Decrease in Problem Behaviour following discontinuation of antipsychotics in Individuals with Intellectual Disability

32% of residents in living facilities for individuals with intellectual disability use antipsychotic drugs. This medication is more often prescribed to alleviate challenging behaviours rather than for psychotic disorders. However, discontinuation or dose lowering of antipsychotics leads to decrease in challenging behaviour in a majority. Most participants in the study also lost weight, and the odds for the presence (components of) the Metabolic Syndrome decreased. Presence of the metabolic syndrome (comprising the components: too high waist circumference, too elevated blood glucose, abnormal blood plasma levels of triglycerides and HDL, and hypertension)increases the risk of cardiovascular disease. These are among the findings from research carried out by Gerda de Kuijper, Intellectual Disability physician and researcher at the UMCG. She will be awarded a PhD for her thesis by the University of Groningen on 4 September 2013.

Antipsychotic drugs are primarily indicated to alleviate psychotic disorders. However, the prescription of antipsychotic medication has been shown to exceed the expected prevalence of psychoses in persons with intellectual disability. This may be explained by the prescription of these agents for behavioural problems, outside their licensed indication, as off-label use. However, there is no scientific evidence for the effectiveness of antipsychotics in this indication. De Kuijper found that approximately 80% of those residents who used antipsychotics these drugs had used for more than 10 years. Behavioural problems were the reason for prescription of antipsychotic drugs in 58% of cases and psychotic disorder or psychotic symptoms in 22.5%. Long-term use of antipsychotics may cause neurological, metabolic and hormonal side effects. Therefore, and because the lack of scientific evidence for the effectiveness of antipsychotics in this indication, De Kuijper investigated in her research, whether antipsychotics prescribed for problem behaviour could be tapered off in a period of 14 or in 28 weeks.

Achievement of discontinuation

De Kuijper’s study showed that complete discontinuation could be achieved in 43% of the 98 participants; at follow-up, 12 weeks after the scheduled complete discontinuation 36% were still not using antipsychotics. There was no worsening in behavioural function in a majority, both in those participants who had completed and in those who not completed discontinuation of antipsychotics. The results in both discontinuation schedules were similar.

Beneficial metabolic outcomes

Antipsychotics may increase the risks for being overweight or obese for glucose dysregulation, dyslipidaemia and increased calcium boneloss. The results of De Kuijper’s study showed beneficial effects on metabolic parameters: a decrease in waist circumference meaning less abdominal fat mass, decrease in Body Mass Index and decrease in blood pressure.

Clinical implications

De Kuijper: “The results of this thesis should have clear clinical implications. Clinicians should carefully balance the pros and cons of prolonged use of antipsychotics, especially in case of off-label prescriptions, e.g. behaviour problems. My research showed an association between the severity of neurological symptoms of side effects of antipsychotics with more severe behavioural dysfunction. So neurological side effects may play a role in maintaining problem behaviour. Therefore, discontinuation should be considered, especially in case of metabolic and neurological side effects. Tapering-off may take place in a period of 3-4 months. De Kuijper also advocates training and coaching of caregivers and healthcare professionals in managing problem behaviour of their clients.

Curriculum Vitae

Gerda de Kuijper (Enkhuizen, 1955) works as an Intellectual Disability physician at VanBoeijen, Intellectual Disability Centre Assen, the Netherlands, and as a researcher at the University Medical Centre Groningen (UMCG). She carried out her research in the Child and Adolescent Psychiatry Department of the UMCG. Her thesis is entitled ‘Aspects of long-term use of antipsychotic drugs on an off-label base in individuals with intellectual disability’. Once she has been awarded her PhD, she will start to work as an ID pysician at the Centre for Intellectual Disability and Mental Health/ Mental Health Service (GGZ Drenthe) in Assen , the Netherlands and will continue her research work in collaboration with the UMCG, Department (Child and Adolescent) Psychiatry.