Withdrawal of antipsychotic drugs from adults with intellectual disabilities

Abstract

Objectives: There is a view that antipsychotic drugs can be successfully withdrawn from people with intellectual disabilities with resultant health gain. This study critically examines whether antipsychotic drug withdrawal is beneficial.Methods: 119 adults with intellectual disabilities were included in a programme of antipsychotic drug withdrawal.Results: The clinical outcomes of this programme are poor. Only 7.6% completely withdrew from antipsychotic drugs, and 48.7% experienced onset/deterioration in problem behaviours or mental ill-health. Significant drug side effects with the introduction of new drugs were experienced by 23.3%. Resultant mean antipsychotic drug doses were higher compared with those at the start of the programme. The cost to the intellectual disabilities psychiatric service (over and above that of routine psychiatric care) was £258,050 (€391,693), and the human cost was considered high. Primary care, social care and family costs were not calculated. The only specific factors found to be associated with poor outcome were increased severity of intellectual disabilities and female gender.Conclusions: The successful role of antipsychotic drugs in the management of problem behaviours in people who do not have verbal communication skills may relate to the pathoplastic effect of intellectual disabilities on clinical presentation, with problem behaviours being markers of eg. psychosis and anxiety disorders. Our original findings challenge the view that routine withdrawal of antipsychotic drugs is good practice; we reinterpret the existing literature, and recommend caution and vigilance in pharmacotherapy.

A survey of off‐label prescribing for inpatients with mild intellectual disability and mental illness

“…However, studies in which antipsychotics have been withdrawn from these patients have reported that a significant proportion deteriorate in their behaviour (Branford 1996; Ahmed et al. 2000; Stevenson et al. 2004).…”

“…A systematic review of the effectiveness of antipsychotics for problem behaviour in patients with ID found no definite evidence for efficacy, while recognising this is an underresearched area (Brylewski & Duggan 1999). However, studies in which antipsychotics have been withdrawn from these patients have reported that a significant proportion deteriorate in their behaviour (Branford 1996;Ahmed et al 2000;Stevenson et al 2004).…”

Reduction or discontinuation of antipsychotics for challenging behaviour in adults with intellectual disability: a systematic review

“…Stevenson and colleagues, writing in the aftermath of the restrictions imposed on the use of the first-generation agent thioridazine in 2000, contested that wide-scale antipsychotic withdrawal in this group is likely to cause serious harm, including precipitating increases in behaviour problems and mental ill-health. 60 Overall results from studies that report behavioural outcomes are inconclusive. Both deKuijper et al 47 and Ahmed et al 32 report no change, or even improvement in behaviour after antipsychotic discontinuation, although those whose behaviour deteriorated did not complete the withdrawal programme.…”

“…Studies with no individual outcomes reported, including those reporting average changes in medication use only Findholt and Emmett 81 Luchins et al 59 Bisconer et al 82 Branford 57 Howerton et al 83 Ruggerini et al 84 Lim 85 Observational studies with no active intervention to reduce or discontinue antipsychotic drugs Wressell et al 86 Etherington et al 87 Gravestock 88 Branford 89 Studies reporting no new suitable information Branford 90 Studies where most or all participants were taking antipsychotic for mental illness Pary et al 91 Sovner 92 Davies et al 93 Margetić and Aukst-Margetić 94 Stonecipler et al 95 Janowsky et al 96 Studies describing switch of antipsychotics Matthews and Weston 58 Stevenson et al 60…”

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

“…Significant minorities experienced onset or deterioration of adverse effects with the introduction of new drugs or of challenging behaviour or mental ill health, and costs to the specialist psychiatric service rose. 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).…”