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Evidence of overprescribing of psychotropic medicines to manage challenging behaviour in people with intellectual disabilities has led to national programmes within the UK to promote deprescribing, such as stopping the overprescribing of medication in people (with learning disabilities, autism or both). To successfully implement deprescribing initiatives, we need to understand how to engage stakeholders in the process.

In a published systematic review, we reported evidence about the process of deprescribing psychotropic medicines for people of all ages with intellectual disabilities and challenging behaviour. As a part of the original review, we searched for evidence about stakeholders’ experiences of the psychotropic deprescribing process, which was synthesised and reported within the current study.

Six studies were identified. Involving carers and people with intellectual disabilities, providing ongoing support and improving access to non-pharmacological interventions, including positive behaviour support, may contribute to successful outcomes, including reducing or stopping psychotropic medicines and improving quality of life. Implementing psychotropic deprescribing requires a multidisciplinary collaborative care approach and education for stakeholders.

There have been no previous reviews of stakeholder experiences of deprescribing psychotropic medications for people with intellectual disabilities and challenging behaviour. The existing literature is scant, and further research is needed.

This paper aims to provide a commentary response to “Stakeholder experiences of deprescribing psychotropic medicines for challenging behaviour in people with intellectual disabilities”.

The commentary provides some evidence-based perspectives on the risks and challenges of psychiatric drug-withdrawal, emphasising the importance of the patient experience in deprescribing decisions. It also makes the case for clinical clarity and carer-engagement in optimising deprescribing outcomes for individuals. Some clinical reflections are provided.

Whilst efforts to reduce the overmedication of people with learning disabilities are welcomed, there is lacking evidence around this population’s experience of adverse effects from psychiatric deprescribing decisions, including differentiating between withdrawal and relapse effects. Clinical clarity and carer engagement are key to safe and effective prescribing, although in reality, this can be challenging.

This paper will be of value to all professionals with a role in the effective deprescribing of psychiatric medications with and/or for people with intellectual disability. It provides perspectives on aspects of stakeholder experience that warrant further consideration and research.

This commentary aims to define STOMP and STAMP, describes its history and evolution and the authors’ thoughts about future directions given the lack of clear evidence base for prescribing and deprescribing psychotropic medication given for behaviour thought to be challenging.

This commentary defines the authors’ clinical experience and personal thoughts about STOMP achievements and challenges for the future delivery.

This commentary details STOMP development to date and highlights the potential areas for further study and research to grow understanding, professional confidence and delivery.

This commentary highlights much of the currently accepted research and areas that have poor quality evidence or are of interest for future study. STOMP definition, especially of inappropriate prescribing, is key to redefining the work.

This commentary highlights the potential impact of STOMP and STAMP on prescribing rates and the need for better definition, processes and education for workforce development. There is a major need to understand the benefit of behavioural intervention to support the optimisation of medication.

This commentary builds on personal experience and current understanding to postulate considerations to further the delivery of STOMP and STAMP.

Polypharmacy, the concurrent use of multiple medicines by one individual, is a common and growing challenge driven by an ageing population and the growing number of people living longer with chronic conditions. Up to 11% of unplanned hospital admissions in the UK are attributable to, mostly avoidable, harm from medicines. However, this topic is not yet central to integrated practice. This paper reviews the challenge that polypharmacy presents to the health and care system and offers lessons for integrated policy and practice.

Two commonly encountered scenarios illustrate the relevance of addressing inappropriate polypharmacy to integrated practice. An overview of the literature on polypharmacy and frailty, including two recent large studies of policy and practice in Europe, identifies lessons for practitioners, managers, policy makers and commissioners.

Comprehensive change strategies should extend beyond pharmacist led deprescribing initiatives. An inter-professional and systems thinking approach is required, so all members of the integrated team can play their part in realising the value of holistic prescribing, appropriate polypharmacy and shared decision making.

