Antipsychotics

Overview

• Antipsychotic medications are generally used to treat the symptoms of schizophrenia and other psychotic disorders. But they can also be used to treat bipolar disorder and depression.
• Antipsychotics affect people differently. You may experience some side effects with antipsychotics.
• It can take some time to find the right antipsychotic that works for you.
• If you feel like your antipsychotics aren’t working, or if the side effects are difficult to live with, you should discuss this with your healthcare professional.
• You shouldn’t stop taking antipsychotics suddenly. You should talk to your healthcare professional before doing this.
• Your antipsychotics can interact with other medications, alcohol and smoking. Your healthcare professional should advise you on this when they prescribe the medication to you.
• It is important that your doctor is aware of all the medications you are taking. Including any supplements.

About Antipsychotics

What are antipsychotics?

Psychosis is a medical term. If you live with psychosis, you might see or hear things that aren’t there. This is known as hallucinations. Or you might have firm beliefs that don’t match up to the way others see the world. This is known as delusions.

If you live with psychosis, you will process the world around you differently to other people. This can include how you experience, believe or view things.

Some people describe psychosis as a break from reality. Doctors may call these ‘psychotic symptoms’, a ‘psychotic episode’ or a ‘psychotic experience’.

Psychotic symptoms can be part of conditions such as schizophrenia, schizoaffective disorder, personality disorder and bipolar disorder. But some people can experience psychotic symptoms without having any of these conditions.

If you experience psychotic symptoms, your doctor may offer you antipsychotic medication to help you with your symptoms.

Antipsychotics can help manage your symptoms of psychosis. This can help you feel more in control of your life, particularly if you are finding the psychotic symptoms distressing.

Research suggests 4 out of 5 people with severe mental illness, who take antipsychotics, find they’re successful in treating their symptoms. This is according to the Royal College of Psychiatrists.

It isn’t possible to predict which one will work best for you, so you may have to try a few before you find the right one.

It’s important to remember it can take a few weeks for antipsychotics to work. You may not feel better straight away. Everyone responds to antipsychotics differently.

It can take several days or weeks to reduce symptoms such as hallucinations or delusional thoughts. The effects of antipsychotics can take several weeks or months to work.

Some antipsychotics are used to treat mania. Mania is a symptom of bipolar disorder and psychotic symptoms of depression.

How do antipsychotics work?

Your brain contains chemicals which help to carry messages from one part of the brain to another. One of these chemicals is called dopamine. It is thought that high levels of dopamine may cause the brain to function differently and may cause the symptoms of psychosis.

Antipsychotics work by blocking the effect of dopamine. This helps reduce psychotic symptoms for many people.

The Royal College of Psychiatrists say that the evidence suggests that nothing works as well as antipsychotic medications to treat schizophrenia.

For more information see our webpages on the following:

• Psychosis
  
• Schizophrenia
  
• Bipolar disorder
  
• Depression

Types of antipsychotics

What are the different types of antipsychotics?

There are 2 types of antipsychotics. Your doctor might call them the following.

• Typical or ‘1st generation’. These medications have been used since the 1950s. These were the first type of antipsychotics made.
• Atypical or ‘2nd generation’. These medications have been used since the 1990s. These are newer types of antipsychotics.

The main difference between these types is in their side effects. 1st generation antipsychotics may have more of an effect on your body movement than newer antipsychotics. Although this doesn’t mean newer generation antipsychotics don’t have any side effects on your movement.

Recent research continues to suggest that side-effects for all antipsychotics are different. Your psychiatrist should work with you to find which medication works best for you.

It’s important to think about each antipsychotic individually. This is because everyone reacts differently to medication.

You can never be certain how you will be affected by side effects. This can mean that the first medication you try may not be the right one for you.

If after a few weeks you’re still having problems with side affects you can speak to your healthcare professional.

Your doctor may prescribe you a different type of antipsychotic. Or give you a medication to help deal with the side effects. You can read more about side effects in the following section below.

See our webpage on Medication – choice and managing problems for more information.

How are antipsychotics taken?

Antipsychotic medication can come as tablets, a syrup or as an injection. The injections are called a depot. You may find a depot injection useful if you struggle to remember to take your medication.

Your doctor should take your views about the way you would like to take medication into account when prescribing it to you.

We have listed below the antipsychotics which are licenced for use in the UK.

