Nature and quality of antipsychotic prescribing practice in UK psychiatry of intellectual disability services

Nature and quality of antipsychotic prescribing practicein UK psychiatry of intellectual disability servicesjir_1421 665..674

C. Paton,1 A. Flynn,2 A. Shingleton-Smith,3 S. McIntyre,3 S. Bhaumik,4 J. Rasmussen,5

S. Hardy6 & T. Barnes7

1 Pharmacy, Oxleas NHS Trust, Dartford, UK2 Mental Health of Learning Disabilities, Oxleas NHS Trust, London, UK3 Centre for Quality Improvement, Royal College of Psychiatrists, London, UK4 Learning Disability Service, Leicestershire Partnership NHS Trust, Leicester, UK5 GP, Surrey PCT, Merstham, UK6 Estia Centre, London, UK7 Centre for Mental Health, Imperial College, London, UK

Abstract

Background Antipsychotics are perceived to beover-used in the management of behavioural prob-lems in people with an intellectual disability (ID).Published guidelines have set good practice stan-dards for the use of these drugs for behaviouralindications. We sought to identify the range of indi-cations for which antipsychotic drugs are prescribedin people with ID and to audit clinical practiceagainst the standards.Method Data were collected from the clinicalrecords of individuals with ID who were under thecare of mental health services in the UK, and pre-scribed an antipsychotic drug.Results The sample comprised 2319 patients from39 clinical services. Twenty-seven per cent of thepatients had a diagnosis of a psychotic illness(ICD-10 F20–29) and 27% an affective illness(ICD-10 F30–39). The proportion who did not havea psychiatric diagnosis ranged from 6% of thosewith borderline/mild ID to 21% of those withsevere/profound ID. Overall, the most common

indications for prescribing an antipsychotic drugwere comorbid psychotic illness, anxiety and agita-tion, and a range of behavioural disturbances. Theprevalence of use of antipsychotic drugs to managechallenging behaviour in the absence of concomi-tant mental illness increased with the severity of IDand accounted for almost half of prescriptions inthose with severe/profound ID. Adherence to theaudit standards related to documentation of clinicalindications and review of efficacy was high. Sideeffect monitoring was less assiduous.Conclusions In clinical practice, most prescriptionsfor antipsychotic drugs in people with ID are con-sistent with the evidence base and the overallquality of prescribing practice, as measured againstrecognised standards, is good, although in somepatients potentially remedial side effects may not bedetected and treated.

Keywords antipsychotic, audit, challengingbehaviour, intellectual disability, quality

Introduction

Intellectual disability (ID) is a complex diagnosticentity, grouped within the mental disorders in

Correspondence: Ms Carol Paton, Pharmacy, Oxleas NHS Trust,Pinewood House, Pinewood Place, Dartford, Kent DA2 7WG, UK(e-mail: [email protected]).

Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2011.01421.x

volume 55 part 7 pp 665–674 july 2011665

© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd

ICD-10 (WHO 2007). People with ID constitute aheterogeneous population encompassing a broadrange of communicative, cognitive-perceptual andsocial deficits. Furthermore, mental illness, person-ality disorder and behavioural disorder requiringclinical intervention are over-represented in thispopulation (Bernal & Hollins 2005). As the severityof ID increases, mental illness becomes progres-sively more difficult to diagnose with certainty. Oneor more of a wide range of behaviours such asaggression, over-activity and self-injury are exhib-ited by up to 60% of people with ID (Harris 1993;Sigafoos et al. 1993; Branford 1994; Deb et al.2001). These behaviours often have an unclear aeti-ology and clinicians use the term ‘challengingbehaviour’ (CB) to describe them. Where there isno diagnosis of mental illness, guidelines recom-mend that CB should be managed with psychologi-cal, behavioural and environmental interventions,with antipsychotic drugs used only where the risk tothe patient or others is high, rapid intervention isrequired or where other interventions have failed(Deb et al. 2006, 2009). However, surveys revealthat antipsychotic drugs are commonly used to treatCB (Branford 1994; Deb & Fraser 1994), and thecontroversy surrounding this practice has beenre-ignited by a recent randomised controlled trial(RCT) comparing risperidone, haloperidol andplacebo, which failed to find any advantage for theactive treatments (Tyrer et al. 2008).

