Download feature schizophrenia - Royal Pharmaceutical Society

f e at u r e s c h i z o p h r e n i a
This latest practice guidance from the Society on
schizophrenia is part of a mental health toolkit which is under
development. Ziba Rajaei-Dehkordi (lead author) and Denise
Taylor (co-author) provide advice on pharmaceutical care
services for schizophrenia. The RPSGB would like to thank all
those who contributed to a mental health toolkit, including the
focus group members, for their advice and expertise.
Professional
practice
We bring you an update and the
latest expert advice on dealing
with patients suffering from
psychosis and schizophrenia
Practice Guidance:
Pharmaceutical Care in
Psychosis and Schizophrenia
GUIDANCE OBJECTIVES
• T
o gain an understanding of psychosis or schizophrenia and its
management
• Identify pharmaceutical issues and meet patients’ needs
• Explore and implement pharmaceutical care services for
psychosis or schizophrenia in practice
RPSGB competencies for completing a CPD entry (see appendix 6
of “Plan and Record” www.uptodate.org.uk):• “making sound decisions and solving problems in relation to
drug therapy”
• “promoting health and healthy lifestyles”
26
Pharmacy Professional | May 2010
May 2010 | Pharmacy Professional
27
Æ
f e at u r e s c h i z o p h r e n i a
This latest practice guidance from the Society on
schizophrenia is part of a mental health toolkit which is under
development. Ziba Rajaei-Dehkordi (lead author) and Denise
Taylor (co-author) provide advice on pharmaceutical care
services for schizophrenia. The RPSGB would like to thank all
those who contributed to a mental health toolkit, including the
focus group members, for their advice and expertise.
Professional
practice
We bring you an update and the
latest expert advice on dealing
with patients suffering from
psychosis and schizophrenia
Practice Guidance:
Pharmaceutical Care in
Psychosis and Schizophrenia
GUIDANCE OBJECTIVES
• T
o gain an understanding of psychosis or schizophrenia and its
management
• Identify pharmaceutical issues and meet patients’ needs
• Explore and implement pharmaceutical care services for
psychosis or schizophrenia in practice
RPSGB competencies for completing a CPD entry (see appendix 6
of “Plan and Record” www.uptodate.org.uk):• “making sound decisions and solving problems in relation to
drug therapy”
• “promoting health and healthy lifestyles”
26
Pharmacy Professional | May 2010
May 2010 | Pharmacy Professional
27
Æ
f e at u r e s c h i z o p h r e n i a
Background
Psychosis – a syndrome or a collection of
symptoms, which can include delusions and
hallucinations. It can be drug-induced or be
part of another illness such as: schizophrenia,
schizoaffective disorder, intensive psychosis
or brief psychotic disorder.
Schizophrenia is the best-known psychotic
illness and the most common psychotic
disorder. Schizophrenia is not a “split
personality” but a split between the mind
and reality. Schizophrenia is characterised
by positive and negative symptoms (see
Symptoms). The negative symptoms are
less responsive to treatment with medication
and are associated with decreased rates of
recovery and the positive symptoms can also
be very distressing to the patient.
Positive and negative symptoms in schizophrenia
Positive symptoms can present in a number of ways:Hallucinations
Most commonly auditory command (someone telling them to do
things such as jumping off a roof or to kill themselves) or olfactory.
Visual and tactile are less common
Delusions
May be persecutory (i.e. someone is out to hurt them), religious
(i.e. they believe they have religious powers or their god talks
to them), grandiose (e.g. they are a celebrity; have telepathic
powers), bizarre e.g. thought insertion (i.e. thoughts are put into
their mind by others) or thought withdrawal (i.e. thoughts are
removed from their mind) or ideas of reference (the person on the
television/radio is talking just to them).
Formal Thought
Disorder
Disorganised speech, with rapid change of topic or words put
together which make no sense.
Passivity
Emotions, body movements or sensations are experienced as being
caused by an external agency
Prevalence
It is a chronic mental illness affecting 1%
of the population. Schizophrenia normally
presents between the ages of 18 and 30,
and is slightly more prevalent in males than
females.
Possible causes
The actual cause is still unknown but the
following factors may be involved:• Genetic link is strong. Children of people
with schizophrenia are about 9% more
likely to develop schizophrenia.
• Environmental stressors such as poor
maternal upbringing, deprivation in
childhood, relationship problems.
• Viral exposure in-utero can impair
neurodevelopment and possibly lead to
schizophrenia.
• Drugs which may cause or exacerbate
psychosis. Illicit drugs (e.g. cannabis,
“magic mushrooms,” LSD, amphetamines,
cocaine or ecstasy) have been implicated,
and prescribed drugs (e.g. opiates,
corticosteroids) can cause psychosis as a
side effect
Symptoms
The common symptoms of psychosis:
• Odd beliefs or magical thinking
• Anxiety, blunted affect or depression
• Irritability or loss of initiative
• Low energy or poor concentration
• Sleep disturbance
• Social isolation and withdrawal
• Perceptual disturbance
• Odd thinking and speech
• Odd behaviour or appearance
• Paranoid ideation
28
Pharmacy Professional | May 2010
Negative symptoms lead to disturbances in social
or occupational functioning. These include:Affective flattening
Present as if they are depressed
Alogia
Poverty of speech and an inability to talk and communicate to
people
Avolition
Inability to do anything. This can sometimes be interpreted as
laziness but it is part of the illness
Anhedonia
Lack of ability to get pleasure from doing anything
Drug-induced psychosis should be
considered if delusions or hallucinations
occur after the administration of a new
medicine (prescribed or illicit). Treatment
is generally delayed for at least 7 days to
determine whether symptoms abate once the
causative agent is stopped.
