Reducing antipsychotic medication in people with a learning disability

Ahmed, Zahir; Fraser, William; Kerr, Michael Patrick; Kiernan, Chris; Emerson, Eric; Robertson, Janet; Felce, David John; Allen, David G.; Baxter, Helen; Thomas, James

doi:10.1192/bjp.176.1.42

Cited by 125 publications

(123 citation statements)

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“…Brylewski & Duggan (1999), in a systematic review, concluded there was no trial-based evidence that antipsychotic medication was effective for challenging behaviour, and that the use of such medication for this purpose could be argued to be unethical outside a randomised controlled trial. There is also evidence that long-term antipsychotic therapy can be successfully withdrawn in a significant proportion of patients (Ahmed et al, 2000).…”

Section: Discussionmentioning

confidence: 99%

Audit of the use of psychotropic medication for challenging behaviour in a community learning disability service

Marshall¹

2004

Psychiatr. bull.

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Audit of the use of psychotropic medication for challenging behaviour in a community learning disability service AIMS AND METHODThe aims of the study were to identify patients in a community learning disability service receiving psychotropic medication for challenging behaviour, to examine prescribing practice and to compare this against local consensus standards. Local consensus standards were agreed by the consultants and the notes were reviewed by the author. RESULTSA total of102 patients were identified as receiving psychotropic

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Section: Discussionmentioning

confidence: 99%

Audit of the use of psychotropic medication for challenging behaviour in a community learning disability service

Marshall¹

2004

Psychiatr. bull.

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“…Studies of withdrawing medication show that, in some people with ID, the medication can be successfully withdrawn after a long period of use (37,38). In another group, the dose can be reduced, but total withdrawal is not possible.…”

Section: General Principles For Prescribing Psychotropic Medicationsmentioning

confidence: 99%

International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities

et al. 2009

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Intellectual disability (ID) or mental retardation or learning disability is a lifelong condition included in the group of mental disorders in all the international classification systems. It is a syndrome grouping (meta-syndrome) including a heterogeneous range of clinical conditions characterized by a deficit in cognitive functioning prior to the acquisition of skills through learning (1). Over 30% of people with ID have a comorbid psychiatric disorder, which often has its onset in childhood and persists through adolescence and adulthood (2,3).In spite of this evidence, ID and related conditions are still considered a marginal area of psychiatry. In many countries there is little or no training provision on ID during undergraduate medical training or psychiatric specialization. The World Health Organization (WHO) has recently highlighted the unmet care needs of persons with ID (4). Psychiatrists are the first health professionals in contact with this population group and there is a global gap in training and guidelines on mental health issues related to ID.Within the ID field, the assessment, differential diagnosis and treatment of problem behaviours (PBs) deserve special attention. The rate of PBs in people with ID is high (5) and their presentation is determined by many complex factors. The pathogenic contribution of organic conditions, psychiatric disorders, environmental influences, or a combination of these has to be carefully established for every single case.The prevalence of PBs in people with ID seems to be sufficiently high (5,6) to constitute a major concern in this population. Depending on the definition and methodology, rates have been reported to vary from 5.7 to 17% (7-10). Using the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities (DC-LD) (11), Cooper et al (12,13) aggression and self-injurious behaviour to be 9.8% and 4.9%, respectively, among adults (16 years and over) with ID in a community setting.It has been reported that 20-45% of people with ID are receiving psychotropic medication and 14-30% are receiving psychotropic medication to manage PBs such as aggression or self-injurious behaviours (14,15) in the absence of a diagnosed psychiatric disorder. Examples of psychotropic medications used for adults with ID are antipsychotics, antidepressants, anti-anxiety drugs (benzodiazepines, buspirone, beta-blockers), mood stabilizers (lithium, anticonvulsants), psychostimulants, and opioid antagonists. Spreat et al (16) reported that as many as two thirds of psychotropic medications prescribed to people with ID are antipsychotics.Studies suggest that PBs are not only prevalent but also persistent in people with . Totsika et al (20) found that serious physical attacks, self-injury and stereotypy were the most likely types of PBs to persist over time. It is therefore suggested that it may be necessary to start interventions as early as possible to prevent the behaviours from becoming more serious and to reduce the number of emergent behaviours. It has...

