Table 6 Summary table of included pre post studies
Author/Year, Country | Study Design | Participants (n, age, gender, ethnicity, level of intellectual disabilities) | Setting | Intervention (including medication that was targeted, Duration of deprescribing intervention and length of follow up) | Outcome Measures | Summary of Findings |
|---|---|---|---|---|---|---|
Brahm et al. 2003 USA [43] | Prospective Pre post design (no control) | n: 18 mean age: 42.7 (27 to 57) gender: 8% male ethnicity: not reported ID = moderate/severe/profoun d: 100% | Not reported | Intervention: Following warning of QTC with Thioridazine, 18 patients reviewed, antipsychotic medication reduced and QTc prolongation assessed Medication: Thioridazine, mesoridazine Duration: Variable Length of follow up: 8 weeks post discontinuation | ECG | 15 participants discontinued thioridazine, increases in QTc prolongation times in five male patients after discontinuation of thioridazine, three patients slight increases and two patients more marked increases. |
Branford D 1996 U.K. [44] | Retrospective Pre post design (no control) | n: 198 mean age: 43 (18 to 82) gender: 66% male ethnicity: not reported ID = borderline 1% mild 13% moderate: 30% severe: 56% | 47% Inpatient 53% Community | Intervention: Medication review and dosage reduction programme Medication: thioridazine,chlorpromazine, zuclopentixol, haloperidol Duration: Mostly over 3 months Length of follow up: 12 months | Number reducing or discontinuing antipsychotic medication; challenging behaviour reports | 123 patients underwent a reduction of antipsychotics. 16% of the total cohort of 198 were withdrawn from antipsychotics, 28% maintained on reduced dosage of antipsychotics. Out of the 123 undergoing reduction, 31 (25%) of 123 discontinued antipsychotic, 56 (46%) of 123 reduced dose, 27 (22%) of 123 same dose, and 9 (7%) of 123 increased dose; 31 (25%) of 123 no deterioration, 52 (42%) of 123 deterioration in behaviour, and 40 (33%) of 123 not reported |
de Kuijper et al. 2018 The Netherlands [33] | Prospective Pre post design (no control) | n: 129 (includes an unspecified number of participants also reported in de Kuijper et al., 2014 [23] and Ramerman et al., 2019 [32]) mean age: 49 (11.5–84.2) gender: 67% male ethnicity: not reported ID = mild 13% moderate 24% severe 44% profound 16% unspecified 3% | Community | Intervention: antipsychotic reduced over 14 weeks Medication: Not reported (see study [45]) Duration:14 weeks Length of follow up: 6 months following planned discontinuation | Primary outcome measure: Complete discontinuation at 16 weeks Secondary outcome measures: Complete discontinuation at 28 and 40 weeks, ABC, CGI-I, CGI-S | 61% had completely discontinued antipsychotics at 16 weeks, 46% at 28 weeks, and 40% at 40 weeks. CGI-I: at 16 weeks 6% of participants had shown improvement and 9% worsening in behaviour; at 28 weeks, these percentages were 9 and 15%, and at 40 weeks 21 and 7%, respectively. At 28 weeks those who had not achieved complete discontinuation had significantly more often worsening in behaviour according to the CGI-I than those who had successfully discontinued. |
de Kuijper et al. 2018 The Netherlands [45] | Prospective Pre post design (no control) additional reporting of [33] | (includes an unspecified number of participants also reported in de Kuijper et al., 2014 [23] and Ramerman et al., 2019 [32]) |  |  | Primary outcome measure: Complete discontinuation at 16 weeks Secondary outcome measures: Complete discontinuation at 28 and 40 weeks, ABC, Barnes, AIMS Number of times participants experienced new health problems Number of consultations by participants with their physician Number of new medication prescriptions or dosage changes Number of new nonpharmaceutical treatments. Number of changes in living circumstances and life events | 61% had completely discontinued antipsychotics at 16 weeks, 46% at 28 weeks, and 40% at 40 weeks. ABC total scores increased in 49% of participants with unsuccessful discontinuation at 16 weeks Participants who achieved complete discontinuation had less-severe parkinsonism and lower incidence of health worsening during the study period compared with participants with incomplete discontinuation. A lower incidence of complete discontinuation was associated with higher ABC score, higher akathisia score and more frequent worsening of health. |
