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The Rational Use of Psychotropic Medication for Individuals with
Intellectual Disabilities
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Edwin J. Mikkelsen, M.D.
Description:
The central premise far this book Is the thesis that a psychiatric
diagnosis Is a necessary, but not a sufficient, basis to justify the
use of psychotropic medication in individuals with intellectual
disabilities (ID). For example, the diagnosis of a depressive
disorder does not legitimize the use of three antidepressants (or
even one), if efficacy cannot be demonstrated. A corollary thesis is
that in those situations where a psychiatric diagnosis has been
established, there still needs to be a rigorous risk-benefit analysis
with regard to the utilization of the proposed medication.
Historically, psychotropic medications were indiscriminately used to
address behavioral problems that presented in individuals with ID. In
this era, the first-generation antipsychotic agents, such as
Chiorpromazine and Thioridazine (also referred to as “major
tranquilizers”), were often prescribed for their sedative
effects. The publications of pioneering psychiatrists, such as Frank
Menolascino (1970) and Ludwig Szymanski (1977), alerted the
profession to the inappropriateness of the indiscrirninant use of
antipsychotic medication for this population. This early work also
suggested that a valid psychiatric diagnosis could be established in
mmiv individuals with ID, which could then be used to develop
psychopharmacological treatment plans that were effective for the
underlying condition. One of the most significant publications in
this regard was the classic article by Sovner and Hurley, which
appeared in the prestigious Archives of General Psychiatry in 1.983.
This article demonstrated the existence of affective disorders in
individuals with ID. Unfortunately, these efforts were not entirely
sufficient to end the indiscriminate use of psychotropic medication.
Thus, many individuals with ID continue to receive multiple
psychotropic medications, with very little empirical documentation of efficacy.
My own experience in this regard derives from consultations on
individuals with problematic presentations from several states
throughout the country, over many years. It is not uncommon to find
large numbers of individuals who are receiving five to six (and
occasionally as many as eight) psychotropic medications. All of these
individuals have one or more psychiatric diagnoses on record, which
has been used to justify the psychotropic medication regimen. Thus,
the indiscriminate use of psychotropic medication continues. In my
opinion, the only difference between the major tranquilizer era and
now is the indiscriminate use of multiple classes of psychotropic
medications for varied psychiatric diagnoses that have questionable
validity and reliability. This book illustrates empirical methods for
ensuring that psychotropic
medications are utilized in a manner that: 1) can be justified by the
severity of the symptoms related to the underlying psychiatric
diagnosis; 2) clearly establishes their efficacy; and, 3) ensures
that the potential side effects of the medication do not exceed its
therapeutic benefit.
In order to accomplish this goal, the following chapters review the
importance of:
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Risk-benefit considerations in the use of psychotropic medications;
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Neutral data collection methods that present a balanced perspective;
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Establishing the efficacy of medications;
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Ruling out medical and/or behavioral contributions to the disorder; and,
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The formulation(s) of psychopharnrncological algorithms that take
into account the risk-benefit equation.
Some of the chapters are followed by a Notes section, which
elaborates on specific points in the text and/or discusses references
relating to that particular chapter. The final chapter is dedicated
to a discussion of the factors that contribute to unnecessary
polypharnrncy and techniques to help prevent it. The Appendices that
follow are intended to provide a template for the clinical use of
psychopharmacological agents in individuals with ID that incorporates
the principles outlined in the text. |
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ISBN: 1-57256-057-6 Pages: 122
Table of contents
Acknowledgements
Introduction
Chapter I - Risk-Benefit Considerations in the Use of PsychotTopic
Medications in Individuals with Intellectual Disabilities
Chapter II - Neutral Data Collection Methods
Chapter III -Establishing the Efficacy of a Psychotropic Medication
Chapter IV - Differential Diagnosis of Medical Issues and Behavioral
I)isorders Occurring in Individuals with Intellectual Disabilities
Chapter V - Formulation of Psychopharmacologic Algorithms for Adults
with Intellectual Disabilities and Psychiatric Disorders
Chapter VI - Pathways to and from Polypharmacy
Appendix I - Brief Symptom-Based Checklists to Aid in the
Identification of Possible Psychiatric Contributions to
Self-Injurious and/or Aggressive Behavior
Appendix II - The Comprehensive Clinic Consult: Individuals with
Intellectual Disabilities Who Engage in Aggressive and/or Self
Injurious Behavior
Appendix III - The Comprehensive Clinic Consult: A Hypothetical
Example of an Individual with Intellectual Disabilities Who Engages
in Aggressive and/or Self-Injurious Behavior
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