Possible Consequences of
Schizophrenia
Hospitalisation: The first episode often
results in hospitalisation and, of these,
20% of patients will recover fully without
relapse, 20% will never fully recover and
require high levels of social and medical
input. More commonly, patients will
partly recover but not return to baseline
functioning and will suffer further relapses
during their life.
Suicide: The lifetime risk of people with
schizophrenia committing suicide has been
estimated at 10%.
Type-2 diabetes predisposition: People
with schizophrenia are 2 to 4 times more
likely to develop type 2 diabetes than those
who are not. The actual prevalence of type
2 diabetes in people with schizophrenia is
between 15 and 18%, but the prevalence of
impaired glucose tolerance may be as high
as 30% depending on age.
Treatment
The NICE Clinical Guideline for
schizophrenia http://guidance.nice.org.
uk/CG82 outlines a holistic approach to
patient care including pharmacological and
non-pharmacological interventions. It is
an important consideration that medication
forms only part of the overall care package
for people with schizophrenia and that
supported adherence interventions can
improve long-term outcomes in patient care.
Non-Pharmacological
• Talking therapy such as problem-solving
therapy,
• Cognitive behavioural therapy,
• Family therapy and support with social
integration,
• Psychotherapy is recommended if there
is a history of psychological and physical
abuse,
• Patient support groups such as ‘Hearing
Voices’; supports people to live with
auditory hallucinations.
Pharmacological
There are two groups of antipsychotics used
to treat schizophrenia:• Typical (or first generation) and
• Atypical (or second generation) agents.
Their main mode of action is to block
dopamine pathways in the brain, and 5H2
blockade (atypical antipsychotics).
For further information See Practice
Guidance: Supporting Patients on
Antipsychotics
Pregnancy and Breastfeeding – Specialist
input is required to support women who
are planning pregnancy or have become
pregnant during treatment, or wish to
breastfeed.
Practice Points for
Pharmacists
• Encourage and support patients to
undertake activities and address lifestyle
issues, to promote good mental.
Signpost to local and/or national support
resources.
• Drug-induced psychosis – if suspected
refer for medical review to either the
prescriber, GP or local mental healthcare
team.
• Poorly compliant patients may benefit
from a once daily preparation and/or use
of compliance aids.
• Recognition of persistent side effects
requiring support and/or advice and/or
referral for clinical review.
• Check for interactions, including OTC
remedies. See BNF www.bnf.org
• Patients at risk of suicide require urgent
referral to a crisis resolution team
or psychiatric emergency services or
Accident and Emergency Department
or GP.
• Poisoning by antipsychotic drugs requires
immediate referral to doctor. Features
include convulsions, extrapyramidal
symptoms and hypotension.
• Clozapine
• Signs of infection, temperature and
sore throat require immediate patient
reporting to doctor. Explain to patient
that they are likely to need an additional
blood test.
• Caffeine increases and smoking
decreases plasma clozapine levels.
Advice on clozapine dose should be
sought from prescriber if there are any
changes in caffeine intake or smoking
status.
• Clozapine (and olanzapine) can cause
up to 10 to 15kg weight gain. Advise
patients about healthy eating and
exercise.
• Missed doses: if a patient misses
medication for 2 days then clozapine
needs to be re-initiated. Continuing with
the same dose without re-initiation can
result in cardiovascular effects. Refer
urgently
• Chlorpromazine warning - Owing to the
risk of contact dermatitis, avoid direct
contact with chlorpromazine; (tablets
should not be crushed and solutions
should be handled with care)
• Photosensitivity can occur with
chlorpromazine. Advise patient to wear
sun protection in the sun.
Levels of
Pharmaceutical Care
Services for Supporting
People with psychosis
and schizophrenia
In general pharmacists can:
Recognise possible symptoms of
schizophrenia/psychosis especially when
responding to symptoms and refer as
appropriate
Identify people possibly at risk of
schizophrenia/psychosis and refer
appropriately.
Signpost people to support groups and
information on pharmacological and nonpharmacological treatments
Level 1: Pharmacists can:
Provide a medication review service, with
a key focus to support any adherence
problems:• Identify new patients by prescription
(ensure understanding of illness,
its treatment and available support
including information on adverse effects,
concordance, diet and exercise and support
groups)
• Be aware of concomitant medicines that
may cause or exacerbate psychosis
• Identify any pharmaceutical issues
(interactions including OTC medication,
alcohol and smoking).
Pharmacists can offer
support for healthy
lifestyle interventions
Level 2: Pharmacists can:
Recognise symptoms of relapse: e.g.
self-neglect; poor speech and ability to
concentrate or interact with others; strange
thoughts or behaviour. Referral to the
appropriate care team, or, following a preset
agreement for how the patient wishes to
be managed in relapse, and who should be
contacted.
Pharmacists can offer support for healthy
lifestyle interventions, including:• Smoking cessation - Be aware that
smoking reduces clozapine levels resulting
in a need to increase dosages; if a person
on clozapine stops smoking make urgent
referral for blood monitoring and dosage
review
• Use of alcohol NHS Choices: Live well
cut down on alcohol http://www.nhs.uk/
Livewell/Alcohol/Pages/Alcoholhome.
aspx
• Diet and exercise support and advice. Top
Tips for eating more fruit and vegetable
http://www.5aday.nhs.uk/topTips/default.
html
• Sleep hygiene advice and support
• Vascular risk and weight management.
