Wednesday 9 November 2011

Antipsychotics


Antipsychotics

About this leaflet

This leaflet may be helpful if:
  • you have been prescribed antipsychotic medication
  • a friend or relative has been prescribed antipsychotic medication
  • you just want to find out about antipsychotic medication

It includes:
  • What are antipsychotic medications?
  • How are they supposed to help?
  • How do they work?
  • What kinds of antipsychotic medication are there?
  • What are the possible side-effects?
  • How long should it be taken for?
  • How do I stop taking it?
  • What alternatives are there?

What are antipsychotic medications?

They are a range of medications that are used for some types of mental distress or disorder - mainly schizophrenia andmanic depression (bipolar disorder). They can also be used to help severeanxiety or depression.

What can they help with?

  • The experience of hearing voices (hallucinations).
  • Ideas that distress you and don't seem to be based in reality (delusions).
  • Difficulty in thinking clearly (thought disorder).
  • The extreme mood swings of manic depression/bipolar disorder.

How do they work?

They all affect the action of a number of chemicals in the brain called neurotransmitters – chemicals which brain cells need to communicate with each other. Dopamine is the main neurotransmitter affected by these medications. It is involved in how we feel:
  • that something is significant, important or interesting;
  • satisfied;
  • motivated.
It is also involved in the control of muscle movements.
If parts of the dopamine system become overactive, they seem to play a part in producing hallucinations, delusions and thought disorder.
Although these medications were known as‘major tranquillisers’ in the past, they are not designed to make you calmer or sleepy – so they are not the same as medications like Valium or sleeping tablets.
The basic aim is to help you feel better, without making you feel slowed down or drowsy. However, high doses may well make you feel too sleepy or 'drugged up'. They can be used in higher doses if you become very overactive, agitated or distressed - but this should usually only be for a short time.

What kinds of antipsychotic medication are there?

For the past 10 years or so doctors have talked about two different groups of antipsychotics:
  • ‘Typical’ - the older drugs
  • ‘Atypical’ - the newer drugs
Recent large independent research studies - not paid for by the drug companies – suggest that the new drugs are not really different – but are, in some situations, easier to use.

Choosing an antipsychotic

Most antipsychotics seem to be equally as good at controlling psychotic symptoms – Clozapine is the exception and is described later. Even so, individuals react differently to them, particularly with the side-effects. We cannot (yet) predict how well a particular person will respond to a particular drug – even whether a newer, or older drug, will be more helpful. It can often take some time, negotiation and ‘trial and error’ to find the best antipsychotic for a particular person.
Older antipsychotics: these first appeared in the mid-1950s. These older drugs are often called‘typical’ or 'first-generation' antipsychotics. They all block the action of dopamine (see above), some more strongly than others.
Side-effects include:
  • stiffness and shakiness, like Parkinson’s disease
  • feeling sluggish and slow in your thinking
  • uncomfortable restlessness (akathisia)
  • problems with your sex life.
If you have any of these symptoms, you are probably on too high a dose. It should usually be reduced until the side-effects disappear. If you do need a higher dose to stay well, these side-effects can be controlled with anticholinergic drugs - used to treat Parkinson's disease. Orphenadrine and Procyclidine are the two most commonly used anticholinergics in the UK.
A longer-term problem is tardive dyskinesia (TD for short) – continual movements of the mouth, tongue and jaw. This affects about 1 in 20 people every year who are taking these medications.
Some older, ‘typical’ antipsychotics
Tablets
Trade Name
Usual daily dose (mg)
Max. daily dose (mg)
Chlorpromazine
Largactil
75-300
1000
Haloperidol
Haldol
3-15
30
Pimozide
Orap
4-20
20
Trifluoperazine
Stelazine
5-20
Sulperide
Dolmatil
200-800
2400
Newer antipsychotics : over the last 10 years, newer medications have appeared. They still block dopamine, but much less so than the older drugs. They also work on different chemical messengers in the brain (such as serotonin) and are often called ‘atypical’ or ‘second-generation’antipsychotics. This is misleading - they have many of the same effects as the older drugs.
Side-effects
  • Sleepiness and slowness
  • Weight gain
  • Interference with your sex life
  • Increased chance of developing diabetes.
  • In high doses, some have the same Parkinsonian side-effects as the older medications.
  • Long-term use can produce movements of the face (tardive dyskinesia) and, rarely, of the arms or legs.
Compared to the older drugs they seem:
  • less likely to cause Parkinsonian side-effects (see above)
  • less likely to produce tardive dyskinesia.
  • more likely to produce weight gain
  • more likely to produce diabetes
  • more likely to give you sexual problems.
They may also help 'negative symptoms' (poor motivation, lack of interest, poor self-care), on which the older drugs have very little effect. Some people find the side effects less troublesome than those of the older medications.
Some of the newer ‘atypical’antipsychotics
Tablets
Trade Name
Usual daily dose (mg)
Max. daily dose (mg)
Amisulpiride
Solian
50-800
1200
Aripiprazole
Abilify
10-30
30
Clozapine
Clozaril
200-450
900
Olanzapine
Zyprexa
10-20
20
Quetiapine
Seroquel
300-450
750
Risperidone
Risperdal
4-6
16
Sertindole
Serdolect
12-20
24
Zotepine
Zoleptil
75-200
300
Clozapine: seems to be the only antipsychotic medication which works better than any of the others. It also seems to reduce suicidal feelings in people with schizophrenia.
It has many of the same side-effects as other newer antipsychotics, but can also make you produce more saliva.
It is different in that it seems to have very little, if any, effect on the dopamine systems which control movement, and so causes hardly any of the stiffness, shakiness or slowness that you can get with other antipsychotics. Although it does tend to make you drowsy, some people are prepared to put up with this because it makes them feel less sluggish than on the older antipsychotics. It also does not seem to produce the longer-term problem of tardive dyskinesia.
Side-effects
The main drawback is that it can affect your bone marrow, leading to a shortage of white cells. This makes you vulnerable to infection. If this happens, the medication is stopped at once so that the bone marrow can recover. So, if you take Clozapine you will need weekly blood tests for the first 6 months and 2 weekly blood tests after that. It can also cause weight gain, over-production of saliva and make epileptic fits more likely.
These problems mean that Clozapine is usually only suggested after at least two other antipsychotics have been tried. It is a difficult drug to monitor and can be difficult to take, but some people find that it gives them a much better quality of life.

