Withdrawing Antipsychotics for Challenging Behaviours in Adults with Intellectual Disabilities: Experiences and Views of Prescribers

Abstract

International current best practice recommends the discontinuation of antipsychotics for challenging behaviours in people with intellectual disabilities (ID), due to lack of evidence of efficacy and risks of harmful side-effects. In clinical practice, discontinuation may be difficult. The aim of this study was to gain insight into prescribers’ practice by investigating their experiences with the discontinuation of long-term antipsychotics for challenging behaviour. From professionals’ associations thirty-four registered ID physicians, psychiatrists and specialist mental healthcare nurses were recruited who completed an online questionnaire in this survey–study. Almost all participants had attempted to deprescribe antipsychotics for their patients with ID. Sixty-five percent of participants achieved complete discontinuation in 0–25% of their patients, but none in over 50%. Barriers were a lack of non-pharmaceutical treatments for challenging behaviours and caregivers’ and/or family concern. Seventy percent of participants indicated that their institutions had encouraged implementing their discontinuation policies in line with the new Dutch Act on Involuntary care and a new Dutch multidisciplinary guideline on problem behaviour in adults with ID. Support and facilitation of clinicians from institutions’ managers and political and professional bodies may be helpful in further implementation of best practice in the treatment of challenging behaviour in people with ID.

Stakeholder experiences of deprescribing psychotropic medicines for challenging behaviour in people with intellectual disabilities

“…We only found two papers through database searching (Kleijwegt et al , 2019; Deb et al , 2020). We found one additional paper through citation searching (Wrein, 2019) and an additional three more via direct author contact (de Kuijper et al , 2022b; de Kuijper et al , 2022a; Deb et al , 2023). Two papers reported results from the same study, one reporting quantitative data (Deb et al , 2020) and the other reporting qualitative data (Deb et al , 2023).…”

“…In addition to secondary care health-care professionals, primary care practitioners, including GPs and non-medical prescribers, have a significant role in the prescribing and deprescribing of psychotropic medicines in people with intellectual disabilities who display challenging behaviour. However, inadequate resources can hinder effective deprescribing review (Deb et al, 2023(Deb et al, , 2020de Kuijper et al, 2022b). Commentaries by Deb and colleagues (Deb, 2007;Deb et al, 2009) further emphasise the significance of the team approach in implementing psychotropic deprescribing.…”

“…Due to the low number of studies included in this review, the impact of our findings is limited, and therefore it is important to exercise caution in interpreting these findings. The quality appraisal process identified potential bias associated with sampling and recruitment methods across studies, such as direct approaches (de Kuijper et al, 2022b;Deb et al, 2023Deb et al, , 2020, convenience sampling (Kleijwegt et al, 2019) and recruitment by physicians (de Kuijper et al, 2022a).…”

“…In addition to the small number of included studies and despite there being no restriction on country, three out of the five studies were carried out in the Netherlands (de Kuijper et al, 2022a(de Kuijper et al, , 2022bKleijwegt et al, 2019), and two studies were carried out in the UK (Wrein, 2019;Deb et al, 2020). This may limit the external validity and transferability of the overall systematic review when considering settings in other countries where there may be differences in health policy, practices and access to health care.…”

“…The belief that resources can play a significant role in achieving successful psychotropic deprescribing outcomes was reported in one study (Deb et al, 2023(Deb et al, , 2020, where positive behaviour support (PBS) plans were seen as a facilitator to deprescribing. The lack of time, absence of appropriate PBS plans, lack of non-pharmacological interventions for challenging behaviour and inadequate social care provision were reported as barriers to achieving successful deprescribing (de Kuijper et al, 2022b;Deb et al, 2023).…”