James Jordan, M.A.
Group home agencies that serve individuals with mental retardation are frequently challenged by the task of effectively managing clients who present with challenging symptoms that stem from an underlying psychiatric disorder. PRN medication has often been viewed as a chemical restraint used to control behaviors. When used appropriately, however, PRN medications can be used as an effective therapeutic intervention to treat behaviors that are symptomatic of an Axis I diagnosis. A treatment approach that considers the use of PRN medication can decrease the risk of injury to the client, staff, and peers. More importantly, it provides short and long term therapeutic interventions, treating the client's mental disorder(s) while improving quality of life.
Psychotropic PRN medication has always been used cautiously, if used at all, in the majority of group homes that provide services to individuals with mental retardation. Often viewed as a "chemical restraint" this intervention is and should be used cautiously for several reasons as it can be abused-it should be used only to treat maladaptive behaviors; and, group homes are rarely designed primarily to treat violent behaviors associated with Axis I disorders as defined by the DSM-IV. Intermediate Care Facilities/Mental Retardation group homes function to help individuals overcome and cope with various challenges that are systemic to varying developmental disabilities. Few group homes are structured to deal with severe psychiatric disturbances and violent behavior. Yet, people with MR do experience the full spectrum of psychiatric disorders (Nezu, Nezu, & Gill-Weiss, 1992; Reiss, 1994). The reported prevalence of psychopathology in people with MR varies from 10%-40% (Rojahn & Tasse, 1996). Even effectively trained staff persons are generally not physically capable of effectively dealing with severe aggression or self-injury. They do not possess a wealth of psychiatric knowledge; and although most group homes have nursing staff, nurses are generally not present around the clock. Levitas (2000) in a recent article notes that it is impossible to consider developing safe and effective PRN protocols without addressing the inadequacies of the care system. However, structural limitations of group home services should not limit an agency's willingness to use PRN medications. Like the clients they serve, group home agencies need to adapt to challenges. Group homes that house residents with challenging behaviors need to have nurses and/or well trained staff, who are supervised on a daily basis. PRN medications can be used safely and effectively if the group home is well staffed. Having a challenging resident without adequately trained staff to administer PRN medications should be considered a disservice to the resident.
The use of psychotropic PRN medication is often, incorrectly viewed as a chemical restraint. When a medication is prescribed solely for the purpose of behavior control, this constitutes a chemical restraint. This circumstance includes medications prescribed exclusively for maladaptive behaviors in the absence of a psychiatric diagnosis that could be associated with violent and aggressive maladaptive behaviors. When psychotropic PRN medications are used to treat maladaptive behaviors that are symptomatic of a diagnosed psychiatric disorder, a client in question is not being chemically restrained. Generally a client that is diagnosed with a psychiatric disorder is already prescribed psychiatric medications that are delivered on a daily basis. A client that receives PRN psychiatric medication is given additional medication because his or her current drug regimen is not effectively treating symptoms that stem from an active psychiatric disorder that may present variability in symptom manifestation. This perspective is not any different from any other medical disorder that objectively employs PRN medication protocols. For example, an individual with diabetes does not receive PRN insulin to chemically restrain his or her lethargic behavior; rather the insulin is administered because the daily drug regimen is not effectively treating glucose levels that may rise and fall in cyclic or random patterns, and may never be static or even predictable. Would it make any sense to physically restrain the individual with diabetes until insulin levels rose and lethargy diminished? When a client has a headache they receive Tylenol; if prone to asthma they receive inhaler solutions; if prone to migraines they receive Imatrex; if prone to heartburn they receive Mallox, etc&ldots; We propose that psychotropic PRN medications could be used not only to control a client's symptomatic behavior, but also provide such a client with immediate psychiatric therapy aimed at treating an exacerbation of his or her psychiatric illness. When a client displays positive symptoms of a psychiatric disorder that is in remission, the use of psychotropic PRN medication could arrest the progression of the disorder immediately and may also provide long lasting therapeutic benefits.
Interdisciplinary teams will often agree to implement psychiatric recommendations as long as the medications are prescribed on a daily basis, without subjective discussion. Is it logical for an ISP team to approve the use of 10 milligrams of Haldol to be given every day whether the client is symptomatic or not, but then not agree to give the same client an extra 5 milligrams just several times a year when he or she is clearly symptomatic? Our guess is no! Service providers need to adequately staff their group homes in order to be able to implement such a sensitive and potentially abusive procedure. Objective measures can be developed and implemented that are similar to the treatment of other types of medical disorders.
