Optimising antipsychotic use for behaviours that challenge in people with intellectual disability and the role of deprescribing

Introduction: Intellectual disability (ID) affects approximately 1% of the general population and is characterised by reduced intellectual functioning, usually IQ <70, significant impairment of social or adaptive functioning, and onset during childhood [1-3]. Behaviours that challenge (BC) affect approximately 10–15% of people with ID accessing health, social, or educational services, and commonly include aggression, self-injury, irritability, and destruction of property [2,3]. Antipsychotics are widely used to manage these behaviours, often outside approved indications and in contrast with existing clinical guidelines [2,3,4,5].

Aim: To evaluate the evidence supporting antipsychotic use for BC in people with ID, and to summarise data on long-term prescribing, monitoring, and deprescribing.

Methods: A non-systematic literature review was conducted using PubMed to identify articles and guidelines published in the last 15 years, using the keywords “behaviours that challenge”, “intellectual disability”, “learning disability”, and “antipsychotics”. Data were extracted on BC prevalence, prescribing rates, antipsychotic effectiveness, pharmacological versus non-pharmacological interventions, guideline monitoring recommendations, and discontinuation outcomes. Findings were synthesised narratively, with published quantitative outcomes reported where available.

Results: Observational studies report psychotropic prescribing rates of 32–85% in adults with ID; in one cohort, 45.1% were taking antipsychotics, although only 25.9% had a diagnosed psychiatric disorder [5]. NICE recommends considering antipsychotics only when psychological or other interventions fail, treatment of coexisting mental or physical illness does not reduce BC, or risk is very severe. Antipsychotics should be combined with psychological or other interventions, prescribed as a single drug at the minimum effective dose, reviewed after 3–4 weeks, stopped if no response is present at 6 weeks, and reviewed multidisciplinarily at 3 months and at least every 6 months thereafter [2]. Long-term antipsychotic exposure is associated with sedation, weight gain, metabolic changes, extrapyramidal symptoms, autonomic disturbance, endocrine/metabolic disorders, anticholinergic burden, and tardive dyskinesia [3,4]. Evidence for effectiveness was limited and inconsistent. In an RCT of 86 adults with ID allocated to haloperidol, risperidone, or placebo, median aggression scores improved most with placebo: 79% reduction from baseline versus 58% with risperidone and 65% with haloperidol, with secondary outcomes showing no significant differences between groups [3]. A meta-analysis of 82 RCTs including 4637 participants found small effects for overall BC, follow-up BC, aggression, self-injury, and irritability, with no significant differences between pharmacological and non-pharmacological interventions [1]. Recognition of inappropriate medication use for BC has led to national initiatives encouraging medication review and discontinuation, including an NHS England programme, and to calls to reduce antipsychotic prescribing in people with ID [1,4]. In the Cornwall withdrawal programme, gradual 10–25% dose reductions every 6–8 weeks achieved complete antipsychotic withdrawal in 46.5% of adults with ID and >50% dose reduction in an additional 11.3%, without significant worsening of BC [3,5].

Conclusions: Behaviours that challenge should prompt comprehensive assessment before antipsychotic prescribing. Current evidence supports a restricted and actively reviewed role for antipsychotics, with time-limited use, clear treatment targets, and structured deprescribing when clinically appropriate.

References

1. Groves, L., Jones, C., Welham, A., Hamilton, A., Liew, A., Richards, C., 2023. Non-pharmacological and pharmacological interventions for the reduction or prevention of topographies of behaviours that challenge in people with intellectual disabilities: a systematic review and meta-analysis of randomised controlled trials. Lancet Psychiatry 10 (9), 682-692.
2. National Institute for Health and Care Excellence, 2015. Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges. NICE guideline NG11. Available from: www.nice.org.uk/guidance/ng11. [Accessed: 20 April 2026].
3. Pascucci, A., Gerber, F., Besson, M., Kosel, M., 2025. Antipsychotic medication for behaviors that challenge in individuals with intellectual disabilities: a clinically informed review. Front. Psychiatry 16, 1609408.
4. Sheehan, R., Hassiotis, A., 2017. Reduction or discontinuation of antipsychotics for challenging behaviour in adults with intellectual disability: a systematic review. Lancet Psychiatry 4 (3), 238-256.
5. Costello, A., Hudson, E., Morrissey, S., Sharma, D., Kelly, D., Doody, O., 2022. Management of psychotropic medications in adults with intellectual disability: a scoping review. Ann. Med. 54 (1), 2486-2499.