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This publication is available at https://www.gov.uk/government/publications/psychotropic-drugs-and-people-with-learning-disabilities-or-autism/psychotropic-drugs-and-people-with-learning-disabilities-or-autism-executive-summary
In June 2016, NHS England launched a programme, STOMP, to reduce the extent of over-prescribing of antipsychotics and antidepressants to people with learning disabilities, autism or both. The programme drew heavily on a Public Health England (PHE) study documenting the extent of prescribing of these and other psychotropic drugs by GPs [footnote 1]. The current study was commissioned to try and establish a method for assessing the effectiveness of the programme using an established GP research dataset.
This was a quantitative, descriptive study using data from The Health Improvement Network (THIN) database, a large data set providing anonymised records of clinical transactions from GP practices covering approximately 5% of the UK population. Records for patients of English practices with diagnoses of learning disabilities or autistic spectrum conditions were identified. For our identified patients we extracted diagnostic records and prescribing records for drugs in British National Formulary (BNF) [footnote 2] sections:
- 4.1.1: Hypnotics
- 4.1.2: Anxiolytics
- 4.2.1: Antipsychotic drugs
- 4.2.2: Antipsychotic depot injections
- 4.2.3: Antimanics
- 4.3: All antidepressants
- 4.4: CNS stimulants
- 4.8.1: Control of epilepsy
For the years 2010 to 2017, we calculated:
- quarterly prescribing prevalence figures for each drug group
- prevalence in relation to presence or absence of a recorded clinical indication for the drugs
- use of drugs in doses exceeding BNF recommended limits
- use of multiple drugs within groups (within-group polypharmacy) or combinations of drugs from different groups
- amongst those studied (between-group polypharmacy)
- annual rates of inceptions and terminations of prescribing episodes
Finally, using ordinary least squares regression for the quarterly data, we calculated overall trends, and trends before and after the launch of the STOMP programme, in June 2016.
Initial descriptive analysis of the groups of patients identified, indicated surprisingly low numbers of children with learning disabilities and of autistic adults aged 25 and over. Subsequent analysis was limited to adults with learning disabilities and autistic children and young people. The initial analysis also showed that the numbers of patients covered by the database in England was falling fast.
Initial cross-sectional analyses of prescribing prevalence were broadly in line with our previous study [footnote 1] for all groups except anxiolytics where the present study showed a higher rate not in line with the observed trend.
For adults with learning disabilities, before the STOMP launch, prescribing rates for antidepressants, antipsychotics and antiepileptics all showed increasing trends, prescribing of anxiolytics showed no substantial trend. Following the STOMP launch, the trends for antipsychotics and anxiolytics changed to decreasing whilst those for antidepressants changed to no-trend. The trend for antiepileptics did not change significantly.
Prescribing of hypnotics and CNS stimulants for this group was too infrequent for the analyses to be feasible. For autistic children and young people, the prescribing prevalence of all the drug groups showed a rising trend in the pre-STOMP period. The only change in the post-STOMP period was to the trend in the rate of hypnotic prescribing which showed a steeper increase.
For adults with learning disabilities, the rates of prescribing of antipsychotics and antidepressants to individuals without recorded diagnoses of (respectively) psychosis and depressive disorders were both increasing in the pre-STOMP period. In the post-STOMP period, the trend in the rate of prescribing of antidepressants to people without recorded depression levelled. The rate of prescribing of antipsychotics to individuals with recorded diagnoses of psychosis showed a rising trend in the pre-STOMP period. This changed to a falling trend in the post-STOMP period.
Prescribing of antidepressants to individuals with recorded depressive disorders showed a rising trend initially which did not change significantly. This analysis was not done in relation to autistic children and young people because identifying whether individuals had recognised indications was substantially more complex and less likely to be fully recorded in general practitioners case notes.
For adults with learning disabilities, before the STOMP launch, rates of within-group polypharmacy showed falling trends for antipsychotics and antiepileptics which did not change significantly. The rate for antidepressants initially showed a rising trend. This changed to a flatter trend post-STOMP. Between-group polypharmacy showed a rising trend pre-STOMP which changed to a falling trend post-STOMP.
For autistic children and young people, rates of within-group polypharmacy showed initial rising trends for antipsychotics and antiepileptics. Post-STOMP, the trend for antipsychotics increased while the trend for antiepileptics was unchanged. Within-group polypharmacy for antidepressant for this group showed no significant trends. Between-group polypharmacy for autistic children and young people showed an increasing trend which did not change.
This study was successful in setting up a mechanism to monitor the impact of the NHS England STOMP programme and analysing prescribing trends. The statistical models and analyses strategies set up in this study can be used to monitor the trends in prescribing rates and patterns. However, the particular data source used cannot give detail below the national level. It also appears to be losing general practices at a substantial rate. Future work of this type may need to use an alternative source.
For adults with learning disabilities, some changes in prescribing trends were seen following the launch of STOMP in the intended direction. However it should be stressed that it is not possible to say whether or not these were the result of the programme.
Cite as: ‘Mehta H. and Glover G. Psychotropic drugs and people with learning disabilities or autism, 2019. Public Health England’
Glover G., Williams R., Branford, D., Avery, R., Chauhan, U., Hoghton, M. and Bernard, S. Prescribing of psychotropic drugs to people with learning disabilities and/or autism by general practitioners in England. Public Health England. (2015). Accessed 27 Nov. 2018. ↩ ↩2
Joint Formulary Committee. British National Formulary. 73 ed. London: BMJ Group and Pharmaceutical Press. (2017) ↩