Psychosis and antipyschotics: CLICK ABOVE TO SEE FULL MIND FACTSHEET
People who are psychotic perceive things and interpret events differently from those around them. This may include hearing things, such as voices, seeing something other people don't see (a hallucination) or thinking things that are not based on reality (a delusion). A person may believe, for example, that he or she is under the control of an outside force. (For more information, see Understanding psychotic experiences, How to recognise the early signs of mental distress, Understanding bipolar disorder [manic depression] and Understanding schizophrenia.)
Antipsychotics are often effective in controlling the symptoms of psychosis, and enable many people to return to normal life. They may lessen delusions, hallucinations, incoherent speech and thinking, and reduce confusion. The drugs can control anxiety and serious agitation, make the person feel less threatened, and also reduce violent, disruptive and manic behaviour. However, not everybody finds antipsychotics helpful, and they can't cure the problem. They can also have very serious side effects, which cause major concern to users.
Antipsychotic drugs are standard, routine treatment for people who are experiencing psychosis, and doctors believe that drug treatment should be started as soon as possible. But recent research has raised important questions about whether people might not do better without using these drugs.
Some research suggests that someone with schizophrenia, who remains on antipsychotics for a number of years, may be less likely to relapse than someone who is not taking them. But a paper published in the Journal of Medical Hypotheses in 2004 suggests that resorting to antipsychotics straight away, as a matter of routine, may worsen long-term outcomes, and that a considerable percentage of those treated would do better if they were not given drugs. This paper suggests that people experiencing their first episode of psychosis should not be treated with drugs, and that every person who is taking antipsychotics should be given the opportunity to withdraw from them, gradually. It suggests that this would dramatically improve recovery rates and reduce the numbers of people who become ill in the long term.
Other background information on antipsychotics
There are two main types of antipsychotics: the older antipsychotics and the newer atypical antipsychotics.
The older antipsychotics divide, generally, into two chemical groups:
Low-potency drugs, such as chlorpromazine (Largactil), which are taken in relatively large doses, tend to be very sedating and cause more antimuscarinic side effects.
High-potency drugs, such as haloperidol (Dozic, Serenace and Haldol), which require lower doses and tend to cause more neuromuscular side effects.
The newer atypical antipsychotics, such as risperidone, don't produce the most disturbing neuromuscular side effects that characterise the older drugs. However they do cause serious metabolic side effects associated with gross weight gain, for which the term 'metabolic syndrome' is increasingly being used. For a listing of antipsychotics licensed in the UK, see below.
Antipsychotics are also known as major tranquillisers or neuroleptics. Calling them major tranquillisers is misleading, because these drugs don't make people feel tranquil.
Although they can cause drowsiness through their sedative action, they may also cause intense restlessness. Neuroleptic is a better term as it means taking control of the nerves, and refers to the effects these drugs have on thought, behaviour and physical movement.
How does a doctor decide when to prescribe them?
Your doctor has to weigh up the advantages and disadvantages of treatment. The benefits to you, your family and friends have to be balanced against the disadvantage of unpleasant side effects. Doctors also have to ask themselves what might happen if the drugs were not prescribed. A person with psychotic symptoms may show dangerous behaviour, or such disturbed ideas, that they put their own or other people's lives in danger. This may also place great strain on carers and the people they live with. Some people who experience psychosis cope better with it than others. If you have had frequent psychotic episodes, you may have developed your own coping strategies, which could mean you need to rely less on medication than other people.
People respond differently to medication, and doctors have to decide on each case, individually. When a drug is prescribed, your doctor should take into account any medical conditions you are suffering from. It may mean that a particular drug is not suitable for you, or only in low
How do the drugs work?
No one knows precisely how they work. Most of them have a sedative action, and most of them block the effects of dopamine, a chemical neurotransmitter that carries signals between brain cells. This interrupts the flow of messages, which may be too frequent in psychotic states. One specialist at the University of Newcastle has suggested that they work by causing Parkinsonism i.e. producing the psychological symptoms of this disease such as emotional blunting and demotivation, as well as the physical symptoms, which are already well recognised as side effects.
The new atypical drugs work on other brain chemicals as well as dopamine, and have a rather different range of side effects. Clozapine, in particular, may be successful in suppressing psychosis in some people who have not responded to older drugs
How quickly do they work?
This depends partly on how you take them, whether orally or by injection. When they are injected into a muscle, the sedative effect is rapid and reaches a peak within an hour. If you take them by mouth, in tablet or in syrup form, the sedative effect usually takes a few hours longer. However, the psychotic symptoms, such as voices, may take days or weeks to suppress. Nobody knows why.
Some drugs are available in an oil-based, slow-release form given by deep injection, known as a 'depot', into a muscle. Depot injections do not have a fast action, and are given every two to six weeks.
What dosage should I be on?
