Management of psychotropic medications in adults with intellectual disability: a scoping review protocol

Introduction: Psychotropic medications are commonly prescribed among adults with intellectual disability (ID), often in the absence of a psychiatric diagnosis. As such, there is great disparity between the estimated prevalence of mental illness and the rates of psychotropic medication use amongst people with ID. ‘Off-label’ use of these medications may account for much of this discrepancy, in particular their use in the management of challenging behaviour. This has come under scrutiny due to the myriad of side effects and the deficiency of high-quality data supporting their use for this indication. Understanding the causes and justifications for such disparity is essential in discerning the efficacy of current prescription practice. Objective: To explore the existing evidence base regarding the prescription and management of psychotropic medications in adults with ID. The aim will be achieved through identifying the psychotropic medications commonly prescribed, the underlying rationale(s) for their prescription and the evidence available that demonstrates their appropriateness and effectiveness. Additionally, the paper will seek to evaluate the availability of any existing guidance that informs the management of these medications, and the evidence and outcomes of psychotropic medication dose reduction and/or cessation interventions. Inclusion criteria: This review will consider studies that focus on the use of psychotropic medications amongst patients with ID. Methods: Research studies (qualitative, quantitative and mixed design) and Grey Literature (English) will be included. The search will be conducted without time restrictions. Databases will include: Ovid MEDLINE, Embase, CINAHL, JBI Evidence Synthesis, Cochrane Central Register of Controlled Trials, Cochrane Databased of Systematic Reviews, PsycINFO and Scopus. A three-step search strategy will be followed, with results screened by two independent reviewers. Data will be extracted independently by two reviewers using a data extraction tool with results mapped and presented using a narrative form supported by tables and diagrams.

Socioeconomic differences in psychiatric treatment before and after self-harm: an observational study of 4,280 adolescents and young adults

Background Individuals in higher socioeconomic positions tend to utilise more mental health care, especially specialist services, than those in lower positions. Whether these disparities in treatment exist among adolescents and young adults who self-harm is currently unknown. Methods The study is based on Finnish administrative register data on all individuals born 1986–1994. Adolescents and young adults with an episode of self-harm treated in specialised healthcare at ages 16–21 in 2002–2015 (n=4280, 64% female) were identified and followed 2 years before and after the episode. Probabilities of specialised psychiatric inpatient admissions and outpatient visits and purchases of psychotropic medication at different time points relative to self-harm were estimated using generalised estimation equations, multinomial models and cumulative averages. Socioeconomic differences were assessed based on parental education, controlling for income. Results An educational gradient in specialised treatment and prescription medication was observed, with the highest probabilities of treatment among the adolescents and young adults with the highest educated parents and lowest probabilities among those whose parents had basic education. These differences emerged mostly after self-harm. The probability to not receive any treatment, either in specialised healthcare or psychotropic medication, was highest among youth whose parents had a basic level of education (before self-harm 0.39, 95% CI 0.34–0.43, and after 0.29, 95% CI 0.25–0.33 after) and lowest among youth with higher tertiary educated parents (before self-harm: 0.22, 95% CI 0.18–0.26, and after 0.18, 95% CI 0.14–0.22). The largest differences were observed in inpatient care. Conclusions The results suggest that specialised psychiatric care and psychotropic medication use are common among youth who self-harm, but a considerable proportion have no prior or subsequent specialised treatment. The children of parents with lower levels of education are likely to benefit from additional support in initiating and adhering to treatment after an episode of self-harm. Further research on the mechanisms underlying the educational gradient in psychiatric treatment is needed.

A Multidisciplinary Approach to Screen Deployment-Limiting Health Conditions

ABSTRACT Introduction Disease non-battle injuries (DNBIs) are responsible for the majority of hospital admissions for soldiers in combat since the Vietnam War The U.S. Army prepares soldiers to deploy through a multistage process known as the Soldier Readiness Program (SRP). The current processes are reactive and address deployment-limiting health conditions (DLHCs) and the need for intervention and/or medical waivers late in the SRP process. This may compromise the quality and efficiency of pre-deployment medical clearance and result in DNBI medical evacuation from theater, which is costly and reduces the effectiveness of the unit. Implementation of a proactive and standardized screening process focused on behavioral health-related medical evacuations and psychotropic medication use will facilitate timely and effective interventions to improve readiness. Methodology The primary objective of this proof-of-concept (POC) study was to develop a standardized and sustainable process, known as the deployment-limiting medication (DLM) surveillance process, to screen soldiers for DLHCs that prevent mobilization. The A-3 performance improvement model was utilized to identify the root causes of limitations with the current medical SRP and to develop solutions. This process utilized the DLHC tool, a report created by the Defense Health Agency, as a basis to identify soldiers that require continued chart review based on prescription fill history. The results of the report were further assessed using published deployment eligibility standards and focused on psychotropic medications. Secondary measures [included] validation of the DLHC tool by assessing the accuracy of the DLHC report. This was determined by the proportion of soldiers screened who actually required intervention and/or waivers per deployment policy. This study took place within an Infantry Brigade Combat Team (IBCT). Results From August 2019 to March 2020, 959 soldiers in the IBCT were screened under the DLM surveillance process for DLHCs related to mental health and psychotropic medication use. The percentage of completed screenings of psychotropic-related DLHCs in the IBCT reached 100% after 3 months of implementing this POC study. After thorough chart review, a total of 421 soldiers met criteria for a medical intervention and/or waiver with 8% of these soldiers identified with a preexisting medical profile. The DLHC tool’s ability to use medication history to accurately predict the need for an intervention and/or medical waiver was 59% (654/1,112 medications). Soldiers identified using the DLM surveillance process that did not meet criteria predominately involved antidepressant, anticonvulsant, and central nervous system DLHC categories. If the psychotropic-related DLHC categories are optimized in future reports, the report’s accuracy may be increased to 90% while decreasing the time to complete the monthly review. Conclusion The DLM surveillance measures were successfully incorporated into the SRP process to proactively screen for DLHCs. Early identification of DLHCs allowed for proper identification of medical intervention and/or waiver needs and may decrease deployment complications. This process may help to improve a soldier’s deployability and improve overall readiness of the IBCT.

