Principles of the Use of Psychotropic Drugs in Persons with Mental Retardation

Prerequisites for a Successful Treatment Program

·           Comprehensive diagnostic understanding

·           Developing goals of treatment

·           Developing treatment priorities

·           Monitoring treatment results

·           Avoidance of indefinite treatment

·           Team collaboration

Principles of the Use of Psychotropic Drugs in Persons with Mental Retardation

This outline is based largely on an excellent review of Kalachnik and coworkers (1998), Rinck (1998), as well as on the American Academy of Child and Adolescent Psychiatry (1999), and the Health Care Financing Administration (1997).

Purpose of Drug Use

These drugs are used to treat a diagnosed mental disorder toward the goal of maximizing a person’s quality of life. They should not be used merely to suppress a single, objectionable behavior with-out regard to the effect on a person’s global adjustment, func-tioning and quality of life. They cannot be used as punishment, for staff convenience (such as in understaffed facilities), in lieu of appropriate habilitative program (if such is unavailable), or in dosages that interfere with such programs and with a person’s quality of life (Rinck, 1998, p. 52).

Context of Drug Use

These drugs are always used as part of a comprehensive, treat-ment/habilitation program designed and supervised by an inter-disciplinary team of which the psychiatric clinician is an integral part. They should not be prescribed merely in brief “psychop-harmacology consultation” or “medication review”, in isolation from other aspects of the treatment.

Prerequisites for Drug Use

·   Comprehensive psychiatric diagnostic assessment, following the guidelines described earlier (see also Figure 24.1), and re-sulting in a psychiatric diagnosis.

·   Presence of a comprehensive treatment plan and evidence that less intrusive measures have not been effective (such as be-havior modification, psychotherapies, milieu supports, etc.).

·   Comprehensive evaluation to rule out medical conditions that could have caused the presenting symptoms.

·   Existence of a reliable system to collect behavioral data indi-vidualized to the particular patient that measures occurrence of symptoms considered an index of the person’s mental disor-der. This should also provide reliable baseline data and func-tional analysis of behavior that would assess the influence of immediate and more remote antecedents and consequences of the patient’s behaviors and other symptoms.

·   Satisfaction of all relevant regulatory and legal requirements, especially obtaining informed consent of the patient and/or legal guardian.

Follow-up on Drug Effectiveness

·   The members of the interdisciplinary treatment team should follow the patient’s progress regularly (at least quarterly), based on changes in individualized index behaviors, symp-toms, general adjustment, functioning and well-being. Pres-ence of side effects and their findings should be communi-cated among the members of the team. Behavioral changes should be documented by reliable data. The follow-up should include a direct psychiatric interview and/or observation of the patient. The implementation of all aspects of the treatment program and not just the medications should be monitored and adjusted as needed to ensure that medications are not used in lieu of, but concurrently with, a habilitation program.

·           The medication should be tried at an effective dose for an ad-equate period of time. If there is no clear evidence of effec-tiveness it should be discontinued appropriately. It should be kept in mind that “ups and downs” are to be expected, such as in reaction to environmental and physical stressors com-mon in the lives of these patients. Medication effectivenessshould therefore be judged by a pattern evident over reason-able period of time and not by one-point observations. For the same reason, preset dosage schedules linking dosage changes to specific frequencies of index behaviors are impractical. Multiple medications should be tried only if there is evidence that a combination is known to be more effective than a single medication

Dosages and Discontinuation

·   The optimal dosage is the lowest one that achieves the best a compromise between improving the patient’s quality of life and side effects.

·           A trial of dose reduction and possibly discontinuation should be regularly considered but should be implemented only if not contraindicated clinically. Discontinuation, if attempted, should be gradual, and it may need a prolonged period de-pending on the type of medication and expected withdrawal effects. It is essential that all involved caregivers be aware of the possibility of such effects and be ready to deal with them, rather than demand immediate cessation of the discontinua-tion trial (this is particularly important with antipsychotics. As-needed (.3.prn) use of the medication is best avoided to prevent unnecessary use, or limited to clear situations, such as premedication prior to medical tests if stressful for the patient.

Monitoring Side Effects

Side effects should be monitored regularly through direct exami-nation (especially important with nonverbal persons), laboratory tests, tardive dyskinesia examination, and so on, as appropriate for the particular drug. Possible drug interactions should be mon-itored as these patients are often on multiple medications