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“…l Deterioration in behaviour. A previous study 39 showed that measurable behavioural deterioration was uncommon following drug reduction, but other studies have shown greater deterioration and that carer concern can be high. Advice on assessing a meaningful behaviour change was provided in the PI support package.…”

Section: Risks and Expected Benefitsmentioning

confidence: 96%

“…38 However, a randomised controlled withdrawal study reported more positive results. Ahmed et al 39 conducted a trial in which 56 participants were randomised to an experimental group (n = 36) or a control group (n = 20). In the experimental group drug dose was to be reduced over a 6-month period, in four stages, approximately 1 month apart, between baseline and post-intervention evaluation.…”

Section: Withdrawal Of Antipsychotic Medicationmentioning

confidence: 99%

“…We proposed to limit recruitment to patients receiving risperidone or haloperidol in order to increase the feasibility of blinding while including, within the trial, both atypical and typical medications, specifically those found to be ineffective for challenging behaviour by Tyrer et al 20 Moreover, as Ahmed et al 39 found in their open study that reinstatement of medication occurred for almost half of the sample, despite being unrelated to reported or directly observed changes in the level of challenging behaviour, this study was designed to compare the extent of medication change between blinded and unblinded conditions and explore the perceptions of clinicians and carers about medication usage. However, as Chapter 2 describes, poor recruitment led to modified aims for the study.…”

Section: The Andrea-ld Trialmentioning

confidence: 99%

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A pilot randomised controlled trial of community-led ANtipsychotic Drug REduction for Adults with Learning Disabilities

McNamara

Randell

Gillespie

et al. 2017

Health Technol Assess

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Background Data suggest that approximately 50,000 adults with learning disabilities (LDs) in England and Wales are currently prescribed antipsychotic medication. Illness in this population is common, including significant rates of challenging behaviour and mental illness, but there is particular concern over the use of antipsychotics prescribed for reasons other than the treatment of psychosis. Control of challenging behaviour is the primary reason why such medications are prescribed despite the absence of good evidence for any therapeutic effect for this purpose. Objectives To assess the feasibility of recruitment and retention and to explore non-efficacy-based barriers to a blinded antipsychotic medication withdrawal programme for adults with LDs without psychosis compared with treatment as usual. A secondary objective was to compare trial arms regarding clinical outcomes. Design A two-arm individually randomised double-blind placebo-controlled drug reduction trial. Setting Recruitment was through community learning disability teams (CLDTs) in south Wales and south-west England. Participants Adults with LDs who are prescribed risperidone for treatment of challenging behaviour with no known current psychosis or previous recurrence of psychosis following prior drug reduction. Intervention A double-blind drug reduction programme leading to full withdrawal within 6 months. Treatment in the intervention group was gradually reduced over a 6-month period and then maintained at the same level for a further 3 months, still under blind conditions. In the control group, the baseline level of medication was maintained throughout the 9-month period. The blind was broken at 9 months, following final data collection. Main outcome measures Feasibility outcomes were (1) the number and proportion of general practices/CLDTs that progressed from initial approach to recruitment of participants and (2) the number and proportion of recruited participants who progressed through the various stages of the study. Trial arms were also compared regarding clinical outcomes, the Modified Overt Aggression Scale, the Aberrant Behaviour Checklist, the Psychiatric Assessment Schedule for Adults with Developmental Disability checklist, the Antipsychotic Side-effect Checklist, the Dyskinesia Identification System Condensed User Scale, the Client Service Receipt Inventory, use of other interventions to manage challenging behaviour, use of as-required (pro re nata) medication and level of psychotropic medication use. Results Of the 22 participants randomised (intervention, n = 11; control, n = 11), 13 (59%) achieved progression through all four stages of reduction. Follow-up data at 6 and 9 months were obtained for 17 participants (intervention, n = 10; and control, n = 7; 77% of those randomised). There were no clinically important changes in participants’ levels of aggression or challenging behaviour at the end of the study. There were no expedited safety reports. Four adverse events and one serious adverse event were reported during the trial. Limitations Recruitment was challenging, which was largely a result of difficulty in identifying appropriate persons to consent and carer concerns regarding re-emergence of challenging behaviour. Reduced recruitment meant that the full trial became an exploratory pilot study. Conclusions The results indicate that drug reduction is possible and safe. However, concerns about taking part were probably exacerbated by limited availability of alternative (behavioural) interventions to manage behaviour; therefore, focused support and alternative interventions are required. The results of the qualitative study provide important insights into the experiences of people taking part in drug reduction studies that should influence future trial development. Future work We recommend that further work focuses on support for practitioners, carers and patients in reducing antipsychotic medication. Trial registration Current Controlled Trials ISRCTN38126962. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 47. See the NIHR Journals Library website for further project information.

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Reducing antipsychotic medication in people with a learning disability

Abstract: A substantial proportion of people with learning disability prescribed antipsychotic medications for behavioural purposes rather than for treating psychotic illness can have their drugs reduced or withdrawn.

Cited by 125 publications

References 11 publications

Audit of the use of psychotropic medication for challenging behaviour in a community learning disability service

Audit of the use of psychotropic medication for challenging behaviour in a community learning disability service

International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities

A pilot randomised controlled trial of community-led ANtipsychotic Drug REduction for Adults with Learning Disabilities

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