Implications for Canada’s hospitals
By Yona Lunsky
In August, we published the first Canadian population based study on antipsychotic prescription patterns for adults with developmental disabilities, based on over 50,000 Ontario adults. Our study, a collaboration between the Ontario Drug Policy Research Network (www.odprn.ca) and the Health Care Access Research and Developmental Disabilities Program (www.hcardd.ca) revealed that over a six year period (between 2010 and 2016), 39.2 per cent of these adults had at least one antipsychotic prescription filled. This proportion rose to over 50 per cent of adults living in group home settings. These medications are not prescribed in isolation. The median number of drugs dispensed per person in the year prior to the study was seven. One in six adults with developmental disabilities prescribed antipsychotics had diabetes, and one in five had hypertension. Hospitalizations in this group were common. Importantly, not all of the individuals who filled these prescriptions had a psychiatric diagnosis. Forty percent of them had a major mental illness diagnosis and 29 per cent did not have a current psychiatric diagnosis of any type. Those with and without a psychiatric diagnosis differed from one another clinically, and in terms of their health service use.
Antipsychotics in crisis
Hospital staff may be the prescribers of antipsychotic medications. Individuals with developmental disabilities may present to the hospital emergency department as agitated or aggressive. This may be due to a serious mental illness, but it can also be due to unrecognized medical issues or situational factors. Therefore, understanding how to assess mental health problems and knowing best practices with regard to medication prescribing and developmental disabilities is crucial. Guidelines here and from other jurisdictions emphasize that antipsychotics should not be the first line treatment for “challenging behaviour.” According to NICE guidelines from the UK, antipsychotics should only be offered after other interventions targeting challenging behaviours have failed, when treating coexisting health problems does not improve behaviour, and when the risk to the person or others is severe. In practice, this means that we should be careful not to offer an antipsychotic medication as a first line treatment for behaviour when someone comes into hospital, and if it is being used in a crisis situation, it should only be done so on a short term basis.
The importance of medication monitoring to prevent further health issues
Antipsychotic medications, without proper monitoring, can lead to serious health complications, which may even lead to hospital visits and admissions in the developmental disabilities population. One H-CARDD study reported, for example, that adults with developmental disabilities and diabetes were 2.6 times more likely to be hospitalized for a diabetes related complication than other adults with diabetes. Diabetes could be caused by or exacerbated by antipsychotics use. A second H-CARDD study reported on high rates of several adverse outcomes after starting antipsychotics, including death, in a cohort of men and women with developmental disabilities. In the UK, a recent study reported that movement disorder side effects were more commonly observed in those with developmental disabilities than other adults prescribed these same medications. Knowing how to monitor antipsychotic medications and their role in contributing to other health issues is crucial. At the very least, it is essential that any new prescriptions of antipsychotic medications or any medications provided in hospital must include plain language information about why the medication is being prescribed, and what to look for in terms of side effects.
Yona Lunsky, Ph.D., C.Psych. is H-CARDD Director and Senior Scientist at The Centre for Addiction and Mental Health; Professor and Developmental Disability Lead, Department of Psychiatry, University of Toronto.