No rational pharmacological treatment for aggression and/or self injurious behaviors has been found for individuals with mental retardation with the exception of those cases in which behavioral disinhibition is part of a treatable psychiatric disorder. The following recommended PRN protocol is being proposed to treat behavioral symptoms that stem from a DSM-IV psychiatric diagnosis. With this philosophical stance in mind, PRN medication protocols should not be viewed or implemented as chemical restraints, but rather as additional treatment procedures that need to be implemented when a client displays psychiatric symptoms that are or are not generally controlled by his or her daily drug regimen. PRN Protocol Procedures:
King, Fay, and Croghan (2000) provided basic guidelines for administering PRN medications, including pharmacological options. A comprehensive protocol for using PRN medications is proposed here along with additional arguments as to why they are appropriate, safe, effective, and difficult to abuse.
The following questions must first be addressed and answered affirmatively in developing a psychotropic PRN medication protocol.
1. Does the client engage in severe aggression, self-injury, or other potentially dangerous behavior that has been operationally defined and agreed upon?
2. Are preventative techniques that employ positive programming in place?
3. Does a hierarchy of non-intrusive interventions exist that are to be implemented when the client begins to engage in violent, dangerous behaviors?
4. Are violent, dangerous behaviors symptomatic of an underlying mental disorder(s)?
5. Is the client prescribed psychotropic medications that are intended to treat identified mental disorder(s)?
6. Are the behavioral, habilitative, and psychiatric interventions generally successful in treating the individual's mental disorder(s) (Are time limits established for "putting out fires")?
If all of these questions are answered affirmatively, then it is reasonable to consider a PRN protocol to treat a client's episodic psychiatric disturbance. PRN medications are justifiable to treat occasional psychiatric disturbances that are normally controlled with the client's daily drug regimen.
The answers to all of these questions must also be operationally defined. What severe aggression or severe self-injury is must then be discernable from mild aggression or mild self-injury. PRN orders should not be used more than 1-3 times per month. If they are being used more than 3 times per month, the daily drug regimen and psychological programming should be re-evaluated. Hospitalization may also be required.
The use of PRN medications, when used properly, are generally reserved for severe aggression and/or self injury. Ideally, if PRN medications are used safely and efficiently, they can also be used to treat a number of non-dangerous symptoms (anxiety, particular situational anxiety, hallucinations, and insomnia). Administration of PRN protocol:
Operationally defined procedures for staff to follow must be in place to prevent the abuse of the administration of psychotropic PRN medications. Additionally, a trained professional, such as a nurse, should be debriefed in regards to the client's behavior and whether or not lesser intrusive de-escalation procedures have been implemented and have failed before medication is administered. Lesser intrusive interventions that include but are not limited to verbal redirection, alternative environment, and time out should be evaluated before jumping to a PRN. Our argument is that physical and mechanical restraints are more intrusive than PRN medications for two primary reasons:
1.) mechanical and physical restraints treat behavioral symptoms and not the acute psychiatric disturbance, and
2.) risk of physical injury to staff and client are high. PRN medications are also less intrusive, considering the advances made in the administration of medications (e.g. Zyprexa Zydis, which dissolves in the mouth). The field is also moving towards less intrusive administration methods than the more traditional intramuscular injection. Soon there will be dermal patch formats for many intramuscular and oral medications.
Finally, the effectiveness of the PRN protocol must be addressed. Generally a PRN protocol is successful if the following criteria are met: *The client rapidly de-escalates. *The resident sustains little or no physical injury. *Physical restraint is not required. *No side effects or residual effects of the PRN medication are evident. *The administration of PRN medications significantly reduces Emergency Room visits and increases continuity of care. *The client does not display severe symptoms of his or her mental disorder for an extended period of time following the administration of PRN medications.