Deb and colleagues (Deb et al. 2006, 2009) haveproduced guidelines for the use of antipsychoticsfor CB in people with ID. While the limited evi-dence does not allow for prescriptive recommenda-tions about treatment choice, these guidelinesprovide a framework for good practice in terms ofassessment of target behaviours, and monitoringof effectiveness and adverse effects. We sought toexplore the clinical rationale for prescribing antipsy-chotics in a large sample of people with ID and testthe extent to which prescribing practice was consis-tent with good practice guidelines.

Method

The Prescribing Observatory for Mental Health(POMH-UK) invited all National Health ServiceTrusts in the UK providing specialist mental health

services to participate in a project to benchmarkprescribing practice with respect to antipsychoticdrugs for people with ID. All Trusts and clinicalteams were self-selected in that they chose toparticipate.

Clinical teams were invited to include as manypatients as they wished from the ID Consultant’scaseload who were currently prescribed an antipsy-chotic. The following data were collected on eacheligible patient, using a standardised data collectiontool: age, gender, ethnicity, severity of ID, caresetting, comorbid psychiatric diagnoses, comorbiddiagnosis of epilepsy, the main clinical indicationsfor and daily dose of each antipsychotic currentlyprescribed, the duration of antipsychotic drug treat-ment, documented evidence of side effect monitor-ing (specifically extrapyramidal and metabolic sideeffects), and the names of all other medications pre-scribed for mental illness, behavioural problems orepilepsy. The audit data were collected from theclinical records except for the clinical indications forprescribing antipsychotics for individual patients,which the Trusts were asked to obtain by interviewwith clinical team members.

Prescribing practice was audited against recogn-ised standards. We derived two of the audit stan-dards from guidance entitled, ‘Using medication tomanage behaviour problems among adults with alearning disability’ (Deb et al. 2006), and a thirdprimarily from the NICE clinical guideline for themanagement of schizophrenia (NICE 2009). Thethree standards were: (1) The indication for treat-ment with antipsychotic medication should bedocumented in the clinical records; (2) The con-tinuing need for antipsychotic medication should bereviewed at least once a year; and (3) Side effectsof antipsychotic medication should be reviewed atleast once a year, and this review should includeassessment for the presence of extrapyramidal sideeffects (EPS), and screening for the four aspects ofthe metabolic syndrome: blood pressure, obesity,glycaemic control and plasma lipid profile.

Data analysis

The data were submitted online and collected usingsnap (electronic survey software), and stored andanalysed using spss. Data were cleaned to correctany evident data entry errors.

666Journal of Intellectual Disability Research volume 55 part 7 july 2011

C. Paton et al. • Antipsychotic prescribing in intellectual disability


Results

Audit sample

One hundred and forty-five clinical teams from 39

specialist mental health Trusts in England (n = 36

Trusts), Scotland (n = 1),Wales (n = 1) and North-ern Ireland (n = 1) participated in the audit, submit-ting data for 2319 patients, 79% of whom wereoutpatients. All patients had ID and were prescribedone or more antipsychotic drugs. Table 1 providesdetails of the clinical and demographic characteris-tics of the total patient sample and ID severity sub-samples: mild, moderate and severe/profound.

Use of antipsychotic medication

Antipsychotic treatment had been initiated withinthe last year in 328 patients; and initiated over 12

months ago in 1991 of the patients. The clinicalindications for antipsychotic use in the total sampleare listed in Table 2. Nearly half (46%) of the totalsample were prescribed antipsychotic(s) for a singleclinical indication, 25% were prescribed the drug(s)for two different indications, 15% for three indica-tions, 7% for four indications, and 3% were pre-scribed antipsychotics for five or more indications.In the subsample with no psychiatric diagnosis(N = 273), the overall number of indications forwhich an antipsychotic was prescribed for eachpatient was similar. This subgroup was more likelythan the sample as a whole to be prescribed anantipsychotic to manage aggression, threateningbehaviour or self-harm and have severe or profoundID; see Table 2.

