Making sense of antipsychotics

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What should I know before taking these drugs?
What are antipsychotic drugs?
How does a doctor decide when to prescribe them?
How do the drugs work?
How quickly do they act?
What dosage should I be on?
What are the side effects?
What is neuroleptic malignant syndrome?
What is tardive dyskinesia (TD)?
What is tardive psychosis?
Which type of antipsychotic should I be on?
When shouldn't people take them?
Why do people take more than one?
What happens if I am taking other drugs?
What is rapid tranquillisation?
How easy is it to come off these drugs?
Is there an alternative?
The different types of antipsychotics
Older antipsychotics
Atypical antipsychotics
Antipsychotics through depot injection
Anti-Parkinson's drugs
References
Useful organisations
Further reading

This booklet is for anyone who wants to know about this type of medication. It explains why these drugs may be prescribed, what their effects are (including side effects), who should avoid them, what happens when people want to withdraw from them and what the alternative treatments might be.

What should I know before taking these drugs?

Informed consent
The law says that you have the right to make an informed decision about which treatment to have, and whether or not to accept the treatment a doctor suggests. To consent, properly, you need 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, you can only receive treatment that you have specifically agreed to. Once you have given your consent, it isn’t final and you can always change your mind. This consent to treatment is fundamental, and treatment given without it can amount to assault and negligence. To find out more about when treatment can be given without consent, see Mind rights guide 3: consent to medical treatment.

Patient information leaflets
If you are prescribed medication as an outpatient, or from your GP, you should find with it an information sheet called a patient information leaflet (PIL), in accordance with a European Union directive. As an inpatient, you may have to ask for it, specifically. The EU directive sets out what information should be included in the leaflet, and in what order. The order in which the information is given has recently changed, to make it more ‘user-friendly’. Many PILs will still follow the old pattern until they are revised, but the information they include should be the same:

• both the trade and general (generic) names
• the strength of the medicine and the form it takes; for example, ‘each tablet contains 5mg of drug X’
• who it is intended for; for example, adults, children, babies
• the type of medicine it is; for example, an antipsychotic
• what it is licensed to treat; for example, schizophrenia
• things you need to know before taking it, such as conditions which mean you should either not take it at all, or you should take it with caution
• the instructions for taking it: whether by mouth or other route; at what time of day; when to take it in relation to meals (if necessary)
• a list of possible side effects, with an indication of how likely they are to occur
• the expiry date of the drugs and how to store them
• a full list of all the ingredients, including the extra contents that hold it together as a tablet or capsule, such as maize starch, gelatin, cellulose, and colourings. This information is important because some people may be allergic to one or other of the ingredients, such as lactose or gluten or a colouring. Gelatin is unacceptable to some people because it is an animal product.

The final item on the leaflet tells you that it contains only the most important information you need to know about the medicine, and that if you need to know more, you should ask your doctor or your pharmacist.

There is a lot of information to include in the PIL, so it’s often printed in very small type, on a piece of paper that is folded many times, which may get thrown away with the packaging, by mistake. If you do not receive this information with your medicine, you should ask for it from the person who makes up your prescription.

Some of the information is quite hard to understand, and the Commission on Human Medicines (formerly the Committee on Safety of Medicines) has been looking at ways of making it easier. They have produced a leaflet Taking medicines – some questions and answers about side effects which you can find on their website or request by telephone, or may be available in your local pharmacy. There is more information on medicines and their use, in the form of Medicines Guides, available from the Medicines Information Project website. (See Useful organisations.)

You should also consider talking to your pharmacist. Pharmacists are drug specialists, and may be more knowledgeable about your drugs than the doctor who prescribes them. They may be more aware of possible side effects, and also possible interactions with other drugs (this is when a drug changes the effect of other drugs you are taking, makes them less effective, or causes additional side effects). Pharmacists are usually very willing to discuss drugs with patients, and some high-street chemists have space set aside where you can talk privately.

Since January 2006 a new scheme has been in place called the ‘Medicines Use Review’. People who regularly take more than one prescription medicine, or take medicines for a long-term illness, are encouraged to go to pharmacists who are operating the scheme, for a full discussion of their medicines and any problems they may have with them. The Medicines and Healthcare products Regulatory Agency (MHRA), who are responsible for overseeing the licensing of medicines, have produced a guide to the scheme (see their website under Useful websites).

Many people would like to have the information about their proposed treatment before they are given the prescription for it, and not after they have got it from the pharmacist and taken it home. The following are issues you might like to discuss with your doctor when she or he gives you a prescription for a drug:

• What is the name of the drug, and what is it for?
• How often do I have to take it?
• How long will I have to take it for?
• If I am taking any other drugs, will it be all right to take them together?
• Will I still be able to drive?
• What are the most likely side effects, and what should I do if I get them?
• Do I have to take it at any particular time of day? For example, if it is likely to make me sleepy, can I take it at night rather than in the morning? If it is likely to make me feel sick, can I take it with or after food?
• When I want to stop taking it, am I likely to have any problems with withdrawal?

You may well think of other questions you wish to ask.

If you have troublesome side effects, or withdrawal symptoms when you stop taking your medication, you can report them yourself to the MHRA on their website or their hotline (see Useful organisations), or on a form which you can get from your pharmacy. You no longer need to go through a health professional to do this, although you can if you wish. You can also see a full list of side effects reported on the same website.

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What are antipsychotic drugs?

Antipsychotic drugs have been in use since the 1950s. They are sometimes prescribed for anxiety, in very low doses, and occasionally for treating physical problems, such as persistent hiccups, problems with balance, and nausea. Often, they are used for dementia. However, they are generally used to 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.

Psychosis and antipyschotics
People who are psychotic perceive things and interpret events differently from those around them. 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 is under the control of an outside force. (For more information, see Understanding psychotic experiences, How to recognise the early signs of mental distress, Understanding bipolar disorder [manic depression] and Understanding schizophrenia.)

Antipsychotics are often effective in controlling the symptoms of psychosis, and enable many people to return to normal life. They may lessen delusions, hallucinations, incoherent speech and thinking, and reduce confusion. The drugs can control anxiety and serious agitation, make the person feel less threatened, and also reduce violent, disruptive and manic behaviour. However, not everybody finds antipsychotics helpful, and they can't cure the problem. They can also have very serious side effects, which cause major concern to users.

Antipsychotic drugs are standard, routine treatment for people who are experiencing psychosis, and doctors believe that drug treatment should be started as soon as possible. But recent research has raised important questions about whether people might not do better without using these drugs.

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. But a paper published in the Journal of Medical Hypotheses in 2004 suggests that resorting to antipsychotics straight away, as a matter of routine, may worsen long-term outcomes, and that a considerable percentage of those treated would do better if they were not given drugs. This paper suggests that people experiencing their first episode of psychosis should not be treated with drugs, and that every person who is taking antipsychotics should be given the opportunity to withdraw from them, gradually. It suggests that this would dramatically improve recovery rates and reduce the numbers of people who become ill in the long term.

Other background information on antipsychotics
There are two main types of antipsychotics: the older antipsychotics and the newer atypical antipsychotics.

