Pharmacologic Management of Aggression in Adults with Intellectual Disability

Abstract

Introduction: Aggression is a common behavioral problem seen in patients with intellectual disabilities (ID). The safety and efficacy of second generation antipsychotics (SGAs), mood stabilizers and antidepressants in the management of aggression in these individuals have minimally been studied. This review aims to 1) summarize the studies conducted using second generation antipsychotics, mood stabilizers and antidepressants in treating aggressive behaviors in patient with ID and 2) determine based on the existing literature, which medications have been examined in the most rigorous study design that might suggest the most efficacy for use in clinical practice. Methods: Literature searches using PUBMED Central, CINAHL Plus, PsychINFO, and Embase databases were conducted using the following terms: intellectual disability/disabilities, mental retardation, developmental disability/disabilities, aggression, agitation, behavior disorder, adult, treatment, management. Studies predominantly including children with ID, and autism/pervasive developmental disabilities spectrum disorders were excluded. Analyses were done by class of medication: SGAs, mood stabilizers and antidepressants. The primary outcome measure was reduction in aggressive or self injurious behaviors as measured by each individual study. Results: The most rigorous study designs found using these agents were randomized controlled trials (RCT). A total of 10 RCTs were found, the majority being with risperidone (3) and lithium (2). Treatment with risperidone showed reduction in aggression when compared to placebo in most RCTs with the exception of one study in which risperidone was not better than placebo. Both lithium studies showed reduction in aggression when compared to placebo. The most abundant literature exists in retrospective chart reviews. The most commonly studied agent was risperidone which showed reduction in aggression in majority of the studies. Conclusions: Limited data exists for treatment of aggression in adults with ID. There are very few studies examining pharmacologic agents using RCTs. Given that risperidone and lithium were the most commonly studied agents in the most rigorous experimental design, it is suggested that these two agents prove efficacious for treatment of aggression in patients with ID. Limitations to most of these studies included concomitant psychotropic administration with variations in types and dosing, severity of ID, and the idea that a wide variety of aggression scales were used to assess outcome. Further research with more scientific rigor is required in this field.

A guide to psychopharmacological treatment of patients with intellectual disability in psychiatry

“…Strategies to avoid side effects include the discontinuation of treatment in case of severe reactions, dose reduction, substitution by other psychoactive drug, or association of muscarinic anticholinergics (for example, biperiden). Risperidone is usually the first drug of choice especially in children and adolescents with ID, though scientific evidence is limited to a few studies: double-blind placebo-controlled cross-over trial with 27 patients, 21,22,9 another study including 8 patients with MR, 21 and an open-label fashion study with 11 male outpatients with autism and MR. 23…”

“…Carbamazepine in a double blind placebo-controlled cross-over study showed 40% improvement in overactivity; however, those also had elevated mood prior to treatment. 22…”

“…14 Strategies to avoid side effects include the discontinuation of treatment in case of severe reactions, dose reduction, substitution by other psychoactive drug, or association of muscarinic anticholinergics (for example, biperiden). Risperidone is usually the first drug of choice especially in children and adolescents with ID, though scientific evidence is limited to a few studies: double-blind placebo-controlled cross-over trial with 27 patients, 21,22,9 another study including 8 patients with MR, 21 and an open-label fashion study with 11 male outpatients with autism and MR. 23 Finally, some conditions such as behavioral disturbances in patients with ID may be chronic, so prescription of antipsychotics involve considering risks and benefits. It is recommended to restrict its use especially in children's population and try to include treatment breaks when possible.…”

“…aggression, suicide ideation) and combination with other drugs (i.e. association with first-generation antipsychotics) 22 difficults generalizing results to ID population.…”

“…41 Carbamazepine in a double blind placebo-controlled cross-over study showed 40% improvement in overactivity; however, those also had elevated mood prior to treatment. 22 At the moment, there is less available scientific evidence for antiepileptic drugs such as carbamazepine, oxcarbazepine, or lamotrigine, which have not been confirmed as stabilizers in children. Topiramate has been suggested to have a role in the treatment of challenging/maladaptive behaviors in ID individuals, according to a retrospective review study with 22 institutionalized adults with profound ID.…”