Ellenor et al. 1977 USA [46] | Retrospective Pre post design (no control) | n: 208 mean age: not reported gender: not reported ethnicity: not reported ID = mild/moderate 20% Severe/profound 80% | Inpatient | Intervention: Pharmacist involvement in a behavioural review committee with aim of deprescribing psychotropic medicines over a two year programme Medication: anti anxiety/ antidepressants, antipsychotics, sedative/hypnotics, miscellaneous medication for behaviour management Duration: Variable Length of follow up: Variable | ABS (adaptive behaviour scales) Number of prescriptions and changes in dosages of medicines | ABS scores reported for 54 participants revealed a slight increase in adverse behaviours for all three groups; medication reduced, medication stopped and control group who had not been assessed by the behaviour review committee. Through discontinuance of medication a 50% reduction’ in the use of antianxiety-antidepressant agents, 17.5% reduction in antipsychotic agents, 57.6% reduction in sedativehypnotics and a 64.7% reduction in miscellaneous agents was reported. Of the total 183 drugs discontinued, 153 of these, or 83%, were discontinued without being replaced with a pharmacologically equivalent agent. In addition, of the 313 medications being administered to patients for behavior control at the completion of the two years, 124 of these, or 39.6%, were being administered at lower dosages Of the 313 drugs administered at the end of the study period, 87 medications were being administered at higher dosages or had been added to the patient’s drug regimen. Thus, while 39.6% were receiving lower dosages, 28% received. Higher dosages. The remaining 33% received the same dosage. |
Ferguson et al. 1982 USA [47] | Prospective Pre post design (no control) | n: 250 mean age: not reported (adolescents and adults) gender: not reported ethnicity: not reported ID = not reported | Inpatient | Intervention: Introduction of interdisciplinary teams medication reviews with a goal to deprescribe antipsychotic medication typically by 25–50% per 30 day period Medication: antipsychotics Duration: Variable Length of follow up: Not reported | Number of individuals receiving neuroleptic drugs, mean daily drug dose, Number of individuals receiving dosage increases or decreases, number of individuals able to be maintained on lowered dosages or no drug at all | Data-based reviews resulted in decreased numbers of individuals receiving antipsychotic drugs, lower mean daily dosages, and less frequent dosage increases. 97% of the individuals receiving drug discontinuation or dosage decreases were not placed back on a drug or did not receive dosage increases |
Fielding et al. 1980 USA [48] | Retrospective Pre post design (no control) | n: 192 mean age: 35 (SD 14.5) gender: 52% male ethnicity: not reported ID = severe/profound 86% | Inpatient | Intervention: Two phases Phase one: subjects participated in a 50-day assessment period consisting of 20 days during which they received their normal psychotropic medication followed by 30 days during which they received no medication. Medication was not tapered. At the end of the 30 days of non- medication, prescriptions were discontinued for those who did not show an increase in challenging behaviours. The 50-day assessment was repeated for individuals who remained on psychotropic medication. Phase two: 92 subjects who were unable to discontinue psychotropic were exposed to 30 days of 25% dose reduction which was repeated depending on adverse behaviours. Doses were also increased if necessary Medication: The most commonly prescribed medications were Mellaril and Thorazine. Other drugs used less often included Haldol, Trilafon, Quide, Navane, and Prolixin. Duration: 30 days for phase 1, Variable for phase 2 Length of follow up: nearly 2 years | Daily number of incidents of adverse behaviours Number of participants who discontinued or changed dose of psychotropic medicines | 60% of participants who had been taking medications no longer needed them as no increase in frequency of episodes of behaviours that challenge. All but eight of the 68 residents whose medication gradually was reduced under phase two have achieved permanent dosage reductions while maintaining rates of maladaptive behavior comparable to those observed while medicated. While maladaptive behaviors increased slightly for some, they decreased or remained stable for the majority. |