The older antipsychotics divide, generally, into two chemical groups:

• 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.
• High-potency drugs, such as haloperidol (Dozic, Serenace and Haldol), which require lower doses and tend to cause more neuromuscular side effects.

The newer atypical antipsychotics, such as risperidone, don’t produce the most disturbing neuromuscular side effects that characterise the older drugs. However they do cause serious metabolic side effects associated with gross weight gain, for which the term ‘metabolic syndrome’ is increasingly being used. For a listing of antipsychotics licensed in the UK, see below.

Antipsychotics are also known as major tranquillisers or neuroleptics. Calling them major tranquillisers is misleading, because these drugs don't make people feel tranquil.
Although they can cause drowsiness through their sedative action, they may also cause intense restlessness. Neuroleptic is a better term as it means taking control of the nerves, and refers to the effects these drugs have on thought, behaviour and physical movement.

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How does a doctor decide when to prescribe them?

Your doctor has to weigh up the advantages and disadvantages of treatment. The benefits to you, your family and friends have to be balanced against the disadvantage of unpleasant side effects. Doctors also have to ask themselves what might 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. This may also place great strain on carers and the people they live with. Some people who experience psychosis cope better with it 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.

People respond differently to medication, and doctors have to decide on each case, individually. 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.

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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. One specialist at the University of Newcastle has suggested that they work by causing Parkinsonism i.e. producing the psychological symptoms of this disease such as emotional blunting and demotivation, as well as the physical symptoms, which are already well recognised as side effects.

The new atypical drugs work on other brain chemicals as well as dopamine, and have a rather different range of side effects. Clozapine, in particular, may be successful in suppressing psychosis in some people who have not responded to older drugs

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.

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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. Since the advent of the atypical drugs this trend has reversed, and indeed research has suggested that atypical drugs have no advantages over the older drugs, if the older ones are used at the lowest effective dose.

Doses should be kept as low as possible. High doses can have a zombie-like effect, giving you a mask-like expression and strange movements. It can make it very difficult for you to move normally, to get up and get going in the morning, and to take part in normal activities and social events. Moderate to high doses increase the risk of tardive dyskinesia, which is a serious problem causing involuntary movements. Research suggests that low, maintenance doses are as effective in preventing relapse as higher doses. Older people need smaller doses of drugs, and their health is at risk if they are given too high a dose.

You have a right to know what dosage you have been prescribed, and these vary widely. For example, chlorpromazine (Largactil) can be prescribed in tablet form to physically healthy adults in doses ranging from 75mg up to 1g (1000mg) daily. The aim should be to find the dose that lets you lead as normal a life as possible. If the medication is not working, it's important for doctors to reconsider the treatment rather than automatically putting up the dose.

The National Institute for Clinical Excellence (NICE) current guidelines on the treatment of schizophrenia suggest that doctors prescribe antipsychotics at the lowest effective dose, introducing the drugs gradually. They suggest that people should not be given a high starting dose.

Maximum dosage
Among other information, the British National Formulary (BNF) gives maximum doses for some, but not all, of the antipsychotics. A list of drugs appears below, and provides this information, whenever possible. Generally, the drugs aren’t licensed for use above these dosages, but hospital doctors do exceed them, at their discretion. They may also prescribe medication to be given ‘as necessary’ (p.r.n.), which can mean in addition to your regular dose. As a result, your total dose could be above the BNF maximum, although your psychiatrist has a duty to review the total dosage, daily.

If you are taking more than one antipsychotic drug, you can work out the dose of each (including p.r.n. prescribing) as a percentage of the maximum recommended in the BNF. Add the percentages together to see if you are taking more than 100 per cent in total. You can also ask your doctor or a pharmacist to help you work this out. The Prescribing Observatory for Mental Health (see Useful organisations) has created a ready reckoner chart for wards to help with this calculation. If you think you are taking too much medication, you can ask your doctor to review it.

If you are worried about your diagnosis and treatment, and unsure about the advice you have been given, you could ask either your GP or psychiatrist to refer you for a second opinion.

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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, many of the side effects are to do with the neuromuscular system. These neuromuscular effects include: Parkinsonism, loss of movement, restlessness and muscle spasms.

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.
• When walking, you may lean forward, take small steps, and find it difficult to start and stop.
• 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 sometimes misread this as a sign of agitation or anxiety, and may wish to treat it by increasing your dose of antipsychotics. If you are very troubled by akathisia, your doctor may be able to prescribe 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 eye movements. Called ‘oculogyric crisis’, it makes the eyes turn suddenly, so that you can’t control where you look. This is very unpleasant and can make it dangerous crossing the road, or pouring hot water, for instance. It’s also very disconcerting for people around you.

Such neuromuscular symptoms can be reduced with the sorts of drugs that are prescribed to treat Parkinson’s disease (see below for more information on these drugs). These symptoms die down while you are asleep, so if you take the antipsychotics as a single daily dose in the evening, you could avoid the worst of them (as well as avoiding daytime sedation). You may want to discuss this with your doctor 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 is related to some very common sexual side effects for both women and men, who may feel embarrassed to talk about them:

• Breast development and the production of breast milk can affect men as well as women.
• 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 should treat it as an emergency and seek medical advice, because it may cause serious harm to the penis.
• Spontaneous ejaculation is sometimes a problem.
• Loss of periods, vaginal dryness, unwanted hair and acne may occur in women.
• Osteoporosis (loss of bone density) as a consequence of hormone changes is a serious risk for men and women, and increases the risk of fractures.

Some of the atypical antipsychotics have less effect on prolactin and produce fewer of these problems. Note: women who change from an older antipsychotic to an atypical should bear in mind that this may cause prolactin levels to drop back down.  This may cause their periods to return and they may need to think 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; hot baths increase the risk.

Heart rhythm
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 polypharmacy, when people are on several different antipsychotics at the same time. Many of these drugs affect the heart rhythm. The Royal College of Psychiatrists' guidelines suggest that people on high doses of antipsychotics should be given an ECG before treatment starts and every one to three months, while the dose remains high. Whatever your dose, if you have unexplained blackouts, you should have your heart rhythm monitored. Be cautious with grapefruit and grapefruit juice, because it's thought this might 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.

Eye problems
Various antipsychotics may be responsible for different eye disorders. These include 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 above), and glaucoma (increased pressure inside the eye). Any antipsychotic can cause narrow-angle glaucoma, which is a medical emergency. You should not take the low-potency antipsychotics if you have had glaucoma.

Weight gain
Weight gain is a very common side effect with a number of antipsychotics, including some of the atypical drugs, and causes a lot of distress. It is linked to increased appetite and decreased activity, but is mainly caused by changes in metabolism - the way your body uses food and converts it to energy or stores it as fat. This means that dieting may be of limited use. You may put on a lot of weight, and this may increase your risk of developing diabetes, and other physical health problems.

