Dr. Ken Courtenay FRCPsych MRCGP Consultant Psychiatrist in Intellectual Disability. London UK

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1 Dr. Ken Courtenay FRCPsych MRCGP Consultant Psychiatrist in Intellectual Disability London UK EAMHID Zagreb

2 Overuse of Medication in People with ID Clinical Background Case Vignettes Prescribing Practice Challenges

3 Classes of Psychotropics Antipsychotics Stimulants Antidepressants Non-stimulants Mood Stabilisers Hypnotics

4 Clinical Indications Mental Illness Challenging Behaviour

5 Clinical Indications Psychosis - Risperidone Mood Disorders Olanzapine; Valproate Anxiety Pregabalin; Fluoxetine ADHD Atomoxetine; Methylphenidate

6 Role of Psychiatrist Mental Disorder - assess, diagnose, treat Medication - prescribe / monitor Risk - assess / manage Liaise / Advise - carers, service-users, families, GP, colleagues Legislation - MHA / MCA

7 Professional Guidance

8 Challenging Behaviour NICE Guidance NG11 (2015) / QS101 (2015) Challenging Behaviour a Unified Approach (2016) RCPsych & BPS NICE Guidance NG54 (2016) / QS142 (2017)

9 Case 1: Challenging Behaviour? 28 year old woman Smith-Magenis Syndrome Aggression / Trantrums Hypomania

10 Case 1: Drug Regimen Benperidol Haloperidol Lithium Carbonate Quetiapine Haloperidol PRN Clonazepam Lithium Carbonate Lithium Carbonate Olanzapine Semi-Sodium Valproate Lorazepam PRN

11 Case 2: Diagnoses 33 year old man in Supported Living Schizo-affective Disorder? (2004) Tourette s Syndrome (childhood) Autism (2012) ADHD (2012)

12 Case 2: Drug Regimen Risperidone Semisodium Valproate Haloperidol Lorazepam Atomoxetine (ADHD) Pregabalin (Anxiety / ASD) Olanzapine (Tic Disorder) Intensive Support Team PBS

13 Adverse Effects Metabolic Motor Weight Gain Dyslipidemia Hypertension Elevated Prolactin Amenorrhoea Gynaecomastia Extrapyramidal Effects Oculgyric effects Tremor Dystonias Tardive Dyskinesia

14 Case 3: Adverse Effects 73 year old man Institutional care Supported Living Molesting female support workers Restless not sitting still

15 Case 3: Drug Regimen Trifluoperazine 30mg Nil Sulpiride 400mg

16 Monitor Adverse Effects Rating Scales Metabolic GASS (Glasgow Antipsychotic Side effect Scale) Motor LUNSERS (Liverpool University Neuroleptic Side Effects Rating Scale)

17 Challenges to Psychiatrist Psychiatrist Others Mental Illness? Change in behaviour Prescribe? Resistance Reduction / withdrawal Substitution? Resources to monitor changes Withdrawal period

18 Impact of Medication Person Clinical Effectiveness Quality of Life impact of side effects Prescriber Monitoring of drug regimens Health Service Expenditure on medication

19 Clinical Practice Clinical Discussion service-user; family; carer; colleagues Clear explanation Reasonable Adjustment ; easy-read Time to consider Agree desired outcome Clinical Review Measurement - clinical effects / side effects

20 Clinical Practice Operationalise - CB Care Pathway Alternatives to medication support plan Everyone s business professionals; carers; families; service-users

21 Transforming Care Programme 2012 BBC Panorama 31 May 2011 Winterbourne View Hospital

22

23 Why is it important? Prevalence rates of mental disorders (SCZ 3%) High rates of physical disorders Medication use in People with ID Polypharmacy Clinical effectiveness Adverse effects

24 What we know Glover (2015): GP data Antipsychotics 17% Antidepressants 16% Mood stabilisers 7% Sheehan (2015): THIN Database Disproportionate use of Psychotropics in People with ID

25 STOMP Pledge 2016

26 What does it mean in Clinical Practice? Mental Disorder or Challenging Behaviour? Drug reduction / withdrawal? (Sheehan 2017) Terminology: Withdrawal; Optimisation; Deprescribing Resources in Clinical Services

27

28 Whose Business Is It? Psychiatrists Pharmacists Clinical Teams Families / Carers Primary Care People with ID

29 Clinical Practice Clinical Discussion service-user; family; carer; colleagues Clear explanations Time to consider Clinical Review Measurement - clinical effects / side effects Care and Treatment Reviews Agree desired outcome

30 Summary Role of Psychiatrist Challenging Behaviour / Mental Disorder? Managing medication Alternatives to medication Working with others especially the person

31 MiXiT v=pdilynhpmrs

32 Dr. Ken Courtenay FRCPsych MRCGP Consultant Psychiatrist in Intellectual Disability London UK EAMHID Zagreb

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