Dr. Ken Courtenay FRCPsych MRCGP (k.courtenay@ucl.ac.uk) Consultant Psychiatrist in Intellectual Disability London UK EAMHID Zagreb 27.4.2018
Overuse of Medication in People with ID Clinical Background Case Vignettes Prescribing Practice Challenges
Classes of Psychotropics Antipsychotics Stimulants Antidepressants Non-stimulants Mood Stabilisers Hypnotics
Clinical Indications Mental Illness Challenging Behaviour
Clinical Indications Psychosis - Risperidone Mood Disorders Olanzapine; Valproate Anxiety Pregabalin; Fluoxetine ADHD Atomoxetine; Methylphenidate
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
Professional Guidance
Challenging Behaviour NICE Guidance NG11 (2015) / QS101 (2015) Challenging Behaviour a Unified Approach (2016) RCPsych & BPS NICE Guidance NG54 (2016) / QS142 (2017)
Case 1: Challenging Behaviour? 28 year old woman Smith-Magenis Syndrome Aggression / Trantrums Hypomania
Case 1: Drug Regimen 2006 2009 2010 2016 Benperidol Haloperidol Lithium Carbonate Quetiapine Haloperidol PRN Clonazepam Lithium Carbonate Lithium Carbonate Olanzapine Semi-Sodium Valproate Lorazepam PRN
Case 2: Diagnoses 33 year old man in Supported Living Schizo-affective Disorder? (2004) Tourette s Syndrome (childhood) Autism (2012) ADHD (2012)
Case 2: Drug Regimen 2006 2016 Risperidone Semisodium Valproate Haloperidol Lorazepam Atomoxetine (ADHD) Pregabalin (Anxiety / ASD) Olanzapine (Tic Disorder) Intensive Support Team PBS
Adverse Effects Metabolic Motor Weight Gain Dyslipidemia Hypertension Elevated Prolactin Amenorrhoea Gynaecomastia Extrapyramidal Effects Oculgyric effects Tremor Dystonias Tardive Dyskinesia
Case 3: Adverse Effects 73 year old man Institutional care Supported Living Molesting female support workers Restless not sitting still
Case 3: Drug Regimen 2006 2009-2016 Trifluoperazine 30mg Nil Sulpiride 400mg
Monitor Adverse Effects Rating Scales Metabolic GASS (Glasgow Antipsychotic Side effect Scale) Motor LUNSERS (Liverpool University Neuroleptic Side Effects Rating Scale)
Challenges to Psychiatrist Psychiatrist Others Mental Illness? Change in behaviour Prescribe? Resistance Reduction / withdrawal Substitution? Resources to monitor changes Withdrawal period
Impact of Medication Person Clinical Effectiveness Quality of Life impact of side effects Prescriber Monitoring of drug regimens Health Service Expenditure on medication
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
Clinical Practice Operationalise - CB Care Pathway Alternatives to medication support plan Everyone s business professionals; carers; families; service-users
Transforming Care Programme 2012 BBC Panorama 31 May 2011 Winterbourne View Hospital
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
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
STOMP Pledge 2016
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
Whose Business Is It? Psychiatrists Pharmacists Clinical Teams Families / Carers Primary Care People with ID
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
Summary Role of Psychiatrist Challenging Behaviour / Mental Disorder? Managing medication Alternatives to medication Working with others especially the person
MiXiT https://www.youtube.com/watch? v=pdilynhpmrs
Dr. Ken Courtenay FRCPsych MRCGP (k.courtenay@ucl.ac.uk) Consultant Psychiatrist in Intellectual Disability London UK EAMHID Zagreb 27.4.2018