The five most commonly used antipsychoticsaccounted for 79% of all antipsychotic prescriptionsin this sample. Table 3 shows the number of pre-scriptions for these antipsychotics and details of thedosages used. The use of high-dose and combinedantipsychotics was relatively uncommon, the preva-lence being 4% and 15% in the sample respectively.In addition to antipsychotic medication, 73% of thetotal sample were prescribed other medication formental illness, behavioural problems or epilepsy.The most commonly prescribed drugs were antide-pressants (33% of the sample), valproate (20%),carbamazepine (17%), a benzodiazepine (15%), ananticholinergic (14%), lamotrigine (5%) and lithium(5%).

Performance against the prescribing standards

The first standard was that the indication for treat-ment with antipsychotic medication should bedocumented in the clinical records. This was met in2194 (95%) of the total sample. The second stan-dard was that the continuing need for antipsychoticmedication should be reviewed at least once a year.This standard was only applied to those patientswho had been prescribed an antipsychotic for atleast a year (n = 1991), and was met in 1913 (96%)of these cases. In 1728 (92%) the clinical rationaleunderpinning the decision made at the review wasdocumented, and in 549 (28%) of cases, this reviewled to a change in dosage. The final standard wasthat antipsychotic side effects should be reviewed atleast once a year, and this review should includeassessment for the presence of EPS, and screeningfor the four aspects of the metabolic syndrome. Thisstandard was only applied to the subsample ofpatients who had been prescribed antipsychoticmedication for a year or more. In 1378 (69%) ofthese cases there was a general statement in theclinical records that side effects were either presentor not present. Evidence of monitoring of specificside effects such as EPS and metabolic problemswas less common. In those patients treated for atleast a year, there was no documented evidence ofany EPS assessment in 1165 (59%), and no assess-ment of weight/body mass index in 883 (44%). Therespective figures for blood pressure, blood glucoseand lipid profile were 1257 (63%), 791 (40%) and848 (43%). In 247 (12%) of cases no documentedevidence of assessment of any of these specific sideeffects was found, nor any general statement aboutthe presence or absence of side effects. The data didnot suggest that patients with more severe ID weremore likely to be targeted for side effect review. Ageneral statement that side effects were present ornot present had been recorded in the casenotesof 72% of those with borderline/mild ID and 66%of those classified as severe/profound ID.

Discussion

Why were antipsychotic drugs prescribed?

In our large sample of people with ID who wereprescribed an antipsychotic drug, the most common




indication for such prescribing was comorbid psy-chotic disorder, although almost 60% of the sampledid not have a formal diagnosis of psychotic illness.The other common indications were anxiety, agita-

tion and aggressive behaviour. More than one clini-cal reason for prescribing an antipsychotic drug wasreported for half of the cases, and three or moreindications in a quarter. In almost all patients, the

Table 1 Clinical and demographic characteristics of the total patient sample and ID severity subsamples

Key demographic characteristics

Totalsample

Mild/borderline Moderate

Severe/profound

n = 2319 n = 1101 n = 672 n = 546

Gender Male 1384 60% 645 59% 411 61% 328 60%Ethnicity White/White British 1955 84% 927 84% 572 85% 456 84%

Black/Black British 59 3% 26 2% 15 2% 18 3%Asian 84 4% 38 3% 18 3% 28 5%Mixed or other 38 2% 22 2% 8 1% 8 1%Not stated 183 8% 88 8% 59 9% 36 7%

Age Mean age in years (SD) 44 (14) 43 (14) 45 (15) 44 (13)Age bands 16–25 years 282 12% 141 13% 93 14% 48 9%

26–35 years 399 17% 220 20% 90 13% 89 16%36–45 years 586 25% 276 25% 168 25% 142 26%46–55 years 560 24% 253 23% 148 22% 159 29%56–65 years 345 15% 148 13% 114 17% 83 15%66 years and over 147 6% 63 6% 59 9% 25 5%

Antipsychoticprescribing

Initiated within 12 months 328 14% 176 16% 95 14% 57 10%Over 12 months 1991 86% 925 84% 577 86% 489 90%

Number ofdocumentedcomorbid psychiatricdiagnoses

None 273 12% 71 6% 85 13% 117 21%One 1540 66% 792 72% 450 67% 298 55%Multiple 396 17% 204 19% 99 15% 93 17%Not known 110 5% 34 3% 34 6% 38 7%