Patients with psychosis and schizophrenia
are more likely to develop diabetes due to
the risk of antipsychotics causing weight
gain.
Level 3: Specialist Mental Health Level;
Pharmacists role in effective care for those
with chronic psychotic illness
Pharmacists can:
• Provide medicine education sessions
• Monitor response and side effects
• Suggest therapeutic changes if poor
response
• Prescribe (if appropriately trained and
qualified) in collaboration with healthcare
team and Community Mental Health Team
(CMHT) if appropriate
• Provide (if appropriately trained and
qualified) a basic talking therapy service
e.g. cognitive based therapy, mindfulness
training
• Provide clozapine dispensing services in
the community.
May 2010 | Pharmacy Professional
29
Æ
f e at u r e s c h i z o p h r e n i a
Background
Psychosis – a syndrome or a collection of
symptoms, which can include delusions and
hallucinations. It can be drug-induced or be
part of another illness such as: schizophrenia,
schizoaffective disorder, intensive psychosis
or brief psychotic disorder.
Schizophrenia is the best-known psychotic
illness and the most common psychotic
disorder. Schizophrenia is not a “split
personality” but a split between the mind
and reality. Schizophrenia is characterised
by positive and negative symptoms (see
Symptoms). The negative symptoms are
less responsive to treatment with medication
and are associated with decreased rates of
recovery and the positive symptoms can also
be very distressing to the patient.
Positive and negative symptoms in schizophrenia
Positive symptoms can present in a number of ways:Hallucinations
Most commonly auditory command (someone telling them to do
things such as jumping off a roof or to kill themselves) or olfactory.
Visual and tactile are less common
Delusions
May be persecutory (i.e. someone is out to hurt them), religious
(i.e. they believe they have religious powers or their god talks
to them), grandiose (e.g. they are a celebrity; have telepathic
powers), bizarre e.g. thought insertion (i.e. thoughts are put into
their mind by others) or thought withdrawal (i.e. thoughts are
removed from their mind) or ideas of reference (the person on the
television/radio is talking just to them).
Formal Thought
Disorder
Disorganised speech, with rapid change of topic or words put
together which make no sense.
Passivity
Emotions, body movements or sensations are experienced as being
caused by an external agency
Prevalence
It is a chronic mental illness affecting 1%
of the population. Schizophrenia normally
presents between the ages of 18 and 30,
and is slightly more prevalent in males than
females.
Possible causes
The actual cause is still unknown but the
following factors may be involved:• Genetic link is strong. Children of people
with schizophrenia are about 9% more
likely to develop schizophrenia.
• Environmental stressors such as poor
maternal upbringing, deprivation in
childhood, relationship problems.
• Viral exposure in-utero can impair
neurodevelopment and possibly lead to
schizophrenia.
• Drugs which may cause or exacerbate
psychosis. Illicit drugs (e.g. cannabis,
“magic mushrooms,” LSD, amphetamines,
cocaine or ecstasy) have been implicated,
and prescribed drugs (e.g. opiates,
corticosteroids) can cause psychosis as a
side effect
Symptoms
The common symptoms of psychosis:
• Odd beliefs or magical thinking
• Anxiety, blunted affect or depression
• Irritability or loss of initiative
• Low energy or poor concentration
• Sleep disturbance
• Social isolation and withdrawal
• Perceptual disturbance
• Odd thinking and speech
• Odd behaviour or appearance
• Paranoid ideation
28
Pharmacy Professional | May 2010
Negative symptoms lead to disturbances in social
or occupational functioning. These include:Affective flattening
Present as if they are depressed
Alogia
Poverty of speech and an inability to talk and communicate to
people
Avolition
Inability to do anything. This can sometimes be interpreted as
laziness but it is part of the illness
Anhedonia
Lack of ability to get pleasure from doing anything
Drug-induced psychosis should be
considered if delusions or hallucinations
occur after the administration of a new
medicine (prescribed or illicit). Treatment
is generally delayed for at least 7 days to
determine whether symptoms abate once the
causative agent is stopped.
Possible Consequences of
Schizophrenia
Hospitalisation: The first episode often
results in hospitalisation and, of these,
20% of patients will recover fully without
relapse, 20% will never fully recover and
require high levels of social and medical
input. More commonly, patients will
partly recover but not return to baseline
functioning and will suffer further relapses
during their life.
Suicide: The lifetime risk of people with
schizophrenia committing suicide has been
estimated at 10%.
Type-2 diabetes predisposition: People
with schizophrenia are 2 to 4 times more
likely to develop type 2 diabetes than those
who are not. The actual prevalence of type
2 diabetes in people with schizophrenia is
between 15 and 18%, but the prevalence of
impaired glucose tolerance may be as high
as 30% depending on age.
Treatment
The NICE Clinical Guideline for
schizophrenia http://guidance.nice.org.
uk/CG82 outlines a holistic approach to
patient care including pharmacological and
non-pharmacological interventions. It is
an important consideration that medication
forms only part of the overall care package
for people with schizophrenia and that
supported adherence interventions can
improve long-term outcomes in patient care.
Non-Pharmacological
• Talking therapy such as problem-solving
therapy,
• Cognitive behavioural therapy,
• Family therapy and support with social
integration,
• Psychotherapy is recommended if there
is a history of psychological and physical
abuse,
• Patient support groups such as ‘Hearing
Voices’; supports people to live with
auditory hallucinations.
