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A high proportion of people with learning disabilities receive psychotropic medications such as antipsychotics, antidepressants, antianxiety drugs including benzodiazepines, buspirone and beta blockers, mood stabilisers such as lithium and some antiepileptic medications, psychostimulants, opioid antagonists and also vitamins and diets. Many receive these for behaviour problems for which these medications have not been indicated. Apart from a few exceptions of recent good quality randomised controlled trials (RCTs) of risperidone on the management of behaviour problems among children and adults with learning disabilities with and without autism, most of the evidence for the effectiveness of medication for the management of behaviour problems comes from non‐controlled or non‐randomised observational studies. The lack of evidence does not automatically mean that there is evidence that these medications are not effective. Current guidelines suggest that a thorough assessment of the cause and effect of the behaviour problems should be carried out before prescribing medications. A formulation should document the assessment and rationale for use of medications. Non‐medication based interventions should always be considered along with medication and where appropriate behavioural and psychological interventions should be employed either instead of or along with the medication. People with learning disabilities and their carers should be involved in the decision‐making process all along. Where necessary other relevant professionals should also be involved. At the outset the time, method and people involved with the follow‐up assessment should be determined. Follow up should involve an objective assessment of target behaviours but, more importantly, an assessment of the quality of life of the person and their carers. At each follow up a reformulation should be carried out along with consideration of non‐medication based management and the possibility of withdrawing medication. Important issues such as capacity, consent and legal issues should always be borne in mind. Medications should be used with some caution because of their adverse effects.

Medication may be used to treat two broad types of mental health problem: psychiatric disorders (such as depression, schizophrenia or obsessive‐compulsive disorder) and challenging behaviours (such as self‐injury, impulsive aggression or inappropriate sexual behaviour). The effectiveness of medication in the treatment of psychiatric disorder is well established for the non‐learning‐disabled population. In clinical practice, medication seems to be broadly as effective for people with learning disabilities. The effectiveness of medication in the treatment of challenging behaviours is less well established, although evidence for effectiveness is accumulating for some types of problem behaviour. When treating behavioural problems, medication is often used in combination with other management strategies. Knowledge of side effects is important, because people who have difficulty communicating may not be able to Report problems before they become severe. When using medication, it is important to try to achieve the best benefit: risk ratio, taking into account the person's other health problems and disabilities. It may be necessary to measure treatment effects, using standardised assessments or individual measures of target symptoms or behaviours.

The purpose of this paper is to investigate if positive behavioural support (PBS) can be an effective alternative to medication, and can aid medication reduction in people with a learning disability, autism or both who are prescribed psychotropic medication for behaviour thought to be challenging. STOMP is an initiative supported by NHS England which aims to reduce inappropriate prescribing of psychotropic medication, i.e. antipsychotics used for challenging behaviour in the absence of a documented mental health diagnosis. PBS has been described as the first line of intervention for behaviours which challenge, (NICE, 2015) and has been highlighted as a non-pharmacological alternative to, medication.

A two-group, experimental design was utilised. Both groups were considered for medication reduction. The experimental group of 25 people received input from a specialist PBS team, while the control group of 29 people underwent unsupported medication challenge.

There was a significantly higher success rate for medication reduction and discontinuation when PBS assessment and intervention was provided as an alternative to medication.

This study indicates that providing PBS is associated with decreased medication and if replicated should be become standard practice for specialist teams.

This is the first study to investigate the effect of PBS on medication reduction in patients prescribed psychotropic medication for behaviour thought to be challenging.

The purpose of this paper is to determine if dually diagnosed (DDx) patients with severe mental illnesses such as bipolar disorder and schizophrenia are at higher risk of not obtaining prescribed medication.

National Veterans Health Administration records from 2010 identified all DDx patients with Bipolar (BP) spectrum (n=98,894) and Schizophrenia (SZ) spectrum (n=80,654) disorders. Pharmacy records identified the total number of prescriptions dispensed per veteran for antidepressants, antipsychotics, sedative‐hypnotics and anxiolytics, mood stabilizers (anti‐convulsants), and lithium. To identify potential sociodemographic and clinical confounders, bivariate analyses compared four groups: BP and SZ with and without DDx. Analysis of covariance (ANCOVA) was used to determine the association of DDx with the number of dispensed prescriptions, and interaction analysis was used to determine whether any “dual‐diagnosis effect” was greater between BP or SZ. Further ANCOVA examined whether significant differences were accounted for by differences in outpatient mental health visits or co‐morbidities.

