Background Antipsychotic medications are used among 19%-58% of adults with intellectual disabilities to manage challenging behaviour against the NICE guideline recommendations. Studies show that it is possible to completely withdraw antipsychotics in about one third of adults with intellectual disabilities and a dose reduction of 50% or more in another third. Method In Cornwall, over three years the present authors developed a structured pathway to withdraw antipsychotics among adults with intellectual disabilities which involved people with intellectual disabilities and their carers, GPs, community learning disability team members and pharmacists. Results The present authors managed to withdraw antipsychotics totally among 46.5% (33/71) and reduced over 50% of dosage in another 11.3% (8/71) of adults with intellectual disabilities. At three months follow-up no one required hospital admission or change in placement. Conclusion It is possible to withdraw/reduce antipsychotics in a high proportion of adults with intellectual disabilities if a concerted effort is made involving all stakeholders from the outset.

A structured programme to withdraw antipsychotics among adults with intellectual disabilities: The Cornwall experience

Neurodevelopmental disorders (NDDs) are a group of complex and heterogeneous disorders, caused by the disruption of normal brain development. Antipsychotic agents are frequently used in these disor...

Safety and tolerability of antipsychotic agents in neurodevelopmental disorders: a systematic review.

Background: Psychotropic medications are sometimes used off-label and inappropriately. This may cause harm to adolescents with intellectual disability. However, few studies have analysed off-label or inappropriate prescribing to this group.AimsTo examine the appropriateness of psychotropic prescribing to adolescents with intellectual disability living in the community in south-east Queensland, Australia.Method: Off-label medication use was determined based on whether the recorded medical condition treated was approved by the Australian Therapeutic Goods Administration. Clinical appropriateness of medication use was determined based on published guidelines and clinical opinion of two authors who specialise in developmental disability medicine (J.N.T. and D.H.).Results: We followed 429 adolescents for a median of 4.2 years. A total of 107 participants (24.9%) were prescribed psychotropic medications on at least one occasion. Of these, 88 (82.2%) were prescribed their medication off-label or inappropriately at least once. Off-label or inappropriate use were most commonly associated with challenging behaviours.Conclusions: Off-label or inappropriate use of psychotropic medications was common, especially for the management of challenging behaviours. Clinical decision-making accounts for individual patient factors and is made based on clinical experience as well as scientific evidence, whereas label indications are developed for regulatory purposes and, although appropriate at a population level, cannot encompass the foregoing considerations. Education for clinicians and other staff caring for people with intellectual disability, and a patient-centred approach to prescribing with involvement of families should encourage appropriate prescribing. The effect of the National Disability Insurance Scheme on the appropriateness of psychotropic medication prescribing should be investigated.

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Appropriateness of psychotropic medication use in a cohort of adolescents with intellectual disability in Queensland, Australia.

The prescribing of psychotropic medications for people with an intellectual disability has changed. In many locations across England, antidepressants have become the most widely prescribed psychotropic. In the context of the current NHS England STOMP programme to reduce inappropriate psychotropic prescribing for people with intellectual disability, there is an urgent need to understand whether this change reflects evidence-based use of the medications involved. There has been little analysis into the benefits or problems associated with the change and whether it is of concern. This paper offers a variety of possible explanations and opportunities to improve clinical practice and policy.

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Antidepressant prescribing for adult people with an intellectual disability living in England

Background Non-pharmacological interventions are recommended for the treatment of challenging behaviours in individuals with intellectual disabilities by clinical guidelines. However, evidence for their effectiveness is ambiguous. The aim of the current meta-analysis is to update the existing evidence, to investigate long-term outcome, and to examine whether intervention type, delivery mode, and study design were associated with differences in effectiveness. Method An electronic search was conducted using the databases Medline, Eric, PsychINFO and Cinahl. Studies with experimental or quasi-experimental designs were included. We performed an overall random-effect meta-analysis and subgroup analyses. Results We found a significant moderate overall effect of non-pharmacological interventions on challenging behaviours (d = 0.573, 95% CI [0.352-0.795]), and this effect appears to be longlasting. Interventions combining mindfulness and behavioural techniques showed to be more effective than other interventions. However, this result should be interpreted with care due to possible overestimation of the subgroup analysis. No differences in effectiveness were found across assessment times, delivery modes or study designs. Conclusions Non-pharmacological interventions appear to be moderately effective on the short and long term in reducing challenging behaviours in adults with intellectual disabilities.

/pdf/non-pharmacological-interventions-for-challenging-behaviours-418t9uvzfz.pdf

Non-pharmacological interventions for challenging behaviours of adults with intellectual disabilities: A meta-analysis.

### Key learning points

Intellectual disability (ID; also known as learning disability) is characterised by significant impairment of both cognitive functioning and adaptive behaviours, and an onset in early childhood. People with ID experience a different pattern of morbidity to the general population and die considerably younger than their counterparts without ID.1 Autism is a neurodevelopmental disorder characterised by troubles with social interaction and communication, and by restricted and repetitive behaviour. In both conditions, complex mental and physical health problems, as well as social issues, are common and are associated with communication difficulties that can result in maladaptive behavioural patterns (often referred to as ‘behaviour that challenges’). Ideally, all people presenting with behaviour that challenges should be assessed by a specialist multidisciplinary team (comprising psychiatrists, psychologists, speech and language therapists, occupational therapists) to develop an understanding of the behaviour and an appropriate support plan with tailored treatment strategies and specialist follow-up.2 Non-pharmacological interventions for challenging behaviour, such as positive behavioural support or cognitive–behavioural therapy and manipulation of environmental triggers, are preferred to psychotropic medication. However, antipsychotic medication is often prescribed to adults with ID and/or autism to manage behaviour that challenges in the absence of severe mental illness, despite there being little research evidence that antipsychotics are effective in this context.3 

There …

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Paula McGowan

Papers

Stopping, rationalising or optimising antipsychotic drug treatment in people with intellectual disability and/or autism.

Why learning disability and autism training should be mandatory