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Deutsch SI, Burket JA. Psychotropic medication use for adults and older adults with intellectual disability; selective review, recommendations and future directions. Prog Neuropsychopharmacol Biol Psychiatry 2021; 104:110017. [PMID: 32544599 DOI: 10.1016/j.pnpbp.2020.110017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022]
Abstract
A growing expert consensus has emerged to guide prescribing behavior and monitoring of psychotropic medications in adults and older adults with intellectual disability (ID). However, there is little empirically-derived evidence to inform physician selection of specific categories of psychotropic medication for treatment of "challenging" behaviors in this vulnerable population (such as aggression to self, others and objects; self-injurious behaviors; repetitive stereotypic behaviors; and hyperactivity). Difficulties with application of formal definitional diagnostic criteria and reliable assignment of psychiatric diagnoses to adults with ID, which is often difficult due to their poor communication skills, contribute to confusion and uncertainty surrounding medication selection. Long-term administration of antipsychotic medications are commonly prescribed for challenging behaviors in spite of their questionable long-term efficacy, leading some to suggest that their "episodic" short-term administration for imminent dangerousness to self and others or when difficult-to-find residential placements are threatened is preferred to their long-term administration. Further, literature supports engagement of interdisciplinary treatment teams to seek causes for challenging behaviors, formulate non-pharmacological psychosocial and behavioral plans for their amelioration and, if medications are initiated, convene regular medication monitoring to identify "drug-related problems". Medication monitoring is important because medication-related adverse events cause or contribute to challenging behaviors, which can sometimes be improved by dose reduction, medication discontinuation and/or elimination of polypharmacy and co-pharmacy. Importantly, medications themselves may interfere with self-reported measures of Quality of Life. The data clearly highlight the need for well-designed randomized controlled clinical trials in samples that are homogeneous with respect to severity of ID and residential setting; moreover, they should include a wider variety of clinical and safety outcome measures. Preclinical studies have suggested novel pharmacological strategies to prevent progressive worsening of adaptive function in adults with Down syndrome in particular, and improvement of cognition in adults with ID in general, irrespective of the etiopathogenesis of the ID. Translational clinical trials to address pathogenic mechanisms of ID, as well as challenging behaviors, are anticipated but raise societal issues pertaining to protection of this vulnerable population enrolling in clinical trials and prioritization of urgent therapeutic targets (e.g., amelioration of challenging behaviors versus improving or preserving intellectual functioning).
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Affiliation(s)
- Stephen I Deutsch
- Department of Psychiatry and Behavior Sciences, Eastern Virginia Medical School, 825 Fairfax Avenue, Suite 710, Norfolk, Virginia 23507, USA.
| | - Jessica A Burket
- Department of Molecular Biology and Chemistry, Christopher Newport University, 1 Avenue of the Arts, Newport News, Virginia 23606, USA; Program in Neuroscience, Christopher Newport University, 1 Avenue of the Arts, Newport News, Virginia 23606, USA
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Folch A, Cortés MJ, Salvador-Carulla L, Vicens P, Irazábal M, Muñoz S, Rovira L, Orejuela C, Haro JM, Vilella E, Martínez-Leal R. Risk factors and topographies for self-injurious behaviour in a sample of adults with intellectual developmental disorders. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2018; 62:1018-1029. [PMID: 29607562 DOI: 10.1111/jir.12487] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 11/14/2017] [Accepted: 03/04/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Self-injurious behaviour (SIB) is a prevalent form of challenging behaviour in people with intellectual developmental disorders (IDD). Existing research has yielded conflicting findings concerning the major risk factors involved, and in addition, SIB shows multiple topographies and presentations. Although presence of autism spectrum disorders (ASD) and severity of intellectual disability (ID) are known risk factors for SIB, there are no studies comparing SIB topographies by severity degrees of ID and ASD. The purpose of the present paper has been to identify risk factors and topographies for SIB in a representative, stratified and randomised sample of adults with IDD. METHOD This study was conducted on the basis of data collected by the POMONA-ESP project, in a sample of 833 adults with IDD. Data concerning demographic and health information, ASD symptoms, psychopathology and ID, have been analysed to determine the presence of risk factors for SIB among participants and to explore the occurrence and topographies of SIB across different severity levels of ID and ASD symptoms. RESULTS Self-injurious behaviour prevalence in the sample was 16.2%. Younger age, oral pain, greater severity of ID, presence of dual diagnosis, psychiatric medication intake and higher scores on Childhood Autism Rating Scale were risk factors for SIB among participants, whereas number of areas with functioning limitations, place of residence, diagnosis of epilepsy and sex were not. SIB was more frequent in participants with ASD symptoms regardless of its severity level, and they displayed a higher number of different topographies of SIB. People with profound ID without co-morbid ASD symptoms showed similar results concerning SIB prevalence and topographies. CONCLUSIONS Knowledge on risk factors and topographies of SIB might play a vital role in the development of prevention strategies and management of SIB in people with IDD. The mere presence of ASD symptoms, regardless of its severity level, can be a crucial factor to be taken into account in assessing SIB. Accordingly, the presence of SIB in people with ID, especially when presented with a varied number of topographies, might provide guidance on ASD differential diagnosis.
