Antipsychotics in severe mental illness

To support review of individuals prescribed antipsychotics. Antipsychotics are used in the management of mental health conditions, symptoms of stress and distress in dementia, and delirium in adults, with an increase in prescribing for non-severe mental illness.^244,245 People who receive antipsychotics commonly experience multimorbidity and polypharmacy,^246,247 therefore proactive routine medication reviews may enable appropriate deprescribing.

This hot topic discusses:

1. antipsychotic use in severe mental illness
2. antipsychotics prescribed for other indications

Antipsychotics in palliative care are out with the scope of this hot topic. Refer to Scottish Palliative Care Guidelines.¹⁵⁸

Antipsychotics are used in schizophrenia, bipolar disorder and other psychotic disorders (e.g. adjunctive treatment of major depression with psychotic features). They should not be reduced or stopped without specialist advice in these conditions, unless an individual is experiencing a medical emergency (e.g. neuroleptic malignant syndrome) or significant adverse drug reactions (ADRs).²¹⁵

The choice of antipsychotic should consider individual preferences, licensed indication, efficacy, side-effect profile, tolerability, person characteristics and co-morbidities. For example, if there is a high risk of diabetes or the individual is overweight, it may be appropriate to initiate an antipsychotic with lower risk of weight gain and cardiometabolic effects.^{180,215,248,249}

The use of non-pharmacological interventions is advised in psychosis and related disorders: combination of psychological therapies (e.g. cognitive behavioural therapy (CBT), family intervention, self-help groups), and social support.

High-dose antipsychotic therapy (HDAT) is defined as a total daily dose of a single antipsychotic drug which exceeds the maximum licensed dose with respect to the age of the patient and the indication being treated, and a total daily dose of two or more antipsychotic drugs which exceeds the maximum licensed dose using the percentage method. Non specialists should be aware of individual’s high dose antipsychotic status and liaise with psychiatrist or mental health team around the use of HDAT when necessary.²⁵⁰ There should be a clear plan for regular clinical review including safety monitoring.²⁵¹

• Follow local and national guidance, including BNF, for baseline and regular monitoring of the individual’s physical health, e.g. blood pressure and pulse, weight, HbA1c, lipids, prolactin and other blood tests.^180,215,248
• The Lester UK Adaptation: Positive Cardiometabolic Health Resource supports the recommendations relating to monitoring physical health in the NICE guidelines on psychosis and schizophrenia in adults²⁴⁸ and young people.²⁵² In addition, it also supports the statement about assessing physical health in the NICE quality standard for psychosis and schizophrenia for adults²⁵³ and the BNF.

Seek specialist advice in severe mental illness.

• adults with pre-existing stroke risk factors²⁵⁴
• cardiometabolic risk: identify (using a suitable tool such as ASSIGN-2, QRisk-3, QDiabetes), monitor and manage modifiable risk factors²⁵³
  • consider lifestyle and other adjustable physical health risks e.g. smoking, alcohol and diet²⁵³
• risk factors for venous thromboembolic events should be identified and prevented²⁵⁵
• individuals taking clozapine:
  • bowel obstruction due to paralysis of bowel wall may occur²⁵⁶
  • regular monitoring required due to increased risk of toxicity²⁵⁴
  • if dose is missed for more than 48 hours, re-titration required. Contact local mental health pharmacist/specialists for further advice.

Seek specialist advice in severe mental illness

Does the person understand the outcomes of the review, including risk and benefits?

• The review should employ a person-centred and shared decision-making approach
• The individual is advised not to stop abruptly due to the risk of discontinuation/withdrawal symptoms
• Provide information on self-monitoring and what to do if experience worsening of mental health and or adverse drug effects (ADRs)

Is drug therapy tailored to the individual?

• The individual’s preferences, values and needs should be considered
• Ensure the individual is supported where medication changes are required, as this improves the acceptability

Agree medication plan

• Where prescribing changes are assessed as appropriate
• Annual physical health monitoring to identify and manage antipsychotic cardiometabolic and other ADRs

self-management/support tools

decision aids

Choice and Medication available via NHS inform

Clozapine TURAS Learn

Mental health information on NHS inform

National Therapeutic Indicators (NTIs) use prescription data in specific areas to provide a measure of prescribing activity for comparison across NHS Boards, Health and Social Care Partnerships (HSCPs), GP clusters and GP practices.
NTIs are available to view online.

NTIs benchmark prescribing across set parameters and are presented in a variety of ways. Examining variation over time can indicate where improvements in prescribing can be made. The indicator detail provides further information and suggested actions.

Indicators for this hot topic include:

• Number of people aged 75 years and over prescribed an antipsychotic as a percentage of all people aged 75 years and over see Chart 6
• People receiving three or more of benzodiazepine/z-drug, opioid (including tramadol), gabapentinoid, antidepressant or antipsychotic (excluding depots)

Number of people aged 75 years and over prescribed an antipsychotic as a percentage of all people aged 75 years and over

(Click on image to enlarge)