Table of Contents

Preface x


Acknowledgements xii


Notes on using The Maudsley Prescribing Guidelines in Psychiatry xiii


List of abbreviations xv


Part 1 Drug treatment of major psychiatric conditions 1


Chapter 1 Schizophrenia and related psychoses 3


ANTIPSYCHOTIC DRUGS 3


General introduction 3


General principles of prescribing 8


Minimum effective doses 9


Licensed maximum doses 12


Equivalent doses 14


High?dose antipsychotics: prescribing and monitoring 16


Combined antipsychotics 20


Antipsychotic prophylaxis 25


Negative symptoms 31


Monitoring 36


Relative adverse effects – a rough guide 39


Treatment algorithms for schizophrenia 40


First?generation antipsychotics – place in therapy 44


NICE guidelines for the treatment of schizophrenia 46


Antipsychotic response – to increase the dose, to switch, to add or just wait – what is the right move? 49


Acutely disturbed or violent behaviour 54


Antipsychotic depots/long?acting injections (LAIs) 66


Depot/LAI antipsychotics – pharmacokinetics 71


Management of patients on long?term depots/LAIs 73


Aripiprazole long?acting injection 75


Olanzapine long?acting injection 77


Paliperidone palmitate long?acting injection 79


Risperidone long?acting injection 82


Electroconvulsive therapy and psychosis 86


Omega?3 fatty acid (fish oils) in schizophrenia 88


ANTIPSYCHOTIC ADVERSE EFFECTS 90


Extrapyramidal symptoms 90


Akathisia 94


Weight gain 97


Treatment of antipsychotic?induced weight gain 99


Neuroleptic malignant syndrome 104


Catatonia 107


ECG changes – QT prolongation 112


Effect of antipsychotic medications on plasma lipids 119


Diabetes and impaired glucose tolerance 123


Blood pressure changes 130


Hyponatraemia 134


Hyperprolactinaemia 137


Sexual dysfunction 141


Pneumonia 148


Switching antipsychotics 150


Venous thromboembolism 153


REFRACTORY SCHIZOPHRENIA AND CLOZAPINE 156


Clozapine initiation schedule 156


Optimising clozapine treatment 158


Alternatives to clozapine 162


Re?starting clozapine after a break in treatment 169


Initiation of clozapine for community?based patients 170


CLOZAPINE ADVERSE EFFECTS 175


Clozapine: common adverse effects 175


Clozapine: uncommon or unusual adverse effects 179


Clozapine: serious haematological and cardiovascular adverse effects 184


Clozapine?induced hypersalivation 189


Clozapine?induced gastrointestinal hypomotility (CIGH) 193


Clozapine, neutropenia and lithium 197


Clozapine and chemotherapy 202


Chapter 2 Bipolar disorder 205


Lithium 205


Valproate 214


Carbamazepine 221


Antipsychotic drugs in bipolar disorder 226


Antipsychotic long?acting injections in bipolar disorder 229


Physical monitoring for people with bipolar disorder 232


Treatment of acute mania or hypomania 235


Rapid?cycling bipolar disorder 241


Bipolar depression 243


Prophylaxis in bipolar disorder 250


Chapter 3 Depression and anxiety disorders 255


Depression: introduction 255


Basic principles of prescribing in depression 255


Official guidance on the treatment of depression 256


Antidepressants: general overview 257


Recognised minimum effective doses of antidepressants 262


Drug treatment of depression 264


Treatment of refractory depression: first choice 267


Treatment of refractory depression: second choice 271


Treatment of refractory depression: other reported treatments 274


Psychotic depression 278


Electroconvulsive therapy and psychotropic drugs 281


Stimulants in depression 285


Post?stroke depression 290


Treatment of depression in the elderly 293


Antidepressants: alternative routes of administration 298


Antidepressant prophylaxis 306


Antidepressant discontinuation symptoms 310


Antidepressants: swapping and stopping 314


Drug interactions with antidepressants 321


Cardiac effects of antidepressants 325


Antidepressant?induced arrhythmia 329


Antidepressant?induced hyponatraemia 333


Antidepressants and hyperprolactinaemia 337


Antidepressants and diabetes mellitus 340


Antidepressants and sexual dysfunction 343


SSRIs and bleeding 347


St John’s wort 355


Antidepressants: relative adverse effects – a rough guide 358


Anxiety spectrum disorders 360


Benzodiazepines in the treatment of psychiatric disorders 373


