Making sense of anti

Making sense of
antipsychotics
(major tranquillisers)
Contents
Making Sense of antipsychotics
What should I know before taking these drugs?
What should my doctor take into account? Which type of antipsychotic should I take? Why do people take more than one antipsychotic? Who should avoid taking antipsychotic drugs? The different types of antipsychotic
Older antipsychotics
Making Sense of antipsychotics
This booklet is for people who are prescribed antipsychotic
drugs, and for their friends, relatives and carers, or anyone
else who has an interest in this type of medication.
What should I know before taking these drugs?
The law says that people have the right to make an informed decision
about which treatment to have, and whether or not to accept the
treatment a doctor suggests. In order to consent properly, a person
needs to have enough information to understand the nature, likely
effects and risks of the treatment, including its chance of success,
and any alternatives to it.
Generally, someone can only receive treatment that they havespecifically agreed to. Once you have given your consent, it isn'tfinal and you can always change your mind. This consent to treatmentis fundamental, and treatment given without it can amount to assaultand negligence. To find out more about when treatment can be givenwithout consent, see Mind Rights Guide 3: Consent to MedicalTreatment. (Details of this and other publications mentioned heremay be found under Further reading, on p. 46.) Patient Information Leaflets
People who are prescribed medication as outpatients, or from their
GP, should find with it an information sheet called a Patient Information
Leaflet (PIL), in accordance with a European Union directive. Inpatients
may have to ask for it, specifically.
The EU directive sets out what information should be included in theleaflet, and in what order. It starts with the precise ingredients of themedicine, including the active ingredient, the drug, and the extracontents that hold it together as a tablet or capsule, such as maizestarch, gelatine, cellulose and colourings. This information is important because some people may be allergic toone of the ingredients, such as lactose. The leaflet gives the name ofthe pharmaceutical company that made the drug. It explains what thedrugs are prescribed for, any conditions which mean you shouldavoid them, and anything else you should know before taking them.
It states whether they are dangerous with other medicines, and, ifso, which types. There are details about how to take them: by mouthor other means, at what time of day, when to take them in relation tomeals (if necessary), the usual dose levels, and what to do if you taketoo many or forget to take them. Next, comes the list of possibleside effects, and then the storage instructions.
The final item on the leaflet tells you that it contains only the mostimportant information you need to know about the medicine, andthat if you need to know more, you should ask your doctor or yourpharmacist. Pharmacists are drug specialists, and may be moreknowledgeable about your drugs than the doctor who prescribesthem. They may be more aware of possible side effects, and alsopossible interactions with other drugs. This is when a drug interactswith other drugs and changes their effects, makes them less effective,or causes additional side effects. Pharmacists are usually very willingto discuss drugs with patients, and some high-street chemists havespace set aside where you can talk privately.
This is a lot of information to include in the PIL, so it’s often printedin very small type, on a piece of paper that is folded many times,which may get thrown away with the packaging, by mistake. If youdo not receive this information with your medicine, you should askfor it from the person who makes up your prescription.
Many people would like to have the information about their proposedtreatment before they are given the prescription for it, and not afterthey have obtained the drugs. The following are questions youmight like to discuss with your doctor when she or he gives you aprescription for a drug:• What is the name of the drug, and what is it for?• How often do you have to take it?• If you are taking any other drugs, will it be all right to take them • Will you still be able to drive?• What are the most likely side effects, and what should you do if • Do you have to take it at any particular time of day? For example, if it is likely to make you sleepy, can you take it at night rather than in the morning? If it is likely to make you feel sick, can you take it with or after food? • When you want to stop taking it, are you likely to have any You may well think of other questions you wish to ask.
What are antipsychotic drugs?
These drugs can help people who are experiencing psychosis, either
as a one-off episode or as part of an ongoing illness. Psychosis is a
broad term, which covers schizophrenia and manic behaviour, but
people may also experience brief episodes during severe depression,
or a physical illness, or sometimes because of taking street drugs.
Someone who is psychotic perceives things and interprets eventsdifferently from those around him. This may include hearing things, such as voices, seeing something other people don’t see (a hallucination) or thinking things that are not based on reality (a delusion). A person may believe, for example, that he or she isunder the control of an outside force. Antipsychotics are often effective in controlling the symptoms ofpsychosis, and enable many people to return to normal life. They maylessen delusions, hallucinations, incoherent speech and thinking, andreduce confusion. The drugs can control anxiety and serious agitation,make the person feel less threatened, and also reduce violent, disruptiveand manic behaviour. However, not everybody finds antipsychoticshelpful, and they can’t cure the problem. They can also have veryserious side effects, which cause major concern to users (see p. 11for more information).
Antipsychotics are also known as major tranquillisers or neuroleptics.
Neuroleptic means taking control of the nerves, and refers to theeffects these drugs have on thought, behaviour and physical movement.
Calling them major tranquillisers is misleading, because these drugsdon’t make people feel tranquil. Although they can cause drowsinessthrough their sedative action, they may also cause intense restlessness. Chlorpromazine was the first antipsychotic used in psychiatry, in the1950s. Since then, many similar drugs have been developed fortreating schizophrenia and other psychotic illnesses and, less commonly,for dementia. They may also be prescribed for anxiety, in very lowdoses, and possibly for treating physical problems, such as persistenthiccups, problems with balance, and nausea in terminal illnesses. There are two main types of antipsychotics: the older, conventionalantipsychotics and the newer atypical drugs.
The conventional antipsychotics divide, generally, into two chemicalgroups:• Low-potency drugs, such as chlorpromazine (Largactil), which are taken in relatively large doses, tend to be very sedating and cause more ‘antimuscarinic’ side effects (see p. 14).
• High-potency drugs, such as haloperidol (Dozic, Serenace, Haldol), which require lower doses and tend to cause more ‘neuromuscular’ side effects (see p. 11).
The atypical antipsychotics, such as risperidone, don’t produce themost disturbing neuromuscular side effects that characterised theolder drugs. For a listing of common antipsychotics, turn to p. 30.
What should my doctor take into account?
Medical history
People respond differently to medication. When a drug is prescribed,
your doctor should take into account any medical conditions you are
suffering from. It may mean that a particular drug is not suitable for
you, or only in low doses.
Severity of symptoms
Psychosis can be extremely distressing, and some people cope better
than others. If you have had frequent psychotic episodes, you may
have developed your own coping strategies, which could mean you
need to rely less on medication than other people.
The impact on friends and family
Acute psychosis is often linked with disturbed and disruptive behaviour
that may place great strain on carers and the people you live with.
What would happen if the drugs were not prescribed?
A person with psychotic symptoms may show dangerous behaviour,
or such disturbed ideas, that they put their own or other people’s
lives in danger.
The risk of relapse
Some research suggests that someone with schizophrenia, who
remains on antipsychotics for a number of years, may be less likely
to relapse than someone who is not taking them.
The pros and cons
Your doctor has to balance the advantages and disadvantages of
treatment. The benefits to you, your family and friends have to be
weighed against the disadvantage of unpleasant side effects.
How do the drugs work?
No-one knows precisely how they work. Most of them have a sedative
action, and most of them block the effects of dopamine, a chemical
neurotransmitter that carries signals between brain cells. This interrupts
the flow of messages, which may be too frequent in psychotic states.
The new atypical drugs are more focused in their action. Clozapine,in particular, may be successful in suppressing psychosis in somepeople who have not responded to older drugs (see p. 35).
How quickly do they act?
This depends partly on how you take them, whether orally or by
injection. When they are injected into a muscle, the sedative effect
is rapid and reaches a peak within an hour. If you take them by mouth,
in tablet or in syrup form, the sedative effect usually takes a few
hours longer. However, the psychotic symptoms, such as voices,
may take days or weeks to suppress. Nobody knows why.
