The Use of Psychotropic Medication on Intellectually Disabled Adults - Essay Example

?The use of psychotropic medication still has a place in the treatment of challenging behaviour in adults with intellectual disability. Critically discuss this statement with reference to the literature. Introduction Intellectual disabilities, otherwise known as mental retardation or learning disability is a lifelong problem same as other mental disorders specified in the international systems of classification. These disabilities include various mental disorders (meta-syndrome) covering different clinical issues characterized as gaps in cognitive functioning seen before skills are acquired through learning (Salvador-Carulla and Bertelli, 2008). About 30% of individuals with intellectual disabilities also suffer from other psychiatric disorders which often sets in during childhood and lingers into adolescence and adulthood (Cooper, et.al., 2007). Even with such evidence, intellectual disabilities and similar issues are a vague aspect of mental health. In most countries, there are limited provisions and trainings on the management of intellectual disabilities. The WHO has established the unmet care issues on individuals with intellectual disability (WHO, 2007). Within the realm of intellectual disability, the assessment and management of problematic behaviours are significant. Most individuals suffering from intellectual disabilities are also suffering from problematic or challenging behaviours (Deb, et.al., 2009). Reports indicate that about 20-45% of individuals with intellectual disabilities are also receiving psychotropic medications and 14-30% are being given psychotropic meds to manage challenging behaviour like aggression and self-injurious behaviours (Clark, et.al., 1990). Some of these psychotropic meds include antipsychotics, antidepressants, anti-anxiety drugs, psychostimulants, and opioid antagonists. Most of the drugs administered to patients with intellectual disabilities manifesting challenging behaviour are antipsychotics (Speat, et.al., 1997). In the past, the issuance of these psychotropic medications has been prevalent, even routine for patients with challenging behaviours suffering from intellectual disabilities. Issues on its use have been raised however, mostly in relation to the general impact of the drug to the patient. Others argue that giving the drugs does not solve the problem or challenging behaviour; when the drugs would wear off, the challenging behaviour would again manifest. This study now seeks to evaluate the use of psychotropic medication and the fact that it still has a place in the treatment of challenging behaviour among adults with intellectual disability. Various studies shall also be discussed in order to support the use of psychotropic drugs in managing challenging behaviour among patients with intellectual disabilities. Body There is still a place for the use of psychotropic medications in the management of patients with intellectual disability and challenging behaviour (Matson, et.al., 2009). The primary goal in the management of patients with intellectual disability must not be actually to treat the behaviour. Finding a cause for challenging behaviours among patients with intellectual disabilities is often difficult and when a cause is established, establishing an intervention must be geared towards reducing the effect of the behaviour on the patient as well as the people around him or her (Antochi, et.al., 2003). There are often different causes for problematic behaviour, including physical and mental health issues. Factors may either be internal or external and may both impact on the manifestation of problematic behaviours. The study by Sokolovski (2012) points out how psychotropic medications have presented with improved outcomes, especially in terms of anti-problem behaviours and the use of psychotropic drugs. This study points out that the use of psychotropic behaviours among adults with intellectual disabilities manifesting challenging behaviour is common and prevalent; however such use is not related to improved outcomes or results in patients (Sokolovski, 2012). Moreover, only 16% of the patients were actually diagnosed with psychiatric health problems, and problem behaviour was seen in only 60% of participants, and yet more than 75% of the respondents were actually administered psychotropic drugs (Sokolovski, 2012). This implies that granting that psychotropic drugs would be effective in managing challenging behaviours from adults with intellectual disabilities, there is still a significant percentage of adult patients who are not actually suffering any intellectual disabilities but are actually being administered psychotropic medications. The important guidelines on the use of medications in the management of specific psychiatric disorders must be established and followed (Mezzich, 2007). Where no treatable physical or psychiatric issues can be seen, then, it is important to use non-medication based therapy for the patients. The issue in the current context is that psychotropic drugs have been over-prescribed for patients manifesting problematic behaviours, without necessary assessments made on their actual psychiatric problems (Huefner, et.al., 2012). Through assessments made on patients manifesting challenging behavior, they may end up needing medication only or medication as an adjunct to non-medication treatment (Huefner, et.al., 2012). The management may also involve counselling or in some cases, using social and environmental elements to secure improved behaviour. Such remedy may be considered a temporary strategy which has to be carefully and regularly assessed at specific intervals (Williamson and Martin, 2012). The use of psychotropic medications can still have its place in the management of patients