A whole population-based cohort study of the trajectory of the prevalence and the incidence of mental illness, challenging behaviour, and psychotropic medication prescribing in adults with intellectual disabilities in the Czech Republic between 2010 and 2022
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Background
It is essential to understand using a sizeable, centralised health database, the complex relationship among mental illness, challenging behaviour and psychotropic medication prescribing to help reduce the inappropriate overmedication of adults with intellectual disabilities. Diagnosing mental illness in adults with intellectual disabilities could be difficult because of the communication challenges and sometimes atypical manifestation, for example, through challenging behaviour.
Method
We explored the change in prevalence between 2010 and 2022 and incidence of mental illness, challenging behaviour and psychotropic medication prescribing between 2015 and 2022 among adults with intellectual disabilities and the relationships among them using a national health register in the Czech Republic. We collected data from the Institute of Health Information and Statistics of the Czech Republic.
Results
62,636 (54% males) adults with intellectual disabilities contributed 704,503 person-years of data. In 2010, the prevalence of overall mental illness was 15·7%, challenging behaviour 29% and any psychotropic prescription 55%, increasing significantly by 2022 to 17·3%, 30·5% and 59%, respectively. The prevalence of overall mental illness, anxiety disorder, autism, ADHD and challenging behaviour increased significantly between 2010 and 2022. On the other hand, the incidence of newly diagnosed cases of most mental illnesses and challenging behaviour decreased significantly between 2015 and 2022. In contrast, the incidence of autism, ADHD, sleep disorders, and dementia increased significantly between 2015 and 2022. The incidence of challenging behaviour correlated significantly with psychoses, bipolar, anxiety and personality disorders. The prevalence of most psychotropic prescriptions increased significantly from 35% for antipsychotics, 17% for antidepressants, and 23% for mood stabilisers in 2010 to 37% for antipsychotics, 25% for antidepressants, and 28% for mood stabilisers in 2022 apart from anxiolytics which decreased from 14% in 2010 to 13% in 2022, despite a drop in the incidence of new prescriptions. The rate of psychotropic prescribing correlated significantly with the rate of mental illness and challenging behaviour. Among those receiving antipsychotics, only 18% in 2010 and 19% in 2022 had severe mental illness for which antipsychotics are indicated. Therefore, in >80% of cases, antipsychotic medications were prescribed off-label primarily for challenging behaviour. Similar trends were observed for other psychotropics. For example, mood stabilisers and antidepressants were prescribed more often for challenging behaviour in 38%-40% and 33%-40% of cases, respectively, than bipolar disorder (1%) and depression (8%-11%), respectively. In 2010, among those with challenging behaviour, 82% were prescribed any psychotropic medications, 62% antipsychotics, 20% antidepressants, and 30% mood stabilisers, increasing significantly by 2022 to 87%, 63%, 33%, and 37%, respectively. However, the prevalence of anxiolytic prescribing decreased significantly from 17% in 2010 to 14% in 2022. The incidence rates of new prescriptions for challenging behaviour fell by 1·1% for any psychotropic medications, 0·8% for antipsychotics, 0·7% for antidepressants and 0·1% for anxiolytics, but increased by 0·3% for hypnotics/sedatives and 0·4% for mood stabilisers.
Conclusions
The prevalence of mental illness and challenging behaviour increased over 12 years despite a drop in their incidences. This may indicate the chronic nature of these conditions. Challenging behaviour was significantly associated with some mental illnesses. Both mental illness and challenging behaviour were significantly associated with psychotropic medication prescribing. The prevalence of all psychotropic medication prescribing overall and especially for challenging behaviour was high and increased significantly over 12 years. This probably indicates long-term use of these medications. Antipsychotic medications were prescribed for severe mental illness only in a minority of cases. This indicates an off-licence use of antipsychotic medications in a very high proportion of cases. This trend of off-licence use was also evident in other psychotropic medications than antipsychotics. On the contrary, these medications were primarily used for challenging behaviour. The incidence of new prescriptions of antipsychotics, antidepressants, and anxiolytics decreased over the years, possibly at the expense of increased new prescriptions of mood stabilisers, primarily antiepileptics and also hypnotics/sedatives. The reasons for the significant increase in already high psychotropic medication prescription over 12 years and the trend of increase in new prescriptions of mood stabilisers and hypnotics/sedatives require scrutiny.