Depot injections
Some drugs are available in an oil-based, slow-release form given
by deep injection, known as a ‘depot’, into a muscle. Depot
injections do not have a fast action, and are given every two to six
weeks (see p. 39).
What dosage should I be on?
The average dose has tended to rise over the years. This is despite
the facts that the most effective dose may be quite low, that increasing
the dose will probably not make it more effective and that it may
make the side effects worse. There are now signs that the trend is
being reversed, especially since the introduction of the newer, atypical
drugs. A recent scientific paper suggests that the most effective
doses of the older, conventional antipsychotics are substantially
lower than has previously been thought necessary.
Dosages of antipsychotics should be kept as low as possible. Thehigher the dose, the greater the unwanted side effects, and someof these can be very distressing. High doses can have a zombie-likeeffect, giving you a mask-like expression and strange movements. It can make it very difficult for you to move normally, to get up andget going in the morning, and to take part in normal activities andsocial events. Moderate to high doses increase the risk of tardivedyskinesia, which is a serious problem causing involuntary movements(see p. 17). Research suggests that low, maintenance doses are aseffective in preventing relapse as higher doses. Elderly people needsmaller doses of drugs, and their health is at risk if they are giventoo high a dose. For information about side effects, see the pageopposite.
You have a right to know what dosage you have been prescribed, andthese vary widely. For example, chlorpromazine (Largactil) can beprescribed in tablet form to physically healthy adults in doses rangingfrom 75mg up to 1g (1000mg) daily. The aim should be to find thedose that lets you lead as normal a life as possible. If the medicationis not working, it’s important for doctors to reconsider the treatmentrather than automatically putting up the dose.
The National Institute for Clinical Excellence (NICE) has issued guidelineson the treatment of schizophrenia and suggests doctors prescribeantipsychotics at the lowest effective dose, introducing the drugsgradually. They suggest that people should not be given a highstarting dose. Regular drug reviews
Your doctor should review your treatment regularly, as a matter of
good practice, to make sure you still need the drugs, that the dose
is still appropriate, and that side effects aren’t troubling you.
Maximum dosage
Among other information, the British National Formulary (BNF) gives
maximum doses for some, but not all of the antipsychotics. A copy
of the BNF should be available in good libraries. A list of common
drugs appears on p. 30 of this booklet, and provides this information,
whenever possible. Your doctor or pharmacist can also tell you.
Generally, the drugs aren’t licensed for use above these dosages,but hospital doctors do exceed them, at their discretion. They mayalso prescribe medication to be given 'as necessary’, which can meanin addition to your regular dose. As a result, your total dose couldbe above the BNF maximum, although your psychiatrist has a duty toreview the total dosage, daily. If you are worried about your diagnosis and treatment, and unsureabout the advice you have been given, you could ask either your GPor your current psychiatrist to refer you to another doctor for asecond opinion.
What are the side effects?
People’s sensitivity and response to drugs varies enormously. One
person may be able to tolerate standard doses with no significant
side effects, while someone else may find the same dose has
intolerable results.
Neuromuscular effects
Antipsychotics, as a group, have a large number of side effects
in common. Because they interfere with dopamine, which is
important in controlling movement, the side effects are largely to
do with the neuromuscular system. These neuromuscular effects
include: Parkinsonism, akinesia, akathisia, distonia, dysphonia and
oculogyric crisis.
Parkinsonism
Some side effects resemble Parkinson’s disease, which is caused by
the loss of dopamine:
• Muscles become stiff and weak, so that your face may lose its
animation, and you find fine movement difficult.
• You may develop a slow tremor (shaking) especially in your hands.
• Your fingers may move as if you were rolling a pill between them.
• When walking, you may lean forward, take small steps, and find • Your mouth may hang open and produce excessive saliva.
Loss of movement (akinesia)
You may find it difficult to move, and your muscles may feel very
weak. This may be mistaken for a symptom of depression.
Restlessness (akathisia)
You may feel intensely restless and unable to sit still. This is more than
just a physical restlessness and can make you feel emotionally tense
and uneasy, as well. The compulsion to move may be overwhelming.
You may rock from foot to foot, shuffle your legs, cross or swing
your legs repeatedly, or continuously pace up and down.
Nursing staff may misread this as a sign of agitation or anxiety, andmay wish to treat it by increasing your dose of antipsychotics. Ifyou are very troubled by akathisia, your doctor may be able toprescribe something to reduce it.
Muscle spasms (dystonia, dysphonia and oculogyric crisis)
These are acute muscle contractions that are uncontrolled and may
be painful. They particularly affect young men. Sometimes the
problem affects the muscles of the larynx (voice box), which makes
it difficult to speak normally (dysphonia). It can be socially
disabling, but is treatable.
Another form of muscle spasm affects the muscles that control eyemovements. Called ‘oculogyric crisis’, it makes the eyes turn suddenly,so that you can’t control where you look. This is very unpleasantand can make it dangerous crossing the road, or pouring hot water.
It’s also very disconcerting for people around you.
Such neuromuscular symptoms can be reduced with the sorts ofdrugs that are prescribed to treat Parkinson’s disease (see p. 40 formore information on these drugs). These symptoms die down whileyou are asleep, so if you take the antipsychotics as a single dailydose in the evening, you could avoid the worst of them (as well asavoiding daytime sedation). You may want to discuss this with yourdoctor to find out whether it would be an option for you. Sexual side effects
Many antipsychotic drugs cause levels of the hormone prolactin to
rise, which has some very common sexual side effects for both
women and men, who may feel too embarrassed to talk about them:
• Breast development and the production of breast milk can affect
• A drop in sexual desire can make men and women less easily aroused, and cause impotence and sterility in men. Some drugs can interfere with erection and affect ejaculation.
• Priapism, a persistent erection of the penis without sexual arousal, sometimes results. This is rare, but if it occurs you shouldtreat it as an emergency and seek medical advice, because it maycause serious harm to the penis.
• Spontaneous ejaculation is sometimes a problem.
• Loss of periods, vaginal dryness, unwanted hair and acne may • Loss of bone density (osteoporosis) can affect both women and men.
Some of the atypical antipsychotics have less effect on prolactin andproduce fewer of these problems. Women who change to an atypicalantipsychotic should bear in mind that when prolactin levels dropback down, their periods may return and that they may need tothink about contraception.
Antimuscarinic or anticholinergic effects
The drugs affect acetylcholine (another chemical messenger) and
this may cause drowsiness, dry mouth, blurred vision, dizziness,
constipation, feeling sick, difficulty passing water and rapid heartbeat.
Constipation may be severe, and should be taken seriously. Low
blood pressure can be a problem, especially in older and frail
people, and it may contribute to falls.
Other effects on the heart
Several antipsychotics have been implicated in sudden deaths. Although
these have been investigated, with no clear conclusion, sudden deaths
have been linked to high doses of antipsychotics (above the BNF
maximum) and to people being on several different antipsychotics
at the same time (see p. 20).
Many of these drugs affect the heart rhythm. The Royal College of Psychiatrists’ guidelines suggest that people on high doses ofantipsychotics should be given an ECG before treatment starts andevery one to three months, while the dose remains high. Whatever your dose, if you are on these drugs and have unexplainedblackouts, you should have your heart rhythm monitored. It mightalso be advisable to avoid drinking grapefruit juice, because it’sthought to increase the impact on heart rhythm.
Sedation
Sleepiness is a common side effect with antipsychotics, but some,
such as chlorpromazine, are more sedating than others (see the list
of drugs on p. 30).
