Psychopharmacology For Patients With Intellectual Disability

Authors: Julie Gentile, M.D., and David Dixon, D.O.

(Originally published in The Carlat Psychiatry Report, September 2017)

Anne, a 23-year-old woman with moderate intellectual disability, comes into your office accompanied by a staff member of her group home. The staff member reports to you that your patient has been aggressive toward a roommate and has appeared to be more aloof over the last week. Staff wonders if you will be able to prescribe a medication to prevent any future episodes of aggression.

Prescribing psychotropic medications in patients with intellectual disabilities (ID) requires some nuances in approach with which not all psychiatrists are familiar. In this article we’ll discuss some aspects of assessment and treatment that you’ll find useful when you encounter such patients.

Assessment

1. Ask about psychosocial issues.

We usually begin by ruling out psychosocial causes of the behavior, because these issues can often be fixed without resorting to psychopharmaceuticals and their attendant side effects. Here are some of the more common issues in my experience.

Staff turnover at group homes is very high; they are often like family to clients, and when they leave this can be a great loss.
Any changes to routine across any setting can commonly trigger behavioral responses in ID patients with poorly developed coping mechanisms and lower tolerance for change.
Past traumas or losses: reminders, or anniversaries, of significant life events may be the cause of the current issues; it takes patients longer to process change and psychotherapy may be helpful.
Has there been any change in family contact? Family members not visiting, or coming less frequently, or a parent developing an illness can result in less contact.

In response to your questions, the staff reports that there were no changes in Anne’s family contact or routine. In addition, they changed the meal menu to items they knew the client prefers, increased her favorite activities, and reached out to family members, but nothing seems to have worked.

2. Ask about medical issues.

Because ID people have difficulty communicating, they may have unrecognized medical symptoms affecting their mood and behavior.

Medication changes: patients with ID are more prone to adverse reactions from prescribed and OTC meds (especially antibiotics and antihistamines), which will often present as behavior problems.
Common medical conditions: ask about eating and drinking habits, bowel/bladder issues, and somatic complaints. ID patients frequently have behavior changes due to conditions such as GERD (gastroesophageal reflux disease), seizure disorders, constipation, infectious disease (UTI, sinusitis, etc) and dental conditions.

Staff says that a recent visit to the client’s PCP revealed no signs of infection or other medical issues that might have caused agitation.

3. Assuming that there is a psychiatric cause of agitation, try to narrow down the underlying disorder.

Anxiety and depression. These are very common and are often missed because the presenting symptoms are behavioral rather than the classic depressive/anxiety symptoms. A careful interview, and looking for observable signs of depression (isolative behavior, crying, refusing to participate in favorite activities) can help.
Psychosis. It can be hard to distinguish psychosis from general behavior change related to the inherent issues with ID, such as concentration and attention span problems, or low frustration tolerance/impulsivity. And because of communication issues, ascertaining the presence of delusions or hallucinations can be a challenge. we sometimes have success asking specific and concrete questions, such as:
- Are you hearing people talk that you know or don’t know?
- Can you start the talking or stop it?
- Are you feeling someone touch your skin but you can’t see them?
- Are your eyes playing tricks on you?
- Does anything help? Or make it worse?

During the interview with Anne you ask her what happened with her roommate, and her reply is that “He told me to.” Staff reports that Anne’s roommate is female and that no males work in her group home. You notice that she seems to be distracted intermittently throughout the interview, and ask her if she knows who “he” is, to which she responds “no.” Further evaluation reveals that Anne has started to hear whispers intermittently. Her eventual diagnosis is schizophrenia.

Psychopharmacologic treatment

The typical ID patient will already be on a number of psychotropic meds from prior treaters, so much of your job will be to evaluate current medications and judge which ones require adjustment. We typically ask family/staff for a timeline of medication trials. You’ll want to know what happened when each medication was started, and when the dosages were changed. It’s also useful to find out what was going on when the patient was last doing well—eg, where were they living, what meds were they taking, were they in school, working, etc. It’s important to find out, for example, that three years ago this person was doing amazing.

Sometimes a regimen was stopped for no reason at all. I had one patient come to me on 25 medications, and eventually I found out she was previously stabilized on risperidone and valproate. A peer told her that risperidone caused weight gain and so she refused to take it, even though she never had weight gain. She was tried on many other medications (resulting in polypharmacy) and never attained stability since the discontinuation of risperidone. Over time, we restarted the prior regimen with great results.

In terms of FDA approval, there are no medications approved specifically for patients with ID, but nonetheless many of the medications used for irritability or agitation in autism and other similar disorders are often effective.

Antipsychotics

If it’s clearly psychosis, consider a low dose second generation antipsychotic (SGA) since these have lower risk of EPS. My go-to antipsychotics in this kind of situation include ziprasidone, aripiprazole or lurasidone due to their better SE profile, particularly regarding weight gain. We start at a low dose, and ask staff to carefully track specific symptoms and behavior and symptoms. In our experience it is best to put these instructions in writing on the doctor’s order form that most programs bring to each appointment. For example, if you’re starting a patient on aripiprazole 2 mg QAM, you’ll want to write on the form: “Track sedation, energy level, aggression, and work attendance daily for 30 days.” Since all written clinical orders are now documented, you can then be assured that these behaviors will indeed be tracked and brought to the next visit. Based on the results, you can choose to maintain the same dose, or increase the dose, including the frequency of dosing, for example, if you see a pattern of decompensation at specific times of the day.