Pharmacological
There are two groups of antipsychotics used
to treat schizophrenia:• Typical (or first generation) and
• Atypical (or second generation) agents.
Their main mode of action is to block
dopamine pathways in the brain, and 5H2
blockade (atypical antipsychotics).
For further information See Practice
Guidance: Supporting Patients on
Antipsychotics
Pregnancy and Breastfeeding – Specialist
input is required to support women who
are planning pregnancy or have become
pregnant during treatment, or wish to
breastfeed.
Practice Points for
Pharmacists
• Encourage and support patients to
undertake activities and address lifestyle
issues, to promote good mental.
Signpost to local and/or national support
resources.
• Drug-induced psychosis – if suspected
refer for medical review to either the
prescriber, GP or local mental healthcare
team.
• Poorly compliant patients may benefit
from a once daily preparation and/or use
of compliance aids.
• Recognition of persistent side effects
requiring support and/or advice and/or
referral for clinical review.
• Check for interactions, including OTC
remedies. See BNF www.bnf.org
• Patients at risk of suicide require urgent
referral to a crisis resolution team
or psychiatric emergency services or
Accident and Emergency Department
or GP.
• Poisoning by antipsychotic drugs requires
immediate referral to doctor. Features
include convulsions, extrapyramidal
symptoms and hypotension.
• Clozapine
• Signs of infection, temperature and
sore throat require immediate patient
reporting to doctor. Explain to patient
that they are likely to need an additional
blood test.
• Caffeine increases and smoking
decreases plasma clozapine levels.
Advice on clozapine dose should be
sought from prescriber if there are any
changes in caffeine intake or smoking
status.
• Clozapine (and olanzapine) can cause
up to 10 to 15kg weight gain. Advise
patients about healthy eating and
exercise.
• Missed doses: if a patient misses
medication for 2 days then clozapine
needs to be re-initiated. Continuing with
the same dose without re-initiation can
result in cardiovascular effects. Refer
urgently
• Chlorpromazine warning - Owing to the
risk of contact dermatitis, avoid direct
contact with chlorpromazine; (tablets
should not be crushed and solutions
should be handled with care)
• Photosensitivity can occur with
chlorpromazine. Advise patient to wear
sun protection in the sun.
Levels of
Pharmaceutical Care
Services for Supporting
People with psychosis
and schizophrenia
In general pharmacists can:
Recognise possible symptoms of
schizophrenia/psychosis especially when
responding to symptoms and refer as
appropriate
Identify people possibly at risk of
schizophrenia/psychosis and refer
appropriately.
Signpost people to support groups and
information on pharmacological and nonpharmacological treatments
Level 1: Pharmacists can:
Provide a medication review service, with
a key focus to support any adherence
problems:• Identify new patients by prescription
(ensure understanding of illness,
its treatment and available support
including information on adverse effects,
concordance, diet and exercise and support
groups)
• Be aware of concomitant medicines that
may cause or exacerbate psychosis
• Identify any pharmaceutical issues
(interactions including OTC medication,
alcohol and smoking).
Pharmacists can offer
support for healthy
lifestyle interventions
Level 2: Pharmacists can:
Recognise symptoms of relapse: e.g.
self-neglect; poor speech and ability to
concentrate or interact with others; strange
thoughts or behaviour. Referral to the
appropriate care team, or, following a preset
agreement for how the patient wishes to
be managed in relapse, and who should be
contacted.
Pharmacists can offer support for healthy
lifestyle interventions, including:• Smoking cessation - Be aware that
smoking reduces clozapine levels resulting
in a need to increase dosages; if a person
on clozapine stops smoking make urgent
referral for blood monitoring and dosage
review
• Use of alcohol NHS Choices: Live well
cut down on alcohol http://www.nhs.uk/
Livewell/Alcohol/Pages/Alcoholhome.
aspx
• Diet and exercise support and advice. Top
Tips for eating more fruit and vegetable
http://www.5aday.nhs.uk/topTips/default.
html
• Sleep hygiene advice and support
• Vascular risk and weight management.
Patients with psychosis and schizophrenia
are more likely to develop diabetes due to
the risk of antipsychotics causing weight
gain.
Level 3: Specialist Mental Health Level;
Pharmacists role in effective care for those
with chronic psychotic illness
Pharmacists can:
• Provide medicine education sessions
• Monitor response and side effects
• Suggest therapeutic changes if poor
response
• Prescribe (if appropriately trained and
qualified) in collaboration with healthcare
team and Community Mental Health Team
(CMHT) if appropriate
• Provide (if appropriately trained and
qualified) a basic talking therapy service
e.g. cognitive based therapy, mindfulness
training
• Provide clozapine dispensing services in
the community.
May 2010 | Pharmacy Professional
29
Æ
f e at u r e s c h i z o p h r e n i a
Practice Guidance:
Supporting Patients on Antipsychotics
GUIDANCE OBJECTIVES
To understand, identify and meet the
pharmaceutical care needs of patients:• initiating antipsychotic therapy
• on maintenance therapy, and
• withdrawing from antipsychotic therapy
RPSGB competencies for completing a
CPD entry (see appendix 6 of “Plan and
Record” www.uptodate.org.uk):“making sound decisions and solving
problems in relation to drug therapy”
“promoting health and healthy lifestyles”
Background
Antipsychotic drugs are also known as
‘neuroleptics’ and (misleadingly) as ‘major
tranquillisers’. Antipsychotic drugs generally
tranquillise without impairing consciousness
and without causing paradoxical excitement
but they should not be regarded merely
as tranquillisers. For conditions such as
schizophrenia the tranquillising effect is of
secondary importance.
