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Research highlights that antipsychotic medications are prescribed more in people with Intellectual Disability (ID) without a diagnosis of severe mental illness. Despite non-pharmacological interventions recommended as alternatives, their application can be challenging due to heterogeneity of the patient group. The purpose of this paper is to discuss application of quality improvement (QI) methodology in adapting interventions, aiming to reduce challenging behaviour of people with ID, thereby reducing use of antipsychotic medication.

Two interventions were introduced as “tests of change”; an “Attention-Deficit Hyperactivity Disorder (ADHD) clinic” and “Positive Behaviour Support (PBS) clinic”. Process (Clinical Global Impression (CGI) and Modified Overt Aggression Scale (MOAS)) and outcome measures (total antipsychotic use) were used to assess the interventions, with each being reviewed as per QI methodology guidelines.

There was an improvement in CGI scores for both interventions. MOAS scores reduced for those attending the ADHD clinic, resulting in reductions of antipsychotic medication. MOAS scores did not reduce for the PBS clinic, so there was no reduction in medication for this group.

Based on the introduction of pilot clinics, this paper provides a commentary on how QI interventions can be used to evaluate and adapt evidence-based interventions, in managing the needs of patients with ID. It further highlights the importance of the diagnosis of ADHD in patients with ID and challenging behaviour. Although PBS is recommended to manage challenging behaviour, this paper demonstrates the importance of continuous evaluation of behavioural interventions. There is currently no existing literature investigating use of QI methodology to reduce challenging behaviour in ID populations, emphasising scope for future research and service evaluation.

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.

Antipsychotic drugs are often used outside their licensed indication to manage aggression in adults with intellectual disabilities in the absence of a diagnosed psychiatric disorder. The current case series shows that antipsychotics could be effective, but they are often used with non‐drug measures and sometimes cause side‐effects. Clinicians did not always carry out a thorough assessment followed by a formulation before prescribing medications, as recommended in the national and international guides (Deb et al, 2009; Unwin & Deb, 2010). It is also apparent that clinicians did not carry out tests to detect side‐effects of risperidone such as metabolic syndrome. Clinicians should use psychotropic medication for a minimum period of time and at the lowest possible dose, and should consider non‐drug management of aggression at the outset and at a regular interval.

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.

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.

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.

There has been increasing concern about inappropriate or excessive medication of people with learning disabilities. Audits of prescribing practice may guide clinicians towards a more rational use of psychotropic drugs. Most previous studies have come from North America or Europe. This paper reports on a survey of prescribing patterns in an institution that cares for adults with severe to profound learning disabilities in Hong Kong. The survey found that 27% of the 294 hospital patients were receiving psychotropic drugs, but this rate was significantly higher (90%) in the ward for people with challenging behaviours. Most patients (67%) received a single psychotropic drug, 26% received two and 7%, three. Around half the patients (151) had epilepsy, of whom 90% received anticonvulsants. Of these, 52% received a single anticonvulsant, 37% received two and 11% received three or more. Dosages were generally within the recommended ranges. This survey revealed several good aspects of prescribing practice at Siu Lam Hospital, but also areas that need improvement. The latter include a drug‐reduction programme for the people with challenging behaviours, trials of drug‐free periods for seizure‐free patients receiving anticonvulsants and replacement of phenytoin and phenobarbitone with safer alternatives.

This case report highlights the complex factors in prescribing psychotropic medication for people with intellectual disability with significant co‐morbid physical and mental health problems. The case study is of a young man with a mitochondrial disorder, secondary sensory impairments, mild intellectual disability, epilepsy and autism spectrum disorder who developed a psychotic illness. The report focuses on the use of psychotropic medication in this man and discusses the issues regarding psychotropic medication that need to be considered with service users and their carers.

The number of mental health professionals able to prescribe has, for a number of years, reached beyond medics, but UK clinical psychologists are not yet permitted to train to prescribe. The purpose of this paper is to ask if prescribing could be part of the clinical psychologist's role.

This article lays out three core areas of discussion: what was the drive for non‐medical prescribing? Could psychologists be trained to prescribe? Could prescribing be another tool for psychologists? Currently, UK clinical psychologists are not able to prescribe unless they have an additional qualification as a medic, pharmacist or nurse. This paper ends by considering the position of a clinical psychologist who is also a registered nurse and wonders about the pros and cons of training to prescribe.

It was argued that clinical clinical psychologists who are also registered nurses are best placed and currently perhaps the only clinical psychologists able to train to prescribe. The author questioned his motives for considering training to prescribe and looked at the risks in prescribing.

The author is unsure if he wants to pursue prescribing privileges but makes no objection to clinical psychologists prescribing.

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.