A Snapshot of Prescribing in Intellectual Disability CAMHS

Abstract

Aims

There is increasing recognition of the use of psychotropic medication in young people with intellectual disability (ID) at a population level but little is known about day-to-day prescribing practice. This project aimed to characterise medication use in this group and assess standards of prescribing practice with reference to RCPsych guidelines.

Methods

Data werecollected by case note review of young people prescribed psychotropic medication within a community ID CAMHS Service. An index prescription was assessed against standards of prescribing - this was the longest standing script for each young person in the study.

Results

73 young people were recruited, aged 7–20 years, predominantly with moderate or severe ID. There was a high degree of comorbidity predominantly with autistic spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD) and anxiety presentations. Diagnoses did not differ by sex (p > 0.05) however behaviours that challenge were proportionately higher in females (p = 0.014). A high proportion of youngsters displayed behaviours that challenge (68.5%, n = 50) and almost all of these young people (96%, n = 48) had an additional diagnosis. ADHD presentations were negatively associated with behaviours that challenge (p = 0.047).

The hypnotic melatonin was most frequently used medication (56.2%, n = 41) followed by SSRI's (49.3%, n = 36) and antipsychotics (20.5%, n = 15). It was common for use of multiple medications (67.1%, n = 49), typically combining melatonin with a stimulant, SSRI or antipsychotic medication (61%, n = 31). Medications were generally used at modest doses.

The index prescription was in place for a median of 25 months (IQR 28.5, Range 1–108). The indication for prescribing was well documented (98.6%, n = 72) however severity (67.1%, n = 49) and frequency (56.2%, n = 41) recording was poorer. 6-monthly review rate was relatively low (62.5%, n = 40) but the likelihood of review did not reduce with increasing prescription length (p > 0.05). Review of medication response (94.2%, n = 65) and side-effects (73.9%, n = 51) was good. Overall there was poor documentation around consent-to-treatment procedures for young people over 16 years of age with only 17.2% (n = 5) having valid authorisation for medication in their case notes.

Conclusion

This study provides rich clinical data about current clinical practice around prescribing in youngsters with ID. Comorbidity is common and results suggest there may be a bias in labelling behaviours that challenge in males as ADHD-related. A range of (multiple) psychotropic medications are used, often for long-periods despite a lack of evidence base. Clinicians are encouraged to ensure rigorous review and consent-to-treatment processes to minimise harms and over-prescribing in this vulnerable population.