Overprescribing of psychotropics for adults with autism

Adults on the autism spectrum are often prescribed psychotropic medication to manage behaviour, despite limited evidence to support this practice, a new report has found.

The longitudinal study, which draws on data from The Cooperative Research Centre for Living with Autism (Autism CRC), found that 14% of psychotropic medications prescribed for adults with autism spectrum disorder (ASD) had no corresponding indication recorded. Also, many adults with ASD were prescribed more than one psychotropic medication. Co-prescribed medications included stimulants, antiepileptics, antipsychotics, anxiolytics, hypnotics/sedatives and antidepressants. There were no approved indications recorded for 25% of antiepileptics and antipsychotics  prescribed for patients with ASD.¹

The researchers noted that the higher rates of neurological or psychiatric disorders among adults with ASD did not entirely explain the increased odds of adults with ASD taking at least one antipsychotic medication. The study reported that ‘even when controlling for the presence of any neurological or psychiatric disorder, individuals with ASD were still more than four times as likely to be currently taking at least one psychotropic medication compared with non-autistic controls.’  

The lead researcher on the study, Dr Rachael Cvejic, said that while there was no single cause for this phenomenon, medicines were being prescribed to manage behavioural problems including aggression; a trend that raised alarm among the researchers. They were concerned because of the limited evidence to support the use of psychotropic medication to manage behavioural features of autism spectrum disorders. As Dr Cvejic said, this practice exposes people to potential harm.

Elizabeth Sarian, Executive Manager at Autism Awareness Australia, agreed.

“Often taking the wrong medication to treat something can make it worse. It leads to a whole new complex set of problems,” she told Australian Pharmacist.  

She recommended a wholistic healthcare plan for adults with ASD to avoid unnecessary prescription medication.

‘Healthcare providers should ensure that they communicate with all the professionals involved in the care of that individual,” she said. She noted that it is important not just to look at the issues in isolation from the GP’s or psychologist’s perspective. It is important for all of the professionals  looking after the healthcare of the individual to communicate and work collaboratively.’

The researchers also recommended that more education is needed for clinicians in this area.¹

The report noted that features associated with ASD (i.e. complex and atypical mental health presentations, particularly among those with intellectual disability, communication difficulties, and high rates of physical comorbidities, are  likely to compound these issues further. This highlights the importance of accessible ASD-specific clinician education and training in assessment and management of mental health disorders.

The report recommended that priorities for training should include considerations for assessment, management and communication strategies.  Neurodiversity should be valued, and physical and mental health comorbidities should be considered. Clinicians should work within a multidisciplinary framework. They should assess challenging behaviours (including discerning the underlying causes), use appropriate non-pharmacological therapies where necessary, and follow recommendations for responsible prescribing.

Ms Sarian echoed this recommendation, noting that mental health symptoms and symptoms of autism are often conflated, making accurate diagnoses difficult. She also cited the need for more education around mental illness in adults with ASD.

‘Communication is definitely a barrier for individuals with autism. So having that self-awareness and realising what is a mental health condition as opposed to a symptom of autism is very much a barrier. They both need to be considered for the individual, but they also recognised as two very separate conditions,’ she said.  

‘So on one hand, I’m aghast that these medications are being handed out without a diagnosis. But on the other, I can see that the education required for clinicians to be able to diagnose correctly just isn’t there. They don’t realise that the tools they have aren’t necessarily appropriate’, stated Ms Sarian.

She encourages pharmacists to be vigilant about questioning the appropriateness of prescriptions, particularly when they are familiar with the patient.

As she stated, people assume they are getting the right medication when it might not be the most appropriate treatment.  If a pharmacist has any doubts or if they’re unsure whether the prescription is suitable, she encourages them to refer on to a GP or mental healthcare professional. This is in the best interests of somebody on the spectrum.

If you as a healthcare professional recognise that there’s something not quite right, Ms Sarian urges you to refer on where possible.   

References

1. Cvejic RC, Arnold SRC, Foley K, Trollor JN. Neuropsychiatric profile and psychotropic medication use in adults with autism spectrum disorder. BJPsych 2018 4(6):461-466. At: https://www.cambridge.org/core/journals/bjpsych-open/article/neuropsychiatric-profile-and-psychotropic-medication-use-in-adults-with-autism-spectrum-disorder-results-from-the-australian-longitudinal-study-of-adults-with-autism/46DC7BD5AEF5ED67116EBEAE8A2F32D4/core-reader