Psychotropic Medication Issues

OVERVIEW

Primary care of adults with developmental disabilities: Canadian consensus guidelines (2011) addresses several issues related to psychotropic medication use in this population.

  •  Problem behavior, such as aggression and self-injury, is not a psychiatric disorder but might be a symptom of a health-related disorder or other circumstance (e.g., insufficient supports). Problem behaviors sometimes occur because environments do not meet the needs of the adult with IDD. Despite the absence of an evidence base, psychotropic medications are regularly used to manage problem behaviors among adults with IDD.  Canadian consensus guidelines state that antipsychotic drugs should not be regarded as a routine treatment of problem behaviors in adults with IDD. (However, the U.S. Food and Drug Administration has approved the use of risperidone and aripiprazole in the treatment of irritability associated with autism spectrum disorders in children ages 6 to 17.)
  • Interventions other than medications are often effective for preventing or alleviating problem behaviors. These may include psychological or behavioral therapy, environmental modification, communication aids or addressing sensory aversions or sensory-seeking behaviors.
  •  Psychiatric disorders and emotional disturbances are substantially more common among adults with IDD, but their manifestations might mistakenly be regarded as typical for people with IDD (i.e., “diagnostic overshadowing”). Consequently, co-existing mental health disturbances might not be recognized or addressed appropriately.
  •  Establishing a diagnosis of a psychiatric disorder in adults with IDD is often complex and difficult, as these disorders might be masked by atypical symptoms and signs. In general, mood, anxiety, and adjustment disorders are underdiagnosed and psychotic disorders are overdiagnosed in adults with IDD.

 Psychotropic Medications

  •  Psychotropic medications are effective for diagnoses of psychiatric disorders in adults with IDD as in the general population. Psychotropic medications, however, can be problematic for adults with IDD and should therefore be used judiciously. Additional care should be used in prescribing medications for geriatric adults with IDD. Patients might be taking multiple medications and can thus be at increased risk of adverse medication interactions. Some adults with IDD may have atypical responses or side effects at low doses. Some cannot describe harmful or distressing effects of the medications that they are taking. The guidelines advocate a “start low, go slow” approach in initiating, increasing or decreasing psychotropic medications, and review at least every three months.
  • The guidelines urge that antipsychotic medications not be prescribed as routine treatments of problem behaviors in adults with IDD without a justifying diagnosis of a psychotic illness or irritability associated with autism spectrum disorders. When only a tentative non-specific psychiatric diagnosis can be made, a clinician may need to focus on one or more behavioral symptoms, such as aggression or self injury, as the treatment target. There should be an effort, over time, to adjust the doses to document ongoing need or the minimum dose at which a medication remains effective. Antipsychotic medications do increase risk of metabolic syndrome and can have other serious side effects (e.g., akathisia, cardiac conduction problems, swallowing difficulties, bowel dysfunction.) You may wish to consult the U.S. Food and Drug Administration for additional drug information: http://www.fda.gov/Drugs/default.htm
  • Adults with IDD have a higher rate of physical conditions, including sensory impairments, cerebral palsy, epilepsy and other neurological disorders, cardiovascular or gastrointestinal problems, any of which, if present, will influence the choice of medication.

 Behavioral Crises

  •  Behavioral crises may require emergency intervention and often are best managed in the controlled and well-staffed environment of an emergency room.  Psychotropic  medications may be used as a temporary stabilizing measure to ensure safety of the patient and/or caregiver(s), and may or may not need to be continued.
  • Debriefing with caregivers and reviewing precipitating events, specific behavioral symptoms, and attempted interventions (both pharmacologic and non-pharmacologic), as well as patient responses, after the crisis has resolved is recommended.  Such a review may minimize the likelihood of recurrence and may help determine the most effective therapeutic interventions.

 Using PRN (“as needed”) medication to manage behavioral crises

  •  Use of PRN psychotropic medications may be restricted by some states. Please consult your state’s regulations, particularly if your patient receives care through a state department of disability services or Medicaid.
  •  If permitted by your state, service agency protocols regarding PRN medications may need to be incorporated.
  •  Note the indication for administering a PRN medication, the minimum interval between doses, and the maximum dose allowed in a 24-hour period.
  • If prescribing more than one medication as a PRN treatment, stipulate the order in which the medications should be administered.
  • Monitor medications from the same therapeutic category that are used concurrently as regular and as PRN medications in order to avoid the risk of inadvertently overdosing.

Recommendations for use of medications for problem behavior outside of a crisis:

  •  The goal is not to treat the behavior per se but to identify the underlying cause of the behavior disturbance and treat that.
  •  Identifying the underlying cause often requires an interdisciplinary team approach.
  •  Where the cause of the behavior remains elusive, despite thorough investigation for medical conditions, environmental contributors to the behaviors of concern, emotional issues or psychiatric disorders, consideration may be given to a trial of medication appropriate to the patient’s symptoms.
  •  Medication trials should be targeted to specific symptoms (e.g., irritable mood) or behaviors (e.g., self injury), and monitored carefully for effectiveness, side effects, and risks vs. benefits of continuation.
  •  “Target” symptoms and behaviors should be monitored daily by the patient or caregiver(s).
  •  Change one medication at a time and wait long enough for an effect.
  •  If anti-seizure medications are used as mood stabilizers, consider the anticonvulsant properties when adjusting the medications.
  •  If starting another medication trial, withdraw the previous trial medication slowly.

Also see:

Psychotropic Medication Therapy Checklist 

Behavioral Problems and Emotional Concerns-Primary Care Providers Checklist

Initial Management of Behavioral Crises in Primary Care

ABC (Antecedent-Behavior-Consequence) Chart 

Original tool: © Surrey Place Centre.
Developed by Bradley, E & Developmental Disabilities Primary Care Initiative Co-editors.

Adapted with permission of Surrey Place Centre. This tool was reviewed and adapted for U.S. use by physicians on this project’s Advisory Committee; for list, view here.

Additional reviewers were Deborah Gatlin, M.D., Deputy Director/Medical Director, Office of Child Health, Tennessee Department of Children’s Services, Nashville, TN, and Victor Schueler, M.D., Medical Director, East Tennessee Region, Tennessee Department of Intellectual and Developmental Disabilities, Greeneville, TN.

References

1. ABC (Antecedent-Behavior-Consequence) Chart. Adapted from Parents’ Education as Autism Therapists of Northern Ireland.

2. Banks R, Bush A, Baker P, Bradshaw J, Carpenter P, Deb S, et al. Challenging behaviour: a unified approach. CR 144. 2007; Available at http://www.rcpsych.ac.uk/publications/collegereports/cr/cr144.aspx  Accessed  November 2017.

3. Bradley E. Section IV: Depression in special populations. In: Guidelines for the diagnosis and pharmacological treatment of depression. 1st ed. Toronto: MUMS Publications Clearinghouse. 1999; 39.

4. Deb S, Carulla LS, Barnhill J, Torr J, Bradley E, Bertelli M, et al. Problem behaviour in adults with intellectual disabilities: International guide for using medications, World Psychiatry 2009 Oct.;8:181-186.

5. Deb S, Clarke D, Unwin G. Using medication to manage behaviour problems among adults with a learning disability: Quick reference guide (QRG). 2006;29. Available at http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.546.1438&rep=rep1&type=pdf Accessed November 2017.

6. Sullivan WF, Berg JM, Bradley E, Cheetham T, Denton R, Heng J, Hennen B, Joyce D, Kelly M, Korossy M, Lunsky Y, McMillan S. Primary care of adults with developmental disabilities: Canadian consensus guidelines. Can Fam Physician 2011; 57:541-53.