MedicationAntipsychotic medicationAntipsychotic 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. National Institute for Health and Clinical Excellence (NICE) 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:
These are the newer, ‘atypical’ antipsychotics commonly used in the UK. Their brand name is in brackets:
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. The NICE guideline on schizophrenia also recommends people who are newly diagnosed should be offered an ‘atypical’ antipsychotic in the first instance. When people start taking antipsychotic drugs, it may take a few days or even a few weeks before they start getting better. ClozapineClozapine 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 (National Institute for Health and Clinical Excellence) 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. Tablets or ‘depot’ injectionsAntipsychotics 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. Some antipsychotics are available as a ‘prolonged-release’ formulation. They are designed to release the drug slowly and continuously over a 24-hour period to provide steady blood levels of the medicine throughout the day. NICE (National Institute for Health and Clinical Excellence) 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:
Taking antipsychotic medication regularlyTo 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 unwell. Taking medication as prescribed is called ‘adherence’ and there is NICE (National Institute for Health and Clinical Excellence) 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. 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. Most people with schizophrenia will continue to take antipsychotics for many years, even for life. Medication for bipolar disorderDifferent sorts of drugs are prescribed for episodes of mania and episodes of depression, and many people need to take medication on a regular basis, even when they are well, to help prevent relapse. The drugs that may be prescribed for mania are antipsychotics (olanzapine, quetiapine and risperidone), and ‘mood stabilisers’ – lithium or valproate. Valproate should not be prescribed for 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. Doctors may also prescribe a benzodiazepine (a sedative and muscle relaxant) to help people calm down and sleep better. These should not be given during pregnancy. 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 such as quetiapine. Sometimes, antidepressants can start an episode of mania, so people may also be prescribed a drug for mania, if they are not already taking one. NICE (the National Institute fo Health and Clinical Excellence) 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. If people experience the symptoms of psychosis, the doctor may prescribe antipsychotic medication in addition to other treatment. If people experience a mixed episode, they will be given medication for mania, but not usually an antidepressant. The medication used for long-term treatment is prescribed to reduce the risk of relapse. In the longer term, NICE recommends doctors offer the same type of medication used for manic episodes – lithium, valproate or an antipsychotic like olanzapine or quetiapine. Sometimes people are prescribed a combination of drugs. The results of a research trial published in 2010 showed that a combination regime of lithium and valproate, or lithium alone, was more effective over two years than valproate alone. People might also be prescribed the anti-convulsant and mood stabilising drugs lamotrigine or carbamazepine for long-term treatment. These should not be offered to women who are pregnant. Medication prescribed for long-term treatment to prevent relapse is called ‘prophylactic’ medication. 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 unwell agrees to this. Side effects of antipsychotic medicationIt’s important to talk to a 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 (National Institute for Health and Clinical Excellence) 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. 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. Some people develop a ‘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. Side effects of other drugs used to treat bipolar disorderSide 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. Lithium can also cause dizziness, drowsiness, shaky movements and vomiting. Rapid tranquilisationGuidance 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 This page was updated 20/3/11
|