Metabolic syndrome, including diabetes
Some side effects, associated especially, but not exclusively, with atypical antipsychotics, are linked, and have begun to be referred to as 'metabolic syndrome'. This group of symptoms: weight gain and obesity; high blood sugar; high blood pressure, and high cholesterol, puts people at risk of heart disease, stroke and diabetes. The risk is increased by dietary factors, such as drinking sugary carbonated drinks and eating a lot of fatty, sugary foods. Everyone, especially those with a family history of diabetes, should have their blood glucose monitored while they are taking these drugs. You should also tell your doctor if you have a family history of cardiovascular disease such as high blood pressure or heart attack. Metabolic syndrome is thought to cause a two- to three-fold increase in the risk of death from cardiovascular disease.

Agranulocytosis
A number of blood disorders are linked to antipsychotics. The most serious is agranulocytosis, a serious blood disorder, which involves the 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, and is a particular risk of clozapine.

Other physical effects
Some people develop blood clots in the veins (thromboembolism), linked to low-potency drugs as well as clozapine. 

Liver disorders and jaundice are sometimes linked to using these drugs.

There are various skin problems that may occur. If you get a rash, you should go to the doctor straight away. Any allergic rashes usually occur within the first two months of starting treatment and disappear when the drug is stopped. Some types of skin may develop a blue-grey discoloration. Your skin may become more sensitive to sunlight, especially at high doses, so you should protect your skin from the sun.

You may have problems with regulating body temperature. It may be too high or too low, both of which may make you feel a little unwell.

Another problem that might occur is difficulty urinating.

Emotional effects
Antipsychotics can sometimes make people more excited, agitated and aggressive. They can also cause emotional changes, such as depression. Others may have an antidepressant effect, although the available information 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 out of touch with reality or strange in familiar surroundings (depersonalised and derealised). It may also cause them to become more withdrawn, socially.

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What is 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 or coma; rapid heartbeat, very rapid breathing and changes in blood pressure. Blood tests show abnormal results. NMS develops rapidly over 24 to 72 hours, and rigidity and a high temperature are usually the first symptoms to appear.

The condition mostly affects people under forty, and is twice as common in men. It can occur if you are taking standard doses of antipsychotics, and if you have been taking the drugs for many years. The main trigger seems to be a change of dose within the last 4 to 11 days. High-potency antipsychotics may produce greater risk, but it can happen with all of these drugs, including the atypical group.

Treatment varies and can include reducing the fever, giving drugs to relax the muscles, and drugs to counter the chemical imbalance that is thought to cause NMS. Electroconvulsive therapy has also been used effectively.

The symptoms may last for days, or even weeks, after stopping the drugs. Although the criteria for making the diagnosis are not clear, it seems that only about one per cent of people on antipsychotics are likely to get NMS. Out of these, 11 per cent may be fatal. Many people who have had NMS once go on to get it again, so you should only take antipsychotics afterwards if they are absolutely essential, and then only the low-potency drugs at the lowest doses.

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What is 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, mainly affecting people who have been taking moderate to high doses for long periods of time, and who have had quite severe Parkinson's symptoms. It's rare in someone who has been taking antipsychotics for less than six months, if the doses have been small. It seems that people are more likely to get TD if they get bad Parkinson's effects. Women, children and older people may be more vulnerable, and possibly those with a mood disorder such as manic depression (bipolar disorder).

The problem may not be discovered until after you stop taking the antipsychotics, because they mask the symptoms of TD. Unfortunately, stopping and starting the drugs may make TD more persistent, once it has developed.

Some people remain on the drugs as a way of dealing with the symptoms, although this may result in further damage. Sometimes when drugs are withdrawn, withdrawal dyskinesias may occur, but this is not necessarily the same as TD.

There's disagreement about how common TD is, and about the number of people who are permanently affected. Estimates of the risks of developing TD, after long-term use, range from 5 to 56 per cent, but 20 per cent is a widely accepted estimate for those treated for four years, or longer. The risk is higher for people on depot preparations. There is believed to be much less risk of TD with the atypical drugs.

Treatment
If you stop taking the drugs, TD may disappear of its own accord. The symptoms improve, spontaneously, in about half of patients, 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 of relapse. This risk must be weighed in the balance against the risk of TD. If you have been taking one of the old antipsychotics, you might be able to switch to an atypical, such as clozapine, risperidone, olanzapine or quetiapine, which may 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 in some cases. If you are taking anti-Parkinson drugs, it may be a good idea to stop. TD doesn't necessarily develop or get progressively worse in all cases, and using the lowest possible dose of antipsychotic minimises the risk. (See Mind's factsheet, Tardive dyskinesia, for more information.)

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What is 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 drug use, or new receptors may develop to replace those that are being blocked by the drugs, which means that higher doses are needed to maintain the antipsychotic effects. Some people who withdraw from these drugs find that their psychotic symptoms have become worse. This is another reason for using no more of the drug than is absolutely necessary.

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Which type of antipsychotic should I be on?

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 to take, but if you are unable to make a choice, then you should be given an atypical. NICE recommends that atypical antipsychotics should be used:

• 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 well to the older drugs.

If you are already on an older antipsychotic, and your symptoms are responding well, without causing you unacceptable side effects, there's no need to change to an atypical antipsychotic. If neither older nor atypical antipsychotics are controlling your symptoms, after an adequate trial period of six to eight weeks, you should try clozapine.

When shouldn't people take them?

Anyone with the following should use these drugs with caution:

• liver or kidney disease
• cardiovascular (heart and circulation) disease – or a family history of 
• family history of diabetes (see above)
• Parkinson’s disease
• epilepsy
• depression
• myasthenia gravis (a disease affecting nerves and muscles)
• an enlarged prostate
• a history of glaucoma, an eye disease (see above)
• 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.

Older people
Doctors should also prescribe them with caution to older 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.

Expectant and new mothers
As a general rule, you should avoid taking any drugs during pregnancy and while breastfeeding, unless 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 with malformations in the developing baby during this period. There have also been reports of temporary muscle disorders in newborn babies, if antipsychotics are used in the last three months of pregnancy. Because long-acting drugs take time to clear from the body, it's important to take your final dose six to eight weeks before the baby's expected delivery date.

The manufacturers advise women not to take the atypical drugs when breastfeeding. It's best to avoid antipsychotics altogether, if possible. Ask your doctor and your pharmacist about the safety of any drug you are advised to take. It's very important to discuss any concerns with your doctor and other professionals responsible for your health during pregnancy and delivery.

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Why do people take more than one?

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. This could mean that a doctor prescribes an oral drug as well as a depot, or a conventional drug as well as an atypical antipsychotic. However, in most cases, doctors should avoid combining conventional with atypical antipsychotics. The atypicals have fewer side effects than the standard antipsychotics, but this benefit is undermined if you are taking both at the same time. There are some cases, though, when doctors may legitimately augment clozapine with sulpiride, for example.

The BNF does not recommend polypharmacy, because even though the individual drugs may be within the recommended dose range, patients may end up having a high total dose. Research has shown that adding a second drug doesn't usually improve 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. They say that two or more antipsychotics should not be given at the same time, except for short periods when you are switching from one to another.

If you are detained in hospital under the Mental Health Act 1983 (current Act at time of print), you are far more likely to be taking more than one antipsychotic, or to be on a high dose, than someone who is a voluntary patient.