with intellectual disability and challenging behaviour. The specific situations when medication-based strategies can be implemented are based on individual specifications (Mahan, 2010). Some of these situations include: failure of non-medication based strategies; risk of harm to patient; risk of harm or distress to others; high frequency or severity of problematic behaviour; treatment of underlying psychiatric disorder; calming an individual to allow implementation of non-medication strategies; previously favourable response to medications; patient/carer choice (Deb, et.al., 2009). These are conditions which are often unmanageable without medications and in some cases, harmful to the patients and to other individuals. In effect, the issuance of these medications must therefore not be made as a routine practice and without carrying out the necessary assessments on the patient (Arshad, et.al., 2011). Courtemanche, et.al., (2011) also point out that the issuance of the medications must be considered as a final resort, especially where the patient is already causing or has a risk of causing not just himself but other individuals harm. Schroeder and colleagues (2013) also emphasize that the use of psychotropic medications must be patient-centred. It must be discussed with the patient and/or carer and the decision must be founded on the individual needs, condition, and preferences of the patient/carer. The decision to prescribe the drug must therefore be taken within the context of each patient, not as a general decision for patients manifesting problematic behaviour (Bradley and Cheetham, 2010). Considering that psychotropic medications can have undesirable side effects on the patient, the administration of the medication must be made under monitored conditions (Tsiouris, et.al., 2012). The administration of psychotropic medications in the past was not adequately monitored, as evidenced by the study of Tsiouris and colleagues (2012) which indicated how psychotropic medications were not monitored in terms of possible side-effects. Not all patients react in the same way to psychotropic medications; monitoring must therefore be strictly made part of the management process for intellectually disabled clients. Specific qualities for each client must then be gathered including data about family members, caregivers, and the multidisciplinary team (Brown and Percy, 2007). Physical data which are pertinent to the assessment would also have to include blood tests and EKG. Trends have been observed on the routine administration of psychotropic drugs without the necessary tests carried out. This was the likely cause for issues seen on the administration of the medication (Brylewski and Duggan, 2004). As a result, the favourable effects of the medication may have been slightly overshadowed by the negative effects of the psychotropic drugs (Valdovinos, et.al., 2009). Administering the drug at the lowest possible dose first can help reduce the possible adverse impact of the drug on the patient. Considerations on non-medication must be made even when the patient is already on medications; in effect, stopping the psychotropic medications must be considered for the client at regular intervals (Baglio, 2010). Where improvements are not seen, a re-evaluation of the care plan must be made. The issue mentioned by various authors on the use of psychotropic medications is that it is often considered for long-term treatment (Davis, et.al., 2008). Long-term use of psychotropic drugs has been known to cause health issues; hence, its use must only be considered with caution (Deb, et.al., 2007). With the observation of these safety measures, the patient would be able to benefit from the psychotropic medication, while still avoiding or minimizing the impact of its adverse effects (DeLeon, et.al., 2009). Admittedly, risks associated with the use of psychotropic medications on clients with intellectual disability and challenging behaviour are the reason why psychotropic medication use is being controlled (De Kuijper, et.al., 2010). Although most medications do carry some form of risk with their use, evidence is based on studies on patients not suffering from intellectual disabilities. For instance, current studies indicate that recent antipsychotic drugs can lead to weight gain as well as metabolic issues relating to glucose tolerance, lipid metabolism, and prolactin secretion (Ucok and Gaebel, 2008). There are limited quality studies which would either support or negate concerns on patients with ID having a higher risk for adverse effects of medication as compared to the general population. Due to these limits in evidence, experts do recommend various points before the psychotropic drugs can be administered (Foxx, 2005). These recommendations include the need to discuss with the patient/family and the carers about the common and serious effects of the medication. Patients must also be advised on what they can do if serious adverse events take place (Ahmed, et.al., 2000). All adverse incidents must also be documented properly. Moreover, as soon as the drug is administered, the risk-benefit profile must be assessed at intervals, mostly focusing on the patient and/or his/her family’s quality of life (Gagiano, et.al., 2005). As was mentioned above, withdrawing drugs which have been prescribed for a prolonged period of time must also be considered for patients (Ahmed, et.al., 2000). For other groups, doses for the drug can be decreased, and total withdrawal may not be possible. There may also be certain instances wherein the drugs cannot be reduced even with prolonged use. Various elements impact on the success of withdrawal, mostly relating to social and environmental factors including staff training and attitude (Unwin and Deb, 2008). These environmental and social elements