1.Pharmaceutical Care at Initiation
People presenting for the first time with
psychosis will generally be initiated
treatment in a secondary care setting. It is
recommended that the potential side effects
are discussed with the patient at the point
of prescribing, to ensure the optimal choice
of medication is aligned with the patient’s
lifestyle.
Advice to patients at Initiation
• Possible side effects (see Side effects)
All can cause side effects; people should be
made aware that these medicines may make
them feel worse (due to side effects) before
they start to feel better.
• Time to onset of action usually has an effect
in a few days, with effect building over 3-4
weeks
• Take at a regular time each day
• Possible withdrawal effects
Do not to stop taking suddenly as may
experience a withdrawal syndrome. (see
Pharmaceutical Care on Withdrawal section)
• Drowsiness may affect performance of
skilled tasks (e.g. driving or operating
machinery), especially at start of treatment;
effects of alcohol are enhanced.
• Avoid alcohol (Alcohol is a CNS
depressant; can also increase sedative side
effects of antipsychotics)
30
Pharmacy Professional | May 2010
• Provide information and signpost: - Leaflets on psychosis/schizophrenia and
medication
- Support resources e.g. audiotapes, peer
support groups, including diet and
lifestyle
Antipsychotic side effect profiles
Antipsychotic drugs are considered to
act by interfering with dopaminergic
transmission in the brain by blocking
dopamine D2 receptors, which may give rise
to the extrapyramidal effects, and also to
hyperprolactinaemia. Extrapyramidal effects
and hyperprolactinaemia are less common
with atypical antipsychotics.
Antipsychotics also interact with a number
of other receptor systems such as histamine
receptors, alpha-receptors and muscarinic
receptors resulting in a range of different
side effects (e.g. weight gain; postural
hypotension and drowsiness respectively).
Typical Antipsychotics
Extrapyramidal symptoms (EPSE) are
the most troublesome. They are easy to
recognise but cannot be predicted accurately
because they depend on the dose, the type of
drug, and on individual susceptibility. The
relative incidence of EPSE is as follows:Most likely
Moderately
likely
Least likely
Fluphenazine,
perphenazine,
trifluoperazine,
zuclopenthixol and
haloperidol
Flupentixol, pipotiazine
Chlorpromazine,
levomepromazine
Pericyazine, sulpiride
Atypical Antipsychotics
Clinically less likely to cause extrapyramidal
side effects including tardive dyskinesia,
or to affect prolactin levels. There is an
increased risk of developing or exacerbating
diabetes with all antipsychotics but
especially some atypical antipsychotics (e.g.
clozapine, olanzapine and quetiapine).
Clozapine has proven benefit in treating
associated negative symptoms of
schizophrenia.
Aripiprazole, clozapine, olanzapine,
quetiapine, cause little or no elevation of
prolactin levels.
Side Effects: Advice on Management
Clozapine used in ‘treatment resistant’
schizophrenia, can cause blood dyscrasias.
Its use is restricted to patients registered
with a clozapine monitoring service (see
Clozapine Monitoring).
Medication
Presenting signs and symptoms
Considerations & Advice
Extrapyramidal
Parkinsonism
Approximately 20% of patients treated with typical antipsychotics
will develop the parkinsonism side effect of rigidity, tremor,
akinesia (lack of movement) and bradykinesia (slowness of
movement). Onset is usually within days or weeks of treatment.
Patient’s medication to be reviewed with their doctor,
potential management options of:Reducing dose of antipsychotic
Prescribing an anticholinergic
Switching to an atypical antipsychotic
Side Effects: Advice on Management
People need to be informed about the most
common side effects to self manage and
identify when to seek urgent medical advice.
Akathisia (restlessness)
Common in over 25% of patients with typical antipsychotics,
characteristically occurs after large initial doses and may resemble
an exacerbation of the condition being treated. Refer to doctor
For a detailed list of side effects see BNF
www.bnf.org
Dystonia (group of muscles go into spasm (e.g torticollis (neck)
oculogyria (eyes))
90% cases of occur in the first 5 days of treatment. Up to 10% of
patients treated with typical antipsychotics will develop dystonia
in one form or another. Immediate medical attention is
required – with administration an anticholinergic and/or change
to an atypical antipsychotic
>> See table opposite
Interactions: prevention and advice
For interactions see BNF www.bnf.org
Key considerations:
• Metabolism by the cytochrome P450
system: Blood levels of antipsychotics can
be affected by concomitantly prescribed
medicines which undergo the same
metabolic pathway. Check for interactions
at all times.
Tardive Dyskinesia (rhythmic, involuntary movements of tongue,
face, & jaw)
Develop over months or even years following chronic exposure to
antipsychotics or with high dosage. May resolve (up to 6 months)
by stopping the drug, but in some cases it is irreversible. Atypical
antipsychotics are thought to have a lower risk. Refer to doctor.
Hormonal – hyperprolactinaemia
e.g. Patient on clozapine prescribed
erythromycin; may increase clozapine levels
and induce adverse effects such as seizure
• Immunosupression can occur with
some antipsychotics, e.g. clozapine and
chlorpromazine. Use with caution and
monitor patient when co-prescribed with
myelosuppressive agents. Regular blood
monitoring is mandatory for clozapine.
