Adherence of clinicians to guidelines for the prescription of antipsychotic drugs to people with intellectual disabilities

Published date02 May 2017
Pages110-125
DOIhttps://doi.org/10.1108/AMHID-02-2017-0005
Date02 May 2017
AuthorLotte Ramerman,Gerda de Kuijper,Pieter J. Hoekstra
Subject MatterHealth & social care,Learning & intellectual disabilities
Adherence of clinicians to guidelines for
the prescription of antipsychotic drugs
to people with intellectual disabilities
Lotte Ramerman, Gerda de Kuijper and Pieter J. Hoekstra
Abstract
Purpose Antipsychotic drugs are frequently prescribed to people with intellectual disabilities (ID) to
ameliorate psychotic symptoms and behavioural symptoms with and without mental condition. Guidelines
recommend systematic evaluation of treatment effects and adverse effects, and limiting the treatment
duration. Studies have shown that adherence to prescription guidelines is beneficial for clientsoutcomes.
Therefore, the purpose of this paper is to investigate the adherence to antipsychotic drug prescription
guidelines in two treatment settings.
Design/methodology/approach A checklist, based on existing antipsychotic drug prescription
guidelines, was used to evaluate the adherence of prescribers to guidelines in two settings in the
Netherlands, i.e., in specialized intellectual disability (ID) care organizations and mental health care
organizations. Data from medical records of clients who used antipsychotic drugs (n ¼299) were compared
to the items of the checklist.
Findings Treatment effects were measured with validated scales in both settings in only 2.7 per cent of
cases. Prescriptions were for problem behaviour in the absence of a psychotic disorder or psychotic
symptoms in 90 per cent (specialized ID care) and in 79 per cent (mental health care) of cases. In specialized
ID care pipamperone (31.9 per cent) and in mental health care risperidone (48.5 per cent) was most often
prescribed. Adverse effects were monitored more frequently in specialized ID care.
Originality/value The adherence to guidelines for prescribing antipsychotic drug to people with ID is
insufficient in the Netherlands, because of shortcomings in the evaluation of treatment and adverse effects.
Keywords Monitoring, Guidelines, Adverse effects, Antipsychotic drugs, Reason for prescription,
Treatment evaluation
Paper type Research paper
Introduction
Antipsychotic drugs are indicated and licensed for the treatment of psychotic disorders and
episodes of psychotic symptoms, and some for the short-term treatment of aggressive
behaviour in people with intellectual disabilities (ID), in addition to psychosocial interventions
(National Institute for Health and Care Excellence (NICE), 2015, 2017). In general, there are three
groups of people with ID that use antipsychotic drugs: those with a diagnosis of a psychotic
disorder or schizophrenia, those with a diagnosis of a non-psychotic mental condition and
comorbid problem behaviour, and those with problem behaviour without a diagnosis of a mental
condition (National Institute for Health and Care Excellence (NICE), 2016).
The evidence for the effectiveness of antipsychotic drugs for the treatment of behavioural
symptoms and problem behaviour is not clear, however (Brylewski and Duggan, 2004; Deb and
Unwin, 2007; De Kuijper et al., 2014; Tyrer et al., 2008). Moreover, antipsychotic drugs
adverse effects, i.e., neurological, metabolic and hormonal adverse events occur frequently
(Haddad and Dursun, 2008; Bhuvaneswar et al., 2009; Matson and Mahan, 2010). These
adverse effects may harm health and negatively influence the quality of life of users.
Unfortunately, many people with ID are not able to effectively communicate discomfort caused
Received 20 February 2017
Revised 20 April 2017
Accepted 21 April 2017
The authors would like to
acknowledge colleagues from
De Trans, De Baalderborg groep,
Vanboeijen, Accare, and the
Centre for Intellectual Disability and
Mental Health for facilitating the
study and support in data
collection. This study was funded
by the Stichting Fonds
Zorgondersteuning and ZonMW
Grant No. 836021020.