First generation or typical antipsychotics

The following medications are typical antipsychotics. They are the older types of antipsychotics licensed for use in the UK. They have been listed by their generic name with the brand name in brackets.

• chlorpromazine (Largactil)
• flupentixol (Depixol)
• haloperidol (Haldol)
• levomepromazine (Nozinan)
• pericyazine
• perphenazine (Fentazin)
• pimozide (Orap)
• prochlorperazine
• promazine
• sulpiride (Dolmatil, Sulpor)
• trifluperazine (Stelazine)
• zuclopenthixol (Clopixol)

Second generation or atypical antipsychotics

The following medication are atypical antipsychotics. They are the newer types of antipsychotics licensed for use in the UK. They have been listed by their generic name with the brand name in brackets.

• amisulpride (Solian)
• aripiprazole (Abilify, Abilify Maintena)
• clozapine (Clozaril, Denzapine, Zaponex)
• lurasidone (Latuda)
• risperidone (Risperdal, Risperdal Consta, Okedi)
• olanzapine (Zypadhera. Zyprexa)
• quetiapine (Seroquel, Seroquel XL)
• paliperidone (Invega, Xeplion, Trevicta, Byannli)            

Clozapine
Clozapine works slightly differently to others. It is usually given to people who are treatment resistant. Treatment resistant means other medication haven’t helped reduce or control symptoms.

The National Institute for Health and Care Excellence (NICE) says that people with schizophrenia should only be offered clozapine after having tried 2 other antipsychotics.

Clozapine can cause your white blood cell numbers to drop. But this is rare. If your white blood cells drop, this may mean you can get infections more easily. If you take clozapine, you will need regular blood tests to make sure your white blood cell count is healthy.

Your GP surgery should invite you to have blood tests at least once a year. It’s important that you attend your check-ups as regular monitoring helps to manage the risks. If you aren’t being invited to have regular blood tests by your GP surgery, you can contact them to ask for these.

If your white blood cell numbers start dropping, you will be asked to stop taking the medication. You will have another blood test after you have stopped clozapine to make sure they are back to normal. Your doctor might decide to change your dose of clozapine or offer you another type of medication.

There is research to suggest that white blood cell numbers are more likely to drop in people from an ethnic minority. This is because some Black and ethnic minority people already have a lower-than-average white cell count. This may mean your psychiatrist may not prescribe you clozapine. Your psychiatrist will discuss the best options with you.

If you have missed any doses of your clozapine, contact a health professional as soon as possible.

There has been a lot of research to suggest the effectiveness of clozapine in treatment resistant schizophrenia.

NICE produce guidelines for the assessment and treatment of mental illnesses, such as psychosis and schizophrenia. Doctors use these guidelines to decide which medication to offer you. You can find these in the further reading section at the bottom of this page.

What side effects might I experience from taking antipsychotics?

Different antipsychotics can have different side effects. So, in this section we only give a general overview of some of the side effects of antipsychotics.

How can I find out about side effects for my medication?

If you want to know more about the side effects off your antipsychotic medication you can.

• Talk to your psychiatrist, GP, or pharmacist. You can ask them any questions you have. If you are unsure about anything you can ask them to explain it. Most pharmacists have a private room where you can discuss things confidentially.
• Read the patient information leaflet for the medication. There should be one in the box the medication comes in. It says what the side effects are and explains what to do if you are experiencing any side effects. You can find the patient information leaflet for your medication on this website: www.products.mhra.gov.uk/substance-index
• Look up your medication on this NHS website: www.choiceandmedication.org/nsft Each medication has a section on side effects.

What side effects can be included?

Below is a list of possible side effects of antipsychotics. But it’s important to remember:

• different people who take the same medication can get different side effects,
• 2 people who take the same medication might get the same side effect. But one person might be affected more than the other,
• The risk of a side effect can depend on the type of antipsychotic you take.

Before you start to take antipsychotics, it’s important to weigh up:

• the benefit the medication will have, and
• the possible side effects of it.

You can discuss this with your psychiatrist, GP, or pharmacist.

What side effects can be included?

