The Rational Use of Psychotropic Medication for Individuals with Intellectual Disabilities

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Edwin J. Mikkelsen, M.D.


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:

  • Risk-benefit considerations in the use of psychotropic medications;

  • Neutral data collection methods that present a balanced perspective;

  • Establishing the efficacy of medications;

  • Ruling out medical and/or behavioral contributions to the disorder; and,

  • 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.

 Produced in 2007.

ISBN:  1-57256-057-6  Pages:  122

Table of contents



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