TREATMENTS FOR "PSYCHOSIS"

Drugs known as ANTIPSYCHOTICS or NEUROLEPTICS

(often incorrectly known as the "major tranquillisers")

DRUG CLASS:- PHENOTHIAZINES, BUTYROPHENONES, THIOXANTHENES and OTHERS

1. Chlorpromazine is also available as suppositories.
2. Clozapine (‘Clozaril’), sertindole ("Serdolect"), amisulpride ('Solian'), sulpiride, olanzapine (‘Zyprexa’), quetiapine (‘Seroquel’), risperidone (‘Risperdal’), sulpiride and zotepine (‘Zoleptil’) have separate sections in this website.
3. Methotrimeprazine is changing name to levomepromazine from 1998.
4. Thioridazine has some changes to it's UK and USA license in 2000. For more details click here.

What are they used for ?

These drugs are usually used to help treat illnesses or conditions such as psychosis, schizophrenia and hypomania. See the links page for some good sources of information on schizophrenia. They can also be used to help manage confusion, dementia, behaviour problems and personality disorders. They are often known as 'neuroleptics', 'anti-psychotic drugs' or wrongly as 'major tranquillisers'. They may also be used in smaller doses to help treat anxiety, tension and agitation. Some of them are used to treat dizziness, nausea and vomiting.

How do they work ?

There is a naturally occurring chemical ("neurotransmitter") in the brain called dopamine. Dopamine is the chemical messenger in the brain mainly involved with thinking, emotions, behaviour and perception. In some illnesses, this dopamine may be overactive and upsets the normal balance of chemicals in the brain. This excess dopamine helps to produce some of the symptoms of the illness. The main effect that these drugs have is to block some dopamine receptors in the brain, reducing the effect of having too much dopamine and correcting the imbalance. This reduces the symptoms caused by having too much dopamine.
For a more detailed explanation, click here.

How should I take them ?

Tablets and capsules:

Tablets and capsules should be swallowed with at least half a glass of water whilst sitting or standing. This is to make sure that they reach the stomach and do not stick in the throat.

"Stelazine spansules" (trifluoperazine modified release capsules) should be swallowed whole and not chewed. This is because this product is made so that it releases the drug over a slightly longer period of time. This can help you to either get less side-effects or need to take your medicine less times a day. Crushing or chewing these capsules will cause the drug to be released too quickly.

Liquids:

Your pharmacist should give you a medicine spoon, dropper or oral syringe. Use it carefully to make sure you measure the correct amount. Ask your pharmacist for a medicine spoon if you do not have one.

Shake the bottle well before use as the drug can settle to the bottom and cause you to receive a lower dose at the start and too high a dose at the end of the bottle.

"Stelazine" syrup (trifluoperazine) may be diluted in a drink of water or orange juice if necessary. You should not, however, dilute "Melleril" suspension (thioridazine).

Suppositories

Chlorpromazine ("Largactil") is available as suppositories. Suppositories are specially shaped to be inserted into the anus (the rectum or "back passage"). After removing a suppository from its wrapping you should insert it as deeply as possible into your anus. You may find it easier to insert if you put one foot on a chair or lie on your side with one leg drawn up as high as possible under the chin. Do not swallow them. If you have any problems using your suppositories ask your pharmacist or doctor for advice.

Injections

It is sometimes necessary or helpful for these drugs to be given as 'depot' injections. A 'depot' injection is a long acting injection usually given into a buttock. The injection releases drug over several weeks and so you will not have to remember to take tablets at regular times each day. Depot injections are otherwise no more or less effective than tablets or capsules. If you are in hospital it will be given to you by a nurse. Outside hospital it may be given to you by a Community Psychiatric Nurse, as a day patient or by your G.P. or community nurse. You may need to have this injection every few weeks for some time. To start with you will be given a 'test dose' to make sure the drug suits you. Then, if there are no problems, 5 to 10 days later you will be given your first full dose injection which will then be repeated every one to four weeks. They are usually given into the buttock although some may be able to be given into the thigh.

When should I take them?

Take your medication as directed on the medicine label. Try to take them at regular times each day. Taking them at mealtimes may make it easier for you to remember as there is no problem about taking any of these drugs with or after food. If the instructions say to take them ONCE a day this is usually best at bedtime as they may make you drowsy at first. They are not sleeping tablets as such.

How long will they take to work?

Some of the effects of these drugs appear soon after taking them, for example the drowsiness. The most important action, however, to help the symptoms of your illness may take weeks or even months of regular medication to become fully effective. In the same way if your dose or treatment is changed it may take an equally long period of time before you notice the effects of such a change.

