Psychopharmacology

Approximately half of the adults with intellectual developmental disabilities (IDD) and autism spectrum disorder (ASD) receive psychotropic medications such as antipsychotics, antidepressants, antianxiety medication, and mood stabilisers including lithium and some antiepileptic medications. These medications are often used off-licence for challenging behaviour. For example, antipsychotics are prescribed for 24–32% of adults with IDD compared with 1% in the general population, even though only 2–4% of adults with IDD have schizophrenia or other psychoses for which antipsychotics are licenced. Antipsychotics are prescribed for psychosis in 22% of cases and challenging behaviour in 58% of cases. The randomised controlled trial (RCT)-based evidence to either support or refute the use of psychotropic medications for challenging behaviour is weak. There is some moderate-quality evidence showing the efficacy of low-dose risperidone in improving irritability and agitation in children with IDD and ASD, but not for adults. Based on primarily drug company-led studies, some preliminary evidence supports aripiprazole’s efficacy in improving irritability and agitation in children with ASD. There is no evidence for aripiprazole for adults with ASD or children or adults with IDD. There is insufficient RCT-based evidence for any other antipsychotics or psychotropic medications for people with IDD or ASD of any age to draw any definitive conclusion about their efficacy. However, the use of antipsychotics carries the risk of adverse effects affecting the quality of life and even increased mortality risk in people with IDD and epilepsy. Antipsychotics are used for 45% of people with IDD who display challenging behaviour. However, challenging behaviour is multifactorial, including physical, psychological, psychiatric and environmental causes for which a multidisciplinary assessment and intervention are needed to achieve a good outcome. Challenging behaviour is often a means of communication for the person with IDD and ASD. Therefore, a non-pharmacological intervention such as stress management, including mindfulness, anger management, Cognitive Behaviour Therapy and Positive Behaviour Support should be used first. A low dose of medication for a short period may be used either along with non-pharmacological intervention or if the non-pharmacological intervention proves ineffective and there is a major risk to the person and others around them, or if there is an underlying psychiatric problem such as depression, psychosis and anxiety leading to challenging behaviour. Medication should be reviewed regularly with the aim of withdrawing them as and when appropriate. World Psychiatric Association has developed good practice guidelines that clinicians should follow. Online training resources like SPECTROM (Short term psychoeducation for caregivers to help reduce the overmedication of people with intellectual disabilities) ( https://spectrom.wixsite.com/project ), backed up by face-to-face training, should empower caregivers and help reduce unnecessary and inappropriate medication use for challenging behaviour.