Dr. Ken Courtenay FRCPsych MRCGP (k.courtenay@ucl.ac.uk)

Consultant Psychiatrist in Intellectual Disability

London UK

EAMHID Zagreb 27.4.2018

Overuse of Medication in People with ID

Clinical Background

Case Vignettes

Prescribing Practice

Challenges

Classes of Psychotropics

Antipsychotics

Antidepressants

Mood Stabilisers

Stimulants

Non-stimulants

Hypnotics

Clinical Indications

Mental Illness

‘Challenging Behaviour’

Clinical Indications

•  Psychosis - Risperidone

•  Mood Disorders – Olanzapine; Valproate

•  Anxiety – Pregabalin; Fluoxetine

•  ADHD – Atomoxetine; Methylphenidate

Role of Psychiatrist

•  Mental Disorder - assess, diagnose, treat

•  Medication - prescribe / monitor

•  Risk - assess / manage

•  Liaise / Advise - carers, service-users, families, GP, colleagues

•  Legislation - MHA / MCA

Professional Guidance

‘Challenging Behaviour’

•  NICE Guidance NG11 (2015) / QS101 (2015)

•  ‘Challenging Behaviour – a Unified Approach’ (2016) RCPsych & BPS

•  NICE Guidance NG54 (2016) / QS142 (2017)

Case 1: Challenging Behaviour?

28 year old woman Smith-Magenis Syndrome Aggression / ‘Trantrums’

Hypomania

Case 1: Drug Regimen

2006 2009 2010 2016 Benperidol Haloperidol Lithium

Carbonate Lithium Carbonate

Quetiapine Lithium Carbonate

Olanzapine

Haloperidol PRN

Clonazepam

Semi-Sodium Valproate

Lorazepam PRN

Case 2: Diagnoses

33 year old man in Supported Living

Schizo-affective Disorder? (2004)

Tourette’s Syndrome (childhood)

Autism (2012)

ADHD (2012)

Case 2: Drug Regimen

2006 2016

Risperidone Atomoxetine (ADHD)

Semisodium Valproate Pregabalin (Anxiety / ASD)

Haloperidol Olanzapine (Tic Disorder)

Lorazepam Intensive Support Team PBS

Adverse Effects

Metabolic

•  Weight Gain •  Dyslipidemia •  Hypertension •  Elevated Prolactin

Amenorrhoea Gynaecomastia

Motor

Extrapyramidal Effects •  Oculgyric effects •  Tremor •  Dystonias

Tardive Dyskinesia

Case 3: Adverse Effects

73 year old man

Institutional care Supported Living

‘Molesting’ female support workers

Restless – not sitting still

Case 3: Drug Regimen

2006 2009 - 2016

Trifluoperazine 30mg Nil

Sulpiride 400mg

Monitor Adverse Effects

•  Rating Scales

Metabolic – GASS (Glasgow Antipsychotic Side effect Scale)

Motor – LUNSERS (Liverpool University Neuroleptic Side Effects Rating Scale)

Challenges to Psychiatrist

Psychiatrist

Mental Illness?

Prescribe?

Reduction / withdrawal Substitution?

Withdrawal period

Others

Change in behaviour

Resistance

Resources to monitor changes

Impact of Medication

•  Person Clinical Effectiveness Quality of Life – impact of side effects

•  Prescriber Monitoring of drug regimens

•  Health Service Expenditure on medication

Clinical Practice

•  Clinical Discussion – service-user; family; carer; colleagues

•  Clear explanation – ‘Reasonable Adjustment’; ‘easy-read’

•  Time to consider

•  Agree desired outcome

•  Clinical Review

•  Measurement - clinical effects / side effects

Clinical Practice

•  ‘Operationalise’ - CB Care Pathway

•  Alternatives to medication – support plan

•  ‘Everyone’s business’ – professionals; carers; families; service-users

Transforming Care Programme 2012

BBC Panorama 31 May 2011 Winterbourne View Hospital

Why is it important?

•  Prevalence rates of mental disorders (SCZ 3%) •  High rates of physical disorders •  Medication use in People with ID •  Polypharmacy •  Clinical effectiveness •  Adverse effects

What we know

•  Glover (2015): GP data Antipsychotics 17% Antidepressants 16% Mood stabilisers 7%

•  Sheehan (2015): THIN Database ‘Disproportionate use of Psychotropics in People with ID’

STOMP Pledge 2016

What does it mean in Clinical Practice?

•  Mental Disorder or Challenging Behaviour?

•  Drug reduction / withdrawal? (Sheehan 2017)

•  Terminology: Withdrawal; Optimisation; ‘Deprescribing’

•  Resources in Clinical Services

Whose Business Is It?

•  Psychiatrists

•  Clinical Teams

•  Primary Care

•  Pharmacists

•  Families / Carers

•  People with ID

Clinical Practice

•  Clinical Discussion service-user; family; carer; colleagues

•  Clear explanations

•  Time to consider

•  Agree desired outcome

•  Clinical Review

•  Measurement - clinical effects / side effects

•  Care and Treatment Reviews

Summary

•  Role of Psychiatrist

•  Challenging Behaviour / Mental Disorder?

•  Managing medication

•  Alternatives to medication

•  Working with others especially the person

MiXiT

•  https://www.youtube.com/watch?v=PdiLYnHPMrs

Dr. Ken Courtenay FRCPsych MRCGP (k.courtenay@ucl.ac.uk)

Consultant Psychiatrist in Intellectual Disability

London UK

EAMHID Zagreb 27.4.2018