Among BP veterans, 33,226 (33.6 percent) were DDx, compared to 19,652 (24.4 percent) among SZ veterans. DDx patients obtained more prescriptions than other patients over a similar period of time, and these effects were somewhat greater for BP DDx patients than for SZ DDx patients. DDx patients also showed more mental health services use and had more co‐morbidities. After controlling for these differences, DDx veterans still were dispensed more total psychotropic prescriptions, but most differences between diagnostic groups and medication class were no longer significant.

The paper shows that DDx veterans consume more resources in terms of both psychotropic medications and clinic visits. Further attention should be paid to the overall complexity of their clinical needs, including the increased likelihood of both licit and illicit drug‐drug interactions rather than just to their substance use.

High‐secure hospital patients often have complex presentations that are marked by co‐morbidity, violence, histories of poor concordance with oral medication, and treatment resistance. The ability to give a long‐acting medication with a low propensity for extra pyramidal side effects is of potential value to clinicians treating these patients. Risperidone Long‐acting Injection (RLAI) is the first long‐acting atypical antipsychotic medication and may be potentially useful in this population. This paper aims to investigate this issue.

This was a retrospective, naturalistic study to investigate the use and effectiveness, using hard outcome measures, of RLAI in the four UK high‐secure psychiatric hospitals. Hospital pharmacy databases at Ashworth, Broadmoor, Carstairs and Rampton hospitals were used to identify all patients who had been prescribed RLAI. Anonymised data were then obtained from the pharmacy databases and case notes which were then pooled.

A total of 159 patients were prescribed RLAI, most of whom had schizophrenia. The mean length of treatment with RLAI was 65 weeks (range two to 260 weeks) and the mean maximum dose was 43.2 mg every two weeks (range 25‐75 mg every two weeks). No serious adverse effects were reported. In total, 42 per cent (67) patients responded to RLAI in as much as that they either remained on it in the long‐term or were discharged to conditions of lower security whilst taking it. As there was no control group, it is not possible to determine if RLAI was a significant factor in such discharges to conditions of lower security. Of those patients who failed to respond to RLAI, 44 per cent were subsequently treated with clozapine.

This pragmatic multi‐centre study of a small but complex patient group demonstrated that RLAI was effective in 42 per cent of patients and was well‐tolerated.

The purpose of this paper is to establish and evaluate a psychotropic medication education group for men with intellectual disability on a secure psychiatric ward.

A multi-disciplinary team was convened to oversee the project. A curriculum was developed that covered major classes of psychotropic drugs as well as broader themes related to taking medication and general wellbeing. Each group session incorporated a range of teaching methods supported by accessible materials. Evaluation was by qualitative and quantitative methods.

There was interest and enthusiasm for the group. Participant feedback was generally positive and most of those who completed the group reported achieving their personal learning goals. There was no significant difference in results of a medication knowledge test at baseline and at the end of the course. Feedback from group members and reflections of the course facilitators are discussed.

The results of this small-scale study may not be applicable to other groups or settings. Evaluation measures seemed unable to capture some elements of the group processes and outcomes.

Establishing and running a psychoeducational group on a low-secure ward for men with intellectual disabilities is possible and potentially valuable. Learning from this project will be useful for others considering group-based interventions for people with intellectual disability.

This paper adds to the limited literature describing interventions to improve medication knowledge in people with intellectual disability.

The purpose of this paper is to establish the relationship between organisational culture and psychotropic medication use in residential care.

Cross-sectional analyses of staff and resident’s record survey in residential aged care facilities in Auckland, New Zealand (NZ). The competing values framework categorised organisational culture as clan, hierarchical, market driven or adhocracy and was completed by all staff. The treatment culture tool categorised facilities as having resident centred or traditional culture and was completed by registered nursing staff and general practitioners (GP). Functional and behavioural characteristics of residents were established by staff report and health characteristics and medications used were ascertained from the health record. Multiple regression was used to test for associations between measures of culture with psychotropic medication use (anxiolytics, sedatives, major tranquillisers).

