NHSL Medicines Guidance
This formulary is not intended as a treatment algorithm for any specific psychosis or related disorder: psychotic symptoms can present as a feature of many mental disorders. Guidance should be sought from the relevant local mental health service, where evidence based practice should form the foundation of any treatment plan.
The choice of antipsychotic medication should be a shared decision made by both the patient and healthcare professional as far as possible. Information should be provided to the patient (and if appropriate, their carer with the patient’s permission) with a focus on likely benefits and possible side effects of potential treatment options. The adverse effect profile of antipsychotics, as well as previous response (where applicable) should largely determine the choice of antipsychotic medication.
Written patient information should be used to support the discussion about the risks and benefits of treatment. Patient information leaflets on psychotropic medicines are available at www.choiceandmedication.org/nhs24/, hosted via NHS Inform. Information must be tailored to the individual’s needs, understanding and capacity.
Consider the preparation of antipsychotic including the use of long-acting injection preparations;
Individuals with schizophrenia who request depot and those with medication adherence difficulties should be offered maintenance treatment with depot antipsychotic medication
Initiating treatment
Do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist and/or with the advice and support of the local CMHT.
For people with an acute exacerbation or recurrence of psychosis or schizophrenia, offer oral antipsychotic medication and/or review existing medication. The choice of drug should be influenced by the same criteria recommended for starting treatment. Take into account the clinical response and side effects of the service user's current and previous medication.
Antipsychotics in dementia
Advice from the relevant local mental health service should be sought if considering an antipsychotic for an elderly patient. Elderly people with dementia are at risk from specific serious and life-threatening side-effects when treated with antipsychotics (MHRA Drug Safety Update May 2012). The risk of fatal side effects is much higher if you prescribe an antipsychotic for Lewy body dementia than for other dementias.
Risperidone is the only antipsychotic licensed for the treatment of dementia-related behavioural disturbances and then only specifically for short term (up to 6 weeks) treatment of persistent aggression in Alzheimer’s dementia unresponsive to non-pharmacological approaches and where there is a risk of harm to the patient or others.
Useful links
BNF: Monitoring in Psychoses and related disorders
NICE guideline CG178 (2014). Psychosis and schizophrenia in adults: prevention and management
SIGN Guideline 131 Management of schizophrenia
NHS Lanarkshire Guideline High Dose Antipsychotic Treatment
NHS Lanarkshire Delirium Guidelines
Guidance for Review of Antipsychotic Prescribing in Patients with Dementia
NHS Lanarkshire Pharmacy – Mental Health Team FirstPort Page (NHSL staff link)