Lotte Ramerman and Gerda de
Kuijper are both based at the
Centre for Intellectual Disability
and Mental Health, GGZ
Drenthe, Assen,
The Netherlands and
Department of Child and
Adolescent Psychiatry,
University Medical Centre
Groningen, University of
Groningen, Groningen,
The Netherlands.
Pieter J. Hoekstra is based at
the Department of Child and
Adolescent Psychiatry,
University Medical Centre
Groningen, University of
Groningen, Groningen,
The Netherlands.
PAGE110
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VOL. 11 NO. 3 2017, pp.110-125, © Emerald Publishing Limited, ISSN 2044-1282 DOI 10.1108/AMHID-02-2017-0005
by adverse effects (Reiss and Aman, 1997) while support professionals often do not recognize
symptoms (Fretwell and Felce, 2007). Clinicians should therefore balance the benefits of ongoing
treatment with antipsychotic drugs vs the risks of the occurrence of adverse events, by carefully
monitoring treatment effects as well as adverse effects.
There are several national and international guidelines that provide recommendations on
prescribing antipsychotic drugs in people with ID. These guidelines all provide similar
recommendations on when and how long to prescribe antipsychotic drugs, how to measure
treatment effects, when additional psychological and psychosocial treatments are needed, how
to monitor adverse effects and when to discontinue the pharmaceutical treatment (NICE, 2015,
2016, 2017; Deb et al., 2009; de Leon et al., 2009; Nederlandse Vereniging van Artsen voor
Verstandelijk Gehandicapten (NVAVG), 2007 (Dutch society for Intellectual Disability Physicians);
Nederlands Huisartsen Genootschap (NHG), 2006 (Dutch General Practice Organization); Cahn
et al., 2008; Dieleman et al., 2011; Nederlandse Vereniging van Artsen Somatisch voor de
Psychiatrie, 2006 (Dutch society for physicians somatic in psychiatry)).
Previous studies concluded that the successful implementation of clinical guidelines into main
stream mental health care improved treatment outcomes (van Dijk et al., 2013), led to lower
relapse rates (Melfi et al., 1998), greater treatment satisfaction (van Dijk et al., 2013) and improved
quality of care (Bauer, 2002). However, studies on adherence to guidelines in people with ID have
pointed to insufficient monitoring of adverse effects (Thalitaya et al., 2011; Griffiths et al., 2012;
Marshall, 2004; Teeluckdharry et al., 2013; Paton et al., 2011, 2016; Cleary et al., 2012; Walter
et al., 2008) and limited evaluation of the need for ongoing treatment and related discontinuation
(Thalitaya et al., 2011; Paton et al., 2011).
Adherence to treatment guidelines may be different across treatment settings. In the
Netherlands, there are two main settings in which antipsychotic drugs are prescribed to
people with an ID: specialized ID care, which mostly offers care through ID physicians or
sometimes specialized general practitioners; and mental health care that provides care through
mostly psychiatrists and sometimes specialized ID physicians. Therefore, we set up a study to
investigate adherence to prescription guidelines of antipsychotic drugs in these two care settings
for people with ID, including the monitoring of treatment effects and adverse effects.
Methods
Study design, settings and sample
We studied randomly selected pharmaceutical and medical records of clients with ID who had
been prescribed antipsychotic drugs from two types of settings: three organizations providing
specialized ID health care and two organizations providing mental health care (a specialized
outpatient clinic for mental health care and an outpatient clinic for child and adolescent
psychiatry). Mental health care in these two types of settings was provided by various
professionals: in specialized ID care by ID physicians, general practitioners, nurses and
behavioural scientists; in mental health care organizations by psychiatrists, behavioural scientists
and/or ID physicians and nurses.
In this study, 299 medical records were included (Figure 1). We took a random sample from the
378 available records from the specialized ID organizations (n¼113) and included all available
records from the mental health care organizations (n¼186).
Selection criteria
Medical records were selected if:
the client used at least one antipsychotic drug at the time of the study;
the client had an ID (IQo70) based on medical records;
the client was aged six years or older; and
the client and/or legal representative provided informed consent.
The use of other medication, including other psychotropic drugs, was no reasons for exclusion.
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