Benzodiazepines: dependence and detoxification 377


Benzodiazepines and disinhibition 381


Chapter 4 Addictions and substance misuse 385


Introduction 385


Alcohol dependence 387


Opioid dependence 405


Nicotine and smoking cessation 431


Pharmacological treatment of dependence on stimulants 439


GHB and GBL dependence 442


Benzodiazepine misuse 445


Synthetic cannabinoid receptor agonists (SCRAs) 447


Interactions between ‘street drugs’ and prescribed psychotropic drugs 450


Drugs of misuse – a summary 454


Part 2 Drug treatment of special patient groups 459


Chapter 5 Children and adolescents 461


Principles of prescribing practice in childhood and adolescence 461


Depression in children and adolescents 463


Bipolar illness in children and adolescents 471


Psychosis in children and adolescents 478


Anxiety disorders in children and adolescents 480


Obsessive compulsive disorder (OCD) in children and adolescents 485


Post?traumatic stress disorder in children and adolescents 491


Attention deficit hyperactivity disorder 496


Autism spectrum disorder 504


Tics and Tourette’s syndrome 512


Melatonin in the treatment of insomnia in children and adolescents 517


Rapid tranquillisation (RT) in children and adolescents 521


Doses of commonly used psychotropic drugs in children and adolescents 524


Chapter 6 Prescribing in older people 525


General principles 525


Dementia 529


Safer prescribing for physical conditions in dementia 570


Management of behavioural and psychological symptoms of dementia 557


A guide to medication doses of commonly used psychotropic drugs in older adults 586


Covert administration of medicines within food and drink 593


Chapter 7 Pregnancy and breastfeeding 599


Drug choice in pregnancy 599


Breastfeeding 619


Chapter 8 Hepatic and renal impairment 635


Hepatic impairment 635


Renal impairment 645


Part 3 Prescribing in specialist conditions 661


Chapter 9 Drug treatment of other psychiatric conditions 663


Borderline personality disorder 663


Eating disorders 667


Delirium 672


Chapter 10 Drug treatment of psychiatric symptoms occurring in the context of other disorders 679


General principles of prescribing in human immunodeficiency virus (HIV) 679


Prescribing psychotropics in HIV 685


Epilepsy 688


22q11.2 Deletion syndrome 696


Learning disabilities 699


Huntington’s disease 704


Multiple sclerosis 709


Parkinson’s disease 715


Atrial fibrillation 719


Bariatric surgery 722


Part 4 Other aspects of psychotropic drug use 729


Chapter 11 Pharmacokinetics 731


Plasma level monitoring of psychotropic drugs 731


Interpreting post?mortem blood concentrations 742


Acting on clozapine plasma concentration results 744


Psychotropic drugs and cytochrome (CYP) function 746


Smoking and psychotropic drugs 750


Drug interactions with alcohol 753


Chapter 12 Other substances 759


Caffeine 759


Nicotine 765


Chapter 13 Psychotropic drugs in special conditions 769


Psychotropic drugs in overdose 769


Driving and psychotropic drugs 776


Psychotropic drugs and surgery 781


Chapter 14 Miscellany 787


Enhancing medication adherence 787


Re?starting psychotropic medications after a period of non?compliance 794


Biochemical and haematological effects of psychotropic medications 798


Summary of psychiatric adverse effects of non?psychotropic medications 808


Prescribing drugs outside their licensed indications (‘off?label’ prescribing) 813


The Mental Health Act in England and Wales 816


Site of administration of intramuscular injections 821


Index 825

About the Author

David M. Taylor BSc, MSc, PhD, FFRPS, FRPharmS, is Director of Pharmacy and Pathology at the Maudsley Hospital and Professor of Psychopharmacology at King's College, London.
Thomas R. E. Barnes, MBBS, MD, FRCPsych, DSc, is Emeritus Professor of Clinical Psychiatry at Imperial College London and joint-head of the Prescribing Observatory for Mental Health at the Royal College of Psychiatrists' Centre for Quality Improvement.
Allan H. Young, MB, ChB, MPhil, PhD, FRCPC, FRCPsych, is Chair of Mood Disorders and is Director of the Centre for Affective Disorders in the Department of Psychological Medicine in the Institute of Psychiatry at King's College London, UK.