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4.2 Mental health disorders

First line drugs Second line drugs Specialist drugs Secondary care drugs

 

Traffic light status (TLS) explained:

 

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

 

4.2.1 Anxiety

Hypnotics and Sedatives(Benzodiazepines)

National Guideline and Important Notes:  


Drugs included in the new offence that might be used for medicinal purposes:

•Cannabis (tetrahydrocannabinol, THC)
•Cocaine
•Morphine
•Diamorphine
•Methadone
•Ketamine
•Amphetamine
•Flunitrazepam
•Clonazepam
•Diazepam
•Lorazepam
•Oxazepam
•Temazepam

 

 

Chlordiazepoxide hydrochloride

  • Capsules 5mg, 10mg 

 

Diazepam

  • Tablets 2mg, 5mg, 10mg
  • Oral Solution 2mg in 5mL
  • Injection (emulsion - Diazemuls®) 5mg/mL (2-mL amp)
  • Injection (solution) 5mg/mL (2-mL amp)
  • Rectal solution tube 2.5mg, 5mg, 10mg

Notes:

  • Diazepam is the preferred benzodiazepine for the treatment of anxiety and in benzodiazepine withdrawal regimes.
  • Benzodiazepines are associated with a poorer outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder’.

 

 

Serotonin Receptor Agonists

Buspirone hydrochloride (Amber 2)

  • Tablets 5mg, 10mg  

 

 

4.2.2 Attention Deficit Hyperactivity Disorder (ADHD)

 

Local guideline

Medication Treatment Algorithm For Childhