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Am Fam Physician. 2007;75(5):622-624

Author disclosure: Nothing to disclose.

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 antide-pressants have been ineffective, mania is suspected, or a psychotic process is present.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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