Documented diagnosisof epilepsy

519 22% 171 16% 165 25% 183 34%

Documented comorbidpsychiatricdiagnoses: ICD-10

F00–F09: organic, including symptomatic,mental disorders

69 3% 25 2% 29 4% 15 3%

F10–F19: mental and behavioural disordersdue to psychoactive substance use

14 1% 13 1% 1 <1% 0 0%

F20–F29: schizophrenia, schizotypal anddelusional disorders

615 27% 438 40% 153 23% 24 4%

F30–F39: mood [affective] disorders 628 27% 316 29% 192 29% 120 22%F40–F48: neurotic, stress-related and

somatoform disorders169 7% 92 8% 42 6% 35 6%

F50–F59: behavioural syndromes associatedwith physiological disturbances andphysical factors

20 1% 7 1% 6 1% 7 1%

F60–F69: disorders of adult personality andbehaviour

172 7% 111 10% 31 5% 30 5%

F80–F89: disorders of psychologicaldevelopment

481 21% 156 14% 137 20% 188 34%

F90–F98: behavioural and emotionaldisorders with onset usually occurring inchildhood and adolescence

201 9% 62 6% 65 10% 74 14%

F99: unspecified mental disorder 4 <1% 2 <1% 1 <1% 1 <1%Not known 110 5% 34 3% 38 6% 38 7%




indication(s) for antipsychotic medication wasclearly documented and there was evidence ofongoing review leading to dosage change, suggest-ing thoughtful prescribing.

While there is a paucity of RCT evidence sup-porting the efficacy of antipsychotic drugs in thetreatment of psychotic illness in people with ID, itseems appropriate to extrapolate from the consider-able evidence base supporting the efficacy of thesedrugs in people with schizophrenia (Antochi et al.2003). However, the clinical complexity of IDpopulations is illustrated in our sample, in thataround one in six individuals had two or more psy-chiatric diagnoses, almost a quarter had epilepsyand almost three-quarters were prescribed medica-tion other than antipsychotic drugs for mentalillness, behavioural problems or epilepsy.

Surveys have repeatedly found that antipsychoticsare often used to manage behavioural problems inpeople with ID; 20–45% of people with ID are pre-scribed antipsychotic drugs, and up to 30% aretaking these to control behaviour disorders (Deb &Fraser 1994; Marshall 2004; Sawhney et al. 2006;Deb et al. 2006). The use of antipsychotics to

manage a range of behavioural problems was alsocommon in our sample, particularly in the smallsubsample that had no diagnosed psychiatricdisorder in addition to their ID. People withsevere/profound ID were over-represented in thissubsample compared with the sample as a whole.The target behaviours in this group were predomi-nately related to harm to others or to self. To someextent, such behaviours may have been manifesta-tions of psychotic illness that was difficult to elicit,partly perhaps because the patients were less ableto articulate cognitive and perceptual psychoticsymptoms.

A Cochrane review conducted in 2003 concludedthat there were no RCT data that supported antip-sychotic treatment being either helpful or harmfulin adults with ID and CB (Brylewski & Duggan2004), and when considered in the context of theprevalence of antipsychotic use, this led to theassumption that these drugs are used rather indis-criminately in people with ID. However, the conclu-sions of the Cochrane review were based on theabsence of evidence supporting efficacy rather thanconvincing evidence of an absence of effect. Since

Table 2 Clinical indications for antipsychotic medication in a sample of 2319 people with a learning disability, and in the subsamples with andwithout a comorbid psychiatric diagnosis

Clinical indication Whole sample*

Subsample

Comorbid psychiatricdiagnosis (n = 1936)

No comorbid psychiatricdiagnosis** (n = 273)

Comorbid psychotic illness 971 (42%) 927 (48%) 21 (8%)Agitation or anxiety 968 (42%) 803 (42%) 115 (42%)Overt aggression 874 (38%) 666 (34%) 156 (57%)Threatening behaviour 696 (30%) 557 (29%) 100 (37%)Self-harm 298 (13%) 227 (12%) 52 (19%)Obsessive behaviour 257 (11%) 221 (11%) 25 (9%)Unclear 125 (5%) 112 (6%) 9 (3%)Sexual behaviour 75 (3%) 60 (3%) 11 (4%)Defiant behaviour 70 (3%) 65 (3%) 2 (1%)Motor stereotypies 54 (2%) 49 (2%) 3 (1%)Social withdrawal 47 (2%) 44 (2%) 0Other 30 (1%) 16 (1%) 6 (2%)Severity of ID Mild 1101 (48%) 996 (51%) 71 (26%)

