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THE USE OF DRUGS FOR THE TREATMENT OF BEHAVIOUR
DISORDERS IN ADULTS WHO HAVE LEARNING [INTELLECTUAL] DISABILITIES
Shoumitro Deb
Although the rate of functional psychiatric illness such as
schizophrenia and affective disorders(Deb et al, 2001a) seems
similar in adults who have intellectual disability to that in
the general population, the rate of behaviour disorder is quite
high (Deb et al, 2001b). The rate of psychosis is significantly
higher among adults with intellectual disability compared with
the general population, as are other psychiatric diagnoses such
as autistic spectrum disorders and Attention Deficit Hyperactivity
Disorders. Therefore, the overall rate of psychopathology among
adults who have intellectual disability seems much higher compared
with that in the general population (Deb et al, 2001c), as is
the rate of epilepsy (Deb, 2000). Consequently, psychotropic medication
is used more frequently in adults with intellectual disability,
with between 20 and 45% of overall being prescribed psychotropic
medication, of which 14-30% are to control behaviour disorders
(Deb and Fraser, 1994). Clarke et al (1990) had previously found
that 36% of adults with intellectual disability who did not have
a diagnosis of mental illness were receiving psychotropic medication.
Whereas the use of psychotropics in the treatment of mental illness
is justified, their use in the management of behaviour disorders
in people with intellectual disability in the absence of a diagnosable
psychiatric illness remains controversial (see review by Reiss
and Aman 1998; Santosh & Baird 1999; Deb & Weston, 2000;
Aman et al, 2000).
Management of behaviour disorders
At the outset it is important to assess carefully the possible
cause(s) of behaviour disorders. A person with intellectual disability
who has toothache or gastro oesophageal reflux disorder (both
are very common) and is unable to communicate this to her/ his
carer may behave in an aggressive manner out of frustration and
persistent pain. It is therefore important to assess the individual's
physical state carefully and provide necessary symptomatic treatment.
This might help to improve the associated behaviour disorders.
Certain psychiatric syndromes such as psychoses and depression
could manifest as behaviour disorders. Psychological factors such
as stress and learned dysfunctional coping strategies could predispose
and precipitate behaviour disorders. Behaviour therapy and psychological
therapies such as Cognitive Behaviour Therapy may be useful in
the management of such behaviour disorders. Certain social factors
such as under or over stimulation within the immediate environment,
physical and psychological abuse, life events and lack of social
support may also predispose people with an intellectual disability
to behaviour disorders. In many cases, addressing these social
environmental issues may be all that is needed to improve behaviour
disorders. The lack of careful assessment of these factors may
lead to unnecessary prescribing of drugs.
Drug treatment is only one of many strategies that could be employed
to manage psychopathology, and behaviour disorders in people who
have intellectual disability. Treatment should be provided within
the context of a carefully drawn individualised care programme
after proper discussion with the person with intellectual disability,
their carers, and other professionals involved in the care of
the person. The overall aim of the treatment should not only be
symptom control but to provide a better quality of life for an
individual with intellectual disability and his/her carers.
Evidence based practice
The treatment also has to be based on the available evidence of
effectiveness of a particular treatment. Clinicians in the UK
are increasingly asked to abide by the National Institute for
Clinical Excellence (NICE) guidelines (www.nice.org.uk), which
are based primarily on type I and II evidence. Type I evidence
includes good systematic reviews and meta-analysis of studies
which include at least one randomised controlled trial, whilst
type II evidence includes randomised controlled trials. Type III
evidence includes well designed interventional studies without
randomisation, type lV evidence includes well designed observational
studies, and type V evidence includes expert opinion, influential
reports and studies.
Treating mental illness with medication
Indications of drugs for the treatment of psychiatric disorders
such as psychoses (e.g., schizophrenia,), affective disorders
(e.g., depressive or manic episodes), and anxiety related disorders
(e.g., obsessive compulsive disorder, phobias.) should be the
same among people with intellectual disability as they are for
the general population.
Treating behaviour disorder with medication
Types of behaviour disorders among people with intellectual disability
that usually need drug treatment include aggression towards others,
aggression towards property and objects (destructiveness), aggression
toward self (Self injurious behaviour; SIB), severe agitation/
hyperactivity, severe stereotyped behaviour, and severe temper
tantrums including screaming. There are published reports on the
use of many drugs in the treatment of behaviour disorder among
people who have learning disability. These drugs include antipsychotics,
antidepressants, antiepileptics, mood stabilisers, psychostimulants,
beta-blockers, opioid antagonists, and anti anxiety drugs
Among typical antipsychotics, chlorpromazine and haloperidol are
the most widely used drugs for the management of behaviour disorders
in adults with learning disability. The use of thioridazine is
now severely restricted in the UK because of its potential cardio-toxicity.