Geriatric Choosing Wisely choice of recommendations in France: a pragmatic approach based on clinical audits

Background The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication. Methods In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign. Results The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication. Discussion The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing.

A Cluster-randomized Trial of a Complex Intervention to Encourage Deprescribing Antidepressants in Nursing Home Residents With Dementia: a Study Protocol.

Background: The effectiveness of psychotropic medication on behavioral and psychological symptoms in dementia (BPSD) is limited, while associated with a higher risk of adverse events. Non-pharmacological treatment of BPSD is advocated as treatment of first choice. However, many general practitioners (GPs) find it difficult to initiate deprescribing and when attempting to discontinue psychotropic medication in nursing home residents, they face many barriers. Therefore, we hypothesize that an intervention aimed at improving communication with and involvement of nursing home staff, relatives, and patients by GPs can optimize the pharmacological treatment of BPSD. The aim is to reduce the use of antidepressants in nursing home residents with dementia without increasing morbidity or mortality. Objective: The primary outcome is reduction of antidepressant. Secondary outcomes include difference in use of other psychotropic medication, mortality, morbidity, and severity of BPSD. Method: The study is a cluster-randomized controlled trial based in general practices in Denmark. We aim to include 22 practices, each of which will recruit up to 15 patients with dementia living in nursing homes. The intervention period is three months, and the total study period is one year. Randomization is 1:1 to intervention and control group by computer algorithm. Both groups receive education on BPSD and its evidence-based treatment. The intervention includes three tailored components; 1) teaching material and training to be used by the GP to educate nursing home staff on BPSD, 2) a pre-visit reflection tool to encourage nursing home staff to evaluate symptoms and reflect on relatives involvement in the discontinuation process and 3) a dialogue tool to facilitate shared decision making on optimization of BPSD treatment during the visits at the nursing home. The control group includes enhanced care as usual. The primary and secondary outcomes will be assessed at the end of the study period. An evaluation process will be conducted to assess the implementability. Discussion: We anticipate that the intervention will optimize the treatment of BPSD with antidepressants for nursing homes residents and enhance compliance with reduction of medication. The process evaluation should provide insights into the barriers and facilitators to changing the current practice of deprescribing.Trial registration: Clinicaltrials.gov: NCT04985305. Registered 30 July 2021. https://clinicaltrials.gov/ct2/show/NCT04985305

Providing Psychological Support to Parents of Childhood Cancer Survivors: ‘Cascade’ Intervention Trial Results and Lessons for the Future

We conducted a three-armed trial to assess Cascade, a four-module group videoconferencing cognitive behavior therapy (CBT) intervention for parents of childhood cancer survivors currently aged <18 years. We allocated parents to Cascade, an attention control (peer-support group), or a waitlist. The primary outcome was parents’ health-related quality of life (PedsQL-Family Impact/EQ-5D-5L) six months post-intervention. Parents also reported their anxiety/depression, parenting self-agency, fear of recurrence, health service and psychotropic medication use, engagement in productive activities, confidence to use, and actual use of, CBT skills, and their child’s quality of life. Seventy-six parents opted in; 56 commenced the trial. Cascade achieved good parent engagement and most Cascade parents were satisfied and reported benefits. Some parents expressed concerns about the time burden and the group format. Most outcomes did not differ across trial arms. Cascade parents felt more confident to use more CBT skills than peer-support and waitlisted parents, but this did not lead to more use of CBT. Cascade parents reported lower psychosocial health scores for their child than waitlisted parents. Cascade parents’ health service use, psychotropic medication use, and days engaged in productive activities did not improve, despite some improvements in waitlisted parents. Our trial was difficult to implement, but participants were largely satisfied. Cascade did not improve most outcomes, possibly because many parents were functioning well pre-enrolment. We used these findings to improve Cascade and will trial the new version in future.