Psychosis & related disorders

Antipsychotics are inappropriate to use in patients aged 65 years or over

  • other than quetiapine or clozapine in those with parkinsonism or Lewy Body Disease (risk of severe extra-pyramidal symptoms)
  • in patients with behavioural and psychological symptoms of dementia (BPSD) unless symptoms are severe and other non-pharmacological treatments have failed (increased risk of stroke)
  • as hypnotics, unless sleep disorder is due to psychosis or dementia (risk of confusion, hypotension, extra-pyramidal side effects, falls)
  • if neuroleptic with moderate-marked antimuscarinic/ anticholinergic effects (chlorpromazine, clozapine, flupenthixol, fluphenzine, pipothiazine, promazine, zuclopenthixol) and patient has a history of prostatism or previous urinary retention (high risk of urinary retention)
  • phenothiazines should not be used as first-line treatment, since safer and more efficacious alternatives exist (phenothiazines are sedative, have significant anti-muscarinic toxicity in older people, with the exception of prochlorperazine for nausea/vomiting/vertigo, chlorpromazine for relief of persistent hiccoughs and levomepromazine as an anti-emetic in palliative care )
  • if patient has a history of falls (may cause gait dyspraxia, Parkinsonism).

For people with learning difficulties initiate treatment with low doses and titrate cautiously with frequent monitoring for side effects

Additional resources

KMPT Depot Prescription and Administration Chart

KMPT guideline for the use of high dose antipsychotics

KMPT Use of IM injection in community mental health clinics

British Association for Psychopharmacology Evidence-based guidelines for the pharmacological treatment of schizophrenia

British Association for Psychopharmacology guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment

NICE Summary of guidance on psychosis and schizophrenia

NICE CG178 Psychosis and schizophrenia in adults: treatment and management

NICE Evidence search for the treatment of hypersalivation

UKMI Are atypical antipsychotics safe during breast feeding

UKMI Are first generation antipsychotics safe during breast feeding

UKMi Drug-induced hypersalivation - what treatment options are available?

UKMI What is neuroleptic malignant syndrome

UKMI Which drugs can cause neuroleptic malignant syndrome

Formulary medications