anxiolytics, and antidepressants were the most frequent classes contributing to the total ACB score. People living in residential care were more likely exposed to high anticholinergic burden (an ACB score of 3+): both community housing (odds ratio [OR] 4.63, 95%CI 1.08-19.95) and nursing home facility ([OR] 9.99, 95%CI 2.32-43.04). There was also a significant association between an ACB score of 3+ and reporting mental health conditions ([OR] 25.56, 95% CI 8.08-80.89) or a neurological disease ([OR] 4.14, 95%CI 1.32-12.94). Neither demographic characteristics (age and gender) nor other clinical conditions (somatic comorbidity, levels and typology of ID) were associated with higher anticholinergic load. A high burden of anticholinergic was significantly more frequent in laxative users (22.6% ACB3+ vs. 5.1% ACB 0) (p = 0.003). CONCLUSIONS Psychotropics drugs were the highest contributors to the anticholinergic burden in adult and old age ID, especially in those people living in institutional settings with mental health and/or neurological conditions. High anticholinergic load has shown to be associated with the use of laxatives.
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Affiliation(s)
- Luc Pieter De Vreese
- Geriatric Center, Luigi Boni Foundation, Suzzara, Italy
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
| | - Ulrico Mantesso
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
| | - Elisa De Bastiani
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
| | | | - Elisabeth Weger
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
| | - Tiziano Gomiero
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
- * E-mail:
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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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Shankar R, Wilcock M. Improving knowledge of psychotropic prescribing in people with Intellectual Disability in primary care. PLoS One 2018; 13:e0204178. [PMID: 30216381 PMCID: PMC6138382 DOI: 10.1371/journal.pone.0204178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/03/2018] [Indexed: 01/02/2023] Open
Abstract
Purpose People with Intellectual disability (ID) are likely to be prescribed psychotropic medication particularly antipsychotics without a clear clinical indication. This has given rise to a national initiative in the UK to stop overprescribing medication in this vulnerable population. While the goals are simple it is unclear if specialist ID services or primary care services in the UK should look to lead. Further, it is uncertain if primary care practitioners (GPs) can be systematically educated of the latest good practice developments and concerns in this specialised area. This study surveyed the knowledge level of a sample of GPs in Cornwall UK (county of 538,000) post a structured tutorial on psychotropic medication and people with ID. Methods A 21 item questionnaire was delivered in meetings organised for all the county GPs a year after a talk given to the same demographic. The questionnaire conducted an assessment of the knowledge of national guidance on use of psychotropic medication in ID based on the subjects covered in the tutorial. Results Of the 60 expected GP participants the tutorial was attended by 44 GPs (73%) and the follow up meeting by 42 (70%). Ninety percent GPs in the follow up meeting filled the questionnaire. For 16 questions, more than 80% GPs gave correct responses whereas five questions attracted a correct answer from less than 80%. Majority of the GPs felt psychotropic medication management in people with ID should be specialist led. Conclusions GPs’ knowledge of issues relevant to prescribing in people with ID benefitted from the tutorial. However a clear need for the psychotropic medication management to be delivered via specialist care emerged. This raises issues of resource allocation and debate on whether people with ID require specialist provision due to lack of ability in main stream primary care to manage their needs.