Most studies have reported improvement of the target behaviour
following the treatment with atypical antipsychotics including
clozapine, risperidone, olanzapine, amisulpride and quetiapine.
Among antidepressants, most studies have reported the use of
clomipramine and Selective Serotonine Reuptake Inhibitors (SSRIs)
in the management of behaviour disorders among adults with intellectual
disability. As these drugs are known to improve symptoms of depression,
anxiety and obsessive behaviour, it is possible that the improvement
in behaviour disorders was in fact the reflection of improvement
in the above symptoms.
There are reports of studies that have used mood stabilisers e.g.,
lithium, carbamazepine and sodium valproate for the treatment
of behaviour disorders in people who have intellectual disability.
Almost all studies showed improvement in behaviour following the
lithium treatment. 88% of patients treated with valproate showed
improvement in aggression and self-injurious behaviour. There
is a complex relationship between epilepsy and behaviour disorders
in some people who have intellectual disability (Deb & Joyce,
1999). It is possible, therefore, that sodium valproate may be
treating the underlying epileptic activity while showing improvement
in behaviour disorder.
Studies have shown that benzodiazepines, buspirone and beta-blockers
improve behaviour disorders in people with intellectual disability.
These drugs also have an anti-anxiety effect. Anxiety could be
a precipitating factor for behaviour disorders in people with
intellectual disability. The long-term use of benzodiazepines
is contraindicated because of the problems with tolerance, possible
effects on cognition and symptoms associated with withdrawal.
After the initial enthusiasm with buspirone, recent studies have
shown it has a slow onset of action and lower potency. Meanwhile,
high dose beta-blockers can cause cardiac problems.
Some researchers have hypothesised that self-injurious behaviour
is sustained by the release of internal opioids in the body. This
consequently produces a feeling of pleasure, which tends to perpetuate
the behaviour. Therefore, treatment with anti-opioid drugs such
as naloxene and naltrexone has been proposed for the treatment
of self-injurious behaviour in people with intellectual disability.
However, to date the efficacy of naloxene and naltrexone has not
been unequivocally proven in the management of self-injurious
behaviour in people with intellectual disability. Trials with
a lower dose of naltrexone have shown better results. Psychostimulants
such as methylphenidate and dextamphetamine have been successfully
used in the treatment of Attention Deficit Hyperactivity Disorder
(ADHD) in children. Some studies have shown success with the use
of these drugs in the treatment of behaviour disorders in people
with intellectual disability. As many adults with intellectual
disability show symptoms of ADHD, it is possible that psychostimulants
show improvement in behaviour disorders by treating the underlying
ADHD symptoms. The long-term effects of using psychostimulants
have not been properly studied yet.
Clonidine is indicated for the treatment of 'Tic disorder' and
'Tourette's syndrome'. There are studies using clonidine in the
treatment of behaviour disorders in people with intellectual disability.
Both 'Tic disorder' and 'Tourette's syndrome' are known to be
associated with intellectual disability and behaviour disorders.
Vitamins, minerals and dietary treatments (particularly in patients
with Phenylketonuria) have also been used with some success in
the treatment of behaviour disorders in people with intellectual
disability.
Limitations in the evidence base
Many studies have shown the effectiveness of many drugs in the
treatment of behaviour disorders in adults with intellectual disability.
However, we have to be cautious in the interpretation of data
presented in these studies. Most of these studies are case reports
that included a small number of cases. It is well known that studies
with positive findings tend to find their way to publication more
easily than studies that show negative findings, therefore creating
a reporting bias. The number of RCTs is small, and have often
used only small sample sizes, and therefore they provide insufficient
statistical power to draw firm conclusions. The outcome measures
used in these studies are often not appropriate or validated,
and the method of selection of control and the experimental group
is not always clear or appropriate. Also, outcome data are often
not presented in an appropriate manner (e.g., most studies do
not quote 'number needed to treat'). Most studies also do not
distinguish symptoms of psychiatric illness from those of behaviour
disorders.
A systematic review carried out by Brylewski and Duggan (1999)
for the Cochrane Review group highlighted most of the methodological
problems that I have listed above. By using strict criteria for
inclusion of RCTs only, they found only three studies that provided
either enough information or used appropriate methodology qualified
for inclusion in their review. Their review found no evidence
either way to suggest that drugs are either useful or not useful
in the treatment of behaviour disorders in people with intellectual
disability.
Treating ADHD and Autistic spectrum disorders
(ASD) with medication
Psychostimulants such as methylphenidate in association with other
methods of behaviour management are shown to be effective in the
treatment of ADHD. They have been shown to be equally effective
in the treatment of ADHD in children who have intellectual disability.