The National Institute of care excellence (NICE) recommend treatment to the NHS. NICE say side effects of antipsychotics include:

• Extrapyramidal symptoms. They include:
  
  • abnormal movements of the face and body
  • tremor
  • slowness of movement and speed
  • being rigid
  • restlessness
  • irregular movements which you cannot control
• Weight gain
• Raised levels of cholesterol in the blood.
• Hyperprolactinaemia. This is higher-than-normal levels of prolactin in your blood. It can lead to:
  
  • a milky nipple discharge
  • missed periods
  • men’s breasts getting larger than normal
  • the body not producing enough testosterone, sperm, or both
  • sexual dysfunction
  • an increased risk of osteoporosis, a health condition that weakens bones.
• Sedation. Feeling sleepy and relaxed.
• Sleep apnoea syndrome. A condition in which your breathing stops and restarts many times while you sleep.
• Anticholinergic effects. Such as dry mouth, blurred vision, urinary retention, constipation, skin flushing and problems emptying all the urine from your bladder.
• Postural hypotension. A form of low blood pressure that happens when standing after sitting or lying down.
• High blood pressure.
• Seizures.
• Less glucose tolerance.
• Issues with your heart or blood vessels.
• Stroke risk.
• Blood clots in the veins
• Neuroleptic malignant syndrome (NMS). This is a rare but potentially fatal adverse effect of all antipsychotics. Signs and symptoms of NMS include:
  
  • fever
  • increased sweating
  • rigidity
  • confusion
  • fluctuating consciousness
  • fluctuating blood pressure
  • fast heartbeat
  • an increased white blood cell count
  • raised creatine kinase, a type of protein in the blood.
• Pneumonia.
• Neutropenia. A condition where you have a low number of white blood cells called neutrophils in your blood.
• Effects on liver function.
• Photosensitivity. Heightened skin sensitivity.
• Skin disorders.
• Double vision.
• Increase in drug or alcohol use.
• Restless legs syndrome. An overwhelming urge to move your legs.

This NHS chart explains side effects of antipsychotics. It helps you to see some of your options for antipsychotics. This could also help you to make choices about your treatment. A healthcare professional can help explain what the following chart means:
www.choiceandmedication.org/nsft/generate/handychartpsychosis.pdf

You may also find the following websites helpful learn more about antipsychotics:

• British National Formulary (BNF): www.bnf.nice.org.uk/drug

See our webpage on Medication – choice and managing problems for more information.

How might antipsychotics effect my physical health?

Some antipsychotic medications can affect your heart.

Doctors might scan your heart at check-ups, if:

• you have a heart condition, or
• you are at risk of having difficulties with your heart.

They might want to do this once every year, or more regularly. This is done by having an electrocardiogram gram (ECG). This is a painless scan.

GP surgeries have a register of people with severe mental illness, such as schizophrenia. If you are on the register your GP should offer you an annual physical health check. , They might check your heart in these appointments.

You can speak to your GP or psychiatrist if:

• you want a heart check-up before you start taking antipsychotics, or
• if you have any concerns about your heart or blood vessels.

If you live with psychosis or schizophrenia your doctor should offer to check your heart before you start antipsychotics if:

• the manufacturers of your medication say you should,
• a physical health check has found you have a higher risk of heart or blood vessel problems,
• you have heart or blood vessel problems or someone in your family has had them, or
• you have to go into hospital.

You can read our information on ‘Severe mental illness and physical health checks’ here: www.rethink.org/advice-and-information/living-with-mental-illness/wellbeing-physical-health/severe-mental-illness-and-physical-health-checks

What can I do if I have issues with side effects?

You might get side effects that are unpleasant or distressing.

Side effects might go away after a few weeks or months of taking medication. Some side effects might last longer. It is important that you find the right balance between medication that helps your symptoms and has the least side effects.

If you have issues with side effects, you can talk to your psychiatrist or GP. They might change your dose or suggest a different medication. They may also be able to give you other drugs to help with the side effects.

You can use a scale like the Glasgow Antipsychotic Side Effects Scale to monitor your side effects. It’s a questionnaire with 22 questions about different side effects. You can take this to your doctor to help you decide how to manage the side effects. You can download the GASS here:
www.dpt.nhs.uk/download/gwWX3mR9SJ

What is the Yellow Card system?
The Medicines and Healthcare Products Regulatory Agency (MHRA) make sure medicines and medical devices work and are safe.

The MHRA runs the Yellow Card system. You can use the system to report bad side effects. By doing this you can help the MHRA to make sure medicines are safe.