Moderate 672 (29%) 549 (28%) 85 (31%)Severe/profound 546 (24%) 391 (20%) 117 (43%)

Antipsychotic medication was prescribed for more than one indication in * 50% and ** 55% of patients.




that review was published, several RCTs thatrecruited people with ID and disruptive/aggressivebehaviour of non-psychotic origin have been pub-lished, some of which support the efficacy of antip-sychotics in such cases (Turgay et al. 2002; Gagianoet al. 2005), although the most recent did not (Tyreret al. 2008). It is notable that a much larger propor-tion of the subjects (42%) in the study by Tyreret al. (2008) had no diagnosed psychiatric disorder,compared with our sample (12%). Further work,again modest in its scope and applicability, hasshown that in people with ID prescribed an antipsy-chotic for the management of CB, discontinuationof antipsychotics does not always lead to there-emergence of the original behaviours (Janowskiet al. 2006), but if one attempt at antipsychoticwithdrawal has been unsuccessful, future attemptswill succeed in less than 10% of patients (Janowskyet al. 2008).

The use of antipsychotic drugs to manageanxiety, agitation and aggressive behaviour is notunique to people with ID; in acute adult inpatientsettings, these indications are a common reason forprescribing PRN, combined and high-dose antipsy-chotics (Paton et al. 2008). In contrast, the propor-tions of people with ID in our sample who wereprescribed combined (15%) or high-dose antipsy-chotics (4%) were relatively low, suggesting judi-cious practice. There are also parallels between theuse of antipsychotics in the management of aggres-sive behaviour in people with ID, and their use inthe management of persistent aggression in peoplewith schizophrenia; in both populations the driversfor the aggressive behaviours are multi-factorial andclinical trials generally recruit small numbers ofpatients in whom these drivers are poorly defined(Deb et al. 2006, 2009; Tyrer et al. 2008; Volavka &Citrome 2008). Small RCTs that have recruitedrelatively homogeneous populations of people withID and CB in the absence of psychosis, such asthose with conduct disorder (Gagiano et al. 2005)or autistic spectrum disorders (MHRA 2006), havegenerally yielded encouraging findings. Recruitinghomogeneous populations with ID and CB intoadequately powered RCTs is challenging but untilthese studies are conducted, the true efficacy ofantipsychotic drugs in managing the range ofbehavioural problems seen in people with ID willremain largely untested.Ta

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Which antipsychotic drugs?

In our audit sample, over three-quarters of pre-scriptions for antipsychotic medication were forone of five drugs: three second-generation antipsy-chotics (SGAs), risperidone, olanzapine or que-tiapine, and two first-generation antipsychotics(FGAs), chlorpromazine or haloperidol. It is likelythat drug choice is influenced in part by the pub-lished literature, partly by clinical experience andperhaps also by product licences. Of the antipsy-chotic drugs commonly prescribed in this sample,risperidone has been subject to the largest clinicaltrials programme to explore efficacy in the man-agement of behavioural problems associated withchildhood autism (MHRA 2006). It is of note thatover a fifth of patients in our sample had anICD-10 diagnosis in the range F80–89, whichencompasses autistic spectrum disorders. Further-more, two small RCTs support the short-termefficacy of risperidone in the management of dis-ruptive behaviours associated with attention deficithyperactivity disorder/conduct disorder in children(Turgay et al. 2002) and adults (Gagiano et al.2005) with ID. Both of these studies demonstratedthrough open-label extension arms, that the initialtreatment effect was maintained. Reflecting thisevidence, risperidone is licensed for the short-termmanagement of persistent aggression in peoplewith conduct disorder. Almost 10% of our samplehad an ICD-10 diagnosis in the diagnostic group-ing F90–98, where attention deficit hyperactivitydisorder and conduct disorder can be found. Thisevidence supporting the effectiveness of risperidonein the management of behavioural disturbancewhere there is no diagnosis of psychotic illnessmay have been interpreted by clinicians as tenta-tively supporting its use in the management of awide range of behavioural disturbances in peoplewith ID. Cross-sectional and naturalistic studieshave consistently found that risperidone is themost frequently prescribed antipsychotic in peoplewith ID (Bokszanska et al. 2003; Marshall 2004),and this finding was replicated in our sample. Wealso found the median dose of risperidone to be2 mg, which is consistent with that used in RCTsconducted in ID populations.