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What happens if I am taking other drugs?

If you are taking any other drugs (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.

Combining antipsychotics with other dugs that have antimuscarinic properties is likely to increase the antimuscarinic effects (see above). This applies particularly in the case of tricyclic antidepressants and antipsychotics such as chlorpromazine (Largactil) or other low-potency antipsychotics. The anti-Parkinson's drugs are also antimuscarinics, and combining with these can induce delirium, which may be hard to detect in psychosis.

If you are taking tricyclic antidepressants and antipsychotics, it can affect your heart rhythm. If you take the antidepressant trazodone with drugs such as chlorpromazine (Largactil), it can lower your blood pressure. Taking lithium (Camcolit, Liskonum, Priadel and Litarex), together with the older antipsychotics, increases the chances of Parkinson's effects, muscle spasms and neuromuscular restlessness, as well as possibly being toxic. The antipsychotics should be started at a lower dose than usual.

Carbamazepine makes the body process some drugs faster, which will lower the level of the drug in your blood.

If you are taking anti-epileptic drugs, the antipsychotics increase your chance of having a fit.

Taking drugs for anxiety, or to help you sleep, increases the sedative action of the antipsychotics. Drinking alcohol does the same. You should ask your doctor whether it's safe to drink when you are on these drugs.

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What is rapid tranquillisation?

In an emergency situation, if you are endangering yourself or others, doctors may decide you need something to calm you down as quickly as possible. This means you may be given drugs by injection. Clopixol Acuphase is one of the older drugs used. Of the atypical antipsychotics, olanzapine exists in an injectable form for this purpose. The Royal College of Psychiatrists suggests that doctors can avoid using high doses of these drugs by combining moderate doses of an antipsychotic with a benzodiazepine tranquilliser. The NICE guidelines recommend lorazepam (a benzodiazepine) with haloperidol or olanzapine. If using haloperidol, you need an anti-Parkinson's drug 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 it with hospital staff, and to write your own record of the experience if you wish, to be kept in your hospital notes.

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How easy is it to come off these drugs?

Doctors may suggest that once you’re on these drugs, you 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 medication.

To increase your chances of success, you need plenty of support, and this 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 antipsychotics 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 helpful and reduces the risk of relapse.

The best time to try is when you are not currently under stress from other life problems, such as housing, finance, a job or your family, for example. It may be a good idea to postpone withdrawal until you are more relaxed, and can pay attention to how you are feeling. The BNF (British National Formulary – see References) says: ‘Withdrawal of antipsychotic drugs after longtermtherapy should always be gradual and closely monitored,to avoid the risk of acute withdrawal symptoms or rapid relapse.’ For information about withdrawal from antipsychotics, see Mind’s booklet Making sense of coming off psychiatric drugs.

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Is there an alternative?

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. (See Mind's factsheet, Crisis services.)

Talking treatments
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 and Further reading for more information.)

Cognitive behaviour therapy (CBT) is a talking treatment that can provide practical strategies for coping with psychotic experiences and the disruption to everyday life that this may bring. It's based on the idea that people can change negative thought patterns that feed psychotic or paranoid feelings and so bring about a state of wellbeing. 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 and Further reading for more information.)

Looking after yourself
There is increasing evidence to suggest that eating healthily and getting plenty of physical activity can be as beneficial for the mind as it is for the body. Massage, yoga and other methods of increasing relaxation and decreasing stress are also likely to be very helpful. (See Further Reading for more information.)

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. (See Mind's factsheet, Arts therapies.)

Complementary therapies
Complementary and alternative therapies such as herbalism and homeopathy 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. (See Useful organisations for more information.)

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 for more information.)

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The different types of antipsychotics

Side effects common to all the drugs listed in this sectionare covered earlier. It is essential that youread those pages as well as the section on the particulardrug you are taking, in order to get full informationabout possible harmful effects.

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.

Dosages of antipsychotics can vary considerably and details are not given here, except when the BNF specifies a maximum daily dose. Maximum doses are based on what is dangerous, rather than what is most effective. The most effective dose may be considerably lower than the maximum safe dose, in some cases. Where a drug is not recommended for children, this is shown by the symbol * next to the drug name.

Benperidol (Anquil, Benquil) *
Licensed for the control of deviant antisocial sexual behaviour. Similar to haloperidol. Dose: maximum 1.5mg per day. Form: tablets

Chlorpromazine (Largactil)
A low-potency drug, and the one with which all the others are compared. Chlorpromazine is irritant to the skin: tablets should not be crushed, and solutions should be handled with care.
Side effects: one of the most sedating of the older antipsychotics and causes antimuscarinic effects, in particular. Can make skin very sensitive to sunlight. It may cause low blood pressure (especially in people who are old and frail), blurred vision and weight gain. Around 20 to 30 per cent of long-term users have a build up of granular deposits in the cornea and lens. This is partly dose-related. It does not usually affect sight. Avoid it if you have glaucoma. It sometimes causes emotional unease, but may have an antidepressant effect. It has been linked with blood clots (thromboembolism). Chlorpromazine can cause liver toxicity (poisoning) and regular tests of liver function are sometimes advised before starting, and during the first six months of treatment. Jaundice may occur in the first two months. It should disappear in the month after stopping.
Dose: maximum not specified, but 1g (1000mg) per day is the highest dose mentioned in the BNF. This drug may be given to children for childhood 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. Form: tablets, oral solution, intramuscular injection, suppositories.

Flupentixol (Depixol, Fluanxol, Flupenthixol) *
Side effects: less sedating than chlorpromazine, but with more neuromuscular (Parkinson's) effects. It may have an antidepressant effect.
Dose: maximum 18mg per day. (See also flupentixol decanoate) Form: tablets.

Fluphenazine (Moditen) *
Side effects: less sedating and fewer antimuscarinic effects than chlorpromazine, but more neuromuscular reactions, especially muscle spasms and restlessness. It may cause depression. Dose: anything over 20mg per day to be used only with special caution. Form: tablets.

Haloperidol (Dozic, Haldol, Serenace)
Side effects: less sedating and fewer antimuscarinic effects than chlorpromazine, but more neuromuscular effects, especially muscle spasms and restlessness. Rare side effects include altered liver function, gastrointestinal disturbance and weight loss.
Caution: fluoxetine increases levels of this drug in the blood, and carbamazepine lowers them. There are increased risks if haloperidol is taken with lithium.
Dose: no maximum dose is specified in the BNF, but the highest dose mentioned is 30mg per day. This drug may be given to children to treat schizophrenia or dangerously violent or impulsive behaviour, at a maximum dose of 10mg per day. Form: tablets, oral liquid, injection. (See also haloperidol decanoate, below.)

Levomepromazine/methotrimeprazine (Nozinan)
Low potency. Side effects: more sedating than chlorpromazine, and with a risk of lowered blood pressure, particularly in people over 50. Dose: highest mentioned in BNF is 1g (1000mg) per day. No clear advice about children. Form: tablets, injection.