Eye problems
Various antipsychotics may be responsible for different eye disorders,
such as: blurred vision and difficulty reading, a build up of granular
deposits in the cornea and lens (which doesn’t usually affect sight),
degeneration of the retina (the light-sensitive part of the eye) that
restricts vision and may be serious, an oculogyric crisis (see p. 15)
and glaucoma (increased pressure inside the eye). Any antipsychotic
can cause narrow-angle glaucoma, a medical emergency. You should
not take the low-potency antipsychotics if you have had glaucoma.
Other adverse effects
• If you get a rash, you should go to the doctor straight away. Any
allergic rashes usually occur within the first two months of startingtreatment and disappear when the drug is stopped. • A number of blood disorders are linked to antipsychotics. The most serious is agranulocytosis, a serious blood disorder, which involvesthe loss of one type of white blood cell. It reduces resistance to infection and has led to deaths in the past. It’s very rare with the older antipsychotics.
• Weight gain is a very common side effect with a number of antipsychotics and causes a lot of distress. It’s linked to increased appetite and decreased activity, as well as to changes in metabolicrate (the way in which your body uses food and converts it to energy). You may put on a lot of weight, and this may increase the risk of diabetes and other physical health problems. • Difficulty urinating.
• Problems with regulating body temperature. Your temperature may be high or low, both of which may make you feel a little unwell.
• Your skin may burn more easily.
• Blood clots in the veins (thromboembolism) are linked largely to low-potency drugs (but see also clozapine, on p. 35).
• Some types of skin may develop a blue-grey discoloration.
• Antipsychotics can sometimes make people more excited, agitated • Liver disorders and jaundice (see chlorpromazine, on p. 30).
• Antipsychotics can cause emotional changes, such as depression. Others may have an antidepressant effect, although the availableinformation about this is contradictory. Some drugs cause an emotional unease, making people restless, giving them bizarre dreams and disturbing their sleep. They can make people feel strange in familiar surroundings or out of touch with reality (depersonalisation and derealisation). It may also cause them to become more withdrawn, socially.
Neuroleptic malignant syndrome (NMS)
This neurological complication is thought to occur in about one per
cent of hospital patients taking antipsychotic drugs. It can be very
dangerous if it’s not detected and treated, but the symptoms can
be mistaken for an infection.
The symptoms are:• sweating or fever, with a high temperature• tremor, rigidity or loss of movement• difficulty speaking and swallowing• changes in consciousness, from lethargy and confusion to stupor • rapid heartbeat, very rapid breathing and changes in blood pressure• abnormal results from blood tests.
NMS develops rapidly over 24 to 72 hours, and rigidity and a hightemperature are usually the first symptoms to appear. The conditionaffects mostly people under 40, and is twice as common in men. Itcan occur if you are taking standard doses of antipsychotics, and ifyou have been taking the drugs for many years. The main trigger seemsto be a change of dose within the last four to 11 days. High-potencyantipsychotics may produce greater risk, but it can happen with allof these drugs, including the atypical group. Treatment varies andcan include reducing the fever, giving drugs to relax the muscles,and drugs to counter the chemical imbalance that is thought tocause NMS. Electroconvulsive therapy has also been used effectively.
The symptoms may last for days, or even weeks, after stopping thedrugs. Although the criteria for making the diagnosis are not clear,it seems that only about one per cent of people on antipsychoticsare likely to get NMS. Out of these, only 11 per cent may be fatal.
Many people who have had NMS once go on to get it again, so youshould only take antipsychotics afterwards if they are absolutelyessential, and then only the low-potency drugs at the lowest doses.
Tardive dyskinesia (TD)
TD is a disorder of the central nervous system, which causes abnormal,
uncontrollable, disfiguring, and embarrassing movements. These
usually start in the face and mouth, as involuntary tongue movements
and slight grimacing. The problem can spread to the rest of the body,
with writhing movements in the limbs, muscle spasms, tremors and tics.
Most psychiatrists agree that TD is caused by antipsychotics, mainlyaffecting people who have been taking moderate to high doses forlong periods of time, and who have had quite severe Parkinson’ssymptoms. It’s rare in someone who has been taking antipsychoticsfor less than six months, if the doses have been small. It seems that if you get bad Parkinson's effects, you are more likely to get TD. Women, children and older people may be morevulnerable, and possibly those with a mood disorder, such asbipolar disorder (manic depression). The problem may not be discovered until after you stop taking the antipsychotics, because they mask the symptoms of TD. Butunfortunately, stopping and starting them may make TD morepersistent, once it has developed. Some people remain on the drugsas a way of dealing with the symptoms, although this may result infurther damage.
Sometimes when drugs are withdrawn, withdrawal dyskinesias mayoccur, but this is not necessarily the same as TD (see p. 24).
There’s disagreement about how common TD is, and about thenumber of people who are permanently affected. Estimates of therisks of developing TD, after long-term use, range from five to 56 percent, but 20 per cent is a widely accepted estimate for those treatedfor four years, or longer. The risk is higher for people on depotpreparations (see p. 9). There is believed to be much less risk of TDwith the atypical drugs. Dealing with TD
If you stop taking the drugs, TD may disappear of its own accord.
In about half of patients, the symptoms will improve, spontaneously,
although this may take up to five years after stopping the drugs.
However for a lot of people, TD is permanent. Although it’s
incurable, some possible treatments may help, if it’s identified early.
Some people can’t stop taking the drugs, because of the risk ofrelapse. This risk must be weighed in the balance against the riskof TD. If you have been taking one of the old antipsychotics, youmight be able to switch to an atypical such as clozapine, risperidone,olanzapine, or quetiapine, which have been found to help TD. There is evidence that clonazepam (a benzodiazepine used in epilepsy)may be useful, and that vitamin E and also vitamin B6 are helpful insome cases. If you are taking anti-Parkinson drugs, it may be a goodidea to stop. TD doesn’t necessarily develop or get progressivelyworse in all cases, and using the lowest possible dose ofantipsychotic minimises the risk. Tardive psychosis
Sometimes, psychotic symptoms develop during or after using
antipsychotics for long periods of time. Dopamine receptors may
become super-sensitive after long-term use, which means that higher
doses are needed to maintain the antipsychotic effects.
Some people who withdraw from these drugs find that theirpsychotic symptoms have become worse. This is another reason forusing no more of the drug than is absolutely necessary.
Which type of antipsychotic should I take?
Antipsychotic drugs treat the 'positive' symptoms of schizophrenia,
which include delusions and hearing voices. The negative symptoms
include feeling apathetic, not looking after yourself, and being
unable to concentrate. Older antipsychotics usually have no effect
on the negative symptoms, and some of the side effects may even
make them worse. Atypical antipsychotics usually help with both
types of symptoms.
You should be given a choice about which type of antipsychotic totake, but if you are unable to make a choice, then you should begiven an atypical. In its guidelines for using antipsychotic drugs,NICE recommends atypical antipsychotics:• as a first-line treatment, if you are newly diagnosed with schizophrenia. The initial dosage should be at the lower end of the standard range • if you have an acute episode of schizophrenia, and you are not able to discuss the choice of drug with the doctor • if you have had unacceptable side effects on older drugs• if you have had a relapse, and your symptoms did not respond If you are already on a conventional antipsychotic, and your symptomsare responding well, without causing you unacceptable side effects,there’s no need to change to an atypical antipsychotic. If neither conventional nor atypical antipsychotics are controlling your symptoms,after an adequate trial period of six to eight weeks, you should tryclozapine (see p. 35).
Why do people take more than one antipsychotic?
Your doctor may want to prescribe more than one antipsychotic at
a time, if the drug you are currently taking doesn’t seem to be working
well enough. This is known as polypharmacy.
Sometimes a doctor may prescribe an oral drug as well as a depot,sometimes a conventional drug as well as an atypical antipsychotic.
In most cases, doctors should avoid combining conventional withatypical antipsychotics. The atypical have fewer side effects than thestandard antipsychotics, but this benefit is undermined if you aretaking both at the same time. In some cases, however, doctors maylegitimately augment clozapine with sulpiride, for example, (see p. 33).