‘Depot’ antipsychotics

The word ‘depot’ means that the medication is given not as tablets, but as an injection every 2 to 4 weeks. It releases the medication slowly over this time. The effects are generally the same as medications taken by mouth.
What's good about having a depot injection?
Unlike tablets, you only have to think about it once in a while. As there is someone else to remind you, it can be easier to remember to take than tablets.
What's bad about having depot injections?
  • Nobody likes having injections – even though the pain is slight and doesn't last long.
  • It takes a long time to know the effect of changing the dose. If the dose is changed, you may not know what the effect of this change is for several weeks or months – it can take 4 injections or so for the change to work its way through.
  • If a particular dose is giving you side-effects, lowering it may make little difference for several weeks.
How are the injections given?
  • A nurse will give you the injection. There is usually no-one else in the room - just you and the nurse.
  • The first injection is usually a small dose of the medication to check that it does not give you any side-effects.
  • If there are no problems then, a week or so later, you can start having regular injections at a higher dose.
  • After each injection,the medicine will stay in your body for several weeks.
  • The interval between injections is usually between 2 and 4 weeks
Where can you have the injections done?
You can usually decide yourself where to have the injections. This might be:
  • at your local GPs' surgery
  • at a community mental health centre
  • at a special out-patient clinic
  • at your home, when a nurse visits you.
Some common depot antipsychotics
Depot injections
Trade name
Normal 2-weekly dose
Usual max.
Interval
Haloperidol decanoate
Haldol
50
300
4 weeks
Flupenthixol decanoate
Depixol
40
400
2 weeks
Fluphenazine decanoate
Modecate
12.5
100
2 weeks
Pipothiazine palmitate
Piportil
50
200
4 weeks
Zuclopenthixol decanoate
Clopixol
200
600
2 weeks
Newer
Trade name
Normal 2-weekly dose
Usual max.
How often
Risperidone
Risperdal Consta
25
50
2 weeks

How well does medication work?

  • About 4 in 5 people get help from them. They control the symptoms, but do not get rid of them. You have to go on taking the medication to stop the symptoms from coming back.
  • Even if the medication helps, the symptoms may come back. This is much less likely to happen if you carry on taking medication, even when you feel well.

How long should I take an antipsychotic for?