How long will I need to keep taking them for ?

This should be discussed with your doctor as different people respond differently. You will probably, however, need to continue your treatment for a long time, possibly several years after your symptoms have gone to make sure you are fully over your illness. Long term treatment should be reviewed at regular intervals, for example every 3 to 6 months, or even sooner if there are problems.

Are they addictive ?

These drugs are not really addictive. If you have taken them for a long time you may experience some mild effects if you stop them suddenly. The main problems would be your symptoms coming back. For further discussion, click here.

Can I stop taking them suddenly ?

It is unwise to stop taking them suddenly, even if you feel better. Your symptoms can return if treatment is stopped too early. This may occur some weeks or even many months after the drug has been stopped and you may feel well before this happens. You could also experience some mild withdrawal symptoms (as explained above). When the time comes your doctor will usually withdraw the drug by a gradual reduction in the dose taken over a period of several weeks. You should discuss this fully with your doctor.

What should I do if I forget to take them ?

Start again as soon as you remember unless it is nearly time for your next dose then take the next dose as normal. Do not try to catch up by taking two or more doses at once as you may get more side-effects. You should tell your doctor about this next time you meet. If you have problems remembering your doses (as very many people do) ask you pharmacist, doctor or nurse about this. There are some special packs, boxes and devices which can be used to help you remember.

What sort of side-effects might occur ?

Table adapted from UK Psychiatric Pharmacy Group leaflets, with kind permission (www.ukppg.org.uk )

Different drugs within these groups will have different degrees of side effects.

Do not be worried by this list of side effects. You may get none at all. There are other rare side-effects. If you develop any unusual symptoms ask your doctor about them next time you meet.

*If you are taking chlorpromazine ("Largactil") you should avoid direct sunlight on your skin. This drug makes the skin extra-sensitive to sunlight and may cause it to go red and burn very easily. If you do go out in the sun make sure you put on a high factor sunscreen first (e.g. Roc Total Sun Block). Sunbeds and sunlamps are very likely to cause such a reaction and should be avoided.

Will they make me drowsy ?

These drugs may make you feel drowsy or sleepy. You should not drive (see below) or operate machinery until you know how they affect you. You should be careful as they may affect your reaction times or reflexes. They are not, however, sleeping tablets, although if you take them at night they may help you get to sleep.

Will they cause me to put on weight ?

Weight gain with the phenothiazines is quite possible. Of the people who gain weight, most is gained during the first 6 to 12 months of treatment. It then tends to level out. It is thought that these drugs cause an increase in appetite which causes you to eat more and therefore put on weight. It is not possible to say what the effect on your own weight may be because each person will be affected differently. All the phenothiazines seem to have the same soft of effect, but some other the other drugs seem to have less effect. If you do start to put on weight or have problems with your weight, you should tell your doctor. He or she may be able to adjust your drug or the dose of your drug to reduce this effect. Your doctor can also arrange for you to see a dietician for advice. If you do gain weight it is possible to lose it while you are still taking this medication, with expert advice about diet. In some people this can be a serious problem. If it causes you distress make sure your doctor knows about this. There is not thought that the other drugs cause major changes in weight. A small weight change is possible.

Will it affect my sex life?

Drugs can affect desire (libido), arousal (erection) and orgasmic ability. Phenothiazines have been reported to have an adverse effect on all these three stages, partly through causing drowsiness and partly by other means. Thioridazine may be the worse drug for this. Generally, the other drugs in this section have lesser effects eg. The butyrophenones and thioxanthenes. If this happens, you should discuss this with your doctor, as a change in dose or drug may help minimise the problem.

Can I drink alcohol while I am taking these ?

If you drink alcohol while taking these drugs it may make you feel more sleepy. This is particularly important if you need to drive or operate machinery and you must seek advice on this.

Are there any foods or drinks that I should avoid ?

You should have no problems with any food or drink other than alcohol (see above).

Will they affect my other medication ?

You should have no problems if you take other medications although a few problems can occur. The phenothiazines can "interact" with a few drugs including some antidepressants and some anticonvulsants. although your doctor should know about these. Some other medicines e.g. the painkiller co-proxamol and some antihistamines can make you drowsy. Combined with your phenothiazine this could make you even drowsier. This does not necessarily mean the drugs can not be used together, just that you may need to follow your doctors instructions very carefully. You should tell your doctor before starting or stopping these or any other drugs. Make sure your doctor knows about all the medicines you are taking.