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Affiliation(s)
- A Folch
- Intellectual Disability and Developmental Disorders Research Unit (UNIVIDD), Fundació Villablanca, IISPV, Universitat Rovira i Virgili, Reus, Spain
- Department of Psychology, Universitat Rovira i Virgili, Tarragona, Spain
| | - M J Cortés
- Intellectual Disability and Developmental Disorders Research Unit (UNIVIDD), Fundació Villablanca, IISPV, Universitat Rovira i Virgili, Reus, Spain
- Centre of Biomedical Research Network on Mental Health (CIBERSAM), Spain
| | - L Salvador-Carulla
- Centre for Mental Health Research, Research School of Population Health, ANU College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - P Vicens
- Department of Psychology, Universitat Rovira i Virgili, Tarragona, Spain
- Research Center in Behavioral Assessment (CRAMC), Universitat Rovira i Virgili, Tarragona, Spain
- Laboratory of Toxicology and Environmental Health, Universitat Rovira i Virgili, Tarragona, Spain
| | - M Irazábal
- Parc Sanitari Sant Joan de Déu, Spain
- Faculty of Education, Universitat de Barcelona, Barcelona, Spain
| | - S Muñoz
- Plena Inclusión España, Madrid, Spain
| | - L Rovira
- Intellectual Disability and Developmental Disorders Research Unit (UNIVIDD), Fundació Villablanca, IISPV, Universitat Rovira i Virgili, Reus, Spain
| | - C Orejuela
- Intellectual Disability and Developmental Disorders Research Unit (UNIVIDD), Fundació Villablanca, IISPV, Universitat Rovira i Virgili, Reus, Spain
| | - J M Haro
- Centre of Biomedical Research Network on Mental Health (CIBERSAM), Spain
- Parc Sanitari Sant Joan de Déu, Spain
- Department of Psychiatry and Clinical Psychobiology, Universitat de Barcelona, Barcelona, Spain
| | - E Vilella
- Centre of Biomedical Research Network on Mental Health (CIBERSAM), Spain
- Institut Pere Mata, University Psychiatric Hospital, Reus, Spain
| | - R Martínez-Leal
- Intellectual Disability and Developmental Disorders Research Unit (UNIVIDD), Fundació Villablanca, IISPV, Universitat Rovira i Virgili, Reus, Spain
- Centre of Biomedical Research Network on Mental Health (CIBERSAM), Spain
- Department of Psychology, Universitat Rovira i Virgili, Tarragona, Spain
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Molina-Ruiz RM, Martín-Carballeda J, Asensio-Moreno I, Montañés-Rada F. A guide to psychopharmacological treatment of patients with intellectual disability in psychiatry. Int J Psychiatry Med 2017; 52:176-189. [PMID: 28792289 DOI: 10.1177/0091217417720896] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Subjects with intellectual disability are at increased risk of having comorbid psychiatric disorders and worse response to psychotherapeutic and psychopharmacological treatment interventions. On the other hand, available data on best treatment approach in this population are scarce and lack scientific evidence due to methodological limitations. The present study aims to perform a systematic review of the literature to facilitate the use of psychotropic drugs in clinical practice and better establish future research targets in this field. Objectives To review the available psychopharmacological strategies for patients with intellectual disabilities, psychiatric disorders, and behavioural disturbances. Serve as a quick guide for clinicians working in the field of intellectual disability. Methods We conducted a selective evidence-based review of the literature using Pubmed and EMBASE databases and selected most recent and relevant papers for this review. Results There are several available psychotropic drugs for the treatment of patients with intellectual disability and comorbid psychiatric disorders, although scientific evidence is limited. Treatment should be individualized according to risk-benefit balance. Discussion Further studies are needed and new available drugs should be considered to gain knowledge in effectiveness of different therapeutic approaches available in this population.
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Affiliation(s)
- Rosa M Molina-Ruiz
- 1 Department of Psychiatry, Fundación Alcorcón University Hospital-Public Health Agency, Madrid, Spain.,2 Psychiatry Department, Universidad Rey Juan Carlos de Madrid, Madrid, Spain
| | - Julia Martín-Carballeda
- 1 Department of Psychiatry, Fundación Alcorcón University Hospital-Public Health Agency, Madrid, Spain.,2 Psychiatry Department, Universidad Rey Juan Carlos de Madrid, Madrid, Spain
| | - Inmaculada Asensio-Moreno
- 3 Department of Psychiatry, Gómez Ulla Central Defense Hospital-Public Health Agency, Ministry of Defense, Madrid, Spain
| | - Francisco Montañés-Rada
- 1 Department of Psychiatry, Fundación Alcorcón University Hospital-Public Health Agency, Madrid, Spain.,2 Psychiatry Department, Universidad Rey Juan Carlos de Madrid, Madrid, Spain
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Trichotillomania as a Manifestation of Dementia. Case Rep Psychiatry 2016; 2016:9782702. [PMID: 27840761 PMCID: PMC5093278 DOI: 10.1155/2016/9782702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 09/25/2016] [Accepted: 10/04/2016] [Indexed: 12/11/2022] Open
Abstract
Pathological hair-pulling or trichotillomania, which is commonly associated with anxiety and depression, obsessive-compulsive disorder, and neurodevelopmental disorders, has been rarely associated with dementing illnesses. Investigators have not clarified the neural correlates and treatment of trichotillomania in dementia. We report a patient who developed an early-onset cognitive decline with genetic, cerebrospinal fluid biomarker and structural and functional neuroimaging studies consistent with Alzheimer's disease. Eight years into her disease, she developed severe, repetitive hair-pulling behavior leading to marked hair loss, along with other repetitive and “frontal” behaviors. Selective serotonin reuptake inhibitors (SSRIs) were ineffective in controlling her hair-pulling behavior, which subsequently responded to quetiapine 150 mg/day. This patient and a review of the literature suggest that trichotillomania may be a compulsive-related symptom in dementias of different etiologies as they involve frontal areas and release primitive grooming behavior from frontostriatal dysfunction. Dopamine blockade, rather than SSRIs, may be effective in managing trichotillomania in dementia.
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