Findholt et al. 1990 USA [49] | Retrospective Pre post design (no control) | n: 208 mean age: not reported gender: not reported ethnicity: not reported ID = severe / profound: majority | Inpatient | Intervention: Behaviour and Medication review committee reviewed medication of participants at least every 6 months Medication: antipsychotics, antidepressants, anxiolytics Duration: Variable Length of follow up: Variable | Number of patients taking antidepressants, anxiolytics and antipsychotics and Number of patients receiving polypharmacy (defined in study as 2 or more psychotropic medicines) Cost savings based on medicine prices | April 1979 out of a total population of 590 persons, 208 (41%) were receiving antipsychotic medications, 69 (14%) were on antidepressants, and 67 (13%) were taking anxiolytics, with 52 residents on polypharmacy. March of 1987, with a total population of 436, these Numbers decreased to 52 (12%) on antipsychotics, 9 (2%) on antidepressants, 11 (3%) on anxiolytics, and 3 receiving polypharmacy. Cost savings for four most prescribed medicines $119.77 per day. |
Gerrard 2020 U.K. [38] | Retrospective Pre post design (no control) | n: 66 (includes an unspecified number of participants also reported in Gerrard et al., 2019 [37]) mean age: not reported gender: 50% male ethnicity: not reported ID = not reported | Community | Intervention: Pharmacist and PBS nurse reviewed patients with view to deprescribing in conjunction with views of patient, carers and families Medication: Included risperidone, olanzapine, quetiapine, amisulpride, aripiprazole,benzodiazepines Duration: Variable Length of follow up: Variable | Number of medicines stopped, Number of medicines restarted. For antipsychotic prescriptions- FBC, U + Es, LFT, TFT, Lipids, Glucose/HbA1c, prolactin, BP, weight, pulse and ECG | 24 psychotropic medications were stopped; 20 of these were with PBS support. A further 22 people were undergoing the challenge which was not complete at end of study. Ten medications needed to be restarted post-discontinuation or increased post-reduction, with eight being in the unsupported clinic. On average, each person required a minimum of five reviews to fully undertake the challenge. The majority of medications stopped were antipsychotics,. Over half these prescriptions were for risperidone, which reflects the clinical practice that this antipsychotic was the preferred choice in behavioural intervention. Side effect burden reduced by 71% with a reduction of 50% of the starting dose or more. The main issues that improved were sedation, weight gain and postural hypotension. |
Howerton et al. 2002 USA [50] | Prospective Pre post design (no control) | n: 159 mean age: not reported gender: 65% male ethnicity: not reported ID = mild 57 moderate 31 severe 39 profound 21 borderline 5 none 6 | Community | Intervention: Evaluation of an interdisciplinary review team addressing polypharmacy Medication: Typical and atypical antipsychotics, anticonvulsants, SSRIs, antidepressants, lithium Duration: Variable Length of follow up: 3 months | Medicines stopped and started | Decrease in polypharmacy, discontinuation of unnecessary anticonvulsants. Thioridazine use was reduced by 63%, haloperidol by 72%, and chlorpromazine by 100%. Lithium was discontinued in 18 patients. |
Inoue et al. 1982 Canada [51] | Retrospective Pre post design (no control) | n: 251 mean age: not reported gender: not reported ethnicity: not reported ID = borderline 2.5% mild 13.1% moderate: 33% severe:31.3% profound: 16.2% unspecified 3.6% | Inpatient | Intervention: Implementation of a pharmacy patient review service to address overprescribing of psychotropic medicines over 5 years. Medication: antipsychotics 72%, anxiolytics 16%, sedative/hypnotics-11%, antidepressants 9%, and others (e.g. lithium) 1% Duration: Variable Length of follow up: Variable | Number of psychotropic medicines discontinued Number of psychotropic medicines with dose changes | By the end of the five year period, 135 psychotropic medication orders for 121 patients were discontinued. The dosage reductions (25–75%; mean 48.6%) were made for 91 medication orders. |
