Antipsychotics Overprescribed in Intellectually Disabled?

Liam Davenport

September 16, 2015

A substantial proportion of individuals with intellectual disabilities are prescribed antipsychotics in the absence of a diagnosis of severe mental illness ― a finding that raises concerns that these drugs are being used to control behavior in this patient population.

In a study of more than 30,000 people with intellectual disabilities, more than 60% had received a prescription for antipsychotic drugs, of whom more than 70% had no record of severe mental illness. The results suggest that in many cases, the drugs are being used to control challenging behaviors.

"Inappropriate use of drug treatment has implications for the individual and for healthcare systems," the researchers write. "Optimizing drug use is central to improving care outcomes and will be achieved by a combination of interventions."

"Adoption of a comprehensive medicines optimisation programme...enhanced training of front line professionals, timely recognition and accurate diagnosis of mental illness in people with intellectual disability, and improved accessibility to and development of alternative therapeutic strategies could all contribute to reducing excessive use of psychotropic drugs," they add.

The research was published online September 1 in the BMJ.

No Record of Mental Illness

For the study, the team examined data on 31,016 adults, 58% of whom were male. Intellectual disability had been registered through 571 general practices that contributed data to the Health Improvement Network clinical database. The mean follow-up period was 5.5 years, yielding 211,793 person-years of data.

The researchers determined that 21% of patients had a recorded mental illness at study entry, 25% had a record of challenging behavior, and 49% had been prescribed psychotropic drugs, a figure that increased to 63% by the end of the study.

It was calculated that the incidence of new mental illness during follow-up was 262 per 10,000 person-years; the incidence of challenging behavior was 239 per 10,000 person-years. In contrast, the incidence of new psychotropic drug prescriptions was 518 per 10,000 person-years.

Between 1999 and 2013, the incidence rate of new severe mental illness declined by 5% per year (P < .001), and the rate of new antipsychotic prescriptions decreased by 4% per year (P < .001). There was also a significant 4% annual reduction in the number of new prescriptions for mood stabilizers (P < .001).

By the end of the follow-up period, 71% of individuals who had been prescribed an antipsychotic did not have a record of mental illness. Although 47% of individuals with challenging behaviors had a prescription for antipsychotics, only 12% had a record of severe mental illness.

Taking into account sociodemographic factors and comorbidity, the researchers found that the rate of new antipsychotic prescriptions was significantly increased in individuals with challenging behavior, autism, and dementia, at incidence rate ratios of 1.08 (P < .001), 1.79 (P < .001), and 1.42 (P < .003), respectively. It was also increased in those with a diagnosis of mental illness.

Incidence rate ratios were also increased in older individuals. For example, among those aged 80 years or older, the incidence rate ratio was 2.72 compared with individuals aged 18 to 29 years (P < .001).

Last Resort?

Lead author Rory Sheehan, MBChB, MRCPsych, academic clinical fellow, Division of Psychiatry, University College London, United Kingdom, explained that because the study was observational and used routinely collected data, it is not possible to definitively state why antipsychotics were overprescribed.

However, the results did show that having challenging behavior increased the risk of being prescribed the drugs.

"It may be that the alternatives to managing challenging behavior are either inaccessible, not available when they are needed, or may not be effective, so people use medication maybe as a last resort, or maybe before then," he said.

Acknowledging that more research is needed, he told Medscape Medical News: "I don’t think it's that GPs are necessarily unaware of the evidence base or unaware of the principles of good practice."

"It may be that patients or carers request medication because they maybe don't feel confident in the services that are being offered to them and think that medication will in some way help them manage the patient or the person with the learning disability and challenging behavior."

Dr Sheehan nevertheless believes that a number of steps can be taken to improve prescribing patterns in individuals with intellectual disability.

"I think the first thing we can do in the shorter term is a program of medicines optimization for people with intellectual disability who are taking these psychotropic drugs," he said.

"That will mean that there are regular reviews by prescribers to ensure that those medications are still necessary and still being of benefit."

In addition, doctors and healthcare professionals can work with patients and carers and "third sector" organizations, such as charities, to ensure that the best care possible is provided to people with learning disability.

This, Dr Sheehan believes, may reduce not only the development of challenging behaviors but also rates of such behaviors once they have developed, which in turn may reduce reliance on antipsychotic medications.

"In the longer term, probably we'd be looking for new techniques or new ideas, and certainly more research evidence, for what works for people with challenging behavior and intellectual disability, whether that is medication in certain subgroups or psychosocial interventions, such as positive behavior support or communication support," he said.

"The evidence base for managing challenging behavior in people with intellectual disability is relatively limited at the moment: there's no evidence to suggest that antipsychotics are going to be helpful in this presentation, and relatively little evidence that any other form of intervention is helpful either," Dr Sheehan added.

"We need to expand the evidence base, but obviously that takes some time. So, in the shorter term, trying to provide the best care that we can and regularly reviewing medication may go some way to reducing this inappropriate prescribing," he concluded.

Threat to Well-being

Commenting on the findings for Medscape Medical News, Gail A. Edelsohn, MD, MSPH, senior medical director, Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh, Pennsylvania, said the study was "well done" and had a number of strengths, including its large data set and longitudinal nature.

Although noting that the overall finding of antipsychotic prescribing in individuals with intellectual disability, including those with challenging behavior, has been reported previously, she said the study makes a "very important contribution" to the literature, because it teased out and described the incidence of challenging behaviors in those diagnosed with intellectual disability.

Dr Edelsohn pointed out that the findings mirror those of her earlier study, which revealed high rates of antipsychotic prescribing in both adults and children with intellectual disabilities, as previously reported by Medscape Medical News.

However, these results are in contrast with the results of a 2013 investigation into the prevalence of psychotropic drug use in adults with intellectual disability, which found that although practitioners "rely too heavily" on the drugs, they were used in only a minority of patients without a formal psychiatric diagnosis.

Dr Edelsohn nevertheless said that challenging behaviors are relatively common in individuals diagnosed with intellectual disability, which "can be quite threatening to both the individual’s well-being and to that of others."

Although it is "best practice" to identify the underlying cause of the behaviors first and then to use behavioral nonpharmacologic interventions to reduce the challenging behaviors, Dr Edelsohn acknowledged that "one needs to have the training, the staff, and knowledge of the interventions, as well as an understanding of the precipitants or antecedents of the behavior."

She added: "Medication does work, it's quicker, it's readily available; so it may be used more quickly perhaps than some of these other strategies that can take longer and usually need a team to support their implementation."

She also pointed out that as antipsychotics are being used for conditions outside of their originally approved indications, it is important for prescribers to know the evidence base for their use to treat specific behaviors and symptoms and to consider both the risks and benefits for the individual.

An individual with intellectual disability may not have the ability to consent to medication on their own behalf. Therefore, Dr Edelsohn concluded, this underscores "the importance of their family members or guardians receiving accurate information about the medication and asking about treatment alternatives."

This study received funding from the Baily Thomas Charitable Fund and the UK National Institute for Health Research. All authors had financial support from the Baily Thomas Charitable Fund and the UK National Institute for Health Research for the submitted work. One coauthor has received research grants from the Wellcome Trust and has acted as an investigator for Roche Pharmaceuticals.

BMJ. Published September 1, 2015. Full text

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