Psychotropic Drugs Often Used for Challenging Behavior

Recent figures on the use of psychotropic drugs among people with intellectual disability suggest that the medications are not always used for legitimate mental illness.

People with intellectual disability develop mental illness at rates similar to or higher than the general population, Dr. Rory Sheehan of University College London, UK, and colleagues explain in the British Medical Journal.

But they add, “Atypical presentations, deficits in communication and health literacy, and difficulties in accessing services might mean that mental illness in people with intellectual disability is under-recorded.” Furthermore, “a significant proportion of people with intellectual disability display challenging behavior.”

For the study, challenging behavior included the following behaviors: aggression, self-injury, stereotypic behavior, agitation, disruptive or destructive acts, withdrawn behavior, arson, and sexual misconduct.

Psychotropic drugs were classed according to the British National Formulary, a standard pharmaceutical reference book. The categories used were antipsychotics, antidepressants, mood stabilizers, anxiolytics (anti-anxiety drugs) together with hypnotics (including benzodiazepines), antidementia drugs, and drugs for attention deficit hyperactivity disorder.

Because concerns are often raised that psychotropic drugs are overused in people with intellectual disability, the team set out to discover the true rates of mental illness, challenging behavior, and psychotropic drug prescriptions in this population.

They used figures from 571 general practices in the UK, covering 33,016 men and women with intellectual disability. Participants contributed different lengths of followup to the study. This is a large, representative database of real-life primary care, researchers say.

In 1999, at the start of the study, 49 percent of the participants had been prescribed psychotropic drugs. This figure reached 63 percent by the end of data collection in 2013. The most common class of drugs to be prescribed was anxiolytics/hypnotics, followed by antidepressants, antipsychotics, and mood stabilizers.

Although many of the participants received a new prescription for antipsychotic or mood stabilizing drugs during this time, the rate of prescribing for these drugs decreased significantly over the study period. This might be expected given the negative publicity surrounding their use and as awareness of adverse side effects (particularly of the second generation agents) has grown. It also mirrors falls in antipsychotic use in other groups.

Of the 11,915 participants with a record of challenging behavior, 47 percent had received antipsychotic drugs, but only 13 percent had a record of severe mental illness. Psychotropic drugs prescriptions “far exceeds the proportion with recorded mental illness,” say the authors.

Prescriptions for antipsychotics among individuals with intellectual disability were also significantly higher for older people and in those with a record of challenging behavior, depression, anxiety, autism, dementia, or epilepsy.

“Antipsychotics are often prescribed to people without recorded severe mental illness but who have a record of challenging behavior,” the authors add.

Dr. Sheehan said recently, “Over 70 percent of people with intellectual disability who have been prescribed antipsychotic medication do not have a record of severe mental illness. Challenging behavior, autism, dementia, and older age, were all independently associated with prescription of antipsychotics.

“The results suggest that these conditions are managed, in some instances, with antipsychotic drugs, which will often reflect a departure from evidence-based clinical guidelines.

“This highlights a need for strategies to improve psychotropic prescribing to people with intellectual disability. Inappropriate use of drug treatment has implications for the individual and for health care systems. Alternative management options, including behavioral and communication support, should be further evaluated and interventions that work should be readily available.”

In addition, they write, “Antipsychotics may be used where the availability of other management strategies, such as psychosocial interventions and communication support, is limited. Reducing reliance on drugs will therefore require investment in a skilled multidisciplinary team of professionals who can provide alternative evidence based management strategies for challenging behavior.

“These alternative management options, including behavioral and communication support, should also be further evaluated and interventions that work should be readily available.”

Excessive use of psychotropic drugs has implications for the individual, and also for the wider health care system. In particular, antipsychotics are linked to several adverse side effects that can impair quality of life and can damage health. Hence reducing their use in this population could cut the health inequalities they face. Furthermore, such drugs may be taken without the individual’s full consent.

Families and other carers must receive “adequate and accessible information on the use of psychotropic drugs, and be empowered to question drug treatment and seek alternatives,” the experts write.

They call for future research on the appropriateness of other types of medication in this group, and on the efficacy and safety of psychotropic drugs when used for challenging behavior.


Sheehan, R. et al. Mental illness, challenging behaviour, and psychotropic drug prescribing in people with intellectual disability: UK population based cohort study. BMJ, 2 September 2015 doi: 10.1136/bmj.h4326
Medication bottles photo by shutterstock.