Pipothiazine palmitate in the management of aggressive mentally handicapped patients

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Representation of people with intellectual disabilities in randomised controlled trials on antipsychotic treatment for behavioural problems

BACKGROUND

Behavioural problems are common in people with intellectual disability (ID) and are often treated with antipsychotics.

AIM

To establish the frequency and characteristics of people with ID included in randomised controlled trials (RCTs) on antipsychotic treatment for behavioural problems, and to investigate the quality of these RCTs.

METHODS

A literature search in EMBASE, PubMed and Cochrane was performed and reviewed.

RESULTS

People with ID participated in 27 of the 100 included RCTs. The RCTs were of good quality but smaller compared with trials in patients with dementia or schizophrenia (average sample sizes = 55, 124 and 374). In 13/27 trials no clear definition of ID was given. Over 25 different outcome measures were used to assess behavioural problems.

CONCLUSIONS

Studies in which people with ID are included are of a sufficient quality, but of a small size. The heterogeneity in the characteristics of the ID population included as well as in the applied assessment instruments makes performing meta-analyses unfeasible.

The effectiveness of antipsychotic medication in the management of behaviour problems in adults with intellectual disabilities

BACKGROUND

Psychopharmacological intervention in the management of behaviour problems in adults with intellectual disabilities (ID) has become a common treatment strategy. This has become a cause for concern, given that the evidence for its effectiveness is uncertain and most drugs are not licensed for this use.

METHODS

A comprehensive systematic review of empirical research on the effectiveness of antipsychotic medication was conducted. Electronic and manual searches of literature were conducted. Stringent scientific methodology determined those primary trials that were worthy of inclusion.

RESULTS

This review revealed one randomized controlled trial (RCT), one controlled, four uncontrolled prospective and three retrospective case series studies in adults. Additionally, two studies in both adults and children--one crossover RCT and one prospective controlled trial--were found.

CONCLUSION

Presently, there is RCT-based evidence for risperidone to be effective in both adults and children; however, this treatment carries a certain amount of risk associated with adverse effects. There is also evidence to support the use of other antipsychotics, primarily atypicals, but the evidence is based on noncontrolled case studies. There is currently not enough evidence available to recommend specific medication for specific behaviour problems. Before prescribing medication, clinicians should carry out a thorough assessment of behaviour, including its causes and consequences, and draw up a formulation providing the rationale for the prescribed intervention after considering all medication- and nonmedication-based management options.

Reviewing the use of antipsychotic drugs in people with intellectual disability

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Antipsychotic medication for challenging behaviour in people with learning disability

BACKGROUND

The term 'challenging behaviour', in the absence of psychiatric disorder, encompasses a wide range of behaviours that may be harmful to people or property, may be difficult to manage and may limit access to community facilities. Antipsychotic medications have been used to modify such behaviours in people with learning disability, but there is little evidence to suggest that the benefits outweigh the risks.

OBJECTIVES

To determine the effectiveness of antipsychotic medication for people with learning disability and challenging behaviour without additional mental illness.

SEARCH STRATEGY

Biological Abstracts, the Cochrane Library, EMBASE, MEDLINE, PsycINFO and BIOSIS were searched. Further references were sought from published trials and pharmaceutical companies. Trials were reliably identified and data extracted.

SELECTION CRITERIA

All randomised controlled trials of antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

Reviewers independently evaluated and analysed data on an intention to treat basis. Data were evaluated at 4, 8 and 12 weeks as longer follow-up data were not available. Reviewers assumed that those subjects lost to follow-up had a bad outcome.

MAIN RESULTS

Only nine randomised controlled trials could be included in the analyses. These provided no evidence of whether antipsychotic medication helps or harms adults with learning disability and challenging behaviour.

REVIEWERS' CONCLUSIONS

There are limited data on this important issue and more research is urgently needed.

Antipsychotic medication for challenging behaviour in people with learning disability

BACKGROUND

The term 'challenging behaviour', in the absence of psychiatric disorder, encompasses a wide range of behaviours that may be harmful to people or property, may be difficult to manage and may limit access to community facilities. Antipsychotic medications have been used to modify such behaviours in people with learning disability, but there is little evidence to suggest that the benefits outweigh the risks.

OBJECTIVES

To determine the effectiveness of antipsychotic medication for people with learning disability and challenging behaviour.

SEARCH STRATEGY

Biological abstracts, the Cochrane Library, the Cochrane Schizophrenia Group's Register, EMBASE, MEDLINE, PsycLIT were searched. Further references were sought from published trials and pharmaceutical companies. Trials were reliably identified and data extracted.