Janowsky et al. 2006 USA [52] | Retrospective Pre post design (no control) | n: 138 (may include participants also reported in Janowsky 2008 [53]) mean age: 48 (18 to 81) gender: 60% male ethnicity: not reported ID = severe to profound 100% | Inpatient | Intervention: Medication review and dosage reduction programme Medication: Typical and atypical antipsychotics Duration: Not reported Length of follow up: 10 years | Number discontinuing antipsychotic medication | 55% Successfully discontinued antipsychotic medication 36% relapsed on withdrawal requiring dose increases or represcribing. |
Janowsky 2008 USA [53] | Retrospective Pre post design (no control) | n: 57 (may include participants also reported in Janowsky 2006 [52]) mean age: 52 (30 to 78) gender: 65% male ethnicity: not reported ID = severe to profound 100% | Inpatient | Intervention: Medication review and dosage reduction programme Medication: haloperidol (n = 24), thioridazine (n = 20), chlorpromazine (n = 7), thiothixine (n = 5), and loxapine (n = 1) Duration: Not reported Length of follow up: Up to 15 years | Number discontinuing antipsychotic medication Number of episodes of challenging behaviour | 4 (8%) of 49 discontinued antipsychotic medication and 45 (92%) of 49 could not discontinue antipsychotic medication; 2 (4%) of 49 no deterioration in behaviour and 47 (96%) of 49 experienced behavioural relapse. |
Jauernig et al. 1995 Australia [54] | Retrospective Pre post design (no control) | n: 25 mean age: not reported gender: not reported ethnicity: not reported ID = not reported | Inpatient | Intervention: Medication review and dosage reduction programme involving maximum monthly dose reduction of 25% Medication: thioridazine,chlorpromazine, haloperidol, fluphenazine, trifluoperazine Duration: Variable Length of follow up: 2 years | Number reducing or discontinuing antipsychotic medication; Number of episodes of challenging behaviour | 3 (12%) discontinued antipsychotic medication, 19 (76%) underwent dose reduction, and 3 (12%) no change in dose; challenging behaviour frequency at follow-up lower than in baseline in all 3 patients (100%) whose antipsychotic had been discontinued and in 15 patients (79%) of 19 who underwent dose reduction. |
LaMendola et al. 1980 USA [55] | Retrospectives Pre post design (no control) | n: not reported mean age: not reported gender: not reported ethnicity: not reported ID = not reported | Inpatient | Intervention: Medication review and dosage reduction programme over 4 years Medication: included antipsychotics and benzodiazepines Duration: not reported Length of follow up: not reported | Percentage of patients prescribed psychotropic medicines, percentage of patients prescribed major and minor tranquilisers. | Patients prescribed psychotropic medication decreased from 34 to 21%, percentage prescribed major tranquillisers fell from 27 to 20% and minor tranquilisers were no longer used having accounted for 5% of patients. |
Lindsay et al. 2004 USA [56] | Prospective Pre post design (no control) | n: 14 mean age: 9.7 (5–13) gender: 93% male ethnicity: not reported ID = 100% borderline to moderate | Community | Intervention: After a mean exposure of 8.9 months because of excessive weight gain, or excessive appetite, or insufficient clinical response, antipsychotic medication stopped Medication: risperidone Duration: sudden discontinuation Length of follow up: 24 months | Body weight | Standardised weight at 12 and 24 months after discontinuation of risperidone was not distinguishable from standardized weight before risperidone was initially prescribed |
Luchins et al. 2004 USA [57] | Retrospective Pre post design (no control) | n: 95 mean age: 32 (18 to 73) gender: 60% male ethnicity: not reported ID = mild / moderate: 70 severe / profound: 25 | Inpatient | Intervention: Interdisciplinary team programme to review psychotropic medication with a view to reduce or discontinue Medication: antipsychotics Duration: Variable Length of follow up: Variable | Dosage changes of antipsychotics and other psychotropic medicines. Unvalidated behaviour rating tool | Reduction of antipsychotics associated with improvement in behaviour. 41 participants were receiving an alternative psychotropic medicine at the end of the study period, with 5 of them receiving two such drugs concurrently. The alternative drugs used were as follows: lithium (n = 26) carbamazepine (n = 9) buspirone (n = 9), and propranolol (n = 2). The prescribing of these other psychotropic medicines were associated with a reduction in the prescribing of antipsychotic medicines, |
