The RCPsych Article of the Month for August is ‘Antidepressant prescribing for adult people with an intellectual disability living in England’ and the blog is written by authors Dr David Branford & Professor Rohit Shankar MBE published in The British Journal of Psychiatry.

What inspired this work?

For the last 30 years the primary focus of most medication studies in people with intellectual disabilities (PwID) has been on antipsychotics. The serious case review (2012) into the atrocities inflicted on PwID at the Winterbourne View Hospital and subsequent scientific papers and reports raised concerns at a national level of significant inappropriate psychotropic medication prescribing in this vulnerable cohort. From this emerged “Stopping overmedication of people with learning disability, autism or both (STOMP)”.  Professor Gyles Glover, Professor Shoumitro Deb, Professor Angela Hassiotis, Professor Andre Strydom, Dr Rory Sheehan and many others furthered this work in the recent years. However, focus still largely remained on antipsychotics.  Suspicions of a culture shift to prescribing antipsychotics to antidepressants, antiseizure medications and/or multiple non-antipsychotic psychotropics emerged in an UK wide national survey on prescribing practices of psychiatrists towards PwID ( https://doi.org/10.1192/bjo.2020.97).

What could the research lead to/what should you or other researchers look into next and why?

Medication research in PwID is very limited. Dominated by surveys and very small open studies it rarely moves beyond jumping to unsubstantiated conclusions and adopting positions of entrenched and often polarised opinions. This is understandable as PwID struggle to represent themselves, can lack abilities to make complex decisions and are overrepresented by multi-morbidity and polypharmacy. This makes research and clinical practice challenging. However, it is important to “embrace complexity” and find logical and pragmatic ways to build evidence for interventions in this cohort. This includes using available “big datasets” such as NHS Digital. The NHS Digital data of 2020-21 had access to 57% of GP data in England involving many thousands of PwID thus enabling generation of robust trends. However, the data quality requires improving and more granularity. GP prescribing and clinical systems presently are not designed for research and the analysis provided by NHS Digital is very limited. This leads to many assumptions which are difficult to directly recommend to clinical practice. The finding that antidepressant prescribing has risen year on year and is now the most widely prescribed psychotropic for PwID is the centre story of the paper and an important point. However, one cannot provide obvious areas to influence it’s reduction via clinical practice or patient education. Such research is well beyond the capability and capacity of local GP practices and specialist ID services and needs specific funding.

Can you share any interesting anecdotes from the research?

STOMP united stakeholders working with PwID under one banner, that there was excessive use of psychotropics usually prescribed irrationally in this population. However, the devil was in the detail. There is a lack of clarity, direction or resource to deliver STOMP. STOMP has turned out to be an onion with multiple layers to peel. We need to keep reminding ourselves that the problem has taken many decades to evolve and thus it will take many years to solve.

Neither the STOMP work nor this paper suggested that clinicians should not prescribe necessary and appropriate psychotropics. What is required though is a continual high level of scrutiny to ensure that only those psychotropics that are demonstrating proven benefit continue. A preparedness to withdraw them if that is not the case or they are no longer necessary is needed. 

The award-winning scientific documentary maker and director Ann Druyan said ‘the greatest thing that science teaches you is the law of unintended consequences’. Considering and explaining to patients the risk of unexpected outcomes from proposed treatments is part of the daily challenge of our clinical practice. How does one consent to or inform people of risks that are unknown and unforeseen? Unintended consequences are an important feature in three of this month’s BJPsych articles.

The national STOMP campaign has proven successful in reducing inappropriate antipsychotic use for challenging behaviour in people with intellectual disability. However, in their important analysis article this month, Branford et al use prescribing data from NHS Digital to argue that this campaign may have unexpectedly led to an increase in antidepressant prescribing in this group instead. They are concerned that this could be resulting in unintended harms as antidepressants are prescribed without indication, for indeterminate lengths of time, with little evidence for prolonged use in people with intellectual disability. Their words are an important reminder to me of the frequent lack of prescribing evidence for people in this vulnerable patient group.

Katherine Adlington
BJPsych Highlights Editor, The British Journal of Psychiatry