Awareness and education about polypharmacy should be embedded in inter-professional training for all practitioners who care for people with multimorbidity or frailty.

This paper will help policy makers, commissioners, managers and practitioners understand the value of addressing polypharmacy within their integrated services. Best practice national guidance developed in Scotland illustrates how to target resources so those at greatest risk of harm from polypharmacy can benefit from effective pharmaceutical care as part of holistic integrated care.

The over-reliance on psychotropic medication for the management of patients with learning disabilities with behaviour that challenges is well documented.This paper aims to discuss the application of the methodology of clinical audit within community learning disability mental health services to adapt interventions including optimising prescribing practice and behavioural interventions aiming to reduce behaviour that challenges in people with learning disabilities.

Questionnaire-based review of documentation in electronic patient records, covering relevant audit standards in line with NICE and Royal College of Psychiatrists, was carried out in the North Essex Community Learning Disability Service, Hertfordshire Partnership NHS Foundation Trust. The audit included patients on the caseload of consultant psychiatrists.

The audit demonstrated that the prescribing of psychotropic medication was within BNF maximum limits for all patients, evidence of “consent” procedures was being followed in the majority, and there was some evidence of deprescribing attempts.Improvement was required in several areas e.g. undocumented off label prescribing in a significant proportion of patients. Objective measures to record the severity of behaviours and the effects of the medication were being used by clinicians in only a small proportion of patients. A significant proportion of patients have prescribed medication in the absence of appropriate psychological or environmental interventions.

As a result of the audit findings, the action plan made recommendations such as the development of a database for tracking the prescribing of psychotropic medicines and routine use of standardised measures. This action has been supported by the pharmacy team. Positive developments include a clinical psychologist taking on the role of leading the development of behavioural intervention strategies.

The purpose of this paper is to investigate how general practitioners’ (GPs) decisions about discontinuation of medication are influenced by their institutional context.

In total, 24 GPs were interviewed, three practices were observed and documents were collected. The Gioia methodology was used to analyse data, drawing on a theoretical framework that integrate the sensemaking perspective and institutional theory.

Most GPs, who actively consider discontinuation, are reluctant to discontinue medication, because the safest course of action for GPs is to continue prescriptions, rather than discontinue them. The authors conclude that this is in part due to the ambiguity about the appropriateness of discontinuing medication, experienced by the GPs, and in part because the clinical guidelines do not encourage discontinuation of medication, as they offer GPs a weak frame for discontinuation. Three reasons for this are identified: the guidelines provide dominating triggers for prescribing, they provide weak priming for discontinuation as an option, and they underscore a cognitive constraint against discontinuation.

The analysis offers new insights about decision making when discontinuing medication. It also offers one of the first examinations of how the institutional context embedding GPs influences their decisions about discontinuation. For policymakers interested in the discontinuation of medication, the findings suggest that de-stigmatising discontinuation on an institutional level may be beneficial, allowing GPs to better justify discontinuation in light of the ambiguity they experience.

The STOMP programme – stopping the over-medication of people with an intellectual disability, autism or both is a three-year programme supported by NHS England. Concern about the overuse of antipsychotic drugs has been a constant theme since the 1970s. However, despite a multitude of guidelines the practice continues. The report into the events at Winterbourne View not only raised concerns about the overuse of antipsychotic drugs but of antidepressants. Part 1 presented the historical background to the use of psychotropic drugs for people with an intellectual disability, autism or both. The purpose of this paper (Part 2) is to present the approach adopted to reduce over-medication (the “Call to Action”) and the progress so far at the half way stage.

The “Call to Action” methodology is described in a Manchester University report – mobilising and organising for large-scale change in healthcare “The Right Prescription: A Call to Action on the use of antipsychotic drugs for people with dementia”. Their research suggested that a social mobilising and organising approach to change operates could provide a mechanism for bringing about change where other approaches had failed.