cannot however indicate which medication can actually be withdrawn or the rate of withdrawal. However, various general recommendations are suggested to manage withdrawal. It is important to stabilize the patient’s challenging behaviour first using the least amount of medications administered at the lowest dose (Grey and Hastings, 2005). The withdrawal must be done one drug at a time and slowly. Where possible, time can be given after withdrawing one medication before another drug is withdrawn. Under the above conditions, it is possible to still opt for non-medication remedies for patients, especially where the patient does not manifest any favourable response to the drug (Aman and Gharabawi, 2004). If the administration of the psychotropic medication would be unavoidable, these studies and these regulations imply that it is important to reduce the impact of the drug on the patient. Based on the recommendations of the Alzheimer’s Association, where non-drug interventions do not succeed after being used consistently, the use of psychotropic medications may be considered, especially if patients manifest severe symptoms or present a risk towards themselves or others (Griffiths and King, 2004). Medications can still be effective in some instances, however, they must be applied carefully and would likely be effective when used as adjuncts to non-drug interventions. In the US, the Center for Medicare and Medicaid Services (CMS) suggest guidelines on the application of antipsychotics for aggressive elderly patients. Their assessment indicates that following the comprehensive assessment of a patient, the medical facility must guarantee that patients who have not used antipsychotics are not administered these drugs unless antipsychotic drug therapy is needed to manage specific diseases (Habler and Reis, 2010). It is also important for residents who utilize antipsychotic drugs to also enjoy eventual dose reductions, as well as other non-drug interventions in order to eventually withdraw the drugs. Although the CMS pointed out that decreasing the administration of psychotropic medications is a favourable element, they also accept the idea that in some instances, these drugs may indeed be indicated (Wisconsin State Legislature, 2012). In effect, the principles of this group do not necessarily intend to totally prevent physicians from prescribing psychotropic medications; but their goal is to simply change the usual practices for the drug administration (Wisconsin State Legislature, 2012). While the above discussion indicates instances which would support the use of psychotropic medications, there are various instances when these drugs are not necessary (Wisconsin State Legislature, 2012). It is important to note that the patient must not be subjected to unnecessary medications. These unnecessary medications are usually those given at excessive doses, for prolonged periods, without sufficient monitoring processes, without indications for use, or those administered with the presence of adverse effects (Haw and Stubbs, 2005). Before psychotropic drugs can also be given to patients, it is important to ask if the challenging behaviour is persistent, harmful, or is caused by other treatable illnesses (Tyrer, et.al., 2008). These questions provide guidelines which can help guide health professionals on the administration of psychotropic medications. Notable again is the question relating to the challenging behaviour possibly caused by other illnesses (Herzinger and Campbell, 2007). The challenging behaviour may often be attributed to other illnesses which can be managed without using psychotropic drugs (Weeden, et.al., 2011). As soon as such connections are made for the patient, then the necessary interventions can be implemented to either manage the disease causing the challenging behaviour, or to manage the challenging behaviour through psychotropic drugs (Weeden, et.al., 2011). Without the necessary assessment processes mentioned above, the pertinent determinations cannot be made. In the use of psychotropic medications, barriers in securing work group goals may be met. One of these barriers includes the insufficient data on the application of psychotropic drugs outside the hospital or the mental health unit (Charlot, et.al., 2011). Although there has been some interest in resolving the application of psychotropic medications in the community and other residences, the outcomes indicate insufficient information on the gravity of the problem beyond the health facilities (Heyvaert, et.al., 2010). It is also important to accept that residents managed in the community may sometimes go to different physicians and this process can present difficulties in monitoring and evaluating drugs (La Malfa, et.al., 2006). Due to the issues seen in the problem and the importance of the work group controlling its impact due to limited available resources, recommendations have been made allowing patients to apply to any facility or physician for medication management McGillivray and McCabe, 2006). One of the pitfalls on the use of psychotropic drugs is that there is not enough data on the use of psychotropic drugs other than antipsychotics. There is also insufficient data on the rates of prescription which can best be applied to patients (Emerson and Einfeld, 2013). Standards have been set by government health agencies on these rates, however, data inaccuracies have been seen and not enough conclusions on prescribing rates have been observed due to resident selectivity. In general, the importance of not making psychotropic medications the default medications for managing challenging behaviours was also emphasized (Campbell, et.al., 2011). The application of psychotropic medications only after other possible causes of challenging behaviour have been made has also been highlighted. This