Antipsychotics Overused in Intellectually Disabled Adults

Megan Brooks

August 24, 2017

Antipsychotics are commonly prescribed to adults with intellectual and developmental disabilities (IDDs), frequently in the absence of a documented psychiatric diagnosis.

Investigators found that more than a third of adults with an IDD, such as autism, Down syndrome, or fetal alcohol syndrome, were dispensed antipsychotic medication and that more than a quarter of these individuals had no documented psychiatric diagnosis.

"Research from many different countries has flagged this issue," lead investigator, Yona Lunsky, PhD, from the Institute for Clinical Evaluative Sciences and the Centre for Addiction and Mental Health, Toronto, Ontario, Canada, told Medscape Medical News.

Dr Yona Lunsky

"There has been increased attention to this issue in the UK [where] they have been writing commentary and flagging this problem for several years. We felt it was important to look at what's going on in Ontario, which is the largest province in Canada, as a first step to try to come up with best practices around prescribing," said Dr Lunsky.

The study was published online August 23 in the Canadian Journal of Psychiatry.

Chemical Restraints?

The researchers examined healthcare data for 51,881 adults with IDDs who were younger than age 65 years as of April 2010 and who were receiving provincial drug benefits in Ontario. They were followed until March 2016.

During the 6-year follow-up period, 39.2% of adults (n = 20,316) were prescribed an antipsychotic medication and 28.9% of them did not have a documented psychiatric diagnosis.

Among a subgroup of 7219 living in group homes, 56.4% (n = 4073) were prescribed antipsychotic medication and 42.9% had no reported psychiatric diagnosis.

"We don't know why they are being prescribed from this study and we can't say how often it was a correct or incorrect prescription," said Dr Lunsky.

However, the results "make us question how often antipsychotics are being used as a tool to manage behavioral issues. We need to understand more about why these medications are prescribed to those without psychiatric disorders, what else has been tried prior to medication, and how well these medications are being monitored," she added in a news release.

"Hopefully [this study] can spark conversations on the why, and the what to do about it. Solutions have to be multipronged," she said.

Commenting on the findings for Medscape Medical News, Melissa Nishawala, MD, medical director of the Autism Spectrum Disorder Clinical & Research Program at NYU Langone Health, New York City, noted that the study mirrors previous research showing overuse of antipsychotics in other populations, including adults with dementia and young people in foster or residential care.

She noted that despite considerable anecdotal evidence indicating similar prescribing patterns in patients with IDDs, few studies have documented US antipsychotic use in this population.

"This important research starts a dialogue on the topic and hopefully will lead to additional attention to the topic here in the US," said Dr Nishawala, who is also clinical director of the Eating Disorders Service at The Child Study Center at NYU Langone Health.

Antipsychotic medications have a "very high side effect profile, including metabolic side effects, such as weight gain, dyslipidemia, and prediabetic states, as well as potentially irreversible movement disorders, such as tardive dyskinesia," she noted.

Therefore, it is "critical that individuals who are prescribed this class of medications have a full psychiatric workup with a clear indication for use of the antipsychotic and close monitoring for both benefit and potential side effects. Careful psychiatric evaluation and monitoring would be expected to lead to more accurate diagnosis, which could result in referral for behavioral treatment or use of medications with more favorable side effect profiles," said Dr Nishawala.

Victor Fornari, MD, director of child and adolescent psychiatry at Zucker Hillside Hospital, Glen Oaks, New York, told Medscape Medical News that because of the side effects of antipsychotics, "we try not to prescribe them unless medically necessary."

"We know that they can be used for behavioral control, but we also know that there are also many nonpharmacological approaches for behavioral control that really should be implemented before using this kind of chemical restraint," Dr Fornari said.

"When followed, behavioral management strategies for this population can be very effective, but they do require intensive staff training and ongoing vigilance to make sure behavioral plans are adhered to. This class of medication can be used when the behavior management strategies haven't been adequate," he added.

"Ideally, if you're going to prescribe an antipsychotic medication, there should be clear documentation of the indication and if it is a psychiatric illness, in addition to the developmental disorder, it should be clearly indicated. But we do know that many times they are used simply for behavioral control, for sedation, as a chemical restraint, and really that should be minimized," said Dr Fornari.

The study was supported by the Institute for Clinical Evaluative Sciences. The authors, Dr Nishawala, and Dr Fornari have disclosed no relevant financial relationships.

Can J Psych. Published online August 23, 2017. Abstract

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