The effectiveness of PRN medications cannot be judged immediately. After six months of use, efficacy of PRN medications can be objectively measured. This can be accomplished by looking at the presentation of identified target symptoms, the increase or decrease of psychiatric hospitalization, and the possibility of titrating daily psychotropic medications, if infrequent use of a PRN medication is helping to keep a client fairly asymptomatic. Case Report Ms. B is a 51-year-old woman with intellectual disability in the profound range. PRN medication has been used with Ms. B leading to improvements in behavior, quality of life, and continuity of care. Prior to the initiation of PRN mediation (6/92 - 11/95), Ms B averaged an Emergency Room visit once every 8 months over a 41 month span to treat severe head banging. Four point physical restraint was also used every time she needed to be transported to the ER while waiting for Emergency Medical Technicians to arrive at the group home. PRN medications were initiated in 11/95. Since that time, Ms. B had one hospital admission spanning 87 months. During those same 87 months, PRN medication was never used more than twice in a one month period. Additionally, self injurious behaviors were significantly reduced. Baseline behavior established in 1992 indicated an average of 8 severe head banging episodes per month. Over the past two years Ms. B averaged only 4 incidents of self injurious behavior per month, two of which required the use of PRN medications. This decrease in overall head banging is statistically significant T(1, 23) = -5.46, p = .05. If PRN medications had not been used over the past two years, Ms. B would probably have been sent to an Emergency Room twice to treat her symptoms. This may have also resulted in hospitalization and an interruption in continuity of care. During the past 87 months physical restraint was not needed to treat her symptoms. Prior to PRN medications Ms. B was physically restrained by staff every time she engaged in head banging. In addition to effectively treating Ms. B's mental disorder and associated symptoms, PRN medications also provided a safe, internal vehicle in reducing Ms. B's daily psychiatric drug regimen. Prior to 11/95 and the initiation of PRN medications, drug reductions often led to increased symptoms, increased restraint, an Emergency Room consultation, and a return to the original drug dosage. Post 11/95, the group home agency has been able to titrate Ms. B's medication without having to increase other daily medications. Since 11/95 the following medications have been reduced at the group home with the understanding that if transitional decompensation occurred during titration of one medication, the titration plan would not be abandoned but supported with the use of PRN medications. Ms. B has had the following medication reductions over the past 7 years: Inderal 120 mg qd to 0; Seroquel 150 mg qd to 0; Naltrexone 50 mg qd to 0; Trazadone 300 mg to 250 mg qd. Ms. B is now prescribed Haldol 20 mg qhs (initially prescribed at this dose on 2/94); Prozac 80 mg (initially prescribed at 100 mg qd on 2/94); Trazadone 250 mg (initially prescribed at 300 mg on 5/01); Neurotin 1000 mg qd (initially prescribed at this dose on 3/01); Cogentin 2 mg qd (initially prescribed at this dose in 8/92).
All people have the right to have their mental disorders treated using a comprehensive approach. Giving a client unnecessary medication is as unethical as withholding necessary medication, if an agency is unable or unprepared to administer PRN medication. A systematic, interdisciplinary approach to the diagnostic assessment of potential underlying precipitants and perpetuants to aggression and SIB is critical in formulating a comprehensive support plan to optimize long-term outcome (Verhoeven & Tuinier, 2001). Group home agencies need to have a written, well-detailed crisis plan that specifies the most likely crises that might occur and the services that will be administered should they happen (Buchard, Atkins, & Burchard, 1996). If psychotropic PRN medication is a service that could potentially serve the client well, all levels of staff must be adequately trained to appropriately serve the client; and means for utilizing PRN medications as a viable option in systematic fashion should be explored, discussed, and initiated if consensus is agreed upon. PRN medications, if used correctly, could decrease symptomatic behavior; decrease the need for physical restraint; more effectively treat the underlying mental disorder; improve an agency's ability to decrease medication internally, and safely; and improve the client's quality of life. PRN medications can be used as a specific therapeutic treatment of psychiatric disorders and/or symptoms; and as such, they should not be considered as chemical restraints.
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King, R. K., Fay, G., & Croghan, P. (2000). Pro Re Nata: Optimal use of psychotropic PRN medication. Mental Health Aspects of Developmental Disabilities. 3, 8-16.
Levitas A. (2000). Editorial Comment: Pro Re Nata: Optimal use of psychotropic PRN medication. Mental Health Aspects of Developmental Disabilities. 3, 17.
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Reiss, S. (1994). Handbook of challenging behavior: Mental health aspects of mental retardation. Worthington, Oh: International Diagnostic Systems.
Rojahn, J., & Tasse, M. J. (1996). Psychopathology in mental retardation. In J. W. Jacobson & J. A. Mulick (Eds.), Manual of diagnosis and professional practice in mental retardation. Washington, DC: American Psychological Association.
Verhoeven, W., & Tuinier, S. (2001). Pharmacotherapy in aggressive and auto- aggressive behavior. In A. Dosen & K. Day (Eds.),Treating mental illness and behavior disorders in children and adults with mental retardation. Washington, DC: American Psychiatric Press.
Author Note: Correspondence concerning this article should be addressed to James Jordan (Jjordan@lorainccc.edu) Northeast Care Center, 12627 York Road, North Royalton, Ohio 44133. The author would also like to thank Stephen Ruedrich, Thomas Gilbert, Michael Wisniewski, and Bruce Werner for their many helpful suggestions in the development of this article.