Drug Treatments
To ensure the most appropriate, cost effective prescribing of drugs, the initiation of any treatment
with the newer atypical antipsychotic drugs should be the responsibility of the psychiatrist. Once
the patients condition is clinically stable, it may be appropriate for GP’s to prescribe for and
monitor patients over the longer term, this best effected via formalised ‘shared-care’ arrangement.
*Discontinuation of antipsychotic medication should only take place with careful assessment and
communication with specialist services.

NICE Guidelines recommended that initiation of treatment with atypical antipsychotic drugs in
primary care should only be considered if (a) there is likely to be a significant delay in the patient
seeing a psychiatrist, and (b) the patient is very distressed and their symptoms are not tolerable.

Atypical Antipsychotics
(Newer Drugs)
• Atypical guidelines are recommended first line on the basis that they are better tolerated than
typical drugs at normal clinical doses. NICE guidelines suggest consideration of amisulpiride,
olanzapine, quetiapine, risperidone and zotepine. It should be noted that these atypical drugs
all have their individual unique profiles.
• Atypicals have fewer side effects than conventional drugs therefore improve treatment compliance.
• Atypicals should ideally be initiated either directly by a consultant psychiatrist or appropriate
secondary care specialist, or in close discussion with such a person - the same principle applies
if there is a need to switch from one atypical to another.
• Atypicals should be prescribed as monotherapy wherever possible, except during tapering of dose
during any change over period, or in treatment resistant schizophrenia.
• NICE guidelines suggest that when there is an inadequate response, despite an adequate trial of
an antipsychotic drug, a trial of Olanzapine or Risperidone should be considered (if not tried
previously).
• Only Clozapine has a proven efficacy in treatment-refractory schizophrenia. Blood monitoring is
required. *Secondary care use only. When prescribing any other medications for a patient on
Clozapine, it is important to check drug interactions.

Typical Antipsychotics
(Conventional Neuroleptics)
• Typical antipsychotics are indicated where
- Treatment is effective and symptoms are controlled and well tolerated.
- No evidence of side effects e.g. extrapyramidal effects, hyperprolactinaemia
and tardive dyskinesia.
- No negative symptoms are evident.

• If poor compliance to neuroleptics then long-acting injection preparations are appropriate.

Monitoring Clinical Response & Management Of Side Effects
• Withdrawal of anticholinergic drugs (given for extrapyramidal side-effects) should be attempted
after 2-3 months if symptom free. These drugs are liable to misuse and may impair memory
and exacerbate akathesia and tardive dyskinesia.
• Anticholinergic treatment should be discontinued gradually once treatment with an atypical
has commenced.
NB - it may take several weeks for the typical antipsychotic drug to clear from the body.
• Consider other side effects
- Cardiovascular
- Weight gain
- Sexual dysfunction
• Chlorpromazine can cause a photosensitive skin response and this is easily prevented if a
sun-screen is used.
• Where a potential to cause weight gain or diabetes has been identified for the atypical drug being
prescribed, there should be routine monitoring in respect of these potential risks - e.g. monitor
weight and blood glucose within routine health checks.

Back

Flowchart 2