The adoption of the “Call to Action” methodology has resulted in widespread acknowledgement across intellectual disability practice that overuse of psychotropic medication and poor review was resulting in over-medication. Many individual local programmes are underway (some are described in this paper) however to what extent the overall use of psychotropic drugs has changed is yet to be evaluated.

STOMP is part of an English national agenda – transforming care. The government and leading organisations across the health and care system are committed to transforming care for people with intellectual disabilities autism or both who have a mental illness or whose behaviour challenges services. This paper describes a new approach to stopping the over-medication of people with an intellectual disability, autism or both.

The therapeutic community (TC) is an environmental intervention where principles of working together democratically can enhance self-agency. While availability of inpatient TCs within the UK National Health Service (NHS) has declined, shorter or alternative interventions using core TC approaches have shown promise in enacting change. The purpose of this paper is to report and reflect on the development and running of a pilot nano-TC.

Foundations Group was a 2-h TC group intervention set up and run within the NHS for 18 months in 2021–2022, and taking place on City Farm premises. The group was convened as part of the complex emotional needs service in a mental health NHS Trust in the South West of England. Over the study period, the group comprised 11 members, one peer member and three staff members.

The authors reflected on the TC stance of working democratically with a fluid hierarchy, taking a non-expert approach, and using support and challenge to enhance self-agency and belongingness. The authors have detailed the structure of the group session including use of community meetings, psychoeducation, creative sessions and reviews. Members took on roles within the group including chairing sessions.

This group was a novel service within the NHS Trust where it was conducted and may represent a standalone therapeutic group. The authors hope it will show that core TC principles can be applied in shorter interventions than have previously been used.

The impact of population ageing is significant, multifaceted and characterised by frailty and multi-morbidity. The COVID-19 pandemic has accelerated care pathways and policies promoting self-management and home-based care. One under-researched area is how patients and family caregivers manage the complexity of end-of-life therapeutic medicine regimens. In this position paper the authors bring attention to the significant strain that patients and family caregivers experience when navigating and negotiating this aspect of palliative and end-of-life care.

Focussing on self-care and organisation of medicines in the United Kingdom (UK) context, the paper examines, builds on and extends the debate by considering the underlying policy assumptions and unintended consequences for individual patients and family care givers as they assume greater palliative and end-of-life roles and responsibilities.

Policy makers and healthcare professionals often lack awareness of the significant burden and emotional work associated with managing and administering often potent high-risk medicines (i.e. opioids) in the domiciliary setting. The recent “revolution” in professional roles associated with the COVID-19 pandemic, including remote consultations and expanding community-based care, means there are opportunities for commissioners to consider offering greater support. The prospect of enhancing the community pharmacist's medicine optimisation role to further support the wider multi-disciplinary team is considered.

The paper takes a person-focused perspective and adopts a holistic view of medicine management. The authors argue for urgent review, reform and investment to enable and support terminally ill patients and family caregivers to more effectively manage medicines in the domiciliary setting. There are clear implications for pharmacists and these are discussed in the context of public awareness, inter-professional collaboration, organisational drivers, funding and regulation and remote care delivery.

The purpose of this paper is to demonstrate how Positive Behavioural Support (PBS) can be used as an alternative to psychotropic medication to improve the quality of life of an individual with a learning disability and behaviour described as challenging.

A single case design was utilised. A unique PBS stopping over medication of people with a learning disability, autism or both (STOMP) clinic model was developed and PBS was used in line with National Institute for Health and Care Excellence (NICE) guidance. This included functional behavioural assessment, to support understanding of the reasons behind behaviour described as challenging, and a gradual medication reduction.

This case study found that antipsychotic medication used to manage behaviour that challenges could be safely reduced and individual quality of life increased when PBS was used as an alternative.

STOMP is a project supported by NHS England aimed at reducing the inappropriate prescribing of psychotropic medication to manage behaviour that challenges. NICE guidance recommends that behaviour should be more appropriately understood through PBS. More research is needed to demonstrate how the two work together for safe medication reduction and improved quality of life.