Letters to the Editor
Re: Atypical Antipsychotic Use in Treating Adolescents and Young Adults
with Developmental Disabilities
Dear Editor:
We work in an interdisciplinary community mental health service for persons
with developmental disabilities (DDs) across the lifespan, and we therefore
read with particular interest the article by Friedlander and others (1)
on the use of atypical antipsychotics to treat adolescents and young adults
with DDs.
In our clinical practice, we have also observed that some persons with
DD at times experience a “dramatic and long-lasting response to low-dose
atypical neuroleptics” but that “this population, however, seems particularly
sensitive to neuroleptic-induced movement disorders (NIMDs), hence caution
and close monitoring are required” (1). What we feel deserves greater emphasis
for practitioners less familiar with this etiologically and symptomatically
diverse population with different types and degrees of DD is that the diagnostic
complexities involved are substantial. Even establishing a diagnosis of
schizophrenia or autism–pervasive developmental disorder (PDD) can be challenging;
differentiating symptoms of psychosis from symptoms of anxiety in persons
with autism–PDD can be still more problematic. Friedlander and others did
not comment on these challenges in their paper, nor did they attempt to
tease apart whether outcome was due to the atypical antipsychotic medication
per se or whether and to what extent associated interventions with other
medications or nonpharmacologic therapies may have contributed (a difficult
thing to establish in a small sample). To identify those for whom atypical
antipsychotics are effective, and in what context, further research on
larger series is warranted.
Friedlander and others note that, even with their clinic’s conservative
prescription practices, one-half the individuals in the sample were taking
atypical antipsychotics—even when psychotic symptoms were not documented.
We agree with the authors that, in the absence of clearly identified psychiatric
disorders for which these medications are indicated, the practice of using
either typical or atypical antipsychotics to treat behaviour disturbances
is no longer tenable. We urge psychiatrists to identify and carefully monitor,
in both their research and clinical practice, the target symptoms that
the antipsychotic is intended to address, particularly when the symptoms
are not psychotic (as may have been the case for many of the individuals
with autism–PDD in the present sample). Proceeding in this way helps to
ensure that the old practice of overprescribing neuroleptics, noted by
Friedlander and others, does not transfer into overprescribing newer antipsychotic
medications, particularly in situations where the prescribing physician
does not have access to a comprehensive multidisciplinary evaluation process.
The study by Friedlander and others is an important step toward evaluating
the use of atypical antipsychotics in individuals with DDs, but the methodological
and other concerns outlined above make it premature to endorse their use.
It is our belief, supported by recent consensus guidelines (2–4), that
a comprehensive evaluation to better understand the underlying cause of
the symptoms and behaviour disturbances is essential—in particular, to
ascertain whether these are indeed caused by a psychiatric disorder. This
approach leads to more effective treatment, more appropriate and targeted
use of antipsychotic medication, and fewer side effects.
References
1. Friedlander R, Lazar S, Klancnik J. Atypical antipsychotic use in treating
adolescents and young adults with developmental disabilities. Can J Psychiatry
2001;46:741–5.
2. Deb S, Matthews T, Holt G, Bouras, N. Consensus practice guidelines
for the assessment and diagnosis of mental health problems in people with
intellectual disability. Brighton (UK): Pavilion Publishing; 2001.
3. Rush, JA, Frances A, editors. Expert consensus guideline series: treatment
of psychiatric and behavioral problems in mental retardation. Am J Ment
Retard (Special Issue) 2000;105:159–228.
4. The Royal College of Psychiatrists. DC-LD: Diagnostic criteria for psychiatric
disorders for use with adults with learning disabilities/mental retardation.
London (UK): Gaskell; 2000.
Elspeth A Bradley, MBBS, PhD, FRCPsych, FRCPC
Yona Lunsky, PhD, CPsych
Joseph M Berg, MB, BCh, FRCPsych, FCCMG
Robin W Brooks-Hill, MD, FRCPC
Donal A O’Leary, MB, BCh, FRCPC
Karen E Harman, MD, FRCPC
Marika Korossy, BA
Toronto, Ontario
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