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Affiliation(s)
- Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Truro, United Kingdom
- University of Exeter Medical School, Exeter, United Kingdom
- * E-mail:
| | - Mike Wilcock
- Royal Cornwall Hospitals Trust, Truro, United Kingdom
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O’Dwyer M, McCallion P, McCarron M, Henman M. Medication use and potentially inappropriate prescribing in older adults with intellectual disabilities: a neglected area of research. Ther Adv Drug Saf 2018; 9:535-557. [PMID: 30181861 PMCID: PMC6116771 DOI: 10.1177/2042098618782785] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/23/2018] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Maire O’Dwyer
- School of Pharmacy and Pharmaceutical Sciences,
University of Dublin Trinity College, Trinity College Dublin, Dublin,
Ireland
| | - Philip McCallion
- School of Social Work, College of Public Health,
Temple University, Philadelphia, PA, USA
| | - Mary McCarron
- Faculty of Health Sciences, University of Dublin
Trinity College, Dublin, Ireland
| | - Martin Henman
- School of Pharmacy and Pharmaceutical Sciences,
University of Dublin Trinity College, Dublin, Ireland
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30
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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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Ramerman L, Hoekstra PJ, de Kuijper G. Exploring barriers and facilitators in the implementation and use of guideline recommendations on antipsychotic drug prescriptions for people with intellectual disability. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2018; 31:1062-1070. [PMID: 29923275 DOI: 10.1111/jar.12461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is unknown why professionals' adherence to guideline recommendations on antipsychotic drug prescription in the intellectual disabilities care is insufficient. This study aimed to explore barriers and facilitators in the implementation and use of these recommendations. METHODS In-depth interviews with four intellectual disability physicians, two psychiatrists and five behavioural scientists were used to explore the implementation and use of guideline recommendations. RESULTS Barriers in adhering to recommendations were lack of collaboration of different disciplines involved in the treatment of psychiatric and behavioural disorders and lack of enforcement of an appropriate monitoring of side- and treatment effects. When guideline recommendations were translated into organizational policies, clinicians were able to divide responsibilities and tasks, needed to appropriately implement guideline recommendations in daily clinical practice. CONCLUSIONS To facilitate the use of guideline recommendations, organizations should translate recommendations into organization-specific policies, involving physicians and behavioural scientists in this process, while simultaneously creating more practical and technological support.
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Affiliation(s)
- Lotte Ramerman
- Centre for Intellectual Disability and Mental Health/GGZ Drenthe, Assen, the Netherlands.,Department of Child and Adolescent Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Pieter J Hoekstra
- Department of Child and Adolescent Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Gerda de Kuijper
- Centre for Intellectual Disability and Mental Health/GGZ Drenthe, Assen, the Netherlands.,Department of Child and Adolescent Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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de Kuijper GM, Hoekstra PJ. An Open-Label Discontinuation Trial of Long-Term, Off-Label Antipsychotic Medication in People With Intellectual Disability: Determinants of Success and Failure. J Clin Pharmacol 2018; 58:1418-1426. [PMID: 29920689 DOI: 10.1002/jcph.1271] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/15/2018] [Indexed: 11/08/2022]
Abstract
Although physicians are aware of the risks of prescribing long-term off-label antipsychotics in people with intellectual disability, attempts to discontinue often fail. This study aimed to identify potential determinants of successful and failed discontinuation. Long-term off-label antipsychotics were tapered in 14 weeks, with 12.5% of baseline dose every 2 weeks. Participants living in facilities offered by intellectual disability service providers, ≥6 years, with an IQ <70 were eligible to discontinue antipsychotic use, as judged by their physicians. The primary outcome was achievement of complete discontinuation at 16 weeks; changes in the Aberrant Behavior Checklist (ABC) and its 5 subscales were secondary outcomes. Potential determinants of the success or failure in discontinuing antipsychotics were psychotropic drug use and participants' living circumstances, medical health conditions, and severity of behavioral symptoms and neurologic side effects. Of 499 eligible clients, 129 were recruited. Reasons for client non-participation were clinician concerns that discontinuation might increase challenging behaviors and changes in clients' environment. Of the 129 participants, 61% had completely discontinued antipsychotics at 16 weeks, 46% at 28 weeks, and 40% at 40 weeks. ABC total scores increased in 49% of participants with unsuccessful discontinuation at 16 weeks. Autism, higher dose of antipsychotic drug, higher ABC and akathisia scores, and more-frequent worsening of health during discontinuation were associated with a lower incidence of complete discontinuation. Thus, in a selected sample of participants whom responsible clinicians had deemed discontinuation of antipsychotics could be attempted, 40% had achieved and maintained discontinuation at end of follow-up. Physicians should try to address patients' conditions that may hamper discontinuation.
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Affiliation(s)
- Gerda M de Kuijper
- Centre for Intellectual Disabilities and Mental Health/GGZ Drenthe Mental Health Institute, the Netherlands.,University of Groningen, University Medical Centre Groningen, University of Groningen, Department of Psychiatry, the Netherlands
| | - Pieter J Hoekstra
- University of Groningen, University Medical Centre Groningen, University of Groningen, Department of Psychiatry, the Netherlands
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