In total 199 staff, 27 GP and 527 residents participated from 14 facilities. On average 8.5 medications per resident were prescribed and 42 per cent of residents received psychotropic medication. Having a diagnosis of anxiety or depression (odds ratio (OR) 3.18, 95 per cent confidence interval (CI) 1.71, 5.91), followed by persistent wandering (OR 2.53, 95 per cent CI 1.59, 4.01) and being in a dementia unit (OR 2.45, 95 per cent CI 1.17, 5.12) were most strongly associated with psychotropic use. Controlling for resident- and facility-level factors, health care assistants’ assignation of hierarchical organisational culture type was independently associated with psychotropic medication use, (OR 1.29, CI 1.08, 1.53) and a higher treatment culture score from the GP was associated with lower use of psychotropic medication (OR 0.95, CI 0.92, 0.98).

Psychotropic medication use remains prevalent in residential care facilities in NZ. Interventions aimed at changing organisational culture towards a less hierarchical and more resident-centred culture may be another avenue to improve prescribing in residential aged care.

The purpose of this paper is to explore the incidence of obesity and its complications in secure psychiatric settings; and to assess changes in body mass index (BMI).

Electronic patient records were used to determine levels of obesity and weight change over a three-year period. BMI levels were related to status, medication and patient characteristics.

The incidence of obesity (34 per cent) in the sample (n=351) was higher than in the general population. One-third of patients were on medication for hyperlipidaemia and 10 per cent were diagnosed with type II diabetes. Patients on regular antipsychotic drugs and sodium valproate and who were less active had higher BMIs. Gender differences over a three-year period showed a tendency for women's weight to continue to increase which may be linked to lower levels of engagement in activities of moderate or vigorous intensity.

Previous surveys using secure psychiatric populations have been point in time reviews. The current study tracks changes over a three-year time period and related this to a range of interventions.

The majority of adults with intellectual disabilities (ID) are prescribed at least one, if not multiple medications, with psychotropic medications being the most commonly prescribed. Direct care staff play an important role in psychotropic medication administration and monitoring, yet little is known about their knowledge and comfort with medication. The paper aims to discuss this issue.

A 15-item survey, focusing on self-reported knowledge and comfort with psychotropic medication, was completed by 152 direct care staff employed at three agencies providing residential services for individuals with ID across Ontario.

In total, 62 per cent of staff respondents reported that psychotropic medications were among the top medications regularly taken by the individuals they support, with behaviour listed as the most commonly reported reason for taking this medication. The majority of staff reported monitoring medication, however, the frequency of monitoring varied considerably. Generally, staff reported feeling comfortable and knowledgeable about medication use, but, most reported a desire for additional medication training.

This is the first Canadian study to examine staff knowledge and comfort regarding medication use, and the first study to assess PRN (“as needed”) as well as regularly administered medications.

The purpose of this paper is to identify psychotropic medication being prescribed for people with intellectual disability “as and when required” (PRN); the indications, frequency of use, rate of poly-pharmacy and contribution of PRN medication towards this. The paper also aimed to identify individual and environmental factors associated with PRN medication prescribing.

Data were collected from nursing and medical records for the 119 service users in the acute assessment and treatment unit and NHS residential care settings managed by specialist intellectual disability services covering Leicester, Leicestershire and Rutland over a month period. Data were analysed using descriptive statistics and logistic regression to calculate adjusted odds ratios for predictor variables.

In total, 72 per cent of the service users were prescribed and 25 per cent were administered PRN medication over the study period. The most common indications for PRN prescribing were aggression and agitation. Lorazepam and chlorpromazine were the most frequently prescribed PRN medications. The rate of poly-pharmacy was 41 and 38 per cent of this was attributable to PRN medication. Male gender and history of challenging behaviour were found to be significant factors associated with PRN medication prescribing.

PRN medications are commonly prescribed in people with intellectual disabilities and contribute to poly-pharmacy. Whilst PRN medication continues to remain an effective therapeutic option in situations where environmental and behavioural approaches are proving insufficient, their use should always be in conjunction with effective review mechanisms.