SELECTION CRITERIA

All randomised controlled trials of antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

Reviewers independently evaluated and analysed data on an intention to treat basis. Data were evaluated at 4 and 8 weeks as longer follow-up data were not available. Reviewers assumed that those subjects lost to follow-up had a bad outcome.

MAIN RESULTS

Only three randomised controlled trials could be included in the analyses. These provided no evidence of whether antipsychotic medication helps or harms adults with learning disability and challenging behaviour.

REVIEWER'S CONCLUSIONS

There is limited data on this important issue and more research is urgently needed.

Antipsychotic medication for challenging behaviour in people with intellectual disability: a systematic review of randomized controlled trials

A study was performed to determine the effectiveness of antipsychotic medication for people with intellectual disability (ID) and challenging behaviour. Randomized controlled trials comparing antipsychotic medication to placebo in people with ID and challenging behaviour were identified by electronic searching and hand-searching. Reviewers independently evaluated and analysed data on an intention-to-treat basis. Only three randomized controlled trials could be included in the analyses. These trials provided no evidence as to whether antipsychotic medication does or does not help adults with ID and challenging behaviour. There is limited data on this important issue and good quality research is urgently needed.

Psychopharmacologic treatment of pathologic aggression

Several drugs are apparently effective in treating pathologic anger and aggression. Because many of the studies on aggressive populations allowed the use of concomitant medications, it is unclear whether the efficacy of each drug in a particular population is dependent on the presence of other medications, such as antipsychotic agents. Finally, one needs to be circumspect in inferring efficacy of a particular drug in aggressive patients with neuropsychiatric conditions other than the ones in which some efficacy has been established. Lithium appears to be an effective treatment of aggression among nonepileptic prison inmates, mentally retarded and handicapped patients, and among conduct-disordered children with explosive behavior. Certainly, lithium would be the treatment of choice in bipolar patients with excessive irritability and anger outbursts, and it has been shown to be effective in this population. Anticonvulsant medications are the treatment of choice for patients with outbursts of rage and abnormal EEG findings. The efficacy of these drugs in patients without a seizure disorder, however, remains to be established, with the exception perhaps of valproate and carbamazepine. In fact, dyphenylhydantoin did not appear to be effective in treating aggressive behavior in children with temper tantrums and was found to be effective in only a prison population. There is some evidence for the efficacy of carbamazepine and valproate in treating pathologic aggression in patients with dementia, organic brain syndrome, psychosis, and personality disorders. As Yudofsky et al point out in their review of the literature, although traditional antipsychotic drugs have been used widely to treat aggression, there is little evidence for their effectiveness in treating aggression beyond their sedative effect in agitated patients or their antiaggressive effect among patients whose aggression is related to active psychosis. Antipsychotic agents appear to be effective in treating psychotic aggressive patients, conduct-disordered children, and mentally retarded patients, with only modest effects in the management of pathologic aggression in patients with dementia. Furthermore, at least in one study, these drugs were found to be associated with increased aggressiveness in mentally retarded subjects. On the other hand, atypical antipsychotic agents (i.e., clozapine, risperidone, and olanzapine) may be more effective than traditional antipsychotic drugs in aggressive and violent populations, as they have shown efficacy in patients with dementia, brain injury, mental retardation, and personality disorders. Similarly, benzodiazepines can reduce agitation and irritability in elderly and demented populations, but they also can induce behavioral disinhibition. Therefore, one should be careful in using this class of drugs in patients with pathologic aggression. Beta-blockers appear to be effective in many different neuropsychiatric conditions. These drugs seem effective in reducing violent and assaultive behavior in patients with dementia, brain injury, schizophrenia, mental retardation, and organic brain syndrome. As pointed out by Campbell et al in their review of the literature, however, systematic research is lacking, and little is known about the efficacy and safety of beta-blockers in children and adolescents with pathologic aggression. Although widely used in the management of pathologic aggression, the use of this class of drugs has been limited partially by marked hypotension and bradycardia, which are side effects common at the higher doses. The usefulness of the antihypertensive drug clonidine in the treatment of pathologic aggression has not been assessed adequately, and only marginal benefits were observed with this drug in irritable autistic and conduct disorder children. Psychostimulants seem to be effective in reducing aggressiveness in brain-injured patients as well as in violent adolescents with oppositional or conduct disorders, particu

Depot neuroleptic usage in adults with learning disabilities

Most previous surveys of depot neuroleptic usage have monitored the consumption of oral psychoactive medications by heterogeneous mental handicap hospital populations. The present study assessed the prevalence, patient, practice and service delivery factors associated with depot neuroleptic usage in community learning disabilities services. The total of 79 adult subjects receiving depot neuroleptics roughly represented 0-5% of local service users. Several significant differences emerged between the factors associated with usage in the 61 (77%) subjects with psychotic disorders and 18 (23%) other subjects. Fitting backward elimination regression models accounted for 67-75% of the depot dosage variance. Comparison of these results with data from previous depot research studies suggested several methodological, clinical, ethical and research issues for future consideration.