is similar to above discussions on the topic which indicates the importance of considering the drug only as a last resort, not a first choice for dealing with challenging behaviour among patients with intellectual disabilities (Singh, et.al., 2005). In the same spirit of patient assessment, current medications also have to be reviewed (Singh, et.al., 2009). Adverse reactions to other drugs can be established through such assessment. Some psychotropic drugs have been known to exacerbate or weaken the effect of other drugs and some drugs have been known to increase the impact of psychotropic drugs (Tsiouris, et.al., 2012). Moreover, some drugs which are already being taken may actually be the cause of the challenging behaviour among individuals with intellectual disabilities or may worsen the manifestation of the challenging behaviour. In such instances, changes in the drug have to be made. The use of psychotropic drugs can work well in the management of patients with intellectual disabilities manifesting challenging behaviour, especially where the right conditions are set (Seyfer, et.al., 2011). Its use therefore includes safeguards, some of which are already mentioned above. A written care plan must be established also in order to monitor the patient and to evaluate the patient’s challenging behaviour (Tyrer, et.al., 2008). The monitoring process must be based on the type of medication given, the possible side effects manifesting, the long-term effects, the duration of intake, and the reduction of drug dose. In some instances, these processes are not carried out; and where negative consequences manifest, the condition of the patient may worsen and decline (Tyrer, et.al., 2009). It is therefore important to monitor these elements after the drug is administered to the patient. Physicians prescribing these drugs place the best interests of the patient at the very forefront. Such consideration must be highlighted in the physician’s mind before decisions are made to prescribe and administer the psychotropic medications (Thakker, 2011). The usual thought process often referring to the use of these psychotropic drugs as default medications must therefore be relinquished (Thakker, 2011). By making the process of prescribing psychotropic medications a more discerning process, it is possible to ensure that the appropriate decisions are made for the patient. Through the proper evaluative processes made by the physician before psychotropics are administered, the different medical options would also be given sufficient consideration, including adjunct treatments for the management of challenging behaviour among individuals with intellectual disabilities (Thakker, 2011). The history of medications for the patient, most especially those which did not work well or those which did work well for the patient form part of the evaluative process before psychotropic medications can be administered (Toogood, et.al., 2011). Where medications administered previously have unfavourable negative effects, these important details must be taken into account before any decisions are made on the administration of psychotropic drugs. Conclusion The above discussion indicates that there is still a place for the use of psychotropic drugs in managing intellectual disability among patients manifesting challenging or problematic behaviour. Admittedly, there are various issues and adverse effects seen in the administration of psychotropic drugs, hence, its use has been discouraged by various experts. However, where the right conditions are set, including the appropriate safeguards for medication administration, these psychotropic drugs may be safely administered. The administration of these drugs must also not be made by default; instead, where all other non-medication based interventions fail to manage the patient’s behaviour, then the drug can be administered. In other words, it must only be considered as a last resort to the management of challenging behaviour. Patient assessment and monitoring precedes and accompanies the safe administration of psychotropic medications. Ultimately, patient interests and patient preferences must form a large part of the decision-making process for the administration of psychotropic medications. In general, the application of psychotropic medications among individuals with intellectual disabilities manifesting challenging behaviours is based on the results of specific and comprehensive biopsychosocial evaluation of the proposed medication or intervention. Various researches indicate that the dominant use of psychotropic medications is based on a reactive first-line application in the management of challenging behaviours. The use of psychotropic drugs which are administered PRN is also a generally acceptable tool in crisis intervention. There may be an increased focus on PRN medications as some jurisdictions control the application of physical restraints and other behavioural procedures which may be intrusive. Still, as indicated in this paper, the efficacy indicated by various studies assessing different pharmacological assessments must be evaluated with caution and with must awareness on the possible methodological assessments. Psychotropic medications in behaviour management for individuals intellectual disability must only be applied where appropriate and after prescription by the physician, and after processes on monitoring are indicated. With time, the improved willingness of the medical community to work with each other on treatment planning can also help ensure improved treatments for these patients. References Ahmed, Z., Fraser, W., and Kerr, M., 2000. Reducing antipsychotic medication in people with a learning disability. Br J Psychiatry, 178, pp. 42–46 Aman, M. and Gharabawi, G., 2004. 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