Polypharmacy is not recommended in the BNF. Patients may end uphaving a high total dose, even though each individual drug is withinthe recommended dose range. If you are detained in hospital underthe Mental Health Act, you are far more likely to be taking more thanone antipsychotic, or to be on a high dose, than someone who is avoluntary patient.
Research has shown that adding a second drug doesn’t usuallyimprove the outcome very much, but does increase the side effects,can diminish your quality of life, and may even be life-threatening.
The NICE guidelines also say that it’s best to use a single drug. Theysay that two or more antipsychotics should not be given at the sametime, except for short periods when you are switching from one toanother.
If you are taking more than one antipsychotic drug, try working outthe dose of each as a percentage of the maximum recommendedin the BNF. Add the percentages together to see if you are takingmore than 100 per cent in total. You can also ask your doctor or apharmacist to help you work this out. What happens if I am taking other drugs?
If you are taking any other drugs as well as the antipsychotic
(whether these are on prescription, or bought over the counter
from a pharmacist or alternative health practitioner) discuss with
your doctor any possible interactions, which could increase adverse
effects or be dangerous. The following information only relates to
combinations of psychiatric drugs.
Drugs with antimuscarinic effects
If certain antipsychotics are combined with other dugs that have
antimuscarinic properties, the antimuscarinic effects are likely to
increase (see p. 16). This applies particularly to tricyclic antidepressants
and to antipsychotics, such as chlorpromazine (Largactil), and other
low-potency antipsychotics. The anti-Parkinson’s drugs are also,
rather confusingly, antimuscarinics (see p. 40). These combinations
can also induce delirium, which may be hard to detect in psychosis.
Antidepressants
The antidepressant trazodone, taken with drugs such as chlorpromazine
(Largactil), can cause lowered blood pressure. There is an increased
risk of disturbances of heart rhythm if antipsychotics are taken with
tricyclic antidepressants.
Antiepileptic drugs
Fits are more likely to happen if you are taking antiepileptic drugs.
Minor tranquillisers
Taking drugs for anxiety, or to help you sleep, increases the sedative
action of the antipsychotics.
Lithium
If lithium (Camcolit, Liskonum, Priadel, Litarex) is taken with the older
antipsychotics, it increases the chances of Parkinson’s effects, muscle
spasms and neuromuscular restlessness, as well as possible toxic effects.
The antipsychotics should be started at a lower dose than usual.
Carbamazepine
Carbamazepine makes the body process some drugs faster. This
lowers the level of the drug in the blood.
Alcohol
Drinking alcohol increases sedation. You should ask your doctor
whether it’s safe to drink when you are on these drugs.
What about rapid tranquillisation?
In an emergency situation, when you are considered to need rapid
tranquillisation (if you are endangering yourself or others), you may
be given drugs by injection. Clopixol Acuphase is one of the drugs
used for this purpose (see p. 34).
The Royal College of Psychiatrists suggests that high doses of suchantipsychotic drugs can be avoided by using a combination ofmoderate doses of benzodiazepine and of an antipsychotic. TheNICE guidelines recommend that the preferred drugs are lorazepam(a benzodiazepine tranquilliser), haloperidol, or olanzapine. Ifhaloperidol is used, then an anti-Parkinson's drug should be given,as well, to minimise the side effects.
The guidelines also say that rapid tranquillisation may be traumatic,and afterwards you should be given the opportunity to discuss itwith hospital staff, and to write your own record of the experienceif you wish, which should be kept in your hospital notes.
How easy is it to come off these drugs?
Once prescribed antipsychotic drugs, you may need to stay on them
for some time. The substantial majority of people tend to remain on
them. However, if you have been taking antipsychotics for some time,
and have been well, you may want to stop and see if you really
need them, or if you can cope successfully in other ways, without
needing medication.
Getting enough support
To increase your chances of success, you need plenty of support,
which should ideally include your doctor. Unfortunately, a lot of
people find that their doctors are not very helpful when it comes to
withdrawing. Some psychiatrists believe that people with a diagnosis
of schizophrenia, who remain on the drugs for a number of years,
have fewer relapses than those who are not on antipsychotics. But
there are other factors that influence relapses, besides taking
medication. Giving families and carers supportive services is also
helpful and reduces the risk of relapse.
The best time to try is when you are not currently under stress (fromproblems to do with housing, finance, a job or your family, forexample). It may be a good idea to postpone withdrawal until youcan be more relaxed, and pay attention to how you are feeling. TheBNF says, ‘Withdrawal of antipsychotic drugs after long-termtherapy should always be gradual and closely monitored, to avoidthe risk of acute withdrawal symptoms or rapid relapse.’.
Reducing your tablets
If you are taking tablets, then one suggested way of cutting down
is to reduce your dose by up to one fifth, at monthly intervals.
However, this may be too fast for some people. If you have been
taking the drug for some years, then the gradual reduction may
take at least a year.
Reducing depot injections
If you are on depot injections, it can take two years to reduce the
dose and cut them out completely, depending on the starting dose.
One psychiatrist advises that the dose should only be reduced once
every three months, by no more than one third of the current dose.
Others suggest that because these drugs are designed to stay in the
body for a long time, it will naturally take a long time to clear them,
so withdrawal will automatically be gradual. If you are on oral
medication as well as depot, reduce and stop the oral medication
first. In all cases, coming off the last quarter of the original dose is
often the most difficult, and you may need to reduce it extremely
slowly.
If you are taking anti-Parkinson’s drugs for the unpleasant sideeffects, you should continue until you have substantially reduced thedose of antipsychotic. Withdrawal effects
You are more likely to get withdrawal effects if you stop taking the
drugs suddenly. Rarely, you may find the following effects within a
few days of stopping:
• You may experience nausea, vomiting, diarrhoea, high blood
pressure, sweating, restlessness, disturbed sleep, runny nose and excessive saliva. This happens, especially, after stopping drugs withantimuscarinic side effects, such as thioridazine (Melleril) and chlorpromazine (Largactil).
• If you have tardive dyskinesia, it may get worse, or signs of it • You may temporarily experience involuntary movements, which • Psychotic symptoms, such as delusions and hallucinations, may emerge as a result of the withdrawal. This may make you or yourdoctors think that you are relapsing.
You may find withdrawal stressful and difficult, but still feel able topersist if it means that you will be able to cope, successfully, withoutthe drugs in the end. What are the chances of relapsing?
Some people find that their psychotic symptoms return if they stop
taking the drugs, but it’s not possible to know this in advance, especially
the first time you try. It’s important to go at your own pace, watching
out for signs of relapse, such as sleeplessness, or feeling tense and
irritable. Once you have come off the drugs, the average time for
relapse, if it happens, is about four to five months afterwards. You
may find it helpful to involve your family or friends and ask them
to tell you if they think you are becoming unwell. Self-help groups
may also be helpful. People who have had symptoms on and off
for years, or who have previously relapsed after stopping, may be
at a higher risk of relapse.
If you show signs of relapse while you are withdrawing, you shoulddelay any further reduction, or possibly go back on the drug for awhile. Your psychiatrist may be prepared to give you or your relativesan emergency supply of oral medication to use, if you need to. Oryou may decide to try and do without, depending on your previousexperience, as long as you have other forms of support.
If you have tried to withdraw in the past, but had a relapse and hadto go back on medication, there may have been a number of reasons:• You tried to withdraw too quickly.
• There were other things happening in your life at the time that • The drugs have made the dopamine receptors in your brain super-sensitive, so it’s much harder for you to withdraw (see tardive psychosis, on p. 21). • You found the stress of withdrawal too difficult to cope with.