There is some RCT evidence to support theefficacy of aripiprazole in managing behaviours

associated with childhood autism (Marcus et al.2009), but the other SGAs have not been tested inRCTs in people with ID and CB, and none ofthese medications is licensed in the UK for behav-ioural indications. The relevant published literatureconsists of very small open studies, case series andcase reports, with the exception of one open-labelstudy of olanzapine in a sample of 40 childrenwith autism (Fido & al Saad 2008). This studyfound that olanzapine reduced irritability andhyperactivity, which is consistent with the effectsshown by risperidone in the same population.Although there is a paucity of data supporting theuse of olanzapine and quetiapine in people withID, the common use of these drugs in our sampleis consistent with the findings of a questionnairesurvey of ID psychiatrists; the respondents indi-cated that these two SGAs were second to risperi-done as their antipsychotics of choice (Deb et al.2006). Risperidone is associated with prolactin-related side effects, and in some patients can causeEPS. Olanzapine or quetiapine may be prescribedin some cases because they are better tolerated inthese regards.

The SGAs were the most frequently prescribedregular antipsychotics, while the FGAs haloperidoland chlorpromazine, were more likely to be pre-scribed on a PRN basis in combination withanother regular antipsychotic; a practice that iscommon in general adult psychiatry inpatient set-tings (Paton et al. 2008). The more frequent use ofthese antipsychotics on a PRN basis is consistentwith their licensed indications; chlorpromazine islicensed for the short-term treatment of severeanxiety, and for impulsive behaviour in childhoodautism, and haloperidol for the short-term treat-ment of psychomotor agitation, excitement andviolent or dangerously impulsive behaviour. Themain concerns regarding their combination with anSGA are that the FGA may negate the improvedtolerability profile of the newer drug with respect toEPS, and that the use of combined antipsychoticswill lead to a high overall dose.

Review of efficacy

The majority of patients (85%) in our sample hadbeen receiving treatment with an antipsychotic formore than a year. This finding is consistent with




other cross-sectional surveys and antipsychotic dis-continuation studies. For example, Marshall (2004)found that the average duration of antipsychotictreatment in a community ID population was over 5

years, Ahmed et al. (2000) reported that it was notpossible to discontinue treatment in the majority ofpeople with ID who were prescribed an antipsy-chotic for the management of behavioural distur-bance, and Davies et al. (2002) found thatdiscontinuation of antipsychotic treatment couldlead to long-term destabilisation in a third ofpatients. In almost all patients in our sample theindication(s) for antipsychotic medication had beenclearly documented, and the medication had beenreviewed within the last year, resulting in a changein the antipsychotic dose in over a quarter of cases.This suggests that, with respect to efficacy, theeffects of treatment were closely and activelymonitored.

Review of side effects

Our findings suggest that side effect assessment wasless assiduous. While there was a general statementin the clinical records indicating that side effectshad been reviewed over the previous year in 7 outof every 10 patients, in 6 out of every 10 patientsthere was no documented evidence that EPS hadbeen assessed. It is possible that clinicians assumedthat, given the relatively low doses of SGAs thatmost patients received, EPS would not be fre-quently encountered, although this has not beenconvincingly demonstrated in ID populations. Onenaturalistic study in people with ID found EPS tobe the most common adverse effect with risperi-done (Bokszanska et al. 2003).

With regard to metabolic side effects, we foundthat blood pressure had not been measured in 6 outof 10 individuals, and for 4 out of every 10 therewas no evidence that they had been weighed, orthat blood glucose or lipids had been checked.These findings are in line with a recent audit ofmonitoring of the metabolic syndrome (Devapriamet al. 2009), which revealed that less than 15% ofadults with ID prescribed SGAs had all the param-eters of metabolic syndrome monitored on a regularbasis. However, there is sufficient evidence tosupport metabolic side effects being problematic inpeople with ID (Bokszanska et al. 2003; Jesner et al.

