Medication

• Antipsychotic medication
• Clozapine
• Tablets or ‘depot’ injections
• Taking antipsychotic medication regularly
• Medication for bipolar disorder
• Side effects of antipsychotic medication
• Side effects of other drugs used to treat bipolar disorder
• Rapid tranquilisation

Antipsychotic medication

Antipsychotic drugs do not ‘cure’ mental illness. They are prescribed to reduce the symptoms of psychosis, including hearing voices and having strange or distressing thoughts. They can also act an antidepressant, a sedative or as an antimanic drug.

There are two types of antipsychotic medication. The first type of drugs are called ‘standard’ or ‘typical’ antipsychotics. More recently developed, ‘second generation’ drugs are called ‘atypical’ antipsychotics. Another name for antipsychotic drugs is ‘neuroleptics’.

All antipsychotic drugs have side effects. The National Institute for Health and Clinical Excellence guidelines say the antipsychotic drug prescribed by doctors should take into account the likely side effects and an individual’s preferences. People should be given information about the proposed drug, including what it will achieve, its likely side effects and what alternatives there are to help them make an informed decision about whether to take it. Family members and other carers should be involved in these discussions, if the person who is being prescribed the medication agrees.

Treatment with medication can be given to adults without their consent under the Mental Health Act or the Mental Capacity Act (see Mental health law and compulsory treatment page)

These are the ‘standard’ or ‘typical’ antipsychotics commonly used in the UK.
Their brand name is in brackets.
• Chlorpromazine (Largactil)
• Flupentixol (Depixol)
• Fluphenazine (Modecate)
• Haloperidol (Dozic, Haldol, Serenace)
• Levomepromazine (Nozinan)
• Pericyazine (Neulactil)
• Perphenazine (Fentazin)
• Pimozide (Orap)
• Prochlorperazine
(Stemetil)
• Sulpiride (Sulpor)
• Trifluoperazine (Stelazine)
• Zuclopenthixol (Clopixol).

These are the newer, ‘atypical’ antipsychotics commonly used in the UK.
Their brand name is in brackets.
• Amisulpride (Solian)
• Aripiprazole (Abilify)
• Clozapine (Clozaril, Denzapine, Zaponex)
• Olanzapine (Zyprexa)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal & Risperdal Consta)
• Sertindole (Serdolect)
• Zotepine (Zoleptil)

People react differently to drugs and doctors should try to find an antipsychotic medicine that controls symptoms but causes the least side effects. If one drug doesn’t work well or causes too many unpleasant side effects, they will probably change the prescription and try another drug.

NICE guidance says doctors should not offer people more than one antipsychotic drug at a time (combined medication), except for short periods – when changing to a new drug, for example.

There is no evidence that higher doses of antipsychotic medication are more effective than standard doses. The NICE guideline on schizophrenia says doctors should initially prescribe a low dosage of the chosen drug and then monitor how well it is working, and its side effects.

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Clozapine

Clozapine can suppress the symptoms of psychosis in people who have not got better after taking other antipsychotics (these people are called ‘treatment-resistant’ by doctors). NICE guidance says people with a diagnosis of schizophrenia should be offered clozapine only after trying at least two other drugs, including one of the newer atypical antipsychotics. Clozapine can damage white blood cells, so people who take it need to be monitored by having regular blood tests.

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Tablets or ‘depot’ injections

Antipsychotics are given as tablets or as a liquid medication. If given orally, they are taken once, twice or three times a day, depending on the drug and the dose. NICE guidelines for schizophrenia say people should be offered oral antipsychotic medication.

Sometimes antipsychotic drugs are given by injection and slowly released into the body over a number of weeks. These are called ‘depot’ injections. Injections mean people are less likely to forget to take their medication on a daily basis. Sometimes depot injections are given to people who are very unwell.

Depot injections currently available in the UK are:
• Flupentixol (Depixol)
• Fluphenazine (Modecate)
• Haloperidol (Haldol)
• Pipotiazine (Piportil)
• Risperidone (Risperidal Consta)
• Zuclopenthixol (Cloxipal)

It is estimated that between a quarter and a third of people with schizophrenia are prescribed depot injections.

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Taking antipsychotic medication regularly

To make sure antipsychotic medication is effective, it’s important to take it regularly and as prescribed.  Yet studies show that about half the people diagnosed with schizophrenia don’t take their drugs as recommended. Many people don’t like the idea of taking drugs every day, forget to take them or decide they don’t need them any more because they feel well.

People also stop taking their antipsychotic medication because of the side effects, or sometimes because they don’t fully understand that they are ill.

Taking medication as prescribed is called ‘adherence’ and there is NICE guidance for health professionals, offering them advice on supporting adherence, which includes involving patients in decisions about their medication. Research has shown that people are more likely to stop medication if they disagree with the need for treatment.

When people start taking antipsychotic drugs, it may take a few days or even a few weeks before they start getting better.

After an acute episode of psychosis, people will be encouraged to take drugs regularly for up to two years. If they stop taking their drugs too soon, their symptoms may return.

When people’s symptoms have improved and they no longer need medication, they should stop taking it gradually with the support of a health professional.

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Medication for bipolar disorder

Bipolar disorder is usually treated with a combination of medicines. Some of them are used to treat particular episodes of mania or depression. Some of them are long-term preventative treatments to stabilise mood.

The drugs used to treat bipolar are:
• Antipsychotic medication and other antimanic drugs
• Antidepressants
• Benzodiazepines, used to treat anxiety. These should not be given during pregnancy.