• You need to go on taking the drugs (many doctors would You may want to discuss these issues with someone you trust, such as a doctor, psychiatric pharmacist, other mental healthprofessionals, or a local drug withdrawal support group.
Who should avoid taking antipsychotic drugs?
Anyone with the following should use these drugs with caution:
• liver or kidney disease
• heart disease
• Parkinson’s disease
• epilepsy
• depression
• myasthenia gravis (a disease affecting nerves and muscles)
• an enlarged prostate
• a history of glaucoma, an eye disease (see p. 17)
• lung disease with breathing problems
• some blood disorders.
Antipsychotics should not be given to people with phaeochromocytoma
(a type of tumour causing very high blood pressure) or anyone in a
state of impaired consciousness, such as a coma.
The elderly
Doctors should also prescribe them with caution to elderly people.
This is because they may be prone to drops in blood pressure when
standing up, leading to falls, and also to both high and low body
temperature.
Sunbathing
Antipsychotics may make the skin more sensitive to sunlight, especially
at high doses, so you should protect your skin from direct sunlight.
Pregnancy and breastfeeding
As a general rule, you should avoid taking any drugs during pregnancy
and while breastfeeding, to avoid any possible risk to the developing
and newborn infant. Taking drugs is only a good idea if the benefits
to you are likely to outweigh the risk to the baby.
If possible, avoid all drugs at least during the first three months.
Prochlorperazine (Stemetil), in particular, is associated withmalformations in the developing baby during this period. Therehave also been reports of temporary muscle disorders in newbornbabies, if antipsychotics are used in the last three months ofpregnancy. Because long-acting drugs take time to clear from thebody, it’s important to take your final dose six to eight weeksbefore the baby’s expected delivery date. The manufacturers advise women not to take the atypical drugswhen breastfeeding. It’s best to avoid antipsychotics altogether, ifpossible, at this time.
Ask your doctor and your pharmacist about the safety of any drugyou are advised to take. It’s very important to discuss any concernswith your doctor and other professionals responsible for yourhealth during pregnancy and delivery. What are the alternatives to drugs?
Most doctors feel that antipsychotic drugs are essential, and that
you will need to take them in order to be able to benefit from any
other sorts of treatment, such as cognitive behaviour therapy, that
may be available. If you have had episodes in the past and know
what is helpful to you and what is not, you may disagree and
prefer to use alternatives to drugs.
Crisis centres
Crisis centres are alternatives to hospital, planned as places of asylum
and refuge. Staff can support people through their experience,
together with others who have been through a similar crisis
themselves. Such services are still too rare in this country.
Cognitive behaviour therapy (CBT)
CBT can help you to cope with psychotic experiences and the
disruption to everyday life that this may bring. Because thoughts
have a powerful impact on feelings and behaviour, it’s possible for
people to think themselves into a state of extreme distress. But it’s
also possible to bring about a state of wellbeing through changing
the negative thought patterns that feed psychotic or paranoid
feelings. You may be offered CBT as part of your care plan. If not,
you could ask your care coordinator or your GP for a referral to see
a clinical psychologist, or you could contact a professional body
(see Useful organisations, on p. 45, and Further reading, on p. 46).
Counselling and psychotherapy
You may find it helpful to talk to a counsellor or a psychotherapist
about your experiences, to try and make sense of them, or to relate
them to events in your life. More and more GPs are employing
counsellors in their practices. If not, your GP or your psychiatrist
may be able to refer you to a psychotherapist or counsellor. (See
Useful organisations, on p. 45, for more information, and see Further
reading, on p. 46, for details of Mind’s booklet Understanding Talking
Treatments.)
Arts therapies
Therapies using art, music, drama, dance or creative writing may
be very powerful aids to recovery, helping you to make sense of
your symptoms and work your way through them. If you have difficulty
putting your feelings into words, they are a means of expressing
yourself. These therapies are available in some psychiatric units and
community mental health facilities, and it’s worth asking local
information providers what is happening in your area.
Complementary therapies
Complementary and alternative therapies may be very helpful when
you are recovering from an episode of distress. They can be a useful
tool for promoting relaxation and inducing a state of wellbeing.
Complementary therapists emphasise the connections between mind
and body and are not concerned with merely treating symptoms.
Self-help groups
Many people experiencing emotional distress find it helpful to
share their feelings with others going through similar difficulties.
There are self-help organisations for people suffering from various
forms of mental distress, including those who hear voices (see
Useful organisations, on p. 45).
The different types of antipsychotic
Older antipsychotics
All these drugs are listed under their general names, with the
manufacturers' names in brackets afterwards. They are all high-
potency drugs, unless otherwise indicated. The drug chlorpromazine
is the standard by which all the others are measured.
Side effects common to all the drugs are covered elsewhere (see p. 11).
Dosages of antipsychotics can vary considerably and details are notgiven here, except when the BNF specifies a maximum daily dose.
Maximum doses are based on what is dangerous, rather than whatis most effective. The most effective dose may be considerably lowerthan the maximum safe dose, in some cases. Where a drug is notrecommended for children, this is shown by the symbol the drug name. For the index of drug names, turn to p. 44.
Benperidol (Anquil) Similar to haloperidol. Dose: maximum 1.5mg per day.
Chlorpromazine (Largactil)A low-potency drug, and the one with which all the others arecompared. Side effects: one of the most sedating of the olderantipsychotics and causes antimuscarinic effects, in particular. Canmake skin very sensitive to sunlight. It may cause low blood pressure,especially in the old and frail, blurred vision and weight gain. Around20 to 30 per cent of long-term users have a build up of granulardeposits in the cornea and lens. This is partly dose-related. It doesnot usually affect sight. Avoid it if you have glaucoma. It sometimescauses emotional unease (see p. 14), but may have an antidepressanteffect. It has been linked with blood clots (thromboembolism).
Chlorpromazine can cause liver toxicity (poisoning) and regulartests of liver function are sometimes advised before starting, andduring the first six months of treatment. Jaundice may occur in thefirst two months. It should disappear in the month after stopping.
Dose: maximum not specified, but 1g (1000mg) per day is the highestdose mentioned in the BNF. This drug may be given to children forchildhood schizophrenia and autism, and for intractable hiccups.
The maximum dose for a child aged one to five is 40mg per day,and for a child aged six to 12 years, 75mg per day.
Flupentixol (Flupenthixol, Depixol, Fluanxol) Side effects: less sedating than chlorpromazine, but with moreneuromuscular (Parkinson’s) effects. It may have an antidepressanteffect. Dose: maximum 18mg per day. (See also flupentixol decanoate,on p. 39.) Fluphenazine (Moditen) Side effects: less sedating and fewer antimuscarinic effects thanchlorpromazine, but more neuromuscular reactions, especiallymuscle spasms and restlessness. It may cause depression. Dose:anything over 20mg per day to be used only with special caution.
Haloperidol (Dozic, Haldol, Serenace)Side effects: less sedating and fewer antimuscarinic effects thanchlorpromazine, but more neuromuscular effects, especially musclespasms and restlessness. Rare side effects include altered liverfunction, gastrointestinal disturbance and weight loss. Caution:fluoxetine increases levels of this drug in the blood, and carbamazepinelowers them. There are increased risks if haloperidol is taken withlithium (see p. 23). Dose: no maximum dose is specified in the BNF,but the highest dose mentioned is 30mg per day. This drug may begiven to children to treat schizophrenia or dangerously violent orimpulsive behaviour, at a maximum dose of 10mg per day.
Loxapine (Loxapac) Low potency. Similar to chlorpromazine, but less sedating. Side effects:nausea and vomiting, weight changes (gain or loss), shortness ofbreath, drooping eyelids, high temperature, flushing, headache,tingling, numbness and excessive thirst. Dose: maximum 250mgper day.