You can report bad side effects online by clicking on the following link:
www.yellowcard.mhra.gov.uk

Stopping and other medication

What if I want to stop taking antipsychotics?

If you want to stop taking antipsychotics, you should discuss this with your doctor.

Your doctor should discuss the negatives and benefits of stopping antipsychotics. You can ask them about these things. It’s important to think about the negatives and benefits of stopping antipsychotics.

If you decide to come off antipsychotics your doctor will help you come off the medication gradually by reducing the dose over a period of time.

If you stop antipsychotics suddenly it can cause 'rebound psychosis'. This means that the symptoms of your illness return suddenly, and you may become unwell again. This is also known as ‘relapse’.

If you or your family or friends think you are becoming unwell again, you should speak to your doctor.

You may find that stopping your medication can lead to your symptoms returning within 3-6 months. Your doctor may suggest that you keep taking the medication because it is keeping you well. If this is the case, you could ask about trying another type of medication.

If you want to stop taking antipsychotics, it is important to consider what happened during previous episodes of illness.

The risk of the same symptoms occurring again needs to be weighed up against not having the side effects of the medication and any other things important to you. Your doctor can talk these things through with you to help you come to the best decision.

Can I experience withdrawal symptoms from stopping antipsychotics?

Antipsychotics aren’t addictive, but your body may get used to them. This is why you may experience ‘withdrawal symptoms’.

The withdrawal symptoms you may experience depends on each individual antipsychotic. Some antipsychotics are unlikely to cause you significant withdrawal symptoms. This is especially the case with depot injections.

You should discuss with your GP or psychiatrist if you might experience withdrawal symptoms. And what you can do to help manage withdrawal symptoms.

Do I have to take antipsychotics?

It’s your choice whether you take antipsychotics.

But you can be forced to take them if you’re detained in hospital under the Mental Health Act if professionals think it’s right for you.

You might lack the mental capacity to make a decision about whether to take antipsychotics. If you do, professionals and people involved in your care will decide if it’s in your best interests to take them.

For more information see our webpages on the following:

• Mental Health Act
• Mental capacity and mental illness

Do antipsychotics affect other medication?

Antipsychotics can interact with many different medications. This means if you take an antipsychotic and another medication, they can affect each other.

For example, some antipsychotics can interact with tricyclic antidepressants. In some cases, this means they shouldn’t be prescribed together.

Some antipsychotics can cause drowsiness, so doctors should be careful about prescribing benzodiazepines too. It could make you feel drowsier.

Your doctor may prescribe you different medications with antipsychotics, which is common. Your doctor will carefully monitor this to ensure your safety.

You should tell your doctor about all the medicines you are taking. This includes any supplements. This will allow your doctor to prescribe the right antipsychotic. It is important to note that supplements, such as ‘natural health products’ can interact with antipsychotics.

If you’re taking a supplement, which your doctor agrees with, always get the same brand. Switching brands, even if it’s the same supplement, can have an effect your antipsychotics.

You may benefit from keeping an up-to-date medication list. This should include all the medication you’re currently taking so you can give it to healthcare professionals.

It’s also very important to not stop or start any medication without checking with a healthcare professional. This could be a doctor or a pharmacist.

Does alcohol affect antipsychotics?

Alcohol can affect antipsychotics.  So, you should:

·       discuss how alcohol use can affect you if you take antipsychotics with your doctor, and

·       carefully read your medication patient information leaflet to see what it says about alcohol use. The box your medication comes in comes in should include the patient information leaflet.

Drinking alcohol can make it harder for your body to absorb medication. This could increase the effects alcohol has on you. Drinking alcohol with antipsychotics might increase the sedative effects. This means you might feel very tired.

What about alcohol use and clozapine?

If you take clozapine drinking alcohol can be very dangerous.

There are risks when drinking alcohol while taking clozapine. It can cause central nervous system depression. This is when the brain and nervous system slows down. If it slows down too much, it can be life-threatening.

It is very important you:

·       discuss alcohol use with your doctor, and

·       carefully read your medication patient information leaflet to see what it says about alcohol use. The box your medication comes in comes in should include the patient information leaflet.

The symptoms of central nervous system depression are shown below. 

You should get help straight away by calling NHS 111. Or in an emergency by going to A&E or calling 999.

·        Over sedated or inappropriately sleepy.

·        Unusually confused or forgetful.

·        Un-coordinated, with slurred speech, slow reflexes or difficulty moving.