Risks of sudden death: Generally only
one antipsychotic at a time should be
prescribed; exceptions are when stopping
one and starting another, or if a depot is
being prescribed and there are breakthrough
symptoms. Risks include sudden death
(especially if doses are above BNF limits)
and Neuroleptic Malignant Syndrome
(NMS). NMS is rare (in approximately 1%
of patients treated with antipsychotics), but
potentially fatal and should be treated as a
medical emergency.
Signs & Symptoms of NMS
Severe muscle rigidity and elevated
temperature with two of the following:
tremor; diaphoresis, dysphagia, incontinence,
changes in consciousness, mutism,
tachycardia, increased blood pressure.
Typical antipsychotics and some atypicals (e.g. risperidone) may
cause increased levels of prolactin, which can cause a number
of symptoms such as gynaecomastia (breast enlargement)
and galactorrhoea (secreting breast milk), increased risk of
osteoporosis, menstrual and sexual dysfunction, acne and
hirsutism.
Counselling Point: Women of childbearing age may need
contraceptive advice when switching from a typical to an
atypical antipsychotic.
Cardiovascular – Hypotention,
arrhythmias and sudden death
Postural hypotension and arrhythmias with some antipsychotics
(especially during initial dose titration). Clozapine: Fatal
myocarditis (most commonly in first 2 months) and
cardiomyopathy reported. Refer to doctor if present with
cardiovascular symptoms
Antimuscarinic
Symptoms such as dry mouth, constipation, difficulty with
micturition, and blurred vision. Advise as appropriate
Blood dyscrasias
Clozapine has the greatest risk of causing neutropenia and
agranulocytosis; not dose-related. Can occur at any time, but
the first 18 weeks are considered the period of highest risk. See
clozapine monitoring below.
Hyperlipidaemia
Can occur with any antipsychotic. Advise and support, provide
cholesterol testing
Diabetes
Antipsychotics, particularly some atypicals have been associated
with increased risk of hyperglycaemia and development of
diabetes. Recognise potential signs and symptoms, advise and
support, provide glucose testing
Weight gain
Associated with all antipsychotic medication. Provide weight
monitoring and management support and advice
Clozapine Monitoring
Monitoring is essential due to risk of blood
dyscrasias (usually reversible neutropenia
in 3-4% patients, which may progress to
agranulocytosis in 0.8% patients over one
year). Patients MUST be registered with a
clozapine patient monitoring service.
• A full blood count must be performed
weekly for 18 weeks, fortnightly up to 52
weeks and 4-weekly thereafter and 4 weeks
after discontinuation.
Other monitoring:
• Check for interactions: concomitant
medication, caffeine ingestion and smoking
affects clozapine blood levels. Report
potential interactions to Doctor immediately.
• Caution if used with drugs which cause
constipation (e.g. antimuscarinic drugs)
or in history of colonic disease or bowel
surgery. Monitor for constipation and refer
to doctor or advise on laxative if required.
• Signs of infection, temperature and
sore throat require immediate patient
reporting to doctor. (Usually an additional
blood test is taken).
2.Pharmaceutical Care for
Maintenance
People prescribed antipsychotics are at
risk of weight gain, metabolic malignant
syndrome and potentially type 2-diabetes.
Diabetes is an independent risk factor for
cardiovascular disease; therefore monitoring
and support should include the following:
Weight gain: provide advice on healthy
eating and weight management
Diabetes and Cardiovascular risk
Lifestyle issues: promote good mental &
physical health
Switching antipsychotics due to
inadequate efficacy Switching is generally
achieved by gradual reduction of the dose
of the first agent and simultaneous titration
up of the second agent (cross-tapering).
For further advice see the BNF www.bnf.
org, Psychotropic Drug Directory and the
Maudsley Prescribing Guidelines
3.Pharmaceutical Care on
Withdrawal
When stopped suddenly, antipsychotics may
produce an acute withdrawal syndrome in
some people. Rapid relapse can also occur.
Withdrawal of antipsychotic agents after longterm therapy should always be gradual and the
patient should be closely monitored for signs
of relapse or discontinuation symptoms.
May 2010 | Pharmacy Professional
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f e at u r e s c h i z o p h r e n i a
Practice Guidance:
Supporting Patients on Antipsychotics
GUIDANCE OBJECTIVES
To understand, identify and meet the
pharmaceutical care needs of patients:• initiating antipsychotic therapy
• on maintenance therapy, and
• withdrawing from antipsychotic therapy
RPSGB competencies for completing a
CPD entry (see appendix 6 of “Plan and
Record” www.uptodate.org.uk):“making sound decisions and solving
problems in relation to drug therapy”
“promoting health and healthy lifestyles”
Background
Antipsychotic drugs are also known as
‘neuroleptics’ and (misleadingly) as ‘major
tranquillisers’. Antipsychotic drugs generally
tranquillise without impairing consciousness
and without causing paradoxical excitement
but they should not be regarded merely
as tranquillisers. For conditions such as
schizophrenia the tranquillising effect is of
secondary importance.
1.Pharmaceutical Care at Initiation
People presenting for the first time with
psychosis will generally be initiated
treatment in a secondary care setting. It is
recommended that the potential side effects
are discussed with the patient at the point
of prescribing, to ensure the optimal choice
of medication is aligned with the patient’s
lifestyle.
Advice to patients at Initiation
• Possible side effects (see Side effects)
All can cause side effects; people should be
made aware that these medicines may make
them feel worse (due to side effects) before
they start to feel better.
