Letters to the Editor
Treatment of Aggression in Patients with Mental Retardation
To the editor: The article, "Medical Care of Adults with Mental Retardation," in American Family Physician, provides a brief introduction to behavioral and psychiatric treatment of patients with mental retardation.1 Psychopharmacologic management in this area is fraught with ethical concerns, diagnostic difficulties, and a tendency toward overmedicating. Physicians often prescribe antipsychotics to control aggressive behavior while missing an underlying mood or anxiety disorder. In many cases, antidepressants or beta blockers may be used to avoid the adverse effects of antipsychotics.
Aggressive behavior is the most common reason for psychiatric referral in persons with mental retardation. Patients who are mentally retarded should undergo a thorough diagnostic work-up to rule out specific medical or psychiatric causes of aggression. If no specific etiology is found, behavior therapy should be the initial approach. Most patients, however, are treated empirically with antipsychotic medications.2 Several studies suggest that patients who are mentally retarded are overmedicated with antipsychotics, resulting in sedation, social withdrawal, and loss of cognitive function.3 Newer antipsychotics have a lower incidence of akathisia and tardive dyskinesia but can predispose patients to obesity and metabolic syndrome. Retrospective data suggest that persons with mental retardation are at higher risk of sedation and weight gain than the general population.4 Therefore, it is desirable to restrict the use of antipsychotics when other classes of medications may have equal or better effectiveness at controlling aggression.
To guide appropriate prescribing, one author identified symptom clusters surrounding aggressive outbursts that may be classified into behavioral profiles responsive to certain medication classes.5 For example, patients with obsessive and ritualistic tendencies who become aggressive when interrupted may be considered to have an anxiety spectrum disorder and should respond to a selective serotonin reuptake inhibitor. Patients with severe affective lability or rage lasting for long periods may be considered manic or as having a mood spectrum disorder and should respond to lithium or an anticonvulsant. Patients with paranoia, delusions, or hallucinations may require the scheduled use of an antipsychotic.5
When there is no clear evidence of mania or an underlying psychotic process, an initial trial of a serotonergic antidepressant is indicated. Antidepressants can improve aggressive outbursts in patients with an underlying depressive or anxiety disorder, allowing for decreased reliance on antipsychotics.6 Occasional use of an antipsychotic may be necessary when aggressive outbursts become severe. Early psychiatric consultation is recommended when initial trials of antidepressants have been ineffective, mania is suspected, or a psychotic process is present.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army service at large.
Author disclosure: Nothing to disclose.
REFERENCES
1. Prater CD, Zylstra RG. Medical care of adults with mental retardation. Am Fam Physician 2006;73:2175-83.
2. Matson JL, Bamburg JW, Mayville EA, Pinkston J, Bielecki J, Kuhn D, et al. Psychopharmacology and mental retardation: a 10 year review (1990-1999). Res Dev Disabil 2000;21:263-96.
3. Ahmed Z, Fraser W, Kerr MP, Kiernan C, Emerson E, Robertson J, et al. Reducing antipsychotic medication in people with a learning disability. Br J Psychiatry 2000;176:42-6.
4. Simeon J, Milin R, Walker S. A retrospective chart review of risperidone use in treatment-resistant children and adolescents with psychiatric disorders. Prog Neuropsychopharmacol Biol Psychiatry 2002;26:267-75.
5. Ryan JM. Pharmacologic approach to aggression in neuropsychiatric disorders. Semin Clin Neuropsychiatry 2000;5:238-49.
6. Janowsky DS, Shetty M, Barnhill J, Elamir B, Davis JM. Serotonergic antidepressant effects on aggressive, self-injurious and destructive/disruptive behaviours in intellectually disabled adults: a retrospective, open-label, naturalistic trial. Int J Neuropsychopharmacol 2005;8:37-48.
Importance of Counseling Patients About Contraception
TO THE EDITOR: In the July 1, 2006, issue of American Family Physician, Drs. Lesnewski and Prine state that the "quick start" method of initiating oral hormonal contraception can be used for women who have had unprotected intercourse within five days of the office visit, after appropriate counseling.1 In counseling such patients, physicians should be aware that women seeking contraception may be opposed to a method that has the theoretical potential to impede implantation of a fertilized ovum.
Although easier access to health care is a worthy goal, physicians should be careful about "over-the-phone" requests for contraception. An office visit is more conducive to the type of patient assessment and education that is often necessary before contraceptives are prescribed. For example, a woman who is the victim of abuse or incest would be more likely to seek help in the setting of a private, secure office visit than during a phone call, perhaps coerced by the perpetrator, to request emergency contraception. Family physicians need to empower women by providing them with the information and support they need to make decisions that may have a profound impact on their lives.
Author disclosure: Nothing to disclose.
REFERENCES
1. Lesnewski R, Prine L. Initiating hormonal contraception. Am Fam Physician 2006;74:105-12.
in reply: Dr. Pisaniello points out that physicians and patients may have moral or religious concerns about the "quick start" method of initiating oral contraception because of the theoretical risk of post-fertilization effects. Women who have had unprotected intercourse within five days of an office visit can take emergency contraception that day and begin their new contraceptive the following day. Levonorgestrel emergency contraception prevents pregnancy primarily by inhibiting ovulation, with some additional effects on sperm motility and cervical mucus.1,2 Research on progestin-only emergency contraception has not demonstrated any post-fertilization mechanism of action. This information should allay patients' concerns about preventing implantation of a fertilized ovum.
The quick start algorithm generally requires an office visit. To prescribe a new hormonal contraceptive method between menses, physicians must take a full patient history, including medical history, concurrent medications, sexual practices, and social issues. All of these areas impact the patient's choice of contraceptive. I agree that office visits present a crucial opportunity to screen for abuse and to optimize health in many other ways. However, patients who need emergency contraception episodically (because a condom broke or a pack of birth control pills was misplaced) must have easy access, unimpeded by a requirement to schedule an office visit. Our wish to identify potential cases of abuse should not prevent teenagers or women from accessing emergency contraception during the brief window of this medication's highest effectiveness.
Author disclosure: Nothing to disclose.
REFERENCES
1. Croxatto HB, Ortiz ME, Muller AL. Mechanisms of action of emergency contraception. Steroids 2003;68:1095-8.
2. Faundes A, Brache V, Alvarez F. Emergency contraception-clinical and ethical aspects. Int J Gynaecol Obstet 2003;82:297-305.
Send letters to Kenny Lin, M.D., Assistant Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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