Levomepromazine/methotrimeprazine (Nozinan)Low potency. Side effects: more sedating than chlorpromazine,and with a risk of lowered blood pressure, particularly in peopleover 50. Dose: highest mentioned in BNF is 1g (1000mg) per day.
No clear advice about children.
Pericyazine (Neulactil)Side effects: more sedating than chlorpromazine, and lowered bloodpressure when treatment starts. Dose: usual maximum 300mg perday. May be given to children for severe mental or behaviouraldisorders only, at a maximum dose of 10mg per day.
Perphenazine (Fentazin) Side effects: less sedating than chlorpromazine, but moreneuromuscular reactions, especially muscle spasms, particularly athigh doses. It may cause blurred vision. Dose: maximum 24mg per day.
Pimozide (Orap) Side effects: less sedating than chlorpromazine. It may causedepression. Caution: serious disturbances in heart rhythm reported,especially when doses are high dose. The Committee on Safety ofMedicines recommends ECG before treatment starts and periodicallythereafter on doses over 16mg daily. If other antipsychotic drugs aretaken at the same time, there may be a greater risk of toxic effectson the heart (see p. 16). Avoid taking it with tricyclic antidepressants.
Prochlorperazine (Stemetil) Side effects: less sedating than chlorpromazine, but moreneuromuscular reactions, particularly muscle spasms.
Promazine (Sparine) Low potency. Similar to chlorpromazine and one of the mostsedating of the older antipsychotics.
Sulpiride (Dolmatil, Sulpitil) Low potency. Side effects: less sedating than chlorpromazine anda different chemical group. Not associated with jaundice or skinreactions. Dose: maximum 2.4g per day (2400mg per day).
Thioridazine (Melleril) Low potency. Side effects: strong antimuscarinic effects (see p. 14)and may cause weight gain, blurred vision, and blood clots(thromboembolism). It may have an antidepressant effect. It is lesssedating than chlorpromazine and lowered body temperature occursrarely. There are fewer neuromuscular reactions. Lowered bloodpressure is more common (especially in the old and frail). Degenerationof the retina of the eye, with restricted vision occurs, rarely, with highdoses. It can interfere with erection, and affect ejaculation, causing,in particular, retrograde ejaculation (in which seminal fluid goes backinto the bladder). Caution: the licence now restricts it to the treatmentof schizophrenia only, under the supervision of a consultant psychiatrist,because, in rare cases, thioridazine may disturb the heart rhythm, andcould put vulnerable people at risk of sudden death. These effectsoccur only while taking thioridazine, and do not continue after it isstopped. People who are taking thioridazine for the first time shouldhave an ECG and basic blood tests before starting treatment, andthese should be repeated after any increase in dose, or every sixmonths. Dose: maximum 600mg per day (hospital patients only).
Trifluoperazine (Stelazine)Side effects: less sedating, less likely to lower body temperature or blood pressure, and causes fewer antimuscarinic effects thanchlorpromazine. Produces neuromuscular reactions, and restlessness,especially when the dose is over 6mg daily. It may causespontaneous ejaculation. May be given to children.
Zuclopenthixol (Clopixol Acuphase) Similar to chlorpromazine. This drug is given by injection and is for up to two weeks' treatment only. It may cause spontaneousejaculation. Dose: maximum 400mg per course and four injections.
Zuclopenthixol dihydrochloride (Clopixol) Similar to chlorpromazine. Dose: maximum 150mg per day. Atypical antipsychotics
The atypical antipsychotics were mostly first licensed in the 1990s,
having been developed with the aim of reducing the neuromuscular
side effects associated with the older drugs. Some of them also have
fewer of the side effects associated with raised prolactin levels. All
of these drugs are licensed for the treatment of schizophrenia.
CautionThey should be used with caution in people with cardiovascular(heart and circulation) disease, those with a history of epilepsy, orParkinson’s disease. They may affect your ability to perform skilledtasks, including driving, and may increase the effects of alcohol. Side effects Main side effects include: weight gain, dizziness, mild and short-livedneuromuscular symptoms, low blood pressure on standing upright,which may be associated with fainting or rapid heart beat in somepeople. Occasionally, tardive dyskinesia may occur after long-termuse; rarely, neuroleptic malignant syndrome. Other side effects arelisted under the individual drugs.
Amisulpride (Solian) This is given for both positive and negative symptoms of schizophrenia.
Caution: it should be used with caution in people with kidneyproblems and in elderly people. It should not be used in pregnancyor while breastfeeding. Side effects: insomnia, anxiety, agitation,raised prolactin levels causing milk production, loss of menstrualperiods, breast development, breast pain and sexual problems.
Occasionally: slow heart beat and fits; changes in heart rhythmmay occur. Dose: maximum 1.2g per day (1200mg per day).
Clozapine (Clozaril) Clozapine is licensed for treatment of schizophrenia when otherantipsychotics are unsuitable. Caution: it carries a three per cent riskof causing agranulocytosis (see p. 17). It can only be prescribed bypsychiatrists. Patients have to be registered with the Clozaril PatientMonitoring Service, and must have regular blood tests, every week,for the first 18 weeks of treatment, and fortnightly thereafter. Bloodcounts must be satisfactory before the drug is started. If blood problemsare detected, the drug must be stopped. The problem is not dose-related, and the risk of developing it decreases after the first year. Itis almost always reversible by stopping the drug. The greatest riskof developing serious blood disorders appears to be between thesixth and 18th weeks of treatment, and is more common in women.
Any infections that develop should be reported to the doctor. It shouldnot be used at the same time as other drugs that cause agranulocytosis,including carbamazepine. Clozapine has also been linked with bloodclots (thromboembolism). SSRI antidepressants may increase itslevels in the blood. It should not be combined with long-acting depotantipsychotics. Smoking may decrease its blood levels, while caffeinemay increase them, so dosage should be monitored accordingly.
Side effects: sedation, drooling saliva, rapid heartbeat, bloodpressure changes (high or low), dizziness, headache, and drymouth. Some of these improve, although rapid heartbeat, droolingand sedation may persist. Less common side effects: fits occur,occasionally (dose-related), constipation, nausea or vomiting, highbody temperature, weight gain, drowsiness, fever and headache.
Movement disorders and tardive dyskinesia are rare, butneuromuscular restlessness, sluggish movements and tremor canoccur. Toxic delirium and sedation requiring withdrawal in a smallpercentage of people. Withdrawal: rebound psychosis has beenreported, and other antipsychotic drugs may not be effectiveafterwards. Clozapine should not be stopped abruptly. Dose:maximum 900mg per day.
Olanzapine (Zyprexa)The BNF suggests that this drug is effective in maintainingimprovements in people who have responded to initial treatment. It may also be used to treat moderate to severe mania. Caution:it should be used with caution in pregnancy, in men with prostateproblems, and in people with paralytic ileus, or liver or kidney problems,or those taking certain types of heart drugs. Anyone with closed-angle glaucoma (an eye disease) or who is breastfeeding shouldnot take it. Carbamazepine lowers the level of this drug in theblood. Side effects: mild, short-lived antimuscarinic effects,drowsiness, increased appetite, peripheral oedema (puffy feet andhands), raised prolactin (but rarely high enough to causesymptoms), occasional blood problems, and sensitivity to sunlight.
There is evidence that olanzapine may cause, or increase, the riskof diabetes in some people. Recent research suggests that it maycause an increase in blood fats, such as cholesterol, in elderlypeople. Olanzapine comes in tablets and also as Velotab, a tabletthat dissolves on the tongue or that can be added to drinks, suchas water, milk or juice. Dose: maximum usually 20mg per day. BNFgives no guidance on use in children.