Pericyazine (Neulactil)
Side effects: more sedating than chlorpromazine, and lowered blood pressure when treatment starts. Dose: usual maximum 300mg per day. May be given to children for severe mental or behavioural disorders only, at a maximum dose of 10mg per day. Form: tablets, oral syrup.

Perphenazine (Fentazin) *
Side effects: less sedating than chlorpromazine, but more neuromuscular reactions, especially muscle spasms, particularly at high doses. It may cause blurred vision.
Dose: maximum 24mg per day. Form: tablets.

Pimozide (Orap) *
Side effects: less sedating than chlorpromazine. It may cause depression.
Caution: serious disturbances in heart rhythm reported, especially when doses are high dose. The Commission on Human Medicines recommends ECG before treatment starts and periodically thereafter on doses over 16mg daily. If other antipsychotic drugs are taken at the same time, there may be a greater risk of toxic effects on the heart. Avoid taking it with tricyclic antidepressants, and other drugs which affect the heart. Dose: up to 20 mg. Form: tablets.

Prochlorperazine (Stemetil) *
Side effects: less sedating than chlorpromazine, but more neuromuscular reactions, particularly muscle spasms. Form: tablets, syrup, injection.

Promazine *
Low potency. Side effects: Similar to chlorpromazine and one of the most sedating of the older antipsychotics. Form: tablets, oral solution.

Sulpiride (Dolmatil, Sulpitil, Sulpor) *
Low potency. Side effects: less sedating than chlorpromazine and a different chemical group. Not associated with jaundice or skin reactions. Dose: maximum 2.4g per day (2400mg per day). Form: tablets, oral solution.

Trifluoperazine (Stelazine)
Side effects: less sedating, less likely to lower body temperature or blood pressure, and causes fewer antimuscarinic effects than chlorpromazine. Produces neuromuscular reactions, and restlessness, especially when the dose is over 6mg daily. It may cause spontaneous ejaculation. May be given to children. Form: tablets, spansules (a sustained release capsule), syrup, oral solution.

Zuclopenthixol (Clopixol Acuphase) *
Side effects: Similar to chlorpromazine. This drug is given by injection, has a rapid sedative action shortly after injection and an antipsychotic action persisting for two to three days, and is for up to two weeks’ treatment only. Spontaneous ejaculation may occur. Dose: maximum 400mg per course and four injections.

Zuclopenthixol dihydrochloride (Clopixol) *
Side effects: Similar to chlorpromazine. Dose: maximum 150mg per day. Form: tablets (see also zuclopentixol decanoate).

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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 (see 'Sexual side effects' above). All of these drugs are licensed for the treatment of schizophrenia, and some of them are also licensed for mania.

Caution
They should be used with caution in people with cardiovascular (heart and circulation) disease, those with a history of epilepsy, or Parkinson's disease. They may affect your ability to perform skilled tasks, including driving, and may increase the effects of alcohol.

In March 2004, the Committee on Safety of Medicines (now the Commission on Human Medicines) issued new advice that the two atypical antipsychotics, risperidone and olanzapine, should not be used to treat behavioural problems in older patients with dementia. This is because there is evidence that these drugs significantly increase the risk of stroke in these patients. These drugs should also be used with caution in all older patients at risk of stroke.

Side effects
The most significant side effects are weight gain and associated metabolic effects, which may be very serious. People’s physical health should be carefully monitored whatever type of antipsychotic they are taking, but with atypicals it is especially important to check weight, blood pressure, blood glucose and cholesterol. Research suggests that monitoring of these side effects is not taken sufficiently seriously by many health professionals. However, The Prescribing Observatory for Mental Health (part of the Royal College of Psychiatrists, which works with a number of NHS Trusts to improve practice with regard to mental health prescribing) has produced a card for users entitled ‘Looking after your physical health’, to encourage people who are taking antipsychotics to have regular health checks and keep their own record (see Useful organisations for details).

Other important side effects include: extreme sleepiness (somnolence), dizziness, mild and short-lived neuromuscular symptoms, low blood pressure on standing upright, which may be associated with fainting or rapid heart beat in some people. Occasionally, tardive dyskinesia may occur after long-term use; rarely, neuroleptic malignant syndrome. Other side effects are listed 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 kidney problems and in older people. It should not be used in pregnancy or while breastfeeding.
Side effects: insomnia, anxiety, agitation, raised prolactin levels causing milk production, loss of menstrual periods, breast development, breast pain and sexual problems. Occasionally: slow heartbeat and fits; changes in heart rhythm may occur. Dose: maximum 1.2g per day (1200mg per day). Form: tablets, oral solution.

Aripiprazole (Abilify)
This drug does not cause as much weight gain as some of the other atypical antipsychotic drugs. Caution:the usual cautions apply regarding people with liver or kidney disease. It should also be used with caution in people with a history of fits. It should not be used during pregnancy or while breastfeeding. Aripiprazole may take days or weeks to have its full antipsychotic effect. The tablets contain lactose. Interactions: Aripiprazole interacts with carbamazepine in such a way that the dose of aripiprazole should be doubled if they are given together. Side effects: light-headedness, trouble sleeping, akathisia, sleepiness, tremor, blurred vision, feeling and being sick, indigestion, constipation, headache, lack of energy. Less common: fast heart beat, low blood pressure on standing. Rare: neuroleptic malignant syndrome, tardive dyskinesia and fits may also occur. Neuromuscular symptoms occur less commonly with aripiprazole than with haloperidol. Aripiprazole is similar to olanzapine in this respect. Dose: the recommended starting dose is 15mg per day; the effective dose range is 15-30mg per day. Maximum dose: 30mg. It has not been studied either in children under 18 or in people aged 65 or older. If it is used in older people, a lower dose should be given. Form: tablets, dissolving tablets, oral solution.

Clozapine (Clozaril, Denzapine, Zaponex) *
Clozapine is licensed for treatment of schizophrenia when other antipsychotics are unsuitable. Because of the severity of the possible side effects, the prescribing psychiatrist, the patient and the supplying pharmacist must all be registered with the Clozaril or Denzapine Patient Monitoring Service, or the Zaponex Treatment Access System (depending which brand they are using). This takes several days. Caution: Blood: Clozapine carries a three per cent risk of causing agranulocytosis (see above), and this is why you must have regular blood tests, every week for the first 18 weeks of treatment, and fortnightly thereafter. Blood counts must be satisfactory before the drug is started. If blood problems are detected, the drug must be stopped. The problem is not dose-related, and the risk of developing it decreases after the first year. It is almost always reversible by stopping the drug. The greatest risk of developing serious blood disorders appears to be between the 6th and 18th weeks of treatment, and is more common in women. Any infections that develop should be reported to the doctor. It should not be used at the sametime as other drugs that cause agranulocytosis, including carbamazepine. Heart: Clozapine is also associated with myocarditis and cardiomyopathy (serious heart disorders), and the CHM has advised that a careful history should be taken before the drug is started, and heart function should be monitored especially in the first two months of treatment. There is a high risk of metabolic syndrome with clozapine (see above). Gut: Gastrointestinal obstruction has been reported; clozapine should be used cautiously with other drugs which cause constipation, and patients should be monitored for constipation. There is a higher risk of diabetes with clozapine and olanzapine than with other antipsychotics. Clozapine has also been linked with blood clots (thromboembolism). Interactions: SSRI antidepressants may increase its levels in the blood. It should not be combined with long-acting depot antipsychotics. Smoking may decrease its blood levels, while caffeine may increase them, so dosage should be monitored accordingly.

