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Pills for everything?
People with learning disability risk using inappropriate medication due to a lack of insight and poor communication.
In 2015 a body of work commissioned by NHS England published ‘Prescribing of psychotropic drugs to people with learning disabilities and/or autism by general practitioners in England’. The report reveals that over half (58.1%) of people studied did not have a diagnosis in their GP record of a condition such as psychosis, bipolar disorder, depression and anxiety, yet were being prescribed medication that was designed to treat these conditions. It states that at any time, around 1 in 6 people known as having a learning disability by their GP are prescribed an anti-psychotic, an antidepressant or both.
Following on from this, the BMJ published ‘Mental illness, challenging behaviour, and psychotropic drug prescribing in people with intellectual disability: UK population based cohort study’ in which the findings are reinforced further. This study examined the incidence of recorded mental illness and challenging behaviour and revealed that 21% of the cohort had a record of mental illness at study entry, 25% had a record of challenging behaviour, and 49% had a record of prescription of psychotropic drugs. The study finds that the incidence of mental illness is disproportionate to the number of adults prescribed these drugs. It concludes that more should be done to strengthen the evidence base for anti-psychotic prescribing in challenging behaviour.
What’s in the trolley?
If you are supporting people who are prescribed medicines such as Risperidone, Stelazine, Clozapine, Chlorpromazine, or Flupenthixol it might be wise to ask the GP to review the care plan. This is particularly important where you are using repeat prescribing; check the last time the medication regime was reviewed before you re-order.
In cases where the service user is reviewed infrequently by a consultant psychiatrist, the GP may be continuing to prescribe a drug that is not designed for long-term use. Lack of communication between carers and GP, then GP and consultant, can mean people go on using the same drugs for years without proper review.
Risperidone is a good example of a drug used frequently in people with challenging behaviour where duration of treatment is important. Long term treatment with this drug is likely to be ineffective and may even be counter-productive. The recognised uses of Risperidone in relation to behaviour are specifically recognised as being appropriate only in the short term, or for periods of up to six weeks. Check the care notes and see how many people prescribed Risperidone have been using it for longer than this.
Keeping an eye on health
Before resorting to medication, it is worth asking the GP to undertake examination of the person to rule out or address any potential medical causes for the behaviour. Make sure that the doctor is aware of the history of that individual and keep close records of how treatments are affecting them, particularly in terms of possible side effects.
With respect to side effect monitoring, a joined up approach between primary and secondary care is required. People with learning disabilities are entitled to an annual physical health checks by their GP practice. However, in some areas this information is not standardised and is not routinely communicated to hospital consultants, who may have initiated prescribing.
Your best weapon is understanding; to empower service users and help articulate concerns over prescribing, two easy-read guides can be found here. The first is around Risperidone, since this is a frequently-used medication. The second is more general information on the NHS England work around medication and challenging behaviour.