This depends on a number of factors.
Schizophrenia
If you have had just one episode of schizophrenia, you have roughly 1 in 4 chance that your symptoms will not return after you get better. So you may well not need to carry on taking an antipsychotic.
For most people with schizophrenia, the symptoms will continue or come and go over the years. Some things to consider are:
  • You may find that antipsychotic medication takes your symptoms away completely. It's more likely that they will just make the symptoms less intense and easier to cope with.
  • As with any medication, you have to balance the help you get from it, against any side-effects it gives you.
  • For many people the symptoms seem to come and go for no obvious reason – so there may be times when it is more helpful to take such medication, and times when you don't need it so much.
  • If you have had more than one period of psychotic symptoms and stop the medication, the symptoms will usually return within 6 months.
  • There is evidence that if major long-term problems are going to develop they do so in the first 5 years or thereabouts. So your doctor may feel that it is important to use medication to try and keep you well through these early years.
Bipolar disorder
Bipolar disorders will almost always return although, during the first episode, it is hard to predict how often this will happen.

What happens if I stop antipsychotic medication?

The symptoms will usually come back - not immediately, but usually within 3 – 6 months.

How do I stop taking it?

If you decide you want to stop taking an antipsychotic, talk it over with your psychiatrist. You and the psychiatrist may disagree about this, but there is a way that can help both sides to feel happier. You can:
  • make a list of feelings/thoughts/behaviours that might warn you that your symptoms are returning. The pattern of symptoms is often very similar from one episode to another.
  • make a similar list – with someone you trust and who knows you well - of what other people might notice if your symptoms start to return.
  • reduce the medication gradually, giving each reduction a few weeks to take effect.
This means that your symptoms are not likely to suddenly return. If they do start to get worse again, you can think about what to do next while you are still well.

If you do stop medication completely, keep in touch with your psychiatrist or mental health worker, even if you have been well for a few months without medication.

What alternatives are there?

The evidence is very clear that nothing else works as well as antipsychotic medications in the treatment of the more troublesome symptoms of psychotic illnesses. Other ways of helping will usually be added to antipsychotic treatment rather than replacing it. These include:
This is a talking treatment which can be helpful if you have distressing psychotic symptoms. It can help you to control them and to feel less distressed by them. It can also be used to help you identify if your symptoms are returning again.
  • Psychoeducation
This helps you to find out more about your disorder, how to manage it and the treatments available. The purpose is to help everyone (including families) understand the illness better so that they can cope better and be more supportive.
  • Family therapy
Professionals will meet with the whole family. The aims are:
  • to reduce tensions between the person with a psychiatric illness and those who care for them;
  • to give the family practical ways of coping with everyday problems.
We know that these tensions can make it more likely that the symptoms will get worse.
  • Hearing voices groups
People who have similar experiences of hearing voices get together to discuss their experiences and how they cope with them.
Not all of these are available in all areas, and they may not be helpful for everybody – if you feel that one of these might be helpful for you, talk it over with your psychiatrist or mental health worker.

Which antipsychotic is right for me?

There are no antipsychotics that are clearly 'better' than any others. Clozapine is more effective, but has potentially dangerous side-effects and means that you have to have regular blood tests.

NICE guidelines (England and Wales) suggest that one of the newer antipsychotics should be tried first and then one of the older ones, depending on how well the medication works for you, and any side-effects they give you.
The best thing is to weigh up the benefits and risks of the different medications with your psychiatrist. Write down the things you are worried about before the appointment so that you don't forget anything important. If you're not sure what questions to ask, download our leaflet on “Questions to ask your psychiatrist” .

Further help

Mindinfoline: 0845 766 0163. Mind provides information and advice, training programmes, Mind in your area, grants and more.
National Schizophrenia Fellowship (Scotland): works to improve the wellbeing and quality of life of those affected by schizophrenia and other mental illness, including families and carers.
Rethink: National voluntary organisation that helps people with any severe mental illness, their families and carers.
Shine: supporting people with mental ill health:
Saneline: Helpline: 0845 767 8000. A national mental health helpline offering emotional support and practical information for people with mental illness, families, carers and professionals.

References

British National Formulary (March 2009). The BNF provides UK healthcare professionals with authoritative and practical information on the selection and clinical use of medicines in a clear, concise and accessible manner.
Schizophrenia: core intervention in the treatment and management of schizophrenia in primary and secondary care. NICE guidelines, 2009.
Schizophrenia: atypical antipsychotics: the clinical effectiveness and cost effectiveness of newer atypical antipsychotic drugs in schizophrenia: NICE guidelines, 2002.