Side effects: sedation, drooling saliva, rapid heartbeat, blood pressure changes (high or low), dizziness, headache, and dry mouth. Some of these improve, although rapid heartbeat, drooling and sedation may persist. Less common side effects: fits occur occasionally (dose-related), constipation, nausea or vomiting, high body temperature, weight gain, drowsiness, fever and headache. Movement disorders and tardive dyskinesia are rare, but neuromuscular restlessness, sluggish movements and tremor can occur. Toxic delirium and sedation, requiring withdrawal in a small percentage of people. Withdrawal: rebound psychosis has been reported, and other antipsychotic drugs may not be effective afterwards. Clozapine should not be stopped abruptly. Dose: maximum 900mg per day. Form: tablets.

Olanzapine (Zyprexa)
This drug is licensed for schizophrenia, mania (in combination with mood stabilisers) and preventing recurrence in bipolar disorder. Caution: See above for cautions about the use of this drug in older people. It should be used with caution in pregnancy, in men with prostate problems, 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) should not take it. It should not be used while breastfeeding. Carbamazepine lowers the level of this drug in the blood. Side effects: mild, short-lived antimuscarinic effects, drowsiness, increased appetite, peripheral oedema (puffy feet and hands), raised prolactin (but rarely high enough to cause symptoms), occasional blood problems, and sensitivity to sunlight. There is a higher risk of diabetes with olanzapine and clozapine than with other antipsychotics. Research suggests that it may cause an increase in blood fats, such as cholesterol, in older people. Dose: maximum daily dose, including the injectable version, is 20mg. Form: tablets, dissolving tablets (Velotab), injection (for rapid control of agitation or disturbed behaviour – this form should be discontinued and replaced with tablets or Velotab as soon as possible).

Paliperidone (Invega) *
This was licensed in June 2007 as a 'new' drug which is in fact an active metabolite of risperidone (see below). It therefore shares most of risperidone's characteristics. The main difference from risperidone and other antipsychotics is that paliperidone is produced in a 'prolonged-release' formulation which means that after the drug is taken it is released steadily over a 24-hour period, minimising peaks and troughs in the level of the drug in the blood. You must swallow the tablet whole with a drink, and must not chew it or divide it or crush it, because it is in a special shell designed to release the drug steadily through the day. The tablet shell is expelled from the body largely unchanged, and you should not worry if you see something that looks like a tablet when you have been to the toilet. You can take it either before food or with food, but you must be consistent – either always take it before food, or always take it with food.

Caution: Because of the structure of the tablet shell, it should not be given to people who have difficulty with swallowing. The 3mg tablet contains lactose; the higher dose tablets do not. Liver: the drug is not extensively metabolised by the liver and is excreted by the kidney largely unchanged, so it can be taken by people with mild or moderate liver disease. It should be used with caution in those with severe liver disease. Kidney: people with mild kidney disease should start on the lowest dose (3mg/day) which may be increased if it is well tolerated. People with moderate kidney disease should remain on 3mg/day, and those with severe kidney problems may be able to take 3 mg on alternate days. Older people: older people with normal kidney function can take a standard dose. Heart: It may cause changes in heart rhythm and should be used with caution in people with a family history of heart disease, stroke or related problems. It should be used with caution in people with a history of fits. Pregnancy and breastfeeding: It should not be used during pregnancy or while breast-feeding. Side effects: The commonest reported side effect is headache. The usual side effects of antipsychotics may occur, including Parkinsonism, and other neuromuscular effects; raised prolactin with sexual effects; affects on heart rhythm. As paliperidone is an active metabolite of risperidone, any of the side effects of risperidone may occur. Dose: range 3mg to 12mg. There is no need to start with a low dose and increase gradually when you start taking it. Form: prolonged release tablets. Withdrawal: There are no guidelines on withdrawal of paliperidone in relation to its gradual-release formulation. Its half-life is about 23 hours.

Quetiapine (Seroquel) *
Licensed for schizophrenia and for manic episodes, either alone or with mood stabilisers. Used especially in people with intolerable Parkinson’s symptoms, or symptoms of raised prolactin levels caused by other drugs. Similar to clozapine, and causes fewer neuromuscular effects than the older antipsychotics. Not associated with serious blood disorders. Caution: it should be used with caution in pregnancy, in people with liver or kidney problems, in older people, and in people who are taking some types of heart drugs, or who have cerebrovascular disease. 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: blood disorders, low thyroid hormone and possible changes in heart rhythm. Dose: maximum 750mg per day. Form: tablets.

Risperidone (Risperdal) *
Licensed for acute and chronic psychoses and mania. Thought to improve both positive and negative symptoms of schizophrenia. It has effects similar to chlorpromazine, but neuromuscular effects are usually less marked. Caution: see above for restrictions on its use in older people. It should be used with caution in people with liver or kidney disease, epilepsy or heart disease, as low blood pressure can occur. It may aggravate Parkinson’s disease. It can impair alertness and can therefore interfere with the ability to drive and operate machinery. It should not be used while breast feeding. Caution is advised if other drugs with similar actions are given. Carbamazepine lowers its blood levels. Side effects: insomnia, agitation, anxiety, and headache, weight gain. Less common side effects: drowsiness, fatigue, dizziness, difficulty concentrating, constipation, indigestion, nausea, abdominal pain, blurred vision, problems with erection and ejaculation, nasal inflammation, and rash. Occasional side effects: low blood pressure, dizziness, nose bleeds and increased heart rate, particularly if high doses are given at the start of treatment. There are rare reports of neuroleptic malignant syndrome, water intoxication and fits. Dose: maximum 16mg per day. Form: tablets and dissolving tablets (Quicklet).

Sertindole (Serdolect)
Licensed for schizophrenia. Sertindole was suspended following reports of serious effects on heart rhythm and sudden death. It has now been reintroduced, on a named patient basis only, and restricted to people who are enrolled in clinical studies and those who are unable to take at least one other antipsychotic. You should be given heart function tests (ECG) before and during treatment with sertindole, and your blood pressure should be monitored during the initial stages of treatment. Low blood levels of potassium and magnesium should be corrected before you start treatment.
Side effects: effects on heart rhythm, low blood pressure on standing, fluid retention in hands and feet (peripheral oedema), dry mouth, stuffy nose, shortness of breath, tingling sensations, abnormal ejaculation (decreased volume). Rare side effects: fits and raised blood sugar. Dose: maximum 24mg per day in exceptional cases only; usual range 12-20mg per day. Form: tablets.

