Intellectual disability (ID), characterised by significant limitations in cognitive functioning and adaptive skills before age 18, affects approximately 1% of the global population.^1,2 In South Africa, limited data suggest a higher prevalence, potentially because of the preventable conditions such as malnutrition, chronic infections (e.g. human immunodeficiency virus [HIV] and/or acquired immunodeficiency syndrome [AIDS], tuberculous meningitis), foetal alcohol-related syndromes and violence-related injuries.^3,4 People with ID (PWID) are a vulnerable population, with a 2.5-fold increased risk of mental illness and a higher likelihood of medical comorbidities and behaviours that challenge (BTC), such as aggression, self-injury and temper tantrums.^5,6,7

Several factors contribute to the complexity of diagnosing and managing mental illness in PWID. First of all, the predominance of medical, including specialist psychiatric training being centred on typically developing individuals, is a key factor in limited clinician confidence in engaging with, and delivering optimal care to PWID.^8,9,10 Diagnosing mental illness in this population is further complicated by the severity of intellectual disability, atypical symptom presentation, communication difficulties, limited health literacy and barriers to accessing services.^6,11,12 Behaviours that challenge may reflect underlying issues including pain, poor emotional regulation, social skill deficits or multimorbidity.^{11,12,13,14,15} These complexities often lead to psychotropic medications being overused or underused, and in some cases, prescribed without adequately investigating their underlying causes.^{2,11,12,13,16,17,18,19,20}

Antipsychotics, which account for 30% – 50% of psychotropic prescriptions in PWID, are frequently used for BTC rather than psychosis, despite limited evidence of efficacy and risks of adverse effects like weight gain and extrapyramidal symptoms.^2,11,13,21 These risks are heightened in PWID because of their reduced ability to report side effects, which may present as BTC and lead to diagnostic overshadowing.^{14,22,23,24,25} A 2010 Dutch study found that 58% of antipsychotic prescriptions were for behavioural issues, with only 25% for psychosis, while a 2015 review noted short-term efficacy of antipsychotics for BTC in children but cautioned against long-term use because of side effects.^11,13,21 Psychotropic polypharmacy is also common, particularly among elderly PWID or those in residential settings.^24,26,27

International guidelines, such as those from the National Institute for Health and Care Excellence (NICE) and the World Psychiatric Association (WPA), emphasise comprehensive assessment before prescribing psychotropics to PWID.^{7,12,20,28,29,30,31,32} However, no South African studies have examined psychotropic prescribing patterns in this population, and local guidelines are absent. This gap is critical given South Africa’s unique socio-economic and health challenges, which may influence ID prevalence and treatment practices.

This study addresses this gap by auditing psychotropic prescribing patterns among outpatients with ID at a specialist psychiatric hospital in South Africa. We aim to: (1) describe current prescribing practices, (2) identify factors associated with psychotropic medication use, and (3) evaluate adherence to international prescribing standards. By providing the first local evidence on this topic, the study seeks to inform best practices and improve care for PWID in South Africa.

This retrospective study reviewed patient folders and prescription charts of outpatients attending the outpatient department (OPD) of an advanced psychiatric institution in the Western Cape, South Africa, with initial consultation occurring between January 2018 and August 2019. The study period was selected to meet a minimum sample size of 72 files, identified following input from a statistician, based on the OPD’s patient volume. A total of 103 files were included at the initial visit, with 87 available at the 6-month follow-up. No exclusion criteria were applied; files of patients discharged or lost to follow-up by 6 months were analysed at initial assessment only.

The method and analysis of this study have been reported elsewhere as part of the author’s master’s thesis at the University of Cape Town.³³

The results presented here are based on findings originally reported in the author’s master’s thesis (Akpabio et al).³³ All figures have been reproduced from the thesis.

This retrospective study audited psychotropic prescribing patterns among 103 outpatients with ID at an advanced psychiatric care institution in the Western Cape, South Africa.³³ The aim was to assess adherence to international guidelines, including those from the WPA and the NICE.^{7,12,20,28,33} Approximately 88% (n = 91) of patients received at least one psychotropic agent, a figure that aligns with global trends of high psychotropic use among people with intellectual disability (PWID).^2,11,28

Prescribing patterns generally reflected clinical diagnoses: stimulants were used for ADHD, and antidepressants for anxiety or mood disorders.^7,16,35 Antipsychotics, however, were the most commonly prescribed class – 59.2% at baseline and 56.3% at 6 months – despite only 10.7% of patients being diagnosed with a psychotic disorder. This mirrors international findings of frequent off-label antipsychotic use to manage BTC, rather than psychosis.^2,11,13,25 Among those prescribed antipsychotics, risperidone was the agent of choice, particularly for children, adolescents and individuals with ASD, and was commonly used in the context of BTC. Encouragingly, it was prescribed at the lowest effective dose, with rationale documented in nearly 69% of cases. However, only 46.8% of BTC cases were initially managed with behavioural strategies alone – despite strong WPA and NICE recommendations to prioritise non-pharmacological interventions.^2,6,11,36,37

Age and living arrangements appeared to shape prescribing trends. Children and adolescents (≤ 18 years) were more likely to receive ADHD medications, while adults (≥ 19 years) were prescribed more anxiolytics, hypnotics and antidepressants – consistent with developmental trajectories of psychiatric diagnoses. Female patients and those in residential facilities were more likely to receive anxiolytics or hypnotics, consistent with evidence linking institutional living to increased exposure to psychotropic medication and polypharmacy.^23,26,28 Notably, medication choices were not influenced by ID severity, which aligns with prevailing guidelines that do not stratify treatment by severity level.^7,12

Despite alignment in many areas, notable gaps emerged in guideline implementation. No reviewed files included standardised review schedules or systematic side-effect monitoring, which are especially critical for PWID given their increased vulnerability to adverse drug effects.²⁵ More than 80% of patients remained on the same medications over a 6-month period, raising concerns about inadequate review of efficacy – particularly in cases involving antipsychotics for BTC, where guidelines explicitly caution against prolonged use without regular reassessment.^12,15,18

Several systemic improvements could enhance adherence to best-practice care. For example, standardised templates for documenting treatment rationale, setting review schedules and recording adverse effects would support clinicians – especially in pressured outpatient settings – in delivering more consistent, guideline-concordant care.^{12,21,29,30,31,32} Additionally, targeted clinician training on ID-specific care could improve confidence in using behavioural approaches and reduce over-reliance on pharmacologic strategies.³⁸ Given South Africa’s unique socio-economic context, there is an urgent need to develop and test locally appropriate behavioural interventions for managing BTC.³⁹

This study provides a valuable initial glimpse into psychotropic prescribing practices for individuals with ID in a South African outpatient psychiatric setting. While prescribing largely aligned with clinical indications for ADHD, anxiety and mood disorders, antipsychotic use was widespread – often for BTC rather than psychosis – and rarely accompanied by behavioural interventions alone. Clinicians demonstrated caution around polypharmacy and prescribed at the lowest effective doses, but gaps remain in review scheduling, rationale documentation and side-effect monitoring. Strengthening clinician training, adopting standardised documentation tools and developing context-specific behavioural interventions are critical next steps. These findings offer a foundation for improving practice at the study site and suggest the need for broader audits and implementation strategies across the country.