Marholin et al. 1979 USA [58] | Prospective Pre post design (no control) | n: 6 mean age: 35 (27 to 53) gender: 100% male ethnicity: not reported ID = severe 100% | Inpatient | Intervention: antipsychotics were withdrawn and readministered using a double-blind B-A-B (drug-placebo-drug) design. Medication: phenothiazine antipsychotics Duration: Sudden discontinuation for 23 days Length of follow up: 48 days | Observations on the ward and during workshop tasks | Findings highly individualised and mixed When chlorpromazine was withdrawn and reinstated, reversible changes occurred in at least one category of behavior for all subjects. |
Matthews et al. 2003 U.K. [59] | Retrospective Pre post design (no control) | n: 77 mean age: 45.5 (16 to 81) gender: 51%male ethnicity: not reported ID = mild 22% moderate: 22% severe / profound: 39% unspecified: 17% | Community | Intervention: Retrospective case note analysis to observe effects of discontinuation Medication: thioridazine Duration: not reported Length of follow up: Not reported | Significant adverse events on /following Thioridazine withdrawal | Over 50% of those on regular thioridazine experienced adverse events during or following drug withdrawal. Adverse events were significantly associated with the duration of previous thioridazine prescription. Problems encountered included reemergence of psychosis or mood disturbance, escalation of arousal, aggression, anxiety, self-injury, sexual disinhibition, and ritualised behaviours. Further details of adverse effects not reported. |
Marcoux 1985 USA [60] | Prospective Pre post design (no control) | n: not reported mean age: not reported gender: not reported ethnicity: not reported ID = not reported | Inpatient | Intervention: Interdisciplinary team programme to review psychotropic medication with a view to reduce or discontinue Medication: chlorpromazine, piperidine, mesoridazine, thioridazine, piperazine,fluphenazine, perphenazine, prochlorperazine, tripfluoperazine, haloperidol, thiothixene, molindone Duration: Not reported Length of follow up: Not reported | antipsychotic dosages | antipsychotic dosages decreased at a projected annual rate of 17% and no significant withdrawal reactions reported. This dosage decrease has saved the Institution approximately $2800 to $3200 in medication costs after a 10-month period. |
May et al. 1995 USA [61] | Prospective Pre post design (no control) | n: 23 mean age: 42 (24–62) gender: 100% male ethnicity: not reported ID = severe/ profound: 100% | Inpatient | Intervention: antipsychotic dose reduced by 10% every 3 months until discontinued Medication: risperidone Duration: Variable Length of follow up:3–4 years | Number of incidents of challenging behaviour | Three groups to describe changes in challenging behaviour: Transient worsening (n = 9; 39% Progressive improvement (n = 5; 22%) Persistent worsening (n = 9; 39%). |
Newell et al. 2000 USA [62] | Prospective Pre post design (no control) | n:6 (may include participants also reported in Newell et al., 2001 [63] and Newell et al., 2002 [64]) mean age: 36.8 (14 to 50) gender:67% male ethnicity: not reported ID = mild moderate 4 severe 1 profound 1 | Inpatient | Intervention: antipsychotic dose reduced by 25% every 3 months until discontinued Medication: haloperidol, thioridazine, mesoridazine Duration: Variable Length of follow up: 6 months to 2 years post discontinuation | Video analysis of lip movement DISCUS | Dyskinetic movements increased during antipsychotic withdrawal followed by a reduction post-discontinuation. |
Newell et al. 2001 USA [63] | s | n:26 (may include participants also reported in Newell et al., 2000 [62] and Newell et al., 2002 [64]) mean age: 34.9 (18 to 52) gender:69% male ethnicity: not reported ID = mild 1 moderate 5 severe 12 profound 8 | Inpatient | Intervention: antipsychotic dose reduced by 25% every 2 to 4 months until discontinued Medication: haloperidol, thioridazine, chlorpromazine, mesoridazine, lozapine, trifluperazine Duration: Variable Length of follow up: 12 months post discontinuation | DISCUS | Mean total DISCUS increased significantly during antipsychotic withdrawal, returning to baseline. Prevalence: baseline 31% during withdrawal 85% follow up 38%. |
