Psychosis & related disorders (Formulary: CNS)
TAM (Treatments and Medicines) NHS Highland
All drugs (except clozapine) have similar antipsychotic efficacy, however the side-effect profile varies greatly; refer to Antipsychotics – relative side-effects. Select drugs on an individual basis and take into account the indication:
- psychosis/schizophrenia – consider oral atypical antipsychotics first-line (see below). Keep the patient on a typical antipsychotic if they are stable.
- short-term sedation – typicals can be used at a sufficiently low dose to avoid side-effects.
- mania/hypomania – patients may be particularly sensitive to developing tardive dyskinesia, so atypical antipsychotics are considered first-line in the longer term, usually as an adjunct to a mood stabiliser. Typical antipsychotics can be used short-term and typical depots are occasionally used in the longer term where compliance has been poor.
- bipolar depression – quetiapine is an effective treatment for bipolar depression and does not appear to be associated with a switch to mania.
- dementia – antipsychotic medication should be reserved for severe non-cognitive symptoms or behaviour that challenges, where other approaches have failed or would be inappropriate.
Introduce clozapine if schizophrenia is inadequately controlled despite the sequential use of 2 or more antipsychotics (one of which should be an atypical antipsychotic) each for at least 4 to 6 weeks.
| Note: • There is a clear increased risk of stroke and a small increased risk of death when antipsychotics (typical or atypical) are used in older people with dementia (www.gov.uk/drug-safety-update 2012). • Antipsychotics may also have adverse effects on cognition. |
MHRA advice: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity (August 2020) (www.gov.uk).