Pediatric psychopharmacotherapy: a review of recent research

In the past 5 years, we have witnessed the continuation of important trends in clinical research that began earlier in the decade. With regard to the treatment of specific disorders in children and adolescents, the most significant developments have been the examination of the tricyclics for the treatment of depression and the initiation of controlled studies for the treatment of Tourette syndrome. Unfortunately, the findings from the depression studies have been uniformly negative, and the results of research on both depression and tic disorders show a relatively high rate of placebo responsivity, which raises nagging questions about the role of case reports and open trials. Another important trend in pediatric psychopharmacotherapy is the search for substitutes for the neuroleptics. Potential candidates include agents such as lithium, naltrexone, fenfluramine, clonidine, and carbamazepine. The most underresearched disorders are a combination of the least common (e.g. schizophrenia, mania) and those that are apparently perceived as less serious (e.g. sleep disorders, certain anxiety disorders). Not surprisingly, the most studied disorder and treatment is hyperactivity and stimulant medication, respectively. Considerable progress has been made in understanding the social implications of the associated symptoms and their response to stimulant drugs, aided greatly by the use of direct observation procedures. Researchers are beginning to attend to the implications of comorbidity for assessing response to medication. There has been additional confirmation of efficacy of stimulant treatment for preschoolers and adolescents. Dose-response issues remain to some extent unresolved, the primary impediments being interpretive misconceptions associated with trend analysis, an overreliance on the syndromal perspective and too little attention to target behaviors and their clinical implications, and the failure to operationalize the minimal effective dose with regard to the normalization and supranormalization of target and collateral behaviors. Disagreement over whether hyperactivity is a learning or a behavior disorder (or both) and what academic underproductivity means clinically and socially is also impeding progress. With regard to developmental disorders, controlled studies indicate that fenfluramine and naltrexone are effective for managing associated symptoms in some individuals. However, given the limited amount of research on these agents, their status as clinically useful palliatives must be considered tentative.(ABSTRACT TRUNCATED AT 400 WORDS)

Pharmacologic control of aberrant behavior in the mentally retarded: toward a more rational approach

Drugs are frequently used to control aberrant behavior in the mentally retarded. However, despite decades of research, this approach to behavioral management has had very limited success. Slow progress in this area can be attributed, in part, to the lack of a theoretical framework to guide research. The main purpose of this review is to integrate clinical research in this area with evidence concerning the neurochemical mechanisms that mediate aberrant behaviors. It is concluded that a theoretical framework that takes into account the biological mechanisms that underlie disordered behavior and the actions of drugs provides the basis for a more rational approach to the development of pharmacological therapies in the mentally retarded.

Reduction in antipsychotic drug dosage in mentally handicapped patients. A hospital study

An investigation in a large mental handicap hospital revealed that 24% of the in-patients were receiving antipsychotic drugs. Chlorpromazine and thioridazine prescriptions accounted for 62% of the total while 10% of patients received depot preparations. Fifty-five per cent of the patients receiving these drugs had no established psychiatric diagnosis; most of these could be categorised as having a behaviour disorder. Patients aged 30-50 received higher doses, and female patients received a significantly higher mean dosage than male ones. In the patients receiving neuroleptic drugs who had also been taking them four years previously, there was a significant reduction in the dosage of the drugs received and the extent of polypharmacy of these agents. A mandatory requirement to review all prescriptions annually, implemented in 1984, may be a reason for this.

Aggressive behavior in hospitalized psychogeriatric patients

The frequency and characteristics of aggressive and hostile behavior in 40 psychogeriatric inpatients was investigated using the Staff Observation Aggression Scale (SOAS). Most aggressive acts were directed towards nursing staff when providing help with activities of daily living. A positive correlation was found between age and the frequency of aggressive behavior, while severity was most strongly correlated to length of admission. A significant decrease in frequency was observed during the six weeks of observation. The causes of this decrease are discussed together with the implications for future studies on the treatment of aggressive behavior in this group of patients.