The main drugs NICE recommends to treat episodes of mania are:
• The atypical antipsychotics olanzapine, quetiapine and risperidone
• Lithium
• Valproate.

Valproate should not be offered to women who are or who may become pregnant as it could harm the baby.

People who are prescribed lithium need to have regular blood tests to make sure the levels of the drug inside their body do not become too high. Too much lithium can be poisonous.

People may be offered a benzodiazepine as well to help calm them down and make them sleep better.

During an episode of depression, people may be prescribed an antidepressant to take only until the symptoms of depression are gone. They may also be prescribed antipsychotic medication.

Sometimes antidepressants can start an episode of mania, so people should be offered an antimanic drug as well as the antidepressant, if they are not already taking one. NICE guidance says doctors should not prescribe antidepressants for people who have rapid cycling bipolar disorder, or for people who have had an episode of hypomania, or for people whose mood has been up and down.

The drugs used for long-term treatment (up to two years after an episode) are prescribed to reduce the risk of relapse. In the longer term, NICE recommends doctors offer:
• Lithium
• Onlanzapine
• Valproate.

If these drugs don’t work, they may offer lamotrigine or carbamazepine. These should not be offered to women who are pregnant.

NICE guidance calls medication used for long term treatment ‘prophylactic’ drugs.

People should be given information about all the drugs they are prescribed, and involved in decisions about which medication to take. Family members and other carers should be included in these discussions, if the person who is ill agrees to this.

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Side effects of antipsychotic medication

All antipsychotic drugs cause side effects. It’s important to talk to the doctor about side effects: if they are particularly severe or unpleasant, a different antipsychotic medication can be prescribed, or the dose of the medication can be altered.

Each person reacts differently to different medication and side effects vary from individual to individual. They also depend on the dosage of the drug being taken. Some side effects come and go quickly – an individual may have them for a few days, or a few weeks. Others are more persistent.

The higher the dose of antipsychotic medication, the more severe the side effects seem to be. NICE guidance recommends doctors prescribe antipsychotics at a low dose in the first instance.

Stiffness, shakiness, drowsiness, dizziness, dry mouth and constipation are among the side effects of the drugs. Some people no longer enjoy things that used to give them pleasure. Some drugs make people get sunburnt more easily, or make people feel slow. The typical antipsychotics cause a rise in the level of the hormone prolactin, which can lead to a lowered sex drive and breast tissue growth in both men and women, and affect women’s periods.

All antipsychotics can make people put on weight, although not everyone does. Doctors should monitor people’s weight regularly: if it becomes an issue, they may consider switching medication, or help people control their weight through a balanced eating plan and exercise.

Some people develop high blood pressure when taking antipsychotic drugs. Being overweight increases the risk of high blood pressure, and some people get a slow and steady rise over time. Some people get a rapid sharp increase in blood pressure when they start a new drug, or increase the dose of one they are already taking. This increase can happen within hours, or within a month.

There is a risk of developing diabetes when on antipsychotic medication, and that risk is greater in young people. Doctors should check for diabetes regularly, at least once a year.

Up to one in 10 people taking an antipsychotic drug will get some sort of ‘movement disorder’, though studies have show that the newer, atypical drugs, are less likely to result in this side effect.

Some people report a sense of inner restlessness that makes it hard for them to keep still. This is called akathisia.

Others find they can only move slowly, or that their limbs, hands or face muscles shake or ‘tremor’. Sometimes a limb may get stuck – this is called dystonia. Other people get oculogyric crisis, a muscle spasm that makes the eyes move suddenly.

These movement disorder side effects are similar to the symptoms of Parkinson’s disease and can be reduced by taking drugs called anticholinergics – medication prescribed to treat Parkinson’s.

People who have been on antipsychotic medication for several years sometimes develop tardive dyskinesia, a type of movement disorder that cause uncontrolled movements of the arms or legs, tongue, cheeks, jaw or face. It can make people do things like smacking their lips and pulling faces. Changing to a different antipsychotic drug straight away can stop the tardive dyskinesia becoming permanent.

Movement disorders are referred to by health professionals as ‘extrapyramidal symptoms’.

Clozapine is less likely to produce movement disorder side effects than other antipsychotic drugs. However clozapine can result in other side effects, including agranulocytosis, where the white blood cells are damaged. People on clozapine need regular blood tests to monitor this.

A high proportion of people who are on antipsychotic medication may have an impaired ability to drive because of the side effects. The DVLA should be told when people are given a diagnosis of psychosis. 

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Side effects of other drugs used to treat bipolar disorder

The combination of drugs used to treat bipolar disorder can make people feel flat and dull. Side effects of antimanic drugs include a hand tremor, thirst, the need to go to the toilet a lot, stomach upset, tiredness, weight gain, nausea and fluid retention. They can also cause dizziness, drowsiness, shaky movements and vomiting.

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Rapid tranquilisation

Guidance from the National Institute for Health and Clinical Excellence (NICE) details when people who are behaving in a violent or disturbed way in hospital should be sedated using drugs.

‘Rapid tranquilisation’ can be achieved using different medications, including benzodiazepines, antipsychotic medication or antihistamines. If people have psychosis, doctors will normally use antipsychotic medication and a benzodiazepine. The medication will by given orally or injected.

If rapid tranquilisation is used, there should be a review of what happened leading up to the sedation and the tranquilisation itself. Family members and carers should be involved in this review, unless an individual does not want that to happen.

For more information, read the NICE guideline, Violence: Information for the public