As an example of how difficult psychosis can be to assess, we once treated a patient with low dose lurasidone for schizophrenia for over a year. His behavior was under control, and he had no obvious psychotic symptoms, but he began to consistently refuse to attend his assisted employment program, for no clear reason that he could verbalize. One day, he attacked his uncle, and in talking to him about what happened it become clear that he was paranoid that people were plotting against him, including a man at his workshop who resembled his uncle. This delusion was the reason for non-adherence to his work program. Once we increased the dose of the SGA, he started going to work five days a week.

You decide to offer Anne treatment with a slow titration of aripiprazole, starting with 2 mg daily for 1 week, then titrating to 5 mg for 1 week before having her return to your office. You ask that staff observe Anne for any common side effects (akathisia, sleep alterations, increased anxiety, GI alterations, seizure, etc.) and document changes to behaviors. Before she leaves the office, you order baseline labs (CBC w/diff, HgbA1c, fasting glucose, fasting lipids, CMP, TSH, ANA, RF, H. pylori, vitamins D/B12 and folate) and perform an AIMS screen. A check-in with the staff over the phone in one week reveals that the patient has not had any demonstrable side effects to aripiprazole, and that she appears to be slightly less distracted, she has not had any further incidents of aggression towards her roommate. You recommend that they continue with the titration and follow-up in another week as previously planned. When Anne returns the next week, she appears to be back to her baseline and denies hearing any voices in the last week. You recommend continuing at the current dose and monitoring for any return of symptoms.

Mood stabilizers

Mood stabilizers can be quite helpful for agitation, and I will use valproate (my go to) or low dose lithium (150mg BID or TID; shoot for a level of 0.5 or 0.6 if possible to allow for variation in fluid intake). We don’t traditionally use Oxcarbazepine as a go-to, but do occasionally I use it. For example, we had a 25-year-old patient with moderate ID and bipolar disorder. She didn’t tolerate antipsychotics in the past, and the family simply did not want either valproate or lithium, for various reasons, but they immediately agreed to oxcarbazepine 500 mg daily. It worked really well for her unstable moods and her obsessions. If mood stabilization is needed but the risk is less imminent, consider oxcarbazapine, topiramate, lamotrigine, or gabapentin. Use great caution when tapering anti-epileptic drugs, even if there is no history of seizure in the past; we’ve had patients seize for the first time when stopping these medications.

If patients are already taking an SGA or a mood stabilizer which was previously effective but the symptoms returned, try adjusting the timing before increasing the total daily amount. For example, in a patient taking valproate 1500mg at bedtime with a return of aggression, try ordering 500mg TID before titrating up. Some behaviors will respond to these changes, the passage of time may reveal other factors, or the patient may show improvement on their own.

Antidepressants/benzodiazepines

For depression and anxiety disorders, we consider SSRIs first, and our top two choices are sertraline or escitalopram for their benign side effect profile and lack of drug interactions. If these aren’t effective, you can try an SNRI or a novel antidepressant, but use extra caution with bupropion since it lowers seizure threshold.

Use benzodiazepines with caution; they can negatively impact memory, cognitive, and respiratory function. They may cause a paradoxical effect in patients with ID, leading to states of disinhibition, which can increase impulse control or problem behaviors. To rule out a paradoxical effect, ask the patient directly, “Have you ever received a medication before a dental procedure or imaging and had the opposite reaction of what you were hoping for?” If using benzos, we prefer low doses of the longer half-life options, such as clonazepam 0.25 mg QD or BID.

Adjunctive agents

If antipsychotics and mood stabilizers have been tried but prove ineffective, intolerable, or have only partial response, our next step would be to prescribe an alpha agonist, beta blocker, or naltrexone. We use clonidine or guanfacine, but at a low dose and. We prefer to prescribe once daily, either in the morning or at 3PM. Ask your patient if symptoms are worse during daytime or evening hours and have staff track progress for one month to gauge efficacy. If the medication is at 3PM and only the evening hours are improved, you can add a morning dose. Most patients with ID have day programming, which is more structured. So if you try a med in the AM and get good results, but symptoms return in the afternoon, you can add a second dose to cover the remaining waking hours. If choosing a beta blocker, start low and go slow, using propranolol or betaxolol, and usually dose using the same timing schedule (AM and/or 3PM). While naltrexone is approved only for alcoholism and opiate use disorder, there is also good data for a variety of impulsive disorders, including sexual aggression, skin picking, overeating, and others. Start with 25 mg, either 3 pm or 8 am, and you can go to BID, but not over 100 mg per day.

Other interventions

Don’t forget to suggest other interventions so you are not focusing only on medications to fix everything; there are multiple psychotherapeutic interventions that are modifiable specifically for the ID population to treat mental health conditions, recommend behavior support assessment for any problem behavior, and OT/PT/speech therapy/sensory assessments for patients of any age group to assist with communication, functional limitations, sensory integration issues, etc. You are not alone and you are one part of a multidisciplinary team; patients in their 20s who cannot communicate will get frustrated and will show us that they are struggling instead of telling us; don’t hesitate to order speech therapy no matter the age. By asking about these extra interventions, you make the point that we will not be successful by solely focusing on medications.

As Freud said, “All behavior is purposeful.” Patients with ID show us their mental health symptoms; identifying these and providing effective treatment is an amazing experience. Imagine being the first person to connect with a patient and to help them tell his story. Isn’t that what psychiatry is all about?

Once Anne has been stable on aripiprazole for a month, you decide to address her reluctance to talk to anyone about her symptoms as they were evolving. You order a speech therapy evaluation to evaluate any communication challenges, and you recommend that she start following with a therapist to learn to identify and express her emotions more freely.