2007; Ruedrich et al. 2007). Failure to screen formetabolic side effects may result in potentiallyremediable problems remaining undiagnosed andtherefore untreated.

In conclusion, most prescriptions for antipsy-chotic drugs in people with ID are consistent withthe evidence base and the overall quality of pre-scribing practice, as measured against recognisedstandards, is good, although in some patients sideeffects may not be detected and treated.

Study limitations

Our data were collected in the context of a retro-spective audit of prescribing practice. We do notknow how many people with ID on the team case-loads were not prescribed an antipsychotic drug, socannot calculate the prevalence of antipsychoticprescribing. All the patients in our sample wereunder the care of mental health of learning disabil-ity services and our findings may not be generalis-able to patients who are cared for in other clinicalsettings. With respect to performance against theaudit standards, our data were drawn from whatwas documented in the clinical records and some ofthe findings are therefore dependent on the qualityof record keeping. For example, any medicationreviews that had been undertaken but not docu-mented would not have been captured. However,the major strength of our study is that our sample islarge and drawn from 39 different Trusts, so is likelyto be representative of prescribing practice in theUK.

References

Ahmed Z., Fraser W., Kerr M. P., Kiernan C., EmersonE., Robertson J. et al. (2000) Reducing antipsychoticmedication in people with a learning disability. BritishJournal of Psychiatry 176, 42–6.

Antochi R., Stavrakaki C. & Emery P. C. (2003) Psycho-pharmacological treatments in persons with dualdiagnosis of psychiatric disorders and developmentaldisabilities. Postgraduate Medicine 79, 139–46.

Bernal J. & Hollins S. (2005) Psychiatric illness and learn-ing disability: a dual diagnosis. Advances in PsychiatricTreatment 1, 138–45.

Bokszanska A., Martin G., Vanstraelen M. et al. (2003)Risperidone and olanzapine in adults with intellectual




disability: a clinical naturalistic study. InternationalClinical Psychopharmacology 18, 285–91.

Branford D. (1994) A study of the prescribing for peoplewith learning disabilities living in the community and inNational health Service care. Journal of Intellectual Dis-ability Research 38, 577–86.

Brylewski J. & Duggan L. (2004) Antipsychotic medica-tion for challenging behaviour in people with learningdisability. Cochrane Database of Systematic Reviews (3),Art.No.: CD000377. DOI:10.1002/14651858.CD000377.pub2.

Davies S. J. C., Cooke L. B., Moore A. G. & Potokar J.(2002) Discontinuation of thioridazine in patients withlearning disabilities: balancing cardiovascular toxicitywith adverse consequences of changing drugs. BritishMedical Journal 324, 1519–21.

Deb S. & Fraser W. (1994) The use of psychotropic medi-cation in people with learning disability: towards ratio-nal prescribing. Human Psychopharmacology 9, 259–72.

Deb S., Thomas M. & Bright C. (2001) The rate ofbehavioural disorders among a community based popu-lation aged between 16 and 64 years. Journal of Intellec-tual Disability Research 45, 506–14.

Deb S., Clarke D. & Unwin G. (2006) Using Medicationto Manage Behaviour Problems among Adults with aLearning Disability. University of Birmingham.Available at: http://www.ld-medication.bham.ac.uk/(retrieved April 2011).

Deb S., Kwok H., Bertelli M., Salvador-Carulla L.,Bradley E., Torr J. et al. for the guideline developmentgroup of the WPA section on psychiatry of intellectualdisability (2009) International guide to prescribing psy-chotropic medication for the management of problembehaviours in adults with intellectual disabilities. WorldPsychiatry 8, 181–6.

Devapriam J., Anand A., Balaraju L. & Bhaumik S.(2009) Monitoring for metabolic syndrome in adultswith intellectual disability on atypical antipsychoticdrugs. The British Journal of Developmental Disabilities55, 3–13.

Fido A. & al Saad S. (2008) Olanzapine in the treatmentof behavioral problems associated with autism: an open-label trial in Kuwait. Medical Principles and Practice 17,415–18.

