RCPsych’s article of the month for September is “Pharmacological Management of Psychopathology in People with Intellectual Disability and/or Autism Spectrum Disorder” by Shoumitro Deb, Meera Roy and Bharati Limbu and published in BJPsych Advances. The author of the blog is Professor Shoumitro Deb.
About 1-3% of the population has an intellectual (learning) disability. They are prone to developing a number of psychiatric disorders just like the general population. Treatment of psychiatric disorders in this population should follow the relevant NICE guidelines. However, many people with intellectual disabilities also exhibit challenging behaviors. There are many reasons for this behavior, including physical (pain such as headache or toothache, constipation, acid reflux, certain genetic disorders, etc.), psychiatric (psychosis, depression, mania, etc.), psychological (stress, trauma, impaired strategy Stress management). etc.), environmental (unsuitable environment, lack of support, etc.). Challenging behavior is often a means of communication for people with intellectual disabilities and autism.
Both pharmacological and non-pharmacological psychosocial interventions have been used for challenging behaviour. However, psychotropic substances are often used for behavior that is challenging in the absence of psychiatric disorders. For example, while 2–4% of adults with an intellectual disability have a diagnosis of psychosis, about 24–32% receive antipsychotic medication, as opposed to 0.9–1% in the general population. Population-based data from the UK and the Netherlands showed that in 71-78%% of cases, antipsychotics were not prescribed for serious mental illness, but often for challenging behavior (58% of cases). This unlicensed use of psychotropic substances is a cause of great public health concern. However, off-label prescription in itself may not be inappropriate as long as proper guidelines are followed and treatment options are regularly reviewed. But in many cases these drugs have been prescribed for many years without proper review and consideration of rationalization. In many cases, the problems are complicated by polypharmacy, a higher than BNF recommended dose and the inability to carry out the necessary tests (eg in the case of clozapine and lithium and also to detect adverse effects) in some people with intellectual disabilities. Therefore, additional protective measures are needed to protect this vulnerable population.
While the evidence for the effectiveness of off-license prescription of psychotropic drugs is weak, the evidence for their harm is strong. Under the circumstances, doctors must carefully weigh the risks and benefits of each drug for each person. Given the multifactorial nature of challenging behavior, it is essential to take an interdisciplinary bio-psycho-social approach to assessment and formulation that leads to multidisciplinary intervention. A multidisciplinary approach and shared decision-making involving people with intellectual disabilities and their families is even more essential as off-label prescribing in the absence of informed consent, which may be the case for many people with severe and profound intellectual disabilities and lack of evidence of efficacy and concerns about adverse drug effects can be considered unethical.
Despite international NICE and WPA guidelines, concerns remain. There needs to be a concerted effort by all stakeholders, including service providers and commissioners, to tackle this problem, which cannot be solved by the NHSE STOMP STAMP initiative launched a few years ago to stop the overmedication of people with learning disabilities and autism alone. Appropriate use of resources is needed along with a culture shift facilitated by appropriate training for professionals, support staff and family carers.
This article discusses a problem of great concern to many observers, including myself, the over-prescription of psychotropic drugs. This paper presents a critical examination, based on the available evidence, of the benefits of these drugs with specific reference to the ID population. It highlights the benefits of some low-dose antipsychotics, but also points to the worrying failure of various guidelines and campaigns to limit the practice in the interest of patient safety. This article is a “must read” for any clinician working with the ID patient cohort.
Patricia Casey
Editor-in-Chief, BJPsych Advances
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