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

Abstract

The use of antipsychotics to manage challenging behaviour in adults with intellectual disability is widespread but controversial, and evidence is scarce. There is a perception that antipsychotics used in this context can be reduced or discontinued, and this has been a major focus of recent national policy. However, such an intervention risks harm as well as having potential benefits. We reviewed the available evidence and found that antipsychotics can be reduced or discontinued in a substantial proportion of adults who use them for challenging behaviour, although not always without adverse effects. There is a group which displays behavioural deterioration on antipsychotic reduction that prevents discontinuation; predictors of poor response could not be reliably identified. In view of the relatively scarce data and methodological limitations of the available studies, we cannot draw firm conclusions to inform a population level approach to this issue. Antipsychotic medication used for behaviour should be reviewed regularly and an individualised approach taken to treatment.

Psychotropic prescribing in people with intellectual disability and challenging behaviour

“…6 Barriers to psychotropic withdrawal include infrequent or ineffective drug reviews, lack of confidence or motivation among general and specialist practitioners, and poor access to specialist psychiatrists or pharmacists to advise on and oversee medication changes. Other important factors in the inappropriate maintenance of psychotropic drugs for challenging behaviour are the lack of supporting evidence for interventions to treat this behaviour and the inconsistent and patchy implementation of alternatives to medication.…”

“…6 A deprescribing algorithm might be one way of changing practice at scale, but any algorithm must be sufficiently flexible to accommodate the considerable heterogeneity in this patient group. Excessive focus on reducing medication might be discriminatory, for example, if it denies people with intellectual disability appropriate treatment for mental illness.…”

Stopping, rationalising or optimising antipsychotic drug treatment in people with intellectual disability and/or autism

“…The authors of a major systematic review (21 studies, 1027 participants) concluded that antipsychotics can be reduced or discontinued in a substantial proportion of adults with ID who use them for behaviour that challenges, although not always without adverse effects 10. There were potential benefits in weight reduction, metabolic markers and cognitive function when antipsychotic drugs were withdrawn.…”

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

“…Drug reduction was not associated with higher levels of challenging behaviour and drug reinstatement was not associated with either staff-reported or directly observed measures of challenging behaviour. A recent systematic review 40 of reduction or withdrawal of antipsychotics concluded that these drugs can be reduced in adults with a LD, although the authors noted that some participants in some studies did experience adverse effects. However, the authors also note that much of the evidence to date is from relatively small and biased samples and that interventions and comparators are generally inadequately described.…”

“…Development of guidance for carers on this issue would also be beneficial. As Sheehan and Hassiotis note in their recent systematic review, 40 a systems approach to this complex issue is required.…”