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This chapter uses Goffman’s concept of total institutions in a comparative case study approach to explore the role of psychotropic drugs in the process of transinstitutionalization.

This chapter interprets psychotropic drug use across four institutionalized contexts in the United States: the active-duty U.S. military, nursing homes and long-term care facilities, state and federal prisons, and the child welfare system.

This chapter documents a major unintended consequence of transinstitutionalization – the questionable distribution of psychotropics among vulnerable populations. The patterns of psychotropic use we synthesize suggest that total institutions are engaging in ethically and medically questionable practices and that psychotropics are being used to serve the bureaucratic imperatives for social control in the era of transinstitutionalization.

Psychotropic prescribing practices require close surveillance and increased scrutiny in institutional settings in the United States. The flows of mentally ill people through a vast network of total institutions raises questions about the wisdom and unintended consequences of psychotropic distribution to vulnerable populations, despite health policy makers’ efforts regulating their distribution. Medical sociologists must examine trans-institutional power arrangements that converge around the mental health of vulnerable groups.

This is the first synthesis and interpretive review of psychotropic use patterns across institutional systems in the United States. This chapter will be of value to medical sociologists, mental health professionals and administrators, pharmacologists, health system pharmacists, and sociological theorists.

The programme – Stopping the over-medication of people with an intellectual disability, Autism or Both (STOMP) 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 and multiple psychotropic drug use. The purpose of this paper is twofold: Part 1 is to present the history and background to the use of psychotropic drugs in intellectual disabilities, autism or both; and Part 2 presents the progress with the STOMP programme.

The review tracks the various concerns, guidelines and attempts to tackle the issue of over medication of people with intellectual disability autism or both.

The review identifies that despite the many studies and guidelines associated with the prescribing of psychotropic drugs for people with an intellectual disability, autism or both the practice is common. Programmes that minimise the use of psychotropic drugs involve a full use of the multidisciplinary team and an availability of alternative methods of managing challenging behaviours.

STOMP is part of an English national agenda – Transforming care. The English 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 review identifies many studies, programmes and guidelines associated with psychotropic drug use for people with an intellectual disability, autism or both.

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.

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.

Simple linear accounts of prescribing do not adequately address reasons “why” doctors prescribe psychotropic medication to people with intellectual disability (ID). Greater understanding of the complex array of factors that influence decisions to prescribe is needed.

After consideration of a number of conceptual frameworks that have potential to better understand prescribing of psychotropic medication to adults with ID, an ecological model of prescribing was developed. A case study is used to outline how the model can provide greater understanding of prescribing processes.

The model presented aims to consider the complexity and multi-dimensional nature of community-based psychotropic prescribing to adults with ID. The utility of the model is illustrated through a consideration of the case study.

The model presented is conceptual and is as yet untested.

The model presented aims to capture the complexity and multi-dimensional nature of community-based psychotropic prescribing to adults with ID. The model may provide utility for clinicians and researchers as they seek clarification of prescribing decisions.

The paper adds valuable insight into factors influencing psychotropic prescribing to adults with ID. The ecological model of prescribing extends traditional analysis that focuses on patient characteristics and introduces multi-level perspectives that may provide utility for clinicians and researchers.

This commentary accompanies Clare et al.’s study investigating psychotropic drug prescribing for adults with intellectual disability who were referred to specialist community learning disability teams in the east of England. The purpose of this paper is to explore some of the background to psychotropic drug prescribing for people with intellectual disability, review important contextual factors that influence prescribing decisions, and consider how we might make the best use of psychotropic drugs in this group.

Narrative summary and opinion, supported by reference to recent research literature.

Psychotropic drug use for people with intellectual disability raises complex issues, not least because of the lack of research evidence that exists on the topic. Psychotropic drugs can be an important part of treatment for people with mental illness but further research is needed to support prescribing for challenging behaviour. Medication optimisation is a framework within which individual preferences and values are considered alongside the evidence base and clinical judgement in order to inform safe, effective, and collaborative management decisions.

Prescribing decisions should be individualised and reviewed regularly, incorporating evidence from patients and carers. Improving the use of psychotropic medication requires concerted action, adequate social support, and the provision of alternative, non-pharmacological interventions that are acceptable and effective.

This paper reviews some of the current concerns about the use of psychotropic drugs and opens up new avenues of discussion.