Zotepine (Zoleptil) *
Licensed for schizophrenia. Caution: It should not be given to people intoxicated with alcohol or other central nervous system depressants, or to people with gout or kidney stones. It should be used with caution in people with epilepsy, people at risk of heart problems and those with high blood pressure, prostate problems, urinary retention, narrow-angle glaucoma, and paralytic ileus. Because of its effects on the heart, people should have an ECG before starting treatment and with each dose increase. Blood levels of sodium and potassium should also be monitored. It should also be used with caution in combination with other antipsychotics, fluoxetine (Prozac) and diazepam (Valium), and with drugs that lower blood pressure. Zotepine should be avoided, if possible, 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 than with the older antipsychotics). Chills, headache, pain, low blood pressure, rapid heart beat, constipation, indigestion, altered liver function, blood effects, depression, dizziness, insomnia and blurred vision were reported during trials. Less common side effects: flu-like symptoms, raised prolactin, sexual problems, appetite changes and convulsions. Sexual side effects should be less of a problem at lower doses. Isolated cases of neuroleptic malignant syndrome and tardive dyskinesia have been reported. Dose: maximum 300mg per day. Form: tablets.

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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 risk of harm to you, versus the benefits, and to find out whether you could have a lower dose.

The depot versions of the older antipsychotics are based on nut oils, to which some people may be hypersensitive or allergic. Sometimes, these are referred to as 'vegetable oil' in the patient information leaflet, but they are either sesame or coconut oil. If you and your doctors are considering depot drugs, and you have a nut allergy, make sure they know this.

Flupentixol/flupenthixol decanoate (Depixol, Depixol Concentrate, Depixol Low Volume) *
Caution: contains coconut oil. Can cause over-excitement if given to people who are agitated or aggressive. Side effects: more neuromuscular reactions than chlorpromazine. Dose: maximum 400mg 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 usually appear a few hours after the dose is given and continue for about two 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.

Risperidone (Risperdal Consta)
Risperidone is the first atypical antipsychotic to be available as a depot injection. It is available for people who have been successfully treated with risperidone tablets and wish to receive their medication by fortnightly injection. It is licensed for the treatment of schizophrenia and other psychotic illnesses. Unlike other depot antipsychotics, Risperdal Consta does not contain nut oil. It is supplied as a powder and a solvent to be made up at the time of injection. Once reconstituted, it should normally be used immediately, but has a shelf-life of six hours.
Caution: see above for restrictions on its use in elderly people. People with no previous history of taking risperidone should take oral risperidone first, for a few days, to make sure they can take it safely. This drug should be used with caution in people who have liver or kidney disease, heart disease, Parkinson's disease, or epilepsy.
Dose: for people currently taking risperidone tablets of up to 4mg daily, initially 25mg every two weeks. For people currently taking oral risperidone of over 4mg daily, initially 37.5mg every two weeks. The dose should then be adjusted at intervals of at least four weeks, in steps of 12.5mg, to a maximum of 50mg (25mg for those over 65 years), every two weeks. Dosage adjustments will take at least three weeks to have an effect. During initiation, risperidone by mouth may be continued, if necessary, for a maximum of three weeks. Maximum dose: 50mg every two weeks. For older people (over 65 years), the maximum dose is 25mg every two weeks. (See above for information about elderly people with dementia.) Side effects: the side effects are very similar to those associated with oral risperidone. The most common side effects include weight gain, depression, fatigue and symptoms mimicking Parkinson's disease, such as slowed movement and tremor, disturbed sleep, constipation, and nausea. Uncommon side effects include weight loss, nervousness, loss of concentration, low blood pressure, fainting and visual problems.

Zuclopentixol decanoate (Clopixol, Clopixol Concentrate) *
Side effects: similar to chlorpromazine but less sedating. Caution: contains coconut oil. Dose: maximum 600mg per week.

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Anti-Parkinson's drugs

These drugs are given to lessen the neuromuscular effects of antipsychotics, which resemble the symptoms of Parkinson's disease. They are called antimuscarinics. 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, make the psychosis worse. Due to their stimulant effect, they have the potential for abuse and can occasionally be habit forming. When withdrawing, you should go gradually and not stop suddenly. The BNF says that no important differences exist between these drugs, but some people tolerate one better than another. Trihexyphenidyl hydrochloride is the standard to which the others are compared.

Benzatropine mesylate/benztropine mesylate (Cogentin)
A sedative rather than stimulant effect, otherwise similar to trihexyphenidyl hydrochloride. May cause depression and high temperature. Caution: Avoid in children under three years old. Dose: maximum 6mg per day. Form: injection.

Orphenadrine hydrochloride (Biorphen, Disipal)
Similar to trihexyphenidyl hydrochloride. Side effects: it can have a euphoric effect and may cause insomnia. Dose: maximum 400mg per day. Form: tablets, oral solution.

Procyclidine hydrochloride (Arpicolin, Kemadrin)
Similar to trihexyphenidyl hydrochloride. Causes sedation rather than stimulation; also gingivitis (inflammation of the gums). Dose: maximum 30mg per day (60mg per day in exceptional circumstances). Form: tablets, syrup, injection.

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 happens the drug should be withdrawn. This drug has a stimulant effect. Dose: maximum 20mg per day. Form: tablets, syrup.