RCPsych logo
This factsheet was produced by the Royal College of Psychiatrists' Public Education Editorial Board .
Series Editor: Dr Philip Timms
Service user input: Janey Antoniou
© January 2010. Due for review: January 2012.
Royal College of Psychiatrists. This factsheet may be downloaded, printed out, photocopied and distributed free of charge as long as the RCPsych is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from the Head of Publications. The College does not allow reposting of its factsheets on other sites, but allows them to be linked to directly.
For a catalogue of public education materials or copies of our leaflets contact: Leaflets Department, The Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG. Telephone: 020 7235 2351 x259

Antibiotic resistance is driven by overusing antibiotics and prescribing them inappropriately


About antibiotic awareness

Antibiotics are important medicines. They help fight infections that are caused by bacteria. Antibiotic resistance (when an antibiotic is no longer effective) is a major problem. It is one of the most significant threats to patients' safety in Europe. Antibiotic resistance is driven by overusing antibiotics and prescribing them inappropriately. It's important that we use antibiotics the right way, to slow down resistance and make sure these life-saving medicines remain effective for us and future generations.

Watch the “Take care, not antibiotics” videos on this page 

European Antibiotic Awareness Day (EAAD)

Every year, European Antibiotic Awareness Day is held on November 18. It's a Europe-wide public health initiative which encourages responsible use of antibiotics. The initiative is supported in England by the Department of Health and its Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI).

What is the problem?

Antibiotic resistance is an everyday problem in all hospitals across England and Europe. The spread of resistant bacteria in hospitals is a major issue for patients' safety.
  • Infections with antibiotic-resistant bacteria increase levels of disease and death, as well as the length of time people stay in hospitals.
  • Inappropriate use of antibiotics may increasingly cause patients to become colonised or infected with resistant bacteria.
  • Few new antibiotics are being developed. As resistance in bacteria grows, it will become more difficult to treat infection, and this affects patient care. 

What is causing this problem?

Inappropriate use and prescribing of antibiotics in hospitals is causing the development of resistance. 
Inappropriate use includes:
  • not completing a course of antibiotics as prescribed
  • skipping doses of antibiotics
  • not taking antibiotics at regular intervals
  • saving some for later
Inappropriate prescribing includes:
  • unnecessary prescription of antibiotics
  • unsuitable use of broad-spectrum antibiotics
  • wrong selection of antibiotics and inappropriate duration or dose of antibiotics

How can the problem be addressed?

Make antibiotic prescribing a strategic priority in hospitals by:
  • targeting antibiotic therapy
  • implementing structured antimicrobial stewardship plans
  • reviewing local surveillance and assessing microbiological data
Make antibiotic prescribing a priority in primary care by:
  • developing specific antibiotic prescribing guidelines for prescribers

Materials to support EAAD, November 18 2011 in England

To support EAAD and the promotion of sensible antibiotic use, the Department of Health (DH) and European Centre for Disease Prevention and Control (ECDC) have created information and educational materials for use in hospitals and primary care settings. You can download these and other materials from the DH website.

Bacteria 'linked' to Parkinson's disease


Bacteria 'linked' to Parkinson's disease

BacteriumCould this bacterium cause Parkinson's disease?