• Time to onset of action usually has an effect
in a few days, with effect building over 3-4
weeks
• Take at a regular time each day
• Possible withdrawal effects
Do not to stop taking suddenly as may
experience a withdrawal syndrome. (see
Pharmaceutical Care on Withdrawal section)
• Drowsiness may affect performance of
skilled tasks (e.g. driving or operating
machinery), especially at start of treatment;
effects of alcohol are enhanced.
• Avoid alcohol (Alcohol is a CNS
depressant; can also increase sedative side
effects of antipsychotics)
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Pharmacy Professional | May 2010
• Provide information and signpost: - Leaflets on psychosis/schizophrenia and
medication
- Support resources e.g. audiotapes, peer
support groups, including diet and
lifestyle
Antipsychotic side effect profiles
Antipsychotic drugs are considered to
act by interfering with dopaminergic
transmission in the brain by blocking
dopamine D2 receptors, which may give rise
to the extrapyramidal effects, and also to
hyperprolactinaemia. Extrapyramidal effects
and hyperprolactinaemia are less common
with atypical antipsychotics.
Antipsychotics also interact with a number
of other receptor systems such as histamine
receptors, alpha-receptors and muscarinic
receptors resulting in a range of different
side effects (e.g. weight gain; postural
hypotension and drowsiness respectively).
Typical Antipsychotics
Extrapyramidal symptoms (EPSE) are
the most troublesome. They are easy to
recognise but cannot be predicted accurately
because they depend on the dose, the type of
drug, and on individual susceptibility. The
relative incidence of EPSE is as follows:Most likely
Moderately
likely
Least likely
Fluphenazine,
perphenazine,
trifluoperazine,
zuclopenthixol and
haloperidol
Flupentixol, pipotiazine
Chlorpromazine,
levomepromazine
Pericyazine, sulpiride
Atypical Antipsychotics
Clinically less likely to cause extrapyramidal
side effects including tardive dyskinesia,
or to affect prolactin levels. There is an
increased risk of developing or exacerbating
diabetes with all antipsychotics but
especially some atypical antipsychotics (e.g.
clozapine, olanzapine and quetiapine).
Clozapine has proven benefit in treating
associated negative symptoms of
schizophrenia.
Aripiprazole, clozapine, olanzapine,
quetiapine, cause little or no elevation of
prolactin levels.
Side Effects: Advice on Management
Clozapine used in ‘treatment resistant’
schizophrenia, can cause blood dyscrasias.
Its use is restricted to patients registered
with a clozapine monitoring service (see
Clozapine Monitoring).
Medication
Presenting signs and symptoms
Considerations & Advice
Extrapyramidal
Parkinsonism
Approximately 20% of patients treated with typical antipsychotics
will develop the parkinsonism side effect of rigidity, tremor,
akinesia (lack of movement) and bradykinesia (slowness of
movement). Onset is usually within days or weeks of treatment.
Patient’s medication to be reviewed with their doctor,
potential management options of:Reducing dose of antipsychotic
Prescribing an anticholinergic
Switching to an atypical antipsychotic
Side Effects: Advice on Management
People need to be informed about the most
common side effects to self manage and
identify when to seek urgent medical advice.
Akathisia (restlessness)
Common in over 25% of patients with typical antipsychotics,
characteristically occurs after large initial doses and may resemble
an exacerbation of the condition being treated. Refer to doctor
For a detailed list of side effects see BNF
www.bnf.org
Dystonia (group of muscles go into spasm (e.g torticollis (neck)
oculogyria (eyes))
90% cases of occur in the first 5 days of treatment. Up to 10% of
patients treated with typical antipsychotics will develop dystonia
in one form or another. Immediate medical attention is
required – with administration an anticholinergic and/or change
to an atypical antipsychotic
>> See table opposite
Interactions: prevention and advice
For interactions see BNF www.bnf.org
Key considerations:
• Metabolism by the cytochrome P450
system: Blood levels of antipsychotics can
be affected by concomitantly prescribed
medicines which undergo the same
metabolic pathway. Check for interactions
at all times.
Tardive Dyskinesia (rhythmic, involuntary movements of tongue,
face, & jaw)
Develop over months or even years following chronic exposure to
antipsychotics or with high dosage. May resolve (up to 6 months)
by stopping the drug, but in some cases it is irreversible. Atypical
antipsychotics are thought to have a lower risk. Refer to doctor.
Hormonal – hyperprolactinaemia
e.g. Patient on clozapine prescribed
erythromycin; may increase clozapine levels
and induce adverse effects such as seizure
• Immunosupression can occur with
some antipsychotics, e.g. clozapine and
chlorpromazine. Use with caution and
monitor patient when co-prescribed with
myelosuppressive agents. Regular blood
monitoring is mandatory for clozapine.
Risks of sudden death: Generally only
one antipsychotic at a time should be
prescribed; exceptions are when stopping
one and starting another, or if a depot is
being prescribed and there are breakthrough
symptoms. Risks include sudden death
(especially if doses are above BNF limits)
and Neuroleptic Malignant Syndrome
(NMS). NMS is rare (in approximately 1%
of patients treated with antipsychotics), but
potentially fatal and should be treated as a
medical emergency.
Signs & Symptoms of NMS
Severe muscle rigidity and elevated
temperature with two of the following:
tremor; diaphoresis, dysphagia, incontinence,
changes in consciousness, mutism,
tachycardia, increased blood pressure.
