The role of the clinical pharmacist in the management of psychotropic polypharmacy in the treatment of patients with mental retardation and development disabilities

Abstract

For many individuals with mental impairments/developmental disabilities (MR/DD) that reside in supported living centers, the potential to be placed on a myriad of psychotropic medications to manage both behavioral and neuropsychiatric disturbances exists. There are distinctive obstacles that a clinical pharmacist that works in a facility providing services to individuals with MR/DD can face as it relates the prescribing of psychotropic medications. As a result of the limited data or clinical trials on the use of psychotropic medications in this particular population, problems can be encountered when multiple psychotropic medications are prescribed. Based on the practice parameters for the assessment and treatment of children, adolescents, and adults with MR/DD, or other comorbid mental disorders published by the American Academy for Child and Adolescent Psychiatry, the problems can include irrational prescribing, inappropriate medication for a given diagnosis, or questionable monitoring of adverse effects. 1 The role of the clinical pharmacist in this practice setting can consist of a continuous assessment of the clinical justification and rationale for why psychotropic polypharmacy is warranted. Polypharmacy can be defined in many different ways and may differ based on the patient population being evaluated. 2 According to Fulton and Allen (2005), polypharmacy is defined as the use of medications that are not clinically indicated; and in clinical practice it is the use of more than a certain number of drugs to treat a condition regardless of its appropriateness. 3 Within an assisted living facility, periodic reviews of drug utilization can be associated with funding for the facility so the evaluation of the appropriateness of medication use, including polypharmacy, may need to be performed on a quarterly, biannual, or yearly basis. The co-occurring use of multiple psychoactive medications in a single patient is becoming an increasingly common and current practice in clinical psychiatry which largely based more on experience rather than evidence. 6 Any patient receiving more than one medication from a specific class (e.g. two antidepressants, two antipsychotics), should have regular reassessment to confirm the necessity of the polypharmacy. In general, polypharmacy is considered to a major health issue not only in primary care setting but in other practice setting as it can lead to unnecessary expenses, wasted time, and possibly mismanagement on the part of the attending clinician if the indication for psychotropic polypharmacy is not routinely evaluated. Furthermore, patients with MR/ DD have an increased potential for drug-drug interactions , side effects of psychotropic medications such as extrapyramidal effects from antipsychotic medications and delirium from benzodiazepines, and possibly unrecognized complications.