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The bacteria responsible for stomach ulcers have been linked to Parkinson's disease, according to researchers in the US.
Mice infected with Helicobacter pylori went onto develop Parkinson's like symptoms.
The study, presented at a meeting of the American Society for Microbiology, argues that infection could play "a significant role".
The charity Parkinson's UK said the results should be treated with caution.
Parkinson's disease affects the brain and results in slow movements and a tremor.
Middle-aged mice, the equivalent of being between 55 and 65 in humans, were infected. Six months later they showed symptoms related to Parkinson's, such as reduced movement and decreased levels of a chemical, dopamine, in the brain.
These changes were not noticed in younger mice.
Toxic
Dr Traci Testerman, from the Louisiana State University Health Sciences Center, said: "Our findings suggest that H. pylori infection could play a significant role in the development of Parkinson's disease in humans.
"The results were far more dramatic in aged mice than in young mice, demonstrating that normal ageing increases susceptibility to Parkinsonian changes in mice, as is seen in humans."
The researchers believe the bacteria are producing chemicals which are toxic to the brain.
They said H. pylori was able to "steal" cholesterol from the body and process it by adding a sugar group.
Stomach ulcerThe bacteria responsible for stomach ulcers may have a role in Parkinson's say researchers.
Dr Testerman said this new chemical was almost identical to one found in seeds from the cycad plant, which had been shown to trigger a Parkinson's-like disease among people in Guam.
She told the BBC: "H. pylori eradication in late stage Parkinson's disease is unlikely to result in significant improvement.
"Certain neurons are killed before symptoms begin, and more are killed as the disease progresses. Those neurons will not grow back."
Dr Kieran Breen, director of research at Parkinson's UK, said: "We believe Parkinson's is most likely caused by a combination of environmental factors together with an individual's genetic susceptibility to developing the condition.
He said there was some evidence that bacteria can prevent the main drug to treat Parkinson's, levodopa, being absorbed, but there was no strong evidence that people who have H. pylori in their gut are actually more likely to develop Parkinson's.
He added: "The current study is interesting and suggests that the bacteria may release a toxin that could kill nerve cells.
"However, the results should be treated with caution. The research was carried out in mice that were infected with relatively high doses of the bacterium or its extract.
"While they developed movement problems, we don't know whether this was actually due to the death of nerve cells. Further research needs to be carried out".

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A new technique could improve the quality of life for patients with Parkinson's Disease


Cardiff University new Parkinson's therapy hope

MRI scan of a patient with Parkinson's DiseaseA brain scan of a patient with Parkinson's disease. The blue box highlights a damaged region

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A new technique could improve the quality of life for patients with Parkinson's Disease, according to research led by Cardiff University.
Patients with the early stages of the disease were trained to control areas of the brain associated with movement by using the power of thought alone.
A clinical evaluation later found their movement had improved by up to a third.
The charity Parkinson's UK described the research as "exciting" but stressed "these are very early days".
The study, published in The Journal of Neuroscience, involved ten patients with the disease that affects the brain and results in slow movements and a tremor.
Five patients received the brain regulation feedback technique and five acted as a control.
Activity mapping

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We wanted them to activate the brain regions associated with movement through the force of their mind”
Professor David LindenCardiff University
Patients undergoing the training were placed in a Magnetic Resonance Imaging (MRI) scanner in Bangor, Gwynedd. At first, they were asked to squeeze a hand as the team mapped the regions of the brain responsible for controlling movement.
Then, in real time, the subjects were shown the level of activity in these regions displayed on a gauge above them.
They were asked to imagine making complex movements in order to activate the brain centres, and saw a corresponding increase on the gauge. With practice, they were able to increase and decrease the level of activity at will, through thought alone.
Prof David Linden from Cardiff University, who led the research, described the process as "real-time neural feedback".
Motor function
"Self-regulation of brain activity in humans based on real-time feedback is emerging as a powerful technique," said Prof Linden.
Diagram from Cardiff University showing the principle of feedback in the researchPatients experienced a feedback effect as they learnt to control motion centres in their brain
"In this study we assessed whether patients with Parkinson's disease are able to alter their brain activity to improve their motor function. We wanted them to activate the brain regions associated with movement through the force of their mind," he explained.
The professor stressed that the technique did not offer a cure but he said that improved function could lead to a better quality of life.
"We found that the five patients who received neuro feedback were able to increase activity in brain networks important for movements and that this intervention resulted in an overall improvement in motor speed - in this case, finger tapping," said Prof Linden.
"The training resulted in clinically relevant improvement of motor functions - so assuming patients can learn to transfer the strategies used during neuro feedback into real-life settings, it might also become possible to sustain the clinical benefits," he added.
The research team said the study was a small scale proof of principle and they now hope to stage a larger, randomised, clinical trial.

Start Quote

While these results are exciting, these are very early days”
Claire BaleParkinson's UK
'Amazing' brain
Claire Bale, senior research communications officer at Parkinson's UK, said: "This study showed that people with Parkinson's were able to alter their own brain activity to improve their movement symptoms using neurofeedback from brain scans. This highlights the amazing ability of the brain to change and adapt".
"While these results are exciting, these are very early days. We need much larger, in-depth studies to help us understand the potential these techniques may have to tackle some of the symptoms of Parkinson's," said Ms Bale.
The research into Parkinson's disease was the result of a collaboration between Cardiff University and scientists and doctors from north Wales, London and the Netherlands.
Prof Linden has also carried out a pilot trial using the neuro feedback technique on patients suffering with depression. The findings of that study are yet to be published.

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