The Maudsley Prescribing Guidelines in Psychiatry

David Taylor is Chief Pharmacist at the South London and Maudsley NHS Foundation Trust, Professor of Psychopharmacology at King s College London, and Pharmacy Lead for the UK Mental Health Research Network. The lead author of all editions of The Maudsley Prescribing Guidelines, Professor Taylor is the author of several other texts and editor of Therapeutic Advances in Psychopharmacology. Carol Paton is Chief Pharmacist at Oxleas NHS Foundation Trust, London: she is also joint Head of the Prescribing Observatory for Mental Health and an Honorary Research Fellow at Imperial College London. Shitij Kapur is Professor of Schizophrenia, Imaging and Therapeutics and the Dean and Head of School at the Institute of Psychiatry, King′s College London.

Preface xi
Acknowledgements xii


Notes on using The Maudsley Prescribing Guidelines xiii


List of abbreviations xv


Chapter 1 Plasma level monitoring of psychotropic drugs 1


Interpreting sample results 2


Acting on clozapine plasma concentration results 11


Interpreting post–mortem blood concentrations 13


Chapter 2 Schizophrenia 15


Antipsychotic drugs 15


General introduction 15


General principles of prescribing 20


Minimum effective doses 22


Quick reference for licensed maximum doses 24


Equivalent doses 26


High–dose antipsychotics: prescribing and monitoring 28


Antipsychotic prophylaxis 31


Combined antipsychotics 37


Negative symptoms 41


Monitoring 45


Relative adverse effects a rough guide 48


Treatment algorithms for schizophrenia 49


First ]generation antipsychotics place in therapy 52


Omega–3 fatty acid (fish oils) in schizophrenia 54


New and developing drugs to treat schizophrenia 56


NICE guidelines for the treatment of schizophrenia 59


Antipsychotic response to increase the dose, to switch, to add or just wait what is the right move? 61


Antipsychotic long ]acting injections 66


Depot antipsychotics pharmacokinetics 70


Management of patients on long ]term depots 72


Aripiprazole LAI 74


Olanzapine LAI 75


Paliperidone palmitate LAI 77


Risperidone LAI 80


ANTIPSYCHOT ICS ADVERSE EFFECTS 84


Extrapyramidal side–effects 84


Akathisia 88


Weight gain 90


Treatment of drug–induced weight gain 92


Tardive dyskinesia 97


Neuroleptic malignant syndrome 102


Catatonia 105


QT prolongation 110


Dyslipidaemia 117


Diabetes and impaired glucose tolerance 121


Hypertension 128


Hyponatraemia 130


Hyperprolactinaemia 133


Sexual dysfunction 137


Pneumonia 143


Switching antipsychotics 144


REFRACTORY SCHIZOPHRENIA AND CLOZAPINE 147


Clozapine dosing regimen 147


Optimising clozapine treatment 149


Alternatives to clozapine 153


Restarting clozapine after a break in treatment 159


Initiation of clozapine for community–based patients 160


CLOZAPINE ADVERSE EFFECTS 165


Common adverse effects 165


Clozapine: uncommon or unusual adverse effects 168


Clozapine: serious haematological and cardiovascular adverse effects 170


Clozapine–induced hypersalivation 174


Clozapine–induced gastrointestinal hypomotility (CIGH) 177


Clozapine, neutropenia and lithium 181


Clozapine and chemotherapy 186


Chapter 3 Bipolar affective disorder 189


Lithium 189


Valproate 197


Carbamazepine 203


Antipsychotics in bipolar disorder 208


Treatment of acute mania or hypomania 211


Bipolar depression 216


Rapid–cycling bipolar affective disorder 223


Prophylaxis in bipolar affective disorder 225


Physical monitoring for people with bipolar affective disorder 228


Chapter 4 Depression and anxiety 231


Introduction 231


Basic principles of prescribing in depression 231


Official guidance on the treatment of depression 232


Antidepressants: general overview 233


St John s wort 246


Recognised minimum effective doses of antidepressants 250


Drug treatment of depression 252


Treatment of refractory depression 255


Psychotic depression 266


Electroconvulsive therapy and psychotropic drugs 269


Psychostimulants in depression 272


Post–stroke depression 276


Treatment of depression in the elderly 279


Antidepressant discontinuation symptoms 283


Antidepressant prophylaxis 287


Antidepressants: alternative routes of administration 290


Antidepressants: swapping and stopping 296


Drug interactions with antidepressants 303


Cardiac effects of antidepressants 307


Antidepressant–induced arrhythmia 312


Antidepressant–induced hyponatraemia 316


Antidepressants and hyperprolactinaemia 319


Antidepressants and diabetes mellitus 321


Antidepressants and sexual dysfunction 324


SSR Is and bleeding 328


Antidepressants: relative adverse effects a rough guide 332


Anxiety spectrum disorders 334


Benzodiazepines in the treatment of psychiatric disorders 343


Benzodiazepines: dependence and detoxification 346


Benzodiazepines and disinhibition 350


Chapter 5 Children and adolescents 353


Principles of prescribing practice in childhood and adolescence 353


Depression in children and adolescents 355


Bipolar illness in children and adolescents 362


Psychosis in children and adolescents 367


Anxiety disorders in children and adolescents 369


Obsessive compulsive disorder in children and adolescents 374


Post–traumatic stress disorder in children and adolescents 379


Attention deficit hyperactivity disorder 384


Autism spectrum disorders 390


Tics and Tourette s syndrome 397


Melatonin in the treatment of insomnia in children and adolescents 402


Rapid tranquillisation in children and adolescents 405


Doses of commonly used psychotropic drugs in children and adolescents 408


Chapter 6 Substance misuse 409


Introduction 409


Alcohol dependence 411


Opioid misuse and dependence 429


Nicotine and smoking cessation 456


Pharmacological treatment of dependence on stimulants 463


Benzodiazepine misuse 466


GBL and GHB dependence 467


Drugs of misuse: a summary 469


Interactions between street drugs and prescribed psychotropic drugs 472


Chapter 7 Use of psychotropic drugs in special patient groups 477


The elderly 477


Dementia 487


Safer prescribing of physical health medicines in dementia 507


Management of non–cognitive symptoms of dementia 517


Parkinson s disease 529


Multiple sclerosis 533


Huntington s disease 538


Pregnancy 541


Breastfeeding 559


Renal impairment 576


Hepatic impairment 590


HIV infection 598


Eating disorders 607


Acutely disturbed or violent behaviour 611


Borderline personality disorder 618


Learning disabilities 621


Delirium 625


Epilepsy 632


Surgery 637


Velo–cardio–facial syndrome 643


Cytochrome (CY P) function 646


Psychiatric side–effects of non–psychotropic drugs 650


Atrial fibrillation 656


Chapter 8 Miscellaneous conditions and substances 659


Psychotropic drugs in overdose 659


Biochemical and haematological effects of psychotropics 665


Prescribing drugs outside their licensed indications ( off–label prescribing) 673


Observations on the placebo effect in mental illness 676


Drug interactions with alcohol 679


Nicotine 684


Smoking and psychotropic drugs 688


Caffeine 690


Complementary therapies 695


Enhancing medication adherence 700


Driving and psychotropic medicines 706


Covert administration of medicines within food and drink 714


Index 717