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Psychotropic drugs

Little change in antipsychotic prescribing in decade despite withdrawal recommendations, study finds

A study published in BMJ Open has also found a “striking” increase in antidepressant prescriptions in the decade between 2004 and 2014 in the Greater Glasgow area.

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Significant incentives and support may be needed for drug withdrawal recommendations to be followed more closely

Prescriptions of antipsychotic drugs for adults with intellectual disabilities did not change significantly in the decade between 2004 and 2014 in the Greater Glasgow area, despite concerns and guidelines recommending their withdrawal, a study published in BMJ Open has said.

The study also described a “striking” increase in antidepressant prescriptions in the same ten-year period.

For the study, the researchers carried out a comparison of two cross-sectional cohorts by way of a primary care intellectual disabilities register of adults in the NHS Greater Glasgow and Clyde area: 1,190 adults in 2002–2004, which was referred to as T1, and 3,906 adults in 2014, which was referred to as T2.

They found that 50.7% of adults in T1 and 48.2% of adults in T2 were prescribed at least one psychotropic drug.

Rates of prescribing of antipsychotic medicines did appear to be lower in T2 than in T1, at 16.7% and 24.5%, respectively, although the authors said that the rate was “still high”.

However, a significant increase was seen in prescriptions for antidepressants, which rose from 11.2% in T1 to 19.1% in T2.

Overall, prescriptions for psychotropics increased from 47% in T1 to 57.8% in T2.

The authors said that while fewer antipsychotic prescriptions were initiated by T2 than in T1, people were not withdrawn from them once commenced, and that people with “problem behaviours” had increased prescribing.

“Despite numerous calls and guidelines in the UK for the withdrawal of antipsychotic drugs from people with intellectual disabilities who do not have psychosis/bipolar disorders, our longitudinal, linked cohort analysis shows no progress over a decade,” the authors wrote.

“Adults with intellectual disabilities need frequent and careful medication reviews,” they concluded.

The research was published as the NHS Business Services Authority (NHSBSA) released its annual and quarterly summary statistics on medicines used in mental health, which revealed that the number of prescriptions for medicines used in mental health in England increased between 2015/2016 and 2019/2020. 

The findings in the NHSBSA annual report showed that between 2015/2016 and 2019/2020, there was increased use of prescription medicines in four drug groups: drugs for psychoses and related disorders; antidepressant drugs; central nervous system stimulants and drugs used for attention deficit hyperactivity disorder; and drugs for dementia. The only drug group that saw a reduction in this time period was hypnotics and anxiolytics.

In contrast, the quarterly report highlighted that, during the height of the COVID-19 pandemic from April 2020 to June 2020, four of the five drug groups saw a fall in levels of prescribing in quarter one of 2020/2021 compared to the previous quarter. Drugs used in psychoses and related disorders was the only group to see an increase.

David Branford, an independent pharmacy advisor on learning disabilities and mental health, said that in recent years there had been a “massive move” away from antipsychotics to other psychotropic drugs, such as antidepressants and antiepileptics. 

Branford said that a number of reviews of prescribing have taken place since the ‘Stopping over medication of people with a learning disability, autism or both’ (STOMP) campaign was launched in England in 2016. 

“The main findings are that STOMP is incredibly good at raising the profile of the issue, but in terms of people systematically reviewing people and taking them off the medicines, there hasn’t been a massive change,” he said. 

“We need some kind of CQUIN [Commissioning for Quality and Innovation framework], some kind of payment, or legal framework that requires people to be reviewed or taken off [these medicines]; just having campaigns where you raise the issue along doesn’t do it — you need significant incentives and support.” 

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2020.20208355

Readers' comments (1)

  • Psychotropic Medication Use in Population with Intellectual Disabilities: One Pharmacist’s perspective
    Comment on: Changes over a decade in psychotropic prescribing for people with intellectual disabilities: prospective cohort study



    Inequalities and inequities in health and healthcare for people with intellectual disabilities have been of longstanding concern. Medication use is the major therapeutic intervention in this vulnerable population. The use of medication cannot be separated from the environment –physical and social – in which the person with intellectual disabilities lives and is supported. There is no ‘one size fits all’ regarding psychotropic medication use in this population group.

    The social environment, the physical environment and societal preconditions, and their interconnectivity with one another and with individuals in the setting, play an important role in healthy settings for people with intellectual disabilities[1] . Physical, mental, psychological and spiritual well being may all be influenced by the environment.
    Pharmacists, as medication experts, in all healthcare environments can make positive contributions to the pharmaceutical care of patients with intellectual disabilities, in collaboration with other healthcare professionals, carers and patients themselves [2,3].

    The expertise of pharmacists is often an untapped resource for the optimisation of medication use in this population group.

    Research has shown that many people with intellectual disabilities who can make decisions about their daily life aren’t given clear information about their medication[4]. Healthcare professionals such as pharmacists and doctors will have to spend longer explaining their medication, use different resources, and explain things ( prescribing and de-prescribing) in simpler language. The person with intellectual disability and their carer will need accessible appropriate information.

    Strategies to reduce inequalities and inequities will require use of data to educate decision makers, including doctors and pharmacists, attention to social determinants, and a life course model with emphasis on leveraging inclusion in mainstream services where possible. Specialist pharmacists with expertise, interest and experience will be required to support generalist pharmacists in the community and other non specialist settings [5].

    All pharmacists and others need to understand ‘the system’ that results in psychotropic medication being prescribed for each person with intellectual disability. There must be an understanding of the various elements at play in ‘the system’ around each person with intellectual disability .

    To optimise medication use and understand prescribing patterns an understanding of the complex interactions and relationships that occur in the lives of people with intellectual disabilities is vital.

    References:
    1.Kristel Vlot-van Anrooij, J Naaldenberg, T I M Hilgenkamp, L Vaandrager, K van der Velden, G L Leusink, Towards healthy settings for people with intellectual disabilities, Health Promotion International, Volume 35, Issue 4, August 2020, Pages 661–670, https://doi.org/10.1093/heapro/daz054
    1. Flood B. Safety of people with intellectual disabilities in hospital. What can the hospital pharmacist do to improve quality of care. Pharmacy (Basel)2017;5:44. doi:10.3390/pharmacy5030044 pmid:28970456CrossRefPubMedGoogle Scholar
    3. O’Dwyer M, Meštrović A, Henman M. Pharmacists’ medicines-related interventions for people with intellectual disabilities: a narrative review. Int J Clin Pharm2015;37:566-78. . doi:10.1007/s11096-015-0113-4 pmid:25903938
    4.Smith MVA, Adams D, Carr C, Mengoni SE . Do people with intellectual disabilities understand their prescription medication? A scoping review. J Appl Res Intellect Disabil2019;32:1375-88. . doi:10.1111/jar.12643 pmid:31338972CrossRef PubMed Google Scholar
    5.Flood,Bernadette. 2016. Thesis. Trinity College Dublin, School of Pharmacy and Pharmaceutical Sciences. www.tara.tcd.ie/bitstream/handle/2262/83126/Flood,%20Bernadette_PhD%20Thesis%2029.08.16.pdf?isAllowed=y&sequence=1

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