·        Breathing unusually slowly or have other breathing difficulties.

·        A slow pulse or heart rate.

·        A dry mouth.

·        Blue lips.

·        Clammy, cold skin. 

Does smoking affect antipsychotics?

You should tell your doctor if you smoke.

This is because smoking interacts with the way medication is absorbed in your body. If you are thinking of quitting smoking, you should discuss this with your doctor. If you stop smoking suddenly, this can affect the levels of medication in your body. This can cause serious side effects.

Can menopause affect psychotic disorders?

There is research to suggest that symptoms of schizophrenia, and psychotic related symptoms may worsen during menopause. Antipsychotic treatment may need to be modified and closely monitored for women during this period.

Can I drive when taking antipsychotics?

Antipsychotics can affect your concentration and make you feel drowsy. This could affect how well you are able to drive especially when you first start taking the medication. You should consider stopping driving during this time if you are affected.

You have to tell the DVLA if you live with certain mental health conditions including psychosis, paranoid schizophrenia and bipolar disorder.

See our webpage on Driving and mental illness for more information.

What if I’m pregnant or planning on having a baby?

You can speak to your doctor about the risks of medication while pregnant or breastfeeding. You could also discuss this with your midwife or health visitor. Taking antipsychotics during pregnancy may have certain risks. You shouldn’t stop taking your antipsychotics without speaking to your doctor first.

It is thought that there may be a small risk of complications if you take antipsychotic drugs during pregnancy. Overall, the research isn’t clear whether first generation or second-generation drugs will affect your unborn child.

If you are pregnant or plan on getting pregnant, you should speak to your doctor. If possible, it is best to tell your doctor before you become pregnant so that you can discuss concerns you might have around medication. And agree a plan moving forward that will be healthy for you and your baby.

If you have had relapses in the past your doctor might suggest that you stay on your medication during and after pregnancy. This could reduce your baby’s exposure to the drug, because if you did relapse you would need a much higher dose. It’s important to discuss with your doctor the risk and benefits of continuing to take antipsychotics.

If you have a mental health condition, you may be seen by your local perinatal mental health service. This is if this team exists in your area. If you don’t have this team in your local area, your usual doctor can support you.

Can I breastfeed if I take antipsychotics?
If you are breastfeeding and taking antipsychotics, some antipsychotics could be passed to your child from your breast milk. Many drug manufacturers advise that you should stop breastfeeding while taking an antipsychotic.

There is evidence that the presence of some antipsychotics such as clozapine and olanzapine in breast milk may cause harmful effects. You should be monitored regularly and should stop breastfeeding if harmful effects are suspected. Speak to your doctor about the risk and benefits of continuing to take antipsychotics whilst pregnant.

Further reading

Psychosis and Schizophrenia in adults: prevention and management
This is the NICE guidance on Schizophrenia and Psychosis.

Website: www.nice.org.uk/guidance/cg178

Bipolar Disorder: assessment and management
This is the NICE guidance on Bipolar disorder.

Website: www.nice.org.uk/guidance/cg185

More contacts

Mood Swings Network
This organisation provides a range of services for people affected by a mood disorder, including their family and friends.

Telephone: 0161 832 37 36
Address: 36 New Mount St, Manchester, M4 4DE.
Email: info@moodswings.org.uk
Website: www.moodswings.org.uk

Bipolar UK
This is a user led charity working to enable people affected by bipolar disorder to take control of their lives

Address: Bipolar UK, 11 Belgrave Road, London, SW1V 1RB
Email: info@bipolaruk.org.uk
Website: www.bipolaruk.org

The Hearing Voices Network
This organization provides support and understanding for those who hear voices or experience other types of hallucination.

Telephone: 0114 271 8210
Address: National Hearing Voices Network (HVN), 86-90 Paul Street, London, EC2A 4NE
Email: nhvn@hotmail.co.uk
Website: www.hearing-voices.org

Action on Postpartum Psychosis
A national charity for women and families affected by postpartum psychosis. They run a peer support service, provide information, training to health professionals, do research and promote awareness.

Telephone: 020 33229900
Address: Action on Postpartum Psychosis, PO Box 137, Swansea, SA3 9BT
Email: app@app-network.org
Website: www.app-network.org

© Rethink Mental Illness 2023

Last updated February 2023
Next update May 2024

Version number 8.1

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