Psychotropic Medication Review and Restrictive Practice in Irish Disability Services

This guide covers Ireland. For the UK equivalent, see our guide: STOMP for Learning Disability and Autism: NHS England's Overmedication Programme Explained.

Medicines such as antipsychotics, sedatives and mood stabilisers can be a legitimate part of treatment for a person with an intellectual disability or autism. They can also drift into use as a way of managing behaviour, which Irish policy treats as a restrictive practice. This guide sets out what the HSE guidance, the 2013 disability regulations and HIQA's guidance say, and what that means for support staff and managers in Dublin and across Ireland. It is not clinical advice: staff should always follow the prescriber's and the service's own procedures.

It sits alongside our wider guide to restrictive practice in designated centres in Ireland, which covers physical and environmental restrictions in more detail.

What counts as a restrictive practice

The Health Act 2007 regulations for designated centres for children and adults with disabilities (S.I. No. 367 of 2013, made on 29 October 2013 and in operation from 1 November 2013) define a restrictive procedure as "the intentional restriction of a person's voluntary movement or behaviour." HIQA's guidance uses the same definition. The regulations refer to "physical, chemical or environmental restraint", but the instrument does not itself define chemical restraint. For a working description of how medication can become a restriction, services have to turn to the HSE guidance below.

What the HSE guidance says about medication

The HSE published Preventing the Need for Restriction: Guiding Principles (Version 1, July 2021, approved by the Schedule V Independent Review Group on 29 July 2021). It applies to adults in HSE-provided and HSE-funded day and residential services and excludes services for children. Its appendix on restrictions makes several points about medicines:

• The use of medication to control or modify a person's behaviour is a restriction when no medically identified condition is being treated.
• Using medication to treat an underlying condition, or to enable treatment, is not a restriction.
• Medication used for disciplinary reasons or staff convenience is "never acceptable."
• Examples of concern include the use of psychotropic medication in the absence of a mental health diagnosis, and the long-term use of medication without a review.

The document also comments on language, saying that referring to medicines as "chemicals" is stigmatising because the term is not used for the general population. It refers to a College of Psychiatrists of Ireland framework on PRN (as-required) medication, but it does not summarise that framework, so the HSE page cannot be used as a source for PRN rules.

The principles behind prevention

The HSE document identifies eight guiding principles to assist organisations, and it describes a human rights based approach built on five core principles: participation, accountability, non-discrimination and equality, empowerment and legality. It says services should "prevent, reduce and eliminate the use of restrictions." It lists situations in which restrictions should never be used, including to force compliance, for organisational convenience, to make up for limited staff, skills or resources, because of an inadequate environment, or without proper assessment and due process.

A second HSE document, A Rights Based Approach to Behavioural Support (Version 1, approved 23 July 2020), treats behaviour as communication of an unmet need and says "all behaviour communicates a message." It applies to adults and children with disabilities in HSE-provided and HSE-funded services, expressly including adults with a dual diagnosis such as intellectual disability with autism. It does not mention medication, but it commits services to avoiding restrictive, aversive or punitive responses.

What Regulation 7 requires

As summarised from the 2013 regulations as made, Regulation 7 on positive behavioural support requires the person in charge to ensure staff have up-to-date knowledge and skills to respond to behaviour that is challenging, including training in de-escalation and intervention techniques. The registered provider must ensure that restrictive procedures, including physical, chemical or environmental restraint, are applied in accordance with national policy and evidence based practice. Every effort must be made to identify and alleviate the cause of the behaviour, alternatives must be considered first, and the "least restrictive procedure, for the shortest duration necessary" must be used. The registered provider must ensure that, where required, therapeutic interventions are implemented with the informed consent of each resident or their representative and reviewed as part of the personal planning process.

Other regulations feed into medication review. Regulation 29 requires medicines to be stored securely and administered as prescribed, and Regulation 5 requires personal plans to be reviewed at least annually, or sooner if needs change, by a multidisciplinary review that maximises the person's participation. Regulation 8 requires residents to be protected from all forms of abuse. Regulation 4 requires written policies that are reviewed at intervals not exceeding three years. This post reflects the regulations as made; later amendments were not checked.