Aim ‐ To describe prescription drug use in a nationwide prison population and compare it with contemporary drug use in other relevant populations as well as in a prison population 25 years ago. Method ‐ Detailed medication sheets from 37 prisons, covering 90% of the Norwegian prison population, were collected. All drugs were transcribed into the Anatomical Therapeutic Chemical classification system, and Defined Daily Doses/100 inmates were calculated. Data enabling relevant comparisons were gathered from reliable sources. Results ‐ Among the 2,617 inmates investigated, 48% used no medication. Sixteen percent used both psychotropic and somatic drugs, 17% psychotropic drugs only, and 19% somatic drugs only. Strong correlations between drug use and gender, age, and prison characteristics were demonstrated. Psychotropic drug use was higher than in the general population but lower than in a psychiatric hospital unit. Somatic drug use was lower than in the general population, except non‐steroid antiinflammatory agents, antihistamines, and drugs to alleviate obstructive airway diseases. Psychotropic drug use, particularly antidepressant use, was higher than in prisons 25 years ago. Conclusion ‐ High levels of use of all psychotropic and a number of somatic drugs were demonstrated in this nationwide prison population. Treatment studies are needed in order to ascertain whether the high levels of use of particularly psychotropic medications are indeed improving the mental health of prisoners.

The purpose of this paper is to provide a commentary on the article by Lee and colleagues, entitled “Positive Behavioural Support as an alternative to medication”, from the perspective of Dimensions, a national provider of social care support to people with learning disabilities and/or autism. As a supporter of the NHS England STOMP campaign, Dimensions recognises that people with learning disabilities and/or autism who have displayed “challenging behaviours” are at risk of being wrongly or over prescribed psychotropic medications intended to control that behaviour, and encourages the use of non-medical support strategies as an effective alternative to psychotropic medications.

Dimensions surveyed the approximately 1,400 people with learning disabilities and/or autism for whom they provide 24-h support. The survey was intended to assess the extent of use of psychotropic medications and the level of adherence to NICE “best practice” guidelines. The survey was the precursor to an awareness raising campaign and development of an operational toolkit intended to inform and empower people supported, families and colleagues to take a more proactive role in the prescription and review of psychotropic medications.

In total, 54 per cent of people surveyed were being prescribed psychotropic medication, of whom 97 per cent had been prescribed one or more medications for at least six months. Around 51 per cent were having six monthly multi-disciplinary reviews and around 31 per cent had not had a multi-disciplinary review within the preceding 12 months. Only 13 per cent of people taking psychotropic medication had a plan in place that was specifically aimed at reducing or stopping the medication.

Empowering people to participate in and challenge clinical decision making can have a transformative effect on the lives of a group of people who have experienced a significant negative impact from prolonged use of psychotropic medications.

The purpose of this paper is to examine the extent to which, in the five integrated community teams for adults with learning disabilities (CTLDs) in an English county-wide service, the use of psychotropic medication for service users was based on the presence of an appropriate mental health condition or epilepsy.

Adult participants were recruited following referral to one of the CTLDs for assessment, treatment and/or support of a possible mental health and/or behavioural need. Data were collected about participant characteristics and psychotropic medication 12 months after recruitment.

While a total of 42 (78 per cent) of the 54 participants were apparently prescribed regular or PRN (as required) psychotropic medication, only 24 (57 per cent) of these individuals had a recorded past or current mental health condition or epilepsy for which such medicine could be appropriate.

There were several limitations: the sample size was small and its representativeness was uncertain; and data collection was compromised by barriers to explicit knowledge exchange within and across the learning disability service.

While recent guidance about the use of psychotropic medication is welcome, minimising inappropriate use requires more comprehensive person-centred interventions (including crisis management plans), underpinned by imaginative, but feasible, data collection methods and integrated formulations. Investment is needed in developments that support multi-disciplinary and inter-agency working to promote “good practice” by CTLDs in responding to referrals for possible mental health and/or behavioural needs.

Complementing recent large studies of primary care (General Practitioner) records, this is the first examination of the use of psychotropic medication by service users in English CTLDs.

The purpose of this paper is to examine the prescribed psychotropic medications taken by newly referred people with a range of substance use disorders (SUD) who attend a specialist community addiction service.

Anonymised data on newly referred people (n=1,537) with SUD attending a specialist community addiction service for their first episode of treatment between August 2007 and July 2010 were obtained from the database of the service. Data were cleaned and the percentage of people taking prescribed psychotropic medications at their first episode of treatment was calculated.

More than half (56.1 percent) of people attending the service were taking prescribed antidepressants and anxiolytics at their first episode of treatment whilst 15.2 percent of people were taking prescribed antipsychotics. Alcohol and opioids were the primary referral substances for 77.4 percent and 15.2 percent of people respectively. People referred for “other” substances (cannabis, stimulants, sedatives, hallucinogens, solvents and polydrug use) made up the remaining 7.5 percent and had the highest percentage of prescribed psychotropics (antipsychotics=47 percent, antidepressants and anxiolytics=64.3 percent) compared to those referred for alcohol and opioids (p<0.0005).

To the best of the authors’ knowledge, this is the first study of psychotropic prescribing among people with a range of SUD in the UK. The high prevalence of psychotropic prescribing raises questions about the appropriateness of these prescriptions and calls for scrutiny of prescribing practice in this group of people.