Many reports have shown effectiveness of different drugs in the
treatment of core symptoms and associated behaviour disorders
in children with autistic spectrum disorders, but the quality
of evidence is poor. Drawing on their clinical experience, Santosh
& Baird (1999) have suggested the use of methylphenidate or
clomipramine for hyperactivity; SSRIs for SIB; haloperidol, risperidone,
buspirone or clonidine for irritability and aggression; and clonazepam,
buspirone or beta-blockers for anxiety symptoms in children with
autistic spectrum disorders. They also recommended the use of
haloperidol, risperidone, sulpiride, clonidine, SSRIs, clomipramine
or a combination of these drugs in the treatment of Tic/Tourette
syndrome. They suggested the use of clonidine for hyperactivity
or aggression or hyper arousal, and trycyclics or buspirone for
children with combined symptoms of autism and ADHD.
Scope for drug withdrawal
Many people who have intellectual disability receive psychotropic
drugs for many years without proper assessment of their treatment.
Ahmed et al (2000) and Branford (1996) carried out important studies
to assess which factors affect the withdrawal of long term use
of these drugs. They successfully reduced antipsychotic medication,
without the resurgence of behaviour disorders in 52% of 36 adults
with learning disability, of whiom 33% completed the full withdrawal
programme. They also found that factors such as staff perceptions,
environmental factors, and staffing ratios influenced prescribing
habits.
Clinicians prescribing drugs for people with intellectual disability
should also be aware of issues relating to capacity, informed
consent, advocacy, Mental Health legislation and relevant Government
policies such as 'Valuing people' (www.doh.gov.uk) and 'Same
as you'. Tables 1 and 2 summarise practice guidelines that
have been proposed by an international consensus group (Reiss
& Aman, 1988). The Department of Psychiatry at the University
of Birmingham is developing a practice guideline for the use of
drugs in the treatment of behaviour disorders in adults who have
an Intellectual Disability (DATABID Project) (www.bham.ac.uk/psychiatry).
This project is funded by the Community Fund and managed by MENCAP
and is developed in association with the Learning Disability Faculty
and the College Research Unit (CRU) of the Royal College of Psychiatrists.
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FIGURE 1: DO'S
- Use psychotropic medications within a co-ordinated multidisciplinary
care plan.
- The type of psychotropic use should be based on adequate
evidence for their effectiveness.
- Use psychotropic medication based on a psychiatric diagnosis
or a specific behavioural-pharmacological hypothesis and
only after conducting complete diagnostic and functional
assessment.
- Assess capacity and obtain informed consent from the
individual or a carer and establish a therapeutic alliance
involving all decision-makers.
- Track treatment efficacy by defining objective index
behaviours and quality of life outcomes, and measure them
using empirical methods.
- Monitor for adverse drug effects using standardised
assessment instruments.
- Conduct clinical and data reviews on a regular basis
and in a systematic way.
- Strive to use the lowest optimal effective dose and
where possible withdrawal of drugs when indicated.
- Evaluate drug and monitoring practices through a peer
or team quality review or improvement group.
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FIGURE 2: DON'T'S
- Don't use psychotropic drugs excessively as a substitute
for meaningful psychosocial services, or in quantities
that interfere with quality of life.
- Avoid frequent drug and dose changes.
- Avoid or minimise interclass polypharmacy to decrease
the likelihood of patient non-compliance and drug adverse
effects.
- Avoid use of high dose antipsychotics.
- Avoid long-term use of benzodiazepines.
- Avoid long-term use of anticholinergic drugs.
- Avoid long-term use of PRN ("as required")
instructions.
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References
Ahmed Z, Fraser W, Kerr M P et al. Reducing antipsychotic medication
in people with a learning disability. British Journal of Psychiatry
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Aman M G, Alvarez N, Benefield W et al. Expert consensus guidelines
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(3) 159-228.
Branford D. Factors associated with the successful or unsuccessful
withdrawal of antipsychotic drug therapy prescribed for people
with learning disabilities. Journal of Intellectual Disability
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Brylewski J., Duggan L. Antipsychotic medication for challenging
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Deb S., Fraser W. The use of psychotropic medication in people
with learning disability: towards rational prescribing. Human
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Deb S. Psychotropic Medication for Behaviour Disorders Associated
with Learning Disabilities.
Psychiatry 2003; Vol 2:9: 66-68.
Deb S., Joyce J. Psychiatric illness and behavioural problems
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Deb S, Thomas M & Bright C. Mental disorder in adults with
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illness among a community-based population aged between 16 and
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Deb S, Thomas M & Bright C. Mental disorder in adults with
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Deb S, Matthews T, Holt G and Bouras N. (eds.) Practice guidelines
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Deb S., Weston S N. Psychiatric illness and mental retardation.
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Santosh P. J., Baird G. Psychopharmacology in children and adults
with intellectual disability. Lancet 1999; 354: 231-240.
This article was first published on the site in 2004.
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