The average dose has tended to rise over the years. This is despite the facts that the most effective dose may be quite low; that increasing the dose will probably not make it more effective; and that it may make the side effects worse. Since the advent of the atypical drugs this trend has reversed, and indeed research has suggested that atypical drugs have no advantages over the older drugs, if the older ones are used at the lowest effective dose.
Doses should be kept as low as possible. High doses can have a zombie-like effect, giving you a mask-like expression and strange movements. It can make it very difficult for you to move normally, to get up and get going in the morning, and to take part in normal activities and social events. Moderate to high doses increase the risk of tardive dyskinesia, which is a serious problem causing involuntary movements. Research suggests that low, maintenance doses are as effective in preventing relapse as higher doses. Older people need smaller doses of drugs, and their health is at risk if they are given too high a dose.
You have a right to know what dosage you have been prescribed, and these vary widely. For example, chlorpromazine (Largactil) can be prescribed in tablet form to physically healthy adults in doses ranging from 75mg up to 1g (1000mg) daily. The aim should be to find the dose that lets you lead as normal a life as possible. If the medication is not working, it's important for doctors to reconsider the treatment rather than automatically putting up the dose.
The National Institute for Clinical Excellence (NICE) current guidelines on the treatment of schizophrenia suggest that doctors prescribe antipsychotics at the lowest effective dose, introducing the drugs gradually. They suggest that people should not be given a high starting dose.
Among other information, the British National Formulary (BNF) gives maximum doses for some, but not all, of the antipsychotics. A list of drugs appears below, and provides this information, whenever possible. Generally, the drugs aren't licensed for use above these dosages, but hospital doctors do exceed them, at their discretion. They may also prescribe medication to be given 'as necessary' (p.r.n.), which can mean in addition to your regular dose. As a result, your total dose could be above the BNF maximum, although your psychiatrist has a duty to review the total dosage, daily.
If you are taking more than one antipsychotic drug, you can work out the dose of each (including p.r.n. prescribing) as a percentage of the maximum recommended in the BNF. Add the percentages together to see if you are taking more than 100 per cent in total. You can also ask your doctor or a pharmacist to help you work this out. The Prescribing Observatory for Mental Health (see Useful organisations) has created a ready reckoner chart for wards to help with this calculation. If you think you are taking too much medication, you can ask your doctor to review it.
If you are worried about your diagnosis and treatment, and unsure about the advice you have been given, you could ask either your GP or psychiatrist to refer you for a second opinion.
What are the side effects?
People's sensitivity and response to drugs varies enormously. One person may be able to tolerate standard doses with no significant side effects, while someone else may find the same dose has intolerable results.
Antipsychotics, as a group, have a large number of side effects in common. Because they interfere with dopamine, which is important in controlling movement, many of the side effects are to do with the neuromuscular system. These neuromuscular effects include: Parkinsonism, loss of movement, restlessness and muscle spasms.
Some side effects resemble Parkinson's disease, which is caused by the loss of dopamine:
Muscles become stiff and weak, so that your face may lose its animation, and you find fine movement difficult.
You may develop a slow tremor (shaking), especially in your hands.
Your fingers may move as if you were rolling a pill.
When walking, you may lean forward, take small steps, and find it difficult to start and stop.
Your mouth may hang open and produce excessive saliva.
Loss of movement (akinesia)
You may find it difficult to move, and your muscles may feel very weak. This may be mistaken for a symptom of depression.
You may feel intensely restless and unable to sit still. This is more than just a physical restlessness and can make you feel emotionally tense and uneasy, as well. The compulsion to move may be overwhelming. You may rock from foot to foot, shuffle your legs, cross or swing your legs repeatedly, or continuously pace up and down. Nursing staff sometimes misread this as a sign of agitation or anxiety, and may wish to treat it by increasing your dose of antipsychotics. If you are very troubled by akathisia, your doctor may be able to prescribe something to reduce it.
Muscle spasms/dystonia (dysphonia and oculogyric crisis)
These are acute muscle contractions that are uncontrolled and may be painful. They particularly affect young men. Sometimes the problem affects the muscles of the larynx (voice box), which makes it difficult to speak normally (dysphonia). It can be socially disabling, but is treatable.
Another form of muscle spasm affects the muscles that control eye movements. Called 'oculogyric crisis', it makes the eyes turn suddenly, so that you can't control where you look. This is very unpleasant and can make it dangerous crossing the road, or pouring hot water, for instance. It's also very disconcerting for people around you.
Such neuromuscular symptoms can be reduced with the sorts of drugs that are prescribed to treat Parkinson's disease (see below for more information on these drugs). These symptoms die down while you are asleep, so if you take the antipsychotics as a single daily dose in the evening, you could avoid the worst of them (as well as avoiding daytime sedation). You may want to discuss this with your doctor to find out whether it would be an option for you.