In this presentation I outline the methodology and results of our research paper 'Mental illness, challenging behaviour, and psychotropic drug prescribing in people with intellectual disability: UK population-based cohort study' published in The BMJ in September 2015. This presentation was originally given at the Royal Society of Medicine in London on 23rd May 2017.

1. Prescription of
psychotropic medication
to people with intellectual
disability
Dr Rory Sheehan
Doctoral Research Fellow
Division of Psychiatry, UCL
23rd May 2017
Royal Society of Medicine

2. Background
• Winerbourne View (2011)
• Transforming Care (2012)
How many?

3. How many receive psychotropic drugs
Study Country Setting Total psychotropics Psychotropic by type
Hsu, 2014 Taiwan Community
(n=93,914)
23% AP 13%
AD 5%
AX 14%
Doan, 2013 Australia Community
(n=117)
35% AP 21%
MS 26%
AD 20%
AX 7%
Tsiouris, 2013 USA Community
(n=4,069)
58% AP 45%
MS 19%
AD 23%
AX 16%
Cooper, 2007
(unpublished results)
UK Community
(n=1,023)
49.5% AP 23.2%
Holden, 2004 Norway Community
(n=300)
37% AP 31%
MS 6%
AD 11%
AX 2%
Nottestad & Linaker, 2003 Norway Community
(n=109)
54% AP 28%
MS 26%
AD 4%
AX 1%
Spreat, 2004 USA Community
(n=3,187)
35% AP 20%
MS 7%
AD 16%
AX 11%
Molyneaux, 1999 UK Community
(n=299)
53% AP 21%
MS 27%
AD 10%
AX 10%

4. Prescribing study
To explore psychotropic prescribing to people with ID in UK
primary care and associations with prescribing of major
psychotropic drug classes
Funding
Aim

5. Data source
• THIN primary care database
• >500 GP practices
• Approx 6% population of UK
• Representative
• Symptoms, diagnoses, treatments (as Read codes)
• Prescribing data

6. Cohort
• Adults with ID
• Demographic characteristics
• Followed electronically / retrospectively
• Noted new diagnoses mental illness, challenging behaviour
while contributing data
• New prescriptions of psychotropic medication

7. Read code lists
Intellectual disability Neuropsychiatric diagnosis
Severe mental illness
Depression
Anxiety
Autism
Dementia
Epilepsy
Psychotropic medication
Antipsychotics
Mood stabilisers
Antidepressants
Anxiolytic/hypnotic
Drugs for dementia
Drugs for ADHD
Challenging behaviour
Aggression
Self-injury
Stereotypic behaviour
Disruptive behaviour
Sexually-inappropriate behaviour
Withdrawn behaviour
Sleep disorders
Non-specific
Specific

8. Analysis
• Incidence rates
• Poisson regression for incidence rate ratios and associations
with prescribing

9. Results
BMJ 2015;351:h4326

10. Results
33,016 people with ID
58% male
15% autism
23% epilepsy
1% dementia
Mean age at study entry 36.3 years (SD 16.4)
Median follow-up time 5.5 years (IQR 2.2-11.5)

11. Incidence – mental illness and challenging behaviour
Mental illness Number of events Incidence per 10,000 PYs 95% confidence interval
Any mental illness 3,998 262 254 to 271
SMI 617 32 29 to 34
Depression 3,054 171 165 to 177
Anxiety 2,512 139 134 to 145
Number of events Incidence per 10,000 PYs 95% confidence interval
Challenging behaviour 3,615 239 231 to 247

12. Incidence – psychotropic prescribing
Incidence per 10,000PYs (95% confidence interval)
Any psychotropic 518 (503 to 533)
Anxiolytic/hypnotic 330 (321 to 339)
Anti-depressant 313 (305 to 323)
Antipsychotic 132 (127 to 138)
Mood stabiliser 82 (78 to 87)
Recorded SMI:
32 per 10,000PYs
Recorded mental illness:
262 per 10,000PYs

13. Associations – antipsychotic prescribing
Adjusted IRR (95%CI) p-value
Severe mental illness 6.69 (5.83 to 7.68) <0.001
Depression 1.79 (1.62 to 1.98) <0.001
Anxiety 1.63 (1.47 to 1.81) <0.001
Autism 1.79 (1.56 to 2.04) <0.001
Challenging behaviour 2.08 (1.90 to 2.27) <0.001
Dementia 1.42 (1.12 to 1.81) 0.003

15. Associations – mood stabiliser prescribing
Adjusted IRR (95%CI) p-value
Severe mental illness 2.49 (2.13 to 2.91) <0.001
Depression 1.43 (1.25 to 1.63) <0.001
Anxiety 1.01 (0.87 to 1.16) 0.906
Autism 1.36 (1.14 to 1.63) 0.001
Challenging behaviour 1.30 (1.15 to 1.45) <0.001
Dementia 1.88 (1.48 to 2.39) <0.001

16. Associations – antidepressant prescribing
Adjusted IRR (95%CI) p-value
Severe mental illness 0.96 (0.86 to 1.07) 0.457
Depression 6.79 (6.37 to 7.24) <0.001
Anxiety 1.97 (1.84 to 2.11) <0.001
Autism 1.24 (1.13 to 1.36) <0.001
Challenging behaviour 1.23 (1.16 to 1.31) <0.001
Dementia 0.95 (0.75 to 1.18) 0.624

17. Associations – anxiolytic/hypnotic prescribing
Adjusted IRR (95%CI) p-value
Severe mental illness 1.44 (1.30 to 1.58) <0.001
Depression 1.67 (1.56 to 1.78) <0.001
Anxiety 2.05 (1.91 to 2.19) <0.001
Autism 1.40 (1.28 to 1.54) <0.001
Challenging behaviour 1.67 (1.57 to 1.77) <0.001
Dementia 0.85 (0.67 to 1.04) 0.112

18. What have we shown?
Evidence of relatively high level of psychotropic use in people with
ID
Disproportionate to level of recorded mental illness
Use associated with presentations outside license and not
supported by evidence base (challenging behaviour, autism,
dementia)
r.sheehan@ucl.ac.uk