Review processes the sources describe

The HSE guiding principles document sets out a number of review features for restrictions in general, which services can apply when a medicine is being used to manage behaviour:

• Each plan for an area of imminent risk must be reviewed at a minimum once every six months, or more often as required.
• Consent is time limited and a review date is specified.
• A plan that includes a restriction must include a rights reinstatement plan, a method to reduce and remove the restriction.
• Debriefing is required after each occurrence of imminent risk, including a review of any restriction used.
• The document says a restriction recommended in a care and support plan is also reviewed by a Human Rights Committee (or equivalent oversight committee), and that a minimum of two disciplines (healthcare professionals) should be included in assessment and decisions.

HIQA's guidance on promoting a care environment free from restrictive practice (the document shows an effective date of June 2023) says restrictive practices should be reviewed on an ongoing basis and "removed as quickly as possible when no longer required." It also says providers should have a group such as a human rights committee or a restraint committee, and that individual use should be "closely monitored, recorded and regularly reviewed."

One limitation matters here. HIQA states that chemical restraint was not a feature of that thematic inspection programme. So the HIQA documents on this topic give detailed expectations on physical, environmental and rights restrictions, but do not provide a separate set of medication rules.

The role of care staff

The sources do not give support workers decision-making power over medicines, but they do set out expectations that apply to staff:

• Staff should have access to appropriate training on restrictive practices, including prevention and alternatives, covering positive behavioural support, de-escalation and physical intervention (HIQA).
• Restrictions are to be used "as per the written protocol", recorded and monitored (HSE).
• Staff should raise inappropriate use of a restriction as a safeguarding concern with their line manager and their Designated Officer (HSE).
• Records should capture details such as the time of day, the staff involved and the location (HIQA).

Medicines practice and safeguarding duties overlap here. Our guides to medication management training for healthcare staff in Ireland and safeguarding vulnerable adults training in Ireland cover the wider picture.

A practical approach, labelled as our suggestion and not a legal requirement:

• Our suggestion: note in daily records when behaviour changes, what happened just before, and whether any as-required medicine was offered or given, using the service's own forms.
• Our suggestion: tell the keyworker or manager if you notice a medicine being used mainly to settle a person, if drowsiness or other changes appear, or if the same medicine has gone unreviewed for a long time.
• Our suggestion: never stop, withhold or change a medicine yourself. Raise questions with the manager so they reach the prescriber through the service's process.
• Our suggestion: make sure the person and their family or advocate know they can ask for a medication review, and support them to attend it.

What the sources do not say

None of the sources cited here gives dosing guidance, lists specific medicines, or sets a fixed interval for reviewing psychotropic prescriptions. The HSE document gives six-monthly reviews for plans covering imminent risk, which is not the same as a prescribing review schedule. Those decisions stay with the prescriber and the multidisciplinary team under the service's policies.

Learnsignal's offices are off Baggot Street in Dublin, and we offer in-person training from there. For current details, see our CPD pages.

Frequently asked questions

Is giving a psychotropic medicine always a restrictive practice?

No. According to the HSE guiding principles, medication used to treat an underlying condition, or to enable treatment, is not a restriction. It becomes a restriction when it is used to control or modify behaviour and no medically identified condition is being treated.

Does the HSE guidance apply to children?

The Preventing the Need for Restriction document applies to adults and excludes children's services. The behavioural support document covers adults and children in HSE-provided and HSE-funded services.

What should a support worker do if they think medication is being used for convenience?

The HSE document says staff should raise inappropriate use of a restriction as a safeguarding concern with their line manager and their Designated Officer.

Was chemical restraint part of HIQA's restrictive practice thematic programme?

HIQA's guidance on restrictive practice states that chemical restraint was not a feature of its thematic programme. The regulations, however, refer to chemical restraint within Regulation 7, so services are still expected to follow national policy.

Understanding where treatment ends and restriction begins helps staff speak up early, and the HSE and HIQA documents are the places to check for the current wording.