Gagiano C., Read S., Thorpe L., Eerdekens M. & VanHove I. (2005) Short- and long-term efficacy and safetyof risperidone in adults with disruptive behavior disor-ders. Psychopharmacology 179, 629–36.

Harris P. (1993) The nature and extent of aggressivebehaviour amongst people with learning difficulties(mental handicap) in a single health district. Journal ofIntellectual Disability Research 37, 221–42.

Janowski D. S., Barnhill L. J., Khalid A. S. & Davis J. M.(2006) Relapse of aggressive and disruptive behaviour

in mentally retarded adults following antipsychoticdrug withdrawal predicts psychotropic drug use adecade later. Journal of Clinical Psychiatry 67,1272–7.

Janowsky D. S., Barnhill L. J., Khalid A. S. & Davis J. M.(2008) Antipsychotic withdrawal-induced relapse pre-dicts future relapses in institutionalized adults withsevere intellectual disability. Journal of Clinical Psychop-harmacology 28, 401–5.

Jesner O. S., Aref-Adib M. & Coren E. (2007) Risperi-done for autism spectrum disorder. Cochrane Databaseof Systematic Reviews (1), Art.No.: CD005040.DOI:10.1002/14651858.CD005040.pub2.

Marcus R. N., Owen R., Kamen L., Manos G., McQuadeR. D., Carson W. H. et al. (2009) A placebo-controlled,fixed-dose study of aripiprazole in children and adoles-cents with irritability associated with autistic disorder.Journal of the American Academy of Child and AdolescentPsychiatry 48, 1110–19.

Marshall T. (2004) Audit of the use of psychotropicmedication for challenging behaviour in a communitylearning disability service. Psychiatric Bulletin 28, 447–50.

Medicines and Healthcare Regulatory Authority (MHRA)(2006) Variation Assessment Report. Available at: http://www.mhra.gov.uk/home/groups/pl-p/documents/websiteresources/con2025027.pdf (retrieved April 2011).

National Institute for Health and Clinical Excellence(NICE) (2009) Schizophrenia: Core Interventions in theTreatment and Management of Schizophrenia in Primaryand Secondary Care (Update). NICE clinical guideline82. NICE, London.

Paton C., Barnes T. R. E., Cavanagh M. R., Taylor D. &Lelliott P. on behalf of the POMH–UK project team(2008) High-dose and combination antipsychotic pre-scribing in acute adult wards in the UK: the challengesposed by p.r.n. prescribing. British Journal of Psychiatry192, 435–9.

Ruedrich S. L., Swales I. T. P., Rossvanes I. C., Diana L.,Arkadiev V. & Lim K. (2007) Atypical antipsychoticmedication improves aggression, but not self-injuriousbehaviour in adults with intellectual disabilities. Journalof Intellectual Disability Research 52, 132–40.

Sawhney I., Morgan J. & Chandra P. (2006) Survey ofoff-label prescribing in learning disability. Primary Careand Community Psychiatry 1, 153–6.

Sigafoos J., Elkins J., Kerr M. & Attwood T. (1993) Asurvey of aggressive behaviour among a population ofpersons with intellectual disability in Queensland.Journal of Intellectual Disability Research 38, 369–81.

Turgay A., Binder C., Snyder R. & Fisman S. (2002)Long-term safety and efficacy of risperidone for thetreatment of disruptive behaviour disorders in childrenwith subaverage IQs. Pediatrics 110, 1–12.




Tyrer P., Oliver-Africano P. C., Ahmed Z., Bouras N.,Cooray S., Deb S. et al. (2008) Risperidone, haloperi-dol, and placebo in the treatment of aggressivechallenging behaviour in patients with intellectual dis-ability: a randomised controlled trial. Lancet 371, 57–63.

Volavka J. & Citrome L. (2008) Heterogeneity of violencein schizophrenia and implications for long-term

treatment. International Journal of Clinical Practice 62,1237–45.

World Health Organisation (WHO) (2007) ICD-10. Avail-able at: http://www.who.int/classifications/icd/en/(retrieved April 2011).

Accepted 1 March 2011




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Nature and quality of antipsychotic prescribing practice in UK psychiatry of intellectual disability services