Psychotropic Medication Use & Dual Diagnosis:

A Project Overview

Morag BudiselikSenior Clinical PsychologistAccommodation Behaviour Support Team

PROJECT RESEARCHERS

2001:

• Wendy O’Connor, Clinical Psychologist, Accommodation Services Directorate

2008:

• Samantha Barnes, Clinical Psychologist

Accommodation Behaviour Support Team

Current Project overview

• being conducted within WA DSC Accommodation Services Directorate

• aims to increase understanding of local

- patterns of dual diagnosis - trends in psychotropic

prescription

Definitions

• Dual diagnosis – “the coexistence of an intellectual disability and a psychiatric disorder or mental health problem” (Sturmey et al. 2007)

• Psychotropic medication - primarily indicated for the treatment of diagnosed psychiatric illnesses

• Polypharmacy/poly-prescribing – “the prescribing of more than one medication for a particular indication” (Deb et al. 2006)

Prevalence of dual diagnosis reported in research literature

• difficult to determine prevalence

• community population studies cite prevalence ranging from 20-60% (Bailey, 2007)

• some argue rate higher than that of the general population (Chaplin 2004)

Rates of psychotropic use from literature

• 20-45% of people with ID are on psychotropic medication

• 14-30% for behaviour management

• antipsychotics most commonly used psychotropic medication for behaviour management

(Clarke et al., 1990; Deb, 2007; Deb et al., 2006; Deb et al., 1994)

Background to current project

2001 Survey •sample - residents living in DSC Accommodation Services

- 579 adults with ID•survey reported on

– number of residents on psychotropic medications

– what medications were prescribed

2001 findings

Percentage of residents prescribed psychotropic and/or anti-convulsant medication

(2001 n=579)

74%

53%

0%10%20%30%40%50%60%70%80%

Psychotropic Psychotropic and/oranticonvulsant

2001 findings

Percentage of residents prescribed various medication(2001 n=579)

48%38%

15% 13%4% 4%

0%10%20%30%40%50%60%

2001 findings

Number of psychotropic medications per resident(2001 n=579)

188

89

25

7

0

20

40

60

80

100

120

140

160

180

200

1 2 3 4

No meds

No

res

iden

ts

2001

Following questions raised by 2001 Project Summary:

Needs

Psychiatristaccess

Prescriber

Behavioursupport

Formaldiagnosis

?

2008 Project

PHASE ONE

Comparison 2001 data

PHASE TWO Diagnosis, prescribing,

monitoring

Phase one

• Aimcurrent prescription of

psychotropics & comparison of 2001/2008 data

• Sourceresident medication records

(now computerised)

• Sample553 adults with ID living in DSC Accommodation Services

2008 findings

Percentage of residents on psychotropic medication

(2001 n=579; 2008 n=553)

67%

53%

0%

20%

40%

60%

80%

2001 2008

2008 findings

Percentage of residents on psychotropic and/or anticonvulsant medication(2001 n=579; 2008 n=553)

74%

81%

70%

72%

74%

76%

78%

80%

82%

2001 2008

2008 findings

Percentage of residents prescribed various medication(2001 n=579; 2008 n=553)

48%38%

15% 13%4% 4%

55%46%

28%21%

9% 8%

0%10%20%30%40%50%60%

2001

2008

2008 findings

Number of psychotropic medications per resident(2001 n=579; 2008 n=553)

188

89

257 0 0 0 0

173

100

63

266 1 2 0

0

50

100

150

200

1 2 3 4 5 6 7 8

No medications

No re

side

nts

2001

2008

2008 findings

Percentage of residents prescribed multiple psychotropic medications

(2001 n=309; 2008 n=371)

39%

53%

0%

10%

20%

30%

40%

50%

60%

2001 2008

2008 findings

Most commonly prescribed psychotropics were the antipsychotics:

1. Zyprexa (Olanzapine)2. Risperdal (Risperidone)3. Seroquel (Quetiapine)

Key findings• increase in the number of residents

being prescribed psychotropic medication

• increased prescription of each type of medication

• antipsychotics most common followed by antidepressants

• increase in the number of people being prescribed anti-depressant plus antipsychotic

• increase in polypharmacy

Phase Two

• Aimidentify diagnosis, prescribing, monitoring

• Sourceresident records

• Sample553 adults with ID living in DSC Accommodation Services

Where to from here

Identifying:

• Formal psychiatric diagnosis/likely mental health problems?

• Who is prescribing? GP or psychiatrist?

• Why prescribing? Mental health problems or behaviour management?

• Monitoring and review process?

Preliminary themes

• few residents have an ‘official’ psychiatric diagnosis

• common hypothesised diagnoses are bipolar disorder & psychosis

• few DSC residents are in the public mental health system – primarily private

Challenges facing service providers

• access to specialist psychiatric opinion

• prescription in the absence of psychiatric assessment / diagnosis

• medication for behaviour control / restraint

Summary of Issues

• assessment, diagnosis, prescription and review process

• access to specialist psychiatric opinion

• medication as an adjunct to behaviour support interventions

• inclusion of medication within considered treatment plan when indicated

ReferencesBailey N. M. (2007) Prevalence of psychiatric disorders in adults with

moderate to profound learning disabilities. Advances in Mental Health and Learning Disabilities, 1 (2), 36-44

Chaplin R. (2004) General psychiatric services for people with intellectual disability and mental illness. Journal of Intellectual Disability Research, 48, 1-10

Clarke D. J., Kelley S., Thinn K. & Corbett J. A. (1990) Psychotropic drugs and mental retardation: Disabilities and the prescription of drugs for behaviour and for epilepsy in 3 residential settings. Journal of Mental Deficiency Research, 28 (3) 229-233

Deb S. (2007) The role of medication in the management of behaviour problems in people with learning disabilities. Advances in Mental Health and Learning Disabilities, 1 (2), 26-31

Deb S., Clarke D. & Unwin G. (2006) Using Medication to Manage Behaviour Problems Among Adults with a Learning Disability: Quick Reference Guide. Birmingham and London: University of Birmingham, Royal College of Psychiatrists and Mencap. Available from: www.ld-medication.bham.ac.uk

Deb S. & Fraser W. I. (1994) The use of psychotropic medication in people with learning disability: towards rational prescribing. Human Psychopharmacology 9 259-272

Sturmey P., Lindsay W. R. & Didden R. (2007) Editorial special issues: dual diagnosis. Journal of Applied Research in Intellectual Disabilities, 20, 379-383