Newell et al. 2002 USA [64] | Prospective Pre post design (no control) | n:20 (may include participants also reported in Newell et al., 2000 [62] and Newell et al., 2001 [63]) mean age: 36.6 (SD 8.6) gender:75% male ethnicity: not reported ID = severe / profound 100% | Inpatient | Intervention: antipsychotic dose reduced by 25% every 3 months until discontinued Medication: haloperidol, thioridazine, chlorpromazine, lozapine, trifluperazine Duration: Variable Length of follow up: 12 months post discontinuation | Postural stability DISCUS | Postural stability changed significantly during course of medication withdrawal and tended to return to baseline values at follow-up; mean total DISCUS increased significantly from baseline during antipsychotic withdrawal before returning to baseline values at follow up. |
Ramerman et al. 2019 The Netherlands [34] | Prospective Pre post design (no control) | n: 128 (includes participants also reported in de Kujper et al., 2014 [33] and Ramerman et al., 2019 [32]) mean age: 48 (10–68) gender: 71% male ethnicity: not reported ID = mild 15.6% moderate 21.9% severe 46.9% profound 15.6% | Community | Intervention: Antipsychotic reduced over 14 weeks, 12.5% of the baseline dosage every two weeks data combined from two studies and part of clinical care. Medication: risperidone 23.4% olanzapine 8.5%, quetiapine 1.6%, clozapine 2.3%, aripiprazole 0.8%, pipamperone 34%, haloperidol 5.4%, pericyazine 4%, zuclopentixol 5.5%, levomepromazine 2.3%, pimozide 5.5% Duration: 14 weeks Length of follow up: 6 months following planned discontinuation | Primary outcome measure: healthrelated quality of life RAND-36 Secondary outcome measures: ABC, UPDRS, SCOPAAUT | Physical well-being showed an increase in the group that had achieved complete discontinuation. Social functioning showed a decrease in the group that incompletely discontinued, which recovered at follow-up. Mental wellbeing decreased at 16 weeks, but recovered at follow up, regardless of complete or incomplete discontinuation. |
Shankar et al. 2019 U.K. [65] | Retrospective Pre post design (no control) | n: 71 mean age: not reported gender: not reported ethnicity: not reported ID = not reported | Community | Intervention: Usually dose changes were 10–25% of baseline dose reduced every 6–8 weeks Medication: antipsychotics Duration: Variable Length of follow up: 3 months | Number reducing or discontinuing antipsychotic medication Number of patients requiring hospital admission or change in placement | 46.5% (33/71) discontinued antipsychotic medication 11.3% (8/71) reduced over 50% of antipsychotic dosage At three months follow-up no one required hospital admission or change in placement. |
Spreat et al. 1993 USA [66] | Pre post design (no control) | n:86 mean age: not reported gender: not reported ethnicity: not reported ID = not reported | Inpatient | Intervention: Medication reduction trials Medication: haloperidol,mesoridazine, thioridazine,thioxanthene, chlorpromazine,thrifluoperazine,mo lindone,fluphenazine, chlorpromthixene Duration: Variable Length of follow up:12 months post discontinuation | Changes in antipsychotic prescribing | > 50% dose reduction or discontinuation: 14 (16%) ≤50% dose reduction: 26 (30%) No change or increased dose: 46 (53%). |
Stevenson et al. 2004 U.K. [67] | Retrospective Pre post design (no control) | n: 119 mean age:44 (18–72) gender: 58% male ethnicity: Not reported ID = mild 27.7% Moderate: 21.8% Severe: 18 (15.1% Profound:7.6% Not reported: 27.7% | Community | Intervention: Medication withdrawal programme following CSM advice. Medication: Thioridazine Duration: Variable Length of follow up: Variable | Number of people withdrawn from antipsychotic Number of new prescriptions Numbers needing extra carer support, Numbers of placement breakdown, family problems, admissions to hospital | 7.6% completely withdrew from antipsychotic medicines, and 48.7% experienced onset/deterioration in problem behaviours or mental illhealth. The cost to the intellectual disabilities psychiatric service (over and above that of routine psychiatric care) was £258,050. 10 people required increased levels of carer support to be provided; seven were excluded from a day centre placement, one person experienced a placement breakdown and moved to a new home, and six experienced considerable family problems. 14 hospital admissions to an intellectual disabilities psychiatric assessment and treatment unit |