Quetiapine (Seroquel) Used especially in people with intolerable Parkinson’s symptoms, orsymptoms of raised prolactin levels caused by other drugs. Similarto clozapine, and causes fewer neuromuscular effects than theolder antipsychotics. Not associated with serious blood disorders.
Caution: it should be used with caution in pregnancy, in peoplewith liver or kidney problems, in elderly people, and in people whoare taking some types of heart drugs, or who have cerebrovasculardisease. It should not be used while breastfeeding. Side effects:drowsiness, indigestion, mild loss of strength and energy, stuffy nose,fast heartbeat, anxiety, fever, muscle pain, rash. Rare effects: blooddisorders, low thyroid hormone and possible changes in heartrhythm. Dose: maximum 750mg per day.
Risperidone (Risperdal) Thought to improve both positive and negative symptoms ofschizophrenia. It has effects similar to chlorpromazine, butneuromuscular effects are usually less marked. Caution: it shouldbe used with caution in people with liver or kidney disease, epilepsy,or heart disease, as low blood pressure can occur. It may aggravateParkinson’s disease. It can impair alertness and can therefore interferewith the ability to drive and operate machinery. Caution is advisedif other drugs with similar actions are given. Carbamazepine lowersits blood levels. Side effects: insomnia, agitation, anxiety, andheadache, weight gain. Less common side effects: drowsiness,fatigue, dizziness, difficulty concentrating, constipation, indigestion,nausea, abdominal pain, blurred vision, problems with erection andejaculation, nasal inflammation, and rash. Occasional side effects:low blood pressure, dizziness, and increased heart rate, particularlyif high doses are given at the start of treatment. There are rarereports of neuroleptic malignant syndrome, water intoxication andfits. Dose: maximum 16mg per day.
Sertindole (Serdolect)Caution: this drug was suspended following reports of seriouseffects on heart rhythm and sudden death. It is now beingreintroduced in Europe, but initially only for patients enrolled inclinical studies, who will be carefully selected and monitored.
Zotepine (Zoleptil) This is a relatively new antipsychotic. Caution: it should not be givento people intoxicated with alcohol or other central nervous systemdepressants, or to people with gout or kidney stones. It should beused with caution in people with epilepsy, people at risk of heartproblems and those with high blood pressure, prostate problems,urinary retention, narrow-angle glaucoma, and paralytic ileus. Itshould also be used with caution in combination with otherantipsychotics, fluoxetine (Prozac) and diazepam (Valium), and withdrugs which lower blood pressure. Zotepine should be avoided, ifpossible, in pregnancy and while breastfeeding. Side effects:weight gain, drowsiness, loss of strength and energy, dry mouth,akathisia and other neuromuscular effects (but less common thanwith the older antipsychotics). Chills, headache, pain, low bloodpressure, rapid heart beat, constipation, indigestion, altered liverfunction, blood effects, depression, dizziness, insomnia and blurredvision were reported during trials. Less common side effects: flu-likesymptoms, raised prolactin, sexual problems, appetite changes andconvulsions. Sexual side effects should be less of a problems at lowerdoses. Isolated cases of neuroleptic malignant syndrome and tardivedyskinesia have been reported. Dose: maximum 300mg per day.
Antipsychotics through depot injection
Some antipsychotics can be given in a slow-release formulation by
deep injection into a muscle. They may be given weekly, fortnightly,
or every few weeks. Depot injections may cause more neuromuscular
reactions than oral drugs. There can be pain at the site of the injection
and, occasionally, swelling and small lumps. Many people remain
on a high depot dose for many years, because their dose has not
been changed since they were discharged from hospital after an
acute episode of illness. You should have a continuous assessment
of the risks to you, versus the benefits, and to find out whether
you could have a lower dose.
These drug formulations are based on nut oils, to which some peoplemay be hypersensitive or allergic. Sometimes, these are referred toas ‘vegetable oil’ in the Patient Information Leaflet, but they are eithersesame or coconut oil. If you and your doctors are considering depotdrugs, and you have a nut allergy, make sure they know this. Flupentixol/flupenthixol decanoate (Depixol, DepixolConcentrate, Depixol Low Volume) Caution: contains coconut oil. Can cause over-excitement if givento people who are agitated or aggressive. Side effects: moreneuromuscular reactions than chlorpromazine. Dose: maximum400mg per week.
Fluphenazine decanoate (Modecate, Modecate Concentrate) Caution: should not be given to people who are severely depressed.
Contains sesame oil. Side effects: any neuromuscular reactions usuallyappear a few hours after the dose is given and continue for abouttwo days, but may be delayed. Haloperidol decanoate (Haldol Decanoate) See haloperidol. Caution: contains sesame oil.
Pipothiazine palmitate (Piportil Depot) Similar to chlorpromazine. It may cause depression. Caution:contains sesame oil. Dose: maximum 200mg every four weeks.
Zuclopentixol decanoate (Clopixol, Clopixol Concentrate) Side effects: similar to chlorpromazine but less sedating. Caution:contains coconut oil. Dose: maximum 600mg per week.
Anti-Parkinson's drugs
These drugs are given to lessen the neuromuscular effects of
antipsychotics, which resemble the symptoms of Parkinson’s disease.
(Somewhat confusingly, they are also called antimuscarinics,
although they are not used for antimuscarinic side effects.) The
World Health Organisation has stated that anti-Parkinson’s drugs
should not be given routinely to people on antipsychotics, but only
when Parkinsonism has actually developed. Anti-Parkinson’s drugs
should only be used when it is either not advisable to change the
antipsychotic or reduce the dose, or where this has not worked.
These drugs can cause confusion and memory problems and,occasionally, makes the psychosis worse. Due to their stimulanteffect, they have the potential for abuse and can occasionally behabit forming. When withdrawing, you should go gradually andnot stop suddenly. Trihexyphenidyl hydrochloride is the standard towhich the others are compared.
Benzatropine mesylate/benztropine mesylate (Cogentin)A sedative rather than stimulant effect, otherwise similar totrihexyphenidyl hydrochloride. Dose: maximum 6mg per day. Avoid in children under three years old.
Biperiden hydrochloride (Akineton)Similar to trihexyphenidyl hydrochloride. Caution: may causedrowsiness.
Orphenadrine hydrochloride (Biorphen, Disipal)Similar to trihexyphenidyl hydrochloride. Side effects: it can have aeuphoric effect and may cause insomnia. Dose: maximum 400mgper day.
Procyclidine hydrochloride (Arpicolin, Kemadrin)Similar to trihexyphenidyl hydrochloride. Dose: maximum 30mg perday (60mg per day in exceptional circumstances).
Trihexyphenidyl hydrochloride/benzhexol hydrochloride(Broflex) Side effects: dry mouth, gastrointestinal disturbances, dizziness,and blurred vision. Less common side effects: difficulty urinating,rapid heartbeat, hypersensitivity, nervousness and, with high doses,confusion, excitement and psychiatric disturbances. If this happensthe drug should be withdrawn. This drug has a stimulant effect.
Dose: maximum 20mg per day.
