Following on from the response to the Winterbourne View Hospital scandal, where it was discovered many patients suffered serious abuse, the re-evaluation of antipsychotic use in people with learning disabilities has begun, with three separate reports commissioned by NHS England plus a study by Sheehan et al published in The BMJ in September 2015 (
The BMJ 2015;351:h4326
). This study examined the incidence of recorded mental illness and challenging behaviour in 33,016 people with intellectual disability in UK primary care and explored the prescribing of psychotropic drugs in this group. It revealed that 21% of the cohort had a record of mental illness at study entry, 25% had a record of challenging behaviour, and 49% had a record of prescription of psychotropic drugs.
Public Health England published its report, ‘Prescribing of psychotropic drugs to people with learning disabilities and/or autism by general practitioners in England’, in June 2015. It found that a sixth of adults with learning disabilities are being prescribed antipsychotic drugs by their GP, but more than half of these patients do not have a recorded diagnosis of a mental health condition. It has been estimated that, in England, up to 35,000 adults with a learning disability are being prescribed a psychotropic drug without appropriate clinical justification.
For any individual with or without learning disabilities who is displaying challenging behaviour, medical causes must be identified and addressed.
At the Hertfordshire Partnership University NHS Foundation Trust, we are developing suitable information regarding side effects, off-label use of medicines and stopping or reducing antipsychotics so that patients and carers can be empowered to take control of the management of the behavioural issues and understand the treatments being offered.
There is an ideal opportunity at this time for pharmacists in community and secondary care or clinical pharmacists in GP surgeries to get involved with talking to patients and their carers either on a one-to-one basis or at support groups.
With respect to side effect monitoring, a joined up approach between primary and secondary care is required. People with learning disabilities are entitled to an annual physical health checks by their GP practice. However, in some areas this information is not standardised and is not routinely communicated to secondary care. This complicates the issue of side effect monitoring, which includes identifying metabolic syndrome by examining results for HbA1c and blood lipids in addition to weight and blood pressure measurements.
The evidence suggesting inappropriate prescribing of psychotropic drugs in people with learning disabilities is now well established but we need to examine the extent of the problem and how this issue, which is not only confined to mental health trusts, is going to be addressed.
A considerable number of people with learning disabilities prescribed antipsychotics are no longer under secondary care. This will result in GPs performing the medication reviews. In Hertfordshire Partnership University NHS Foundation Trust, clinical pharmacists have been involved with providing education and training to psychiatrists in safely and effectively reducing psychotropic medication. Clinical pharmacists experienced in mental health and learning disability would be well placed to be involved with this medicines optimisation programme to address the polypharmacy and safely review patients both in primary care, working with GPs and learning disability nurses and, in secondary care, working with psychiatrists and mental health nurses. Hertfordshire is currently carrying out a review in primary care to identify the extent of antipsychotic prescribing in the area.
It is important to note that potential improvements in the quality of prescribing may not necessarily lead to a reduction in costs, partly because of the possibility of the additional provision of costly non-drug treatments.
Principal clinical pharmacist
Hertfordshire Partnership University NHS Foundation Trust