The use of antipsychotic drugs for patients who are merely challenging shows an over-stretched system
Edmund Stubbs, 3 September 2015
‘Specialing’ is the hospital jargon for the supervision of patients who cannot be left on their own for risk of harming themselves. In effect, specialing most often involves a Healthcare Assistant sitting with the patient for hours at a time, or at best, a member of staff being permanently present in the patient’s ward bay, constantly checking that the patient remains safe. Such patients do not spend all of their time in hospital, but are usually cared for in the community by specialist nurses and various dedicated social care professionals.
The type of patients that need specialing often exhibit challenging behaviour. Challenging behaviour is defined as any behaviour which puts the safety of the patient or others at risk. Often such patients are confused, wander off, or pull out their intravenous lines. In the hospital environment such behaviour can present a serious, often dangerous, problem, sometimes causing wards to become short staffed due to the supervision required,. This, as a consequence, requires the employment of agency staff to ensure adequate care.
At a time when many hospitals are experiencing unprecedented funding difficulties and the funding of care outside hospital is faring even worse, the safe control of challenging patients is putting the everyday mechanisms of care under even more strain.
A team at University College London has recently published a paper detailing an investigation of the care of patients with intellectual disabilities in primary care. The team used data from the Health Improvement Network to identify 32,000 adults with intellectual disabilities from GP records. They then identified those with severe mental health problems and those who were recorded as exhibiting challenging behavior(the type of patients who would often require specialing in the hospital setting).
They found that in addition to those with intellectual disabilities and a severe mental health problem who were being prescribed antipsychotic drugs appropriately, there were a large number of patients with intellectual disabilities who exhibited challenging behaviour also being prescribed antipsychotic drugs despite having no recorded severe mental illnesses; quite often the elderly with or without dementia.
The team’s findings in essence reveal that a large proportion of antipsychotic drugs are administered to people with intellectual disabilities to manage their behavioural problems rather than treat mental illnesses. This practice is of concern due to the serious side effects that can accompany the use of such drugs, side effects that can significantly impair quality of life, and even sometimes lead to additional physical and mental health problems. Their use in this context further represents a worrying departure from appropriate prescription in relation to evidence-based guidelines, and raises ethical concerns regarding the use of such drugs on patients, usually without their consent.
The fact that these drugs, which should, according to the guidelines, only be given as a last resort and with strong justification, are effectively being used to combat behaviour which is making life difficult for staff and the smooth operation of treatment procedures cannot be ignored. If primary and social care has reached such a low point that challenging patients are being sedated against their will, this shows that carers are being given too little support, and that antipsychotic drugs often represent the only means they have to cope with the intolerable care burden laid upon them.
A patient presenting with a broken leg would not be sent away from A&E with a handful of pain killers and a splint of wood strapped to their thigh; relatively large amounts of resources would be employed at considerable cost to give them appropriate and effective treatment. In the same way, those with intellectual disabilities require appropriate care according to guidelines, and not simply chemically pacified.
Edmund Stubbs is Healthcare Researcher at Civitas, @edmundstubbs1