It is often feared that the mental health subpopulation with comorbid intellectual disabilities receives a disproportionate share of psychotropic medication as a way to control problem behaviors such as aggression. A Pennsylvania managed behavioral healthcare organization researched this subject in response to a request from one of the counties in which it oversees services and found that the adult population with intellectual disabilities in that county did not receive antipsychotics or antidepressants in greater numbers than the group with mental illness only.

“It is always a concern that populations that are disabled in some way may sometimes be prescribed medications as an easy way to address agitation, as a form of chemical restraint,” James Schuster, M.D., chief medical officer at Pittsburgh-based Community Care Behavioral Health Organization, told MHW.

The managed care entity, which operates in more than half of the state’s counties, conducted a five-year review as part of its overall effort to monitor prescribing patterns and educate providers about the risk-benefit analysis associated with medication. The results of their research regarding the population with intellectual disabilities, which was spurred by a request from officials in Chester County, have been published online in advance of print in the journal Psychiatric Services.

Research findings

Past research has found a high prevalence of psychotropic drug prescribing, particularly of antipsychotics, in individuals with intellectual disabilities. A Dutch study, for example, found that nearly one-third of a group of adults with intellectual disabilities received an antipsychotic, and in only one in four of these cases was a psychotic illness listed as the rationale for prescribing the medication.

Community Care, a nonprofit managed care entity owned by the University of Pittsburgh Medical Center (see MHW, Nov. 11), examined prescribing data from fiscal years 2007–2011 in its study. Looking at both the adult and child populations, they compared psychotropic prescribing rates for individuals with a mental health disorder and an intellectual disability with those for individuals with a mental health disorder only.

The research team, led by Community Care Senior Medical Director Gail A. Edelsohn, M.D., looked at four classes of medications in its analysis: antipsychotics, antidepressants, benzodiazepines and mood stabilizers. They also assessed any trends in polypharmacy in the two patient groups, defining polypharmacy for purposes of this analysis as receiving three or more psychotropic drugs for at least 90 days a year in any of the five years examined.

In the adult population, the researchers found that those with a comorbid intellectual disability actually received antidepressants at a significantly lower rate than individuals with a mental illness only. This was also true for antipsychotics in the first three years of the analysis, although the differences were not significant in the fourth and fifth years. No significant differences between the two groups were seen with prescribing patterns for benzodiazepines and mood stabilizers.

Results for the child population under 18 were somewhat different from those seen for adults. The group of children with a diagnosis of both a mental illness and an intellectual disability received mood stabilizers and benzodiazepines at a higher frequency than the group with a mental illness only. Prescribing patterns for antipsychotics and antidepressants did not differ significantly between the two groups of children.

No significant differences were seen in either the adult or child populations in polypharmacy rates, with somewhat more frequency in polypharmacy among those with the comorbid intellectual disability diagnosis.

The study authors wrote in the Psychiatric Services article, “Given the concerns about the increasing use of second-generation antipsychotics and associated adverse effect profiles, it is of interest that, for three of the five years in the study, the prescription rates for antipsychotic medication were lower in the adult codiagnosis group than in the comparison [mental illness only] group.”

Edelsohn told MHW that it is important to emphasize, however, that while there were not significant between-group differences in prescribing rates for antipsychotics, the overall prescribing rates of antipsychotics seen in this study were still substantial, at 31 to 46 percent.

She added that it is important to look at these trends across a large time span, as fourth- and fifth-year numbers for adults receiving antipsychotics differed from data in the first three years of this review. She said that if the review went beyond 2011, it could show different results still, especially given the growing number of clinical indications being identified for the various classes of psychotropic medication.

The research team pointed out in the journal article that the volume of prescribing seen in their analysis should call attention to the importance of pinpointing the cause of certain behaviors — and considering nonmedication approaches as first-line treatment when there is no treatable cause identified.

Schuster said, “The study confirmed people’s anecdotal information about medications being used frequently, but it didn’t appear that antipsychotics were being used universally. It didn’t set off a siren.”

Follow-up activity

Schuster said the findings from this analysis did not lead to any specific follow-up actions on the managed care company’s part. The exercise added more information to an ongoing examination of prescribing patterns in the services the managed care entity oversees.

“We have done a number of activities to educate prescribers, including things such as polypharmacy and optimal drug ranges,” Schuster said.

Regarding the use of psychotropics in children with comorbid disorders, the Community Care team believes its findings could prompt additional inquiry into what constitutes optimal treatment for children in foster care who have intellectual limitations.