References
‘Antipsychotic drugs and heart muscle disorder in internationalpharmacovigilance: Data mining study’ D. M. Coulter, A. Bate, R. H. B. Meyboom, M. Lindquist, I. R. Edwards (2001) BritishMedical Journal 322, 1207-1209 ‘Antipsychotic prescribing – time to review practice’ D. Taylor (2002) Psychiatric Bulletin 26, 401-402 ‘Antipsychotics and risk of venous thrombolysis’ F. Curtin, M. Blum (2002) British Journal of Psychiatry 180, 85 ‘Brain dopamine and obesity’ G. Wang et al (2001) Lancet 357, 354-357 ‘Chlorpromazine equivalents and percentage of British NationalFormulary maximum recommended dose in patients receiving high-dose antipsychotics’ G. Yorston, A. Pinney (2000) PsychiatricBulletin 24, 130-132‘Conventional antipsychotic drug use linked to venousthromboembolism’ G. L. Zornberg, H. Jick (2000) Lancet 356,1219-1223‘Coprescribing of atypical and typical antipsychotics – prescribingsequence and documented outcome’ D. Taylor, S. Mir, S. Mace, E. Whiskey (2002) Psychiatric Bulletin 26, 170-172‘Depot injections and nut allergy’ S. Reeves, R. Howard (2002)British Journal of Psychiatry 180, 188‘Hyperprolactinaemia caused by antipsychotic drugs’ A. Wieck, P. Haddad (2002) British Medical Journal 324, 250-252‘Hyperprolactinaemia caused by antipsychotic drugs’ O. Howes, S. Smith (2002) British Medical Journal 324, 1278‘Olanzapine may increase risk of hyperlipidemia in geriatric patients’C. E. Koro et al (2003) The Brown University GeriatricPsychopharmacology Update 7(2), 1, 4-5‘Olanzapine-associated Diabetes Mellitus’ E. A. Koller, P. MuraliDoraiswamy (2000) Pharmacotherapy 22(7), 841-852‘Physical complications of mental illness must be remembered’S. Winning (2002) British Medical Journal 324, 1278-1279 ‘Psychotropic drugs and sudden death’ S. A. Chong (2001) BritishJournal of Psychiatry 178, 179-180‘Risk of Pregnancy when changing to atypical antipsychotics’A. Gregoire, S. Pearson (2002) British Journal of Psychiatry 180, 83-84‘Sexual dysfunction in patients taking conventional antipsychoticmedication’ S. M. Smith, V. O’Keane, R. Murray (2002) BritishJournal of Psychiatry 181, 49-55‘The influence of patient variables on polypharmacy and combinedhigh dose of antipsychotic drugs prescribed for in-patients’P. Lelliott, C. Paton, M. Harrington, M. Konsolaki, T. Sensky, C. Okocha Psychiatric Bulletin 26, 411-414‘The results of a multi-centre audit of the prescribing ofantipsychotic drugs for in-patients in the UK’ M. Harrington, P. Lelliott, C. Paton, C. Okocha, R. Duffett, T. Sensky (2002)Psychiatric Bulletin 26, 414-418‘Use of serotonin antagonists in the treatment of neuroleptic-inducedakathisia’ I. Maidment (2000) Psychiatric Bulletin 24, 348-351British National Formulary 44 (September 2002) British MedicalAssociation and Royal Pharmaceutical Society of Great BritainElectronic Medicines Compendium (web: www.emc.vhn.net) Insight: South West London and St Georges Mental Health Trust DrugInformation, News, Views and Comment, Issue 4, March 2000Schizophrenia: Core interventions in the treatment andmanagement of schizophrenia in primary and secondary care,Clinical Guideline 1 National Institute for Clinical Excellence (2002)(web: www.nice.org.uk) Index of drugs
Useful organisations
British Association of Behavioural and Cognitive
Psychotherapists (BABCP)
PO Box 9, Accrington, BB5 2GD
tel. 01254 875277, fax: 01254 239114
e-mail: babcp@babcp.org.uk web: www.babcp.org.uk
Full directory of psychotherapists available online
British Association for Counselling and Psychotherapy
BACP House, 35–37 Albert Street, Rugby CV21 2 SG
tel. 0870 443 5252, fax: 0870 443 5161
e-mail: bacp@bacp.co.uk web: www.bacp.co.uk
Contact for details of local practitioners
Hearing Voices Network
91 Oldham Street, Manchester M4 1LW
tel. 0161 834 5768, e-mail: hearingvoices@care4free.net
web: www.hearing-voices.org.uk
User network and local support group for people who hear voices
Manic Depression Fellowship
Castle Works, 21 St George’s Road, London SE1 6ES
tel. 020 7793 2600, fax: 020 7793 2639
e-mail: mdf@mdf.org.uk web: www.mdf.org.uk
Works to enable people affected by manic depression to take
control of their lives
Rethink Serious Mental Illness
28 Castle Street, Kingston-upon-Thames, Surrey KT1 1SS
advice line: 020 8974 6814, tel. 0845 456 0455, fax: 020 8547 3862
e-mail: advice@rethink.org web: www.rethink.org
Working together to help everyone affected by severe mental
illness, including schizophrenia, to recover a better quality of life
Further reading and order form
Drugs used in the Treatment of Mental Health Disorders: FAQs (3rd Edition) S. Bazire (Academic Publishing Services 2002) £8.95Factsheet: Psychosis (2002) 50pHow to Cope as a Carer (Mind 2001) £1How to Look After Yourself (Mind 2002) £1How to Parent in a Crisis (Mind 2002) £1How to Rebuild Your Life After Breakdown (Mind 2000) £1How to Recognise the Early Signs of Mental Distress (Mind 2002) £1Making Sense of Antidepressants (Mind 2002) £3.50Making Sense of Cognitive Behaviour Therapy (Mind 2001) £3.50Making Sense of ECT (Mind 2003) £3.50The Mind Guide to Advocacy (Mind 2000) £1The Mind Guide to Managing Stress (Mind 2002) £1Mind Rights Guide 1: Civil Admission to Hospital (Mind 2003) £1Mind Rights Guide 2: Mental Health and the Police (Mind 1995) £1Mind Rights Guide 3: Consent to Medical Treatment (Mind 2003) £1Mind Rights Guide 4: Discharge from Hospital (Mind 2002) £1Mind Rights Guide 5: Mental Health and the Courts (Mind 1995) £1Mind Rights Guide 6: Supervision Registers and Supervised Discharge(Mind 1997) £1Mind Rights Guide 7: Managing Your Finances (Mind 1999) £1Mind’s Yellow Card for Reporting Drug Side Effects: A report ofusers’ experiences A. Cobb, K. Darton, K. Juttla (Mind 2001) £4Toxic Psychiatry: A psychiatrist speaks out P. Breggin (HarperCollins1993) £9.99Understanding Mental Illness (Mind 2002) £1Understanding Mental Illness: Recent advances in understandingmental illness and psychotic experience (British PsychologicalSociety 2000) £15Understanding Schizophrenia (Mind 2002) £1Understanding Talking Treatments (Mind 2002) £1The Voice Inside: A practical guide to coping with hearing voicesP. Baker (Handsell Publishing/Mind 1997) £3 Your Drug may be Your Problem: How and why to stop takingpsychiatric medications P. Breggin, D. Cohen (Perseus 2000) £12.99 For a catalogue of publications from Mind, send an A4 SAE to theaddress below.
If you would like to order any of the titles listed here, please photocopy or tear out these pages, and indicate in the appropriateboxes the number of each title that you require. Please add 10 per cent for postage and packing, and enclose a cheque for the whole amount, payable to Mind. Return yourcompleted order form together with your cheque to: Mind Publications15–19 Broadway London E15 4BQ tel. 020 8221 9666fax: 020 8534 6399 e-mail: publications@mind.org.uk (Allow 28 days for delivery).
Please send me the titles marked above. I enclose a cheque (including 10 per cent for p&p) payable to Mind for £ Mind works for a better life for everyone
with experience of mental distress
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Scottish Association for Mental Health tel. 0141 568 7000 Northern Ireland Association for Mental Health tel. 0289 032 8474 First published by Mind in 1992. Revised by K. Darton Mind 2003 ISBN: 1-874690-09-XNo reproduction without permissionMind is a registered charity No. 219830 Mind (National Association for Mental Health)15-19 BroadwayLondon E15 4BQtel: 020 8519 2122fax: 020 8522 1725web: www.mind.org.uk

Source: http://www.mentalhealthintheuk.co.uk/Makingsenseofantipsychotics.pdf