If I am taking a contraceptive pill, will this be affected ?

It is not thought that "the pill" is affected by any of these drugs.

What if I want to start a family or discover I'm pregnant?

It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs.

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine.

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press.

It may be helpful to know that in the USA, the FDA (Federal Drug Administration) classifies medicines in pregnancy in five groups:

The phenothiazines available in the USA are all classified as "C". There has been some research on the use of phenothiazines in pregnancy, but mostly only with low doses. This research showed a risk of problems that was about twice that of women not taking such drugs (one in 30 with problems, one in 60 without). Occasional problems of sleepiness and drowsiness in the newborn have been reported. At 2 and 7 years old, the children's development was normal one study of women who took phenothiazines during pregnancy. You should, however, still seek personal advice from your GP, who may then if necessary seek further specialist advice.

Haloperidol is classified as "C". There is no proven evidence of a teratogenic effect, and animal tests show a low risk of danger but some problems have been reported and so you should seek personal advice from your GP, who may then if necessary seek further specialist advice.

Flupenthixol and zuclopenthixol are not classified, as they are not available in the USA. There is no evidence of a teratogenic effect, animal tests show a low risk of danger but some problems have been reported and so you should seek personal advice from your GP, who may then if necessary seek further specialist advice.
 

Will I need a blood test ?

Not usually. Some people who need to take higher doses occasionally need a blood test.

Can I drive while I am taking them ?

These drugs can affect your driving in two ways. Firstly, you may feel drowsy and/or suffer from blurred vision at first when taking any of these drugs. Secondly, the drugs can slow down your reactions or reflexes. This is especially true if you also have a dry mouth, blurred vision, constipation etc. (the so-called "anticholinergic side effects"). Until these wear off, or you know how your drug affects you, do not drive or operate machinery. You should be careful as they may affect your reaction times or reflexes even though you feel well.

It is against the law to drive, attempt to drive or be in charge of a vehicle when unfit, either through illness or from the side effects of medication. Under UK law, it is the drivers responsibility to let the DVLA and insurance company know if you may be "unfit" to drive. If you do not, and you have an accident, it could effect your insurance cover. Your doctor will be able to advise you, and may wish to access the UK Driver and Vehicle Licensing Agency (DVLA) guidelines website, which has the current DVLA guidelines on anxiety/depression, psychotic disorders, mania and other conditions. If your doctor advises you not to drive, and you continue to do so, the doctor can inform the DVLA directly, as he or she would be lawfully responsible were you to have an accident. Once told, the DVLA may wish to carry out an enquiry, but you are entitled to drive until there a decision is made.

Email your comments or feedback.
Several developments have been as a result of feedback from visitors.

No site can be entirely bias-free. No matter how hard someone tries, training and background will always influence your outlook. We have, however, tried to eliminate bias, and we hope you take these pages in the spirit in which they are provided i.e. a genuine attempt to inform, educate and support.

Information here is based on published data. References include the UK British National Formulary (BNF, published by the British Medical Association and Royal Pharmaceutical Society of Great Britain), Martindale (the extra pharmacopoea, published by RPSGB Pharmaceutical Press), Psychotropic Drug Directory (latest edition), Data Sheet Compendium (UK Manufacturers Data Sheets, published by the Association of British Pharmaceutical Industry), MicroMedex (an independent and extensive CD-ROM based drug information source), UK Psychiatric Pharmacy Group leaflets, Royal College of Psychiatrists advice and guidelines and the current medical literature. Thanks also to all those people who left e-mail comments, suggestions and requests, who have helped shape the site.  

Email your comments or feedback.
Many developments have been as a result of feedback from visitors.

No site can be entirely bias-free. No matter how hard someone tries, training and background will always influence your outlook. We have, however, tried to eliminate bias, and we hope you take these pages in the spirit in which they are provided i.e. a genuine attempt to inform, educate and support.

Information here is based on published data. References include the UK British National Formulary (BNF, published by the British Medical Association and Royal Pharmaceutical Society of Great Britain), Martindale (the extra pharmacopoea, published by RPSGB Pharmaceutical Press), Psychotropic Drug Directory (latest edition), Data Sheet Compendium (UK Manufacturers Data Sheets, published by the Association of British Pharmaceutical Industry), MicroMedex (an independent and extensive CD-ROM based drug information source), UK Psychiatric Pharmacy Group leaflets, Royal College of Psychiatrists advice and guidelines and the current medical literature. Thanks also to all those people who left e-mail comments, suggestions and requests, who have helped shape the site.