Typical antipsychotics and some atypicals (e.g. risperidone) may
cause increased levels of prolactin, which can cause a number
of symptoms such as gynaecomastia (breast enlargement)
and galactorrhoea (secreting breast milk), increased risk of
osteoporosis, menstrual and sexual dysfunction, acne and
hirsutism.
Counselling Point: Women of childbearing age may need
contraceptive advice when switching from a typical to an
atypical antipsychotic.
Cardiovascular – Hypotention,
arrhythmias and sudden death
Postural hypotension and arrhythmias with some antipsychotics
(especially during initial dose titration). Clozapine: Fatal
myocarditis (most commonly in first 2 months) and
cardiomyopathy reported. Refer to doctor if present with
cardiovascular symptoms
Antimuscarinic
Symptoms such as dry mouth, constipation, difficulty with
micturition, and blurred vision. Advise as appropriate
Blood dyscrasias
Clozapine has the greatest risk of causing neutropenia and
agranulocytosis; not dose-related. Can occur at any time, but
the first 18 weeks are considered the period of highest risk. See
clozapine monitoring below.
Hyperlipidaemia
Can occur with any antipsychotic. Advise and support, provide
cholesterol testing
Diabetes
Antipsychotics, particularly some atypicals have been associated
with increased risk of hyperglycaemia and development of
diabetes. Recognise potential signs and symptoms, advise and
support, provide glucose testing
Weight gain
Associated with all antipsychotic medication. Provide weight
monitoring and management support and advice
Clozapine Monitoring
Monitoring is essential due to risk of blood
dyscrasias (usually reversible neutropenia
in 3-4% patients, which may progress to
agranulocytosis in 0.8% patients over one
year). Patients MUST be registered with a
clozapine patient monitoring service.
• A full blood count must be performed
weekly for 18 weeks, fortnightly up to 52
weeks and 4-weekly thereafter and 4 weeks
after discontinuation.
Other monitoring:
• Check for interactions: concomitant
medication, caffeine ingestion and smoking
affects clozapine blood levels. Report
potential interactions to Doctor immediately.
• Caution if used with drugs which cause
constipation (e.g. antimuscarinic drugs)
or in history of colonic disease or bowel
surgery. Monitor for constipation and refer
to doctor or advise on laxative if required.
• Signs of infection, temperature and
sore throat require immediate patient
reporting to doctor. (Usually an additional
blood test is taken).
2.Pharmaceutical Care for
Maintenance
People prescribed antipsychotics are at
risk of weight gain, metabolic malignant
syndrome and potentially type 2-diabetes.
Diabetes is an independent risk factor for
cardiovascular disease; therefore monitoring
and support should include the following:
Weight gain: provide advice on healthy
eating and weight management
Diabetes and Cardiovascular risk
Lifestyle issues: promote good mental &
physical health
Switching antipsychotics due to
inadequate efficacy Switching is generally
achieved by gradual reduction of the dose
of the first agent and simultaneous titration
up of the second agent (cross-tapering).
For further advice see the BNF www.bnf.
org, Psychotropic Drug Directory and the
Maudsley Prescribing Guidelines
3.Pharmaceutical Care on
Withdrawal
When stopped suddenly, antipsychotics may
produce an acute withdrawal syndrome in
some people. Rapid relapse can also occur.
Withdrawal of antipsychotic agents after longterm therapy should always be gradual and the
patient should be closely monitored for signs
of relapse or discontinuation symptoms.
May 2010 | Pharmacy Professional
31
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f e at u r e s c h i z o p h r e n i a
Patient Resources and
Support Groups
Useful Resources for Pharmacists
• MIND www.mind.org.uk
• Mental Health Foundation
www.mentalhealth.org.uk
• Rethink www.rethink.org
• Patient UK www.patient.co.uk/selfhelp.asp
• Choice and Medication
www.choiceandmedication.org.uk
• Hearing Voices www.hearing-voices.org
• Saneline www.saneline.org.uk
• PharmacyHealthLink Lifestyle resources
(“resource cards”, leaflets, posters): www.
pharmacyhealthlink.org.uk/?q=leaflets-andfactsheets
• Lifestyle www.nhs.uk/livewell/Pages/
Livewellhub.aspx (weight loss, alcohol, smoking,
sleep, mental health etc.)
• Department of Health ‘Choosing
talking therapies?’ www.dh.gov.uk/en/
Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_4008162
• Mental Health Foundation Talking therapies
www.mentalhealth.org.uk/information/mentalhealth-a-z/talking-therapies/
• United Kingdom Psychiatric Pharmacy Group
www.ukppg.org.uk
• Bazire S. Psychotropic Drug Directory 2009. Aberdeen:
HealthComm UK Ltd; 2009
• Taylor D, Paton C, Shitij K. The Maudsley Prescribing Guidelines
10th Edition. London: Informa Healthcare; 2009
• Francis SA, Patel M. Caring for people with schizophrenia:
family carers’ involvement with medication. Int J Pharm Pract.
2000:8:314-23
• Bleakey S, Weatherill M. Treatments for patients with
schizophrenia. Pharmaceutical Journal 2009:283:101-104 (July
25) www.pjonline.com
• Khan S. Getting ready for NHS Health Checks. Pharmaceutical
Journal 2009:282:417-418 (Apr 11) www.pjonline.com
• RPSGB Practice guidance: obesity www.rpsgb.org/pdfs/
obesityguid.pdf
• Neuroleptic Malignant Syndrome: www.nmsis.org
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Pharmacy Professional | May 2010
Pregnancy and Breastfeeding
• UKMI www.ukmi.nhs.uk/default.asp
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