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References

‘Antipsychotic drugs and heart muscle disorder in international pharmacovigilance’ D. M. Coulter, A. Bate, R. H. B. Meyboom, M. Lindquist, I. R. Edwards (British Medical Journal 2001, 322)
'Antipsychotic drugs – information and choice: a patient survey’ B. Olofinjana, D. Taylor (Psychiatric Bulletin 2005, 29, 369-371)
‘Antipsychotic prescribing – time to review practice’ D. Taylor (Psychiatric Bulletin 2002, 26, 401-402)
‘Antipsychotics and risk of venous thrombolysis’ F. Curtin, M. Blum (British Journal of Psychiatry 2002, 180, 85)
‘Brain dopamine and obesity’ G. Wang et al (The Lancet 2001, 357)
British National Formulary, 53 (British Medical Association and Royal Pharmaceutical Society of Great Britain March 2007)
‘The case against antipsychotic drugs: a 50-year record of doing more harm than good’, R. Whitaker (Medical Hypotheses 2004, 62, 1, 5-13)
‘Chlorpromazine equivalents and percentage of British National Formulary maximum recommended dose in patients receiving high-dose antipsychotics’ G. Yorston, A. Pinney (Psychiatric Bulletin 2000, 24, 130-132)
‘Conventional antipsychotic drug use linked to venous thromboembolism’ G. L. Zornberg, H. Jick (The Lancet 2000, 356, 1219-1223)
‘Coprescribing of atypical and typical antipsychotics – prescribing sequence and documented outcome’ D. Taylor, S. Mir, S. Mace, E. Whiskey (Psychiatric Bulletin 2002, 26, 170-172)
‘Depot injections and nut allergy’ S. Reeves, R. Howard (British Journal of Psychiatry 2002, 180, 188)
‘Effects of antipsychotics on fat deposition and changes in leptin and insulin levels’, Z. J. Zhang, Z. J. Yao, W. Liu, Q. Fang and G. P Reynolds (British Journal of Psychiatry 2004, 184, 58-62)
‘Effects of long-term prolactin-raising antipsychotic medication on bone mineral density in patients with schizophrenia’ A. M. Meaney, S. Smith, O. D. Howes, M. O’Brien, R. M. Murray, V. O’Keane (British Journal of Psychiatry 2004, 184, 503-508)
Electronic Medicines Compendium (web: www.emc.vhn.net)
‘Hyperprolactinaemia caused by antipsychotic drugs’ A. Wieck, P. Haddad (British Medical Journal 2002, 324, 250-252)
S. Smith (British Medical Journal 2002, 324, 1278)
Insight: Drug Information, News, Views and Comment, Issue 4 (SW London and St Georges Mental Health Trust 2000)
‘Monitoring weight and blood glucose in in-patients: how helpful is a protocol?’, O. Runcie, M. Boilson, and R. Hamilton, (Psychiatric Bulletin, 2007, vol 31, pp 88-91)
‘Nose bleeds associated with use of risperidone’ D. W. J. Clark, M. Harrison-Woolrych (British Medical Journal 2004, 328)
‘Olanzapine may increase risk of hyperlipidemia in geriatric patients’ C. E. Koro et al (The Brown University Geriatric Psychopharmacology Update 2003, 7(2), 1, 4-5)
‘Olanzapine-associated diabetes mellitus’ E. A. Koller, P. Murali Doraiswamy (Pharmacotherapy 2000, 22(7), 841-852)
‘Physical complications of mental illness must be remembered’ S. Winning (British Medical Journal 2002, 324, 1278-1279)
‘Psychotropic drugs and sudden death’ S. A. Chong (British Journal of Psychiatry 2001, 178, 179-180)
‘Randomized Controlled Trial of the Effect on Quality of Life of Second- vs First-Generation Antipsychotic Drugs in Schizophrenia’ P.B. Jones et al, (Arch Gen Psychiatry. 2006, 63:1079-1087)
Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care – Clinical Guideline 1 (NICE 2002)
‘Sexual dysfunction in patients taking conventional antipsychotic medication’ S. M. Smith, V. O’Keane, R. Murray (British Journal of Psychiatry 2002, 181, 49-55)
‘The influence of patient variables on polypharmacy and combined high dose of antipsychotic drugs prescribed for inpatients’ P. Lelliott, C. Paton, M. Harrington, M. Konsolaki, T. Sensky, C. Okocha (Psychiatric Bulletin 2002, 26, 411-414)
‘The results of a multi-centre audit of the prescribing of antipsychotic drugs for inpatients in the UK’ M. Harrington, P. Lelliott, C. Paton, C. Okocha, R. Duffett, T. Sensky (Psychiatric Bulletin 2002, 26, 414-418)
‘Use of serotonin antagonists in the treatment of neuroleptic-induced akathisia’ I. Maidment (Psychiatric Bulletin 2000, 24)
‘Why are doctors still prescribing neuroleptics?’, Charlton, B.C., (Medical Hypotheses, 2005, vol 6, pp 1005-1009)

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Useful organisations

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel: 0161 797 4484 web: www.babcp.com
Directory of psychotherapists available online

British Confederation of Psychotherapists (BCP)
tel. 020 7267 3626 web: www.bcp.org.uk
Can provide a register of members

Depression Alliance
tel. 0845 123 2320 web: www.depressionalliance.org
Information, support and understanding depression

Food for the Brain
web: www.foodforthebrain.org
A non-profit educational charity promoting the link between nutrition and mental health

Hearing Voices Network
tel: 08451228641 helpline: 0845 122 8642
web: www.hearing-voices.org
National network and local groups for people who hear voices

The Institute for Complementary Medicine (ICM)
tel. 020 7237 5165 web: www.i-c-m.org.uk
Can send a list of practitioners

The Institute for Optimum Nutrition
web: www.ion.ac.uk
Aim to further the knowledge and practice of nutritional therapy

MDF The Bipolar Organisation
tel. 08456 340 540 web: www.mdf.org.uk
Works to enable affected people to take control of their lives

Prescribing Observatory for Mental Health
Tel: 020 7977 4999/6641
web: www.rcpsych.ac.uk/crtu/centreforqualityimprovement/prescribingobservatory.aspx 
For ‘Looking after your physical health’ cards, email: pomh-uk@cru.rcpsych.ac.uk

Rethink
tel: 0845 456 0455 advice line: 020 8974 6814
web: www.rethink.org
For everyone affected by severe mental illness

Useful websites

http://emc.medicines.org.uk
Access to patient information leaflets

http://medguides.medicines.org.uk/mip.aspx
Medicines Information Project

www.mhra.gov.uk
The Medicines and Healthcare products Regulatory Agency.
Also has information about the Commission on Human Medicines

www.yellowcard.gov.uk
For reporting side effects of any medicine

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Further reading

The BMA new guide to medicines and drugs (6th ed.) (Dorling Kindersley 2004)
Coming off psychiatric drugs: successful withdrawal from neuroleptics, antidepressants, lithium, carbamazepine and tranquillisers P. Lehmann, ed. (Peter Lehmann Publishing,2004)
Coping with coming off: Mind’s research into the experiences of people trying to come off psychiatric drugsJ. Read (Mind, 2005)
Drugs used in the treatment of mental health disorders: FAQs (4th ed.) S. Bazire (Academic Publishing Services 2004)
How to cope as a carer (Mind 2006)
How to look after yourself (Mind 2006)
How to parent when you’re in a crisis (Mind 2004)
How to rebuild your life after breakdown (Mind 2004)
How to recognise the early signs of mental distress (Mind 2004)
Making sense of antidepressants (Mind 2006)
Making sense of cognitive behaviour therapy (Mind 2007)
Making sense of coming off psychiatric drugs (Mind 2005)
Making sense of electroconvulsive therapy (ECT) (Mind 2003)
The Mind guide to advocacy (Mind 2006)
The Mind guide to food and mood (Mind 2006)
The Mind guide to managing stress (Mind 2006)
The Mind guide to massage (Mind 2004)
The Mind guide to physical activity (Mind 2006)
The Mind guide to relaxation (Mind 2006)
The Mind guide to yoga (Mind 2004)
Mind rights guide 1: civil admission to hospital (Mind 2007)
Mind rights guide 2: mental health and the police (Mind 2006)
Mind rights guide 3: consent to medical treatment (Mind 2007)
Mind rights guide 4: discharge from hospital (Mind 2005)
Mind’s Yellow Card for reporting drug side effects: a report of users’ experiences A. Cobb, K. Darton, K. Juttla (Mind 2001)
Toxic psychiatry: a psychiatrist speaks out P. Breggin (Harper Collins 1993)
Understanding bipolar disorder (manic depression) (Mind 2006)
Understanding psychotic experiences (Mind 2004)
Understanding schizophrenia (Mind 2005)
Your drug may be your problem: how and why to stop taking psychiatric medications P. Breggin, D. Cohen (Perseus 2000)

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This booklet was written by K. Darton
First published by Mind 1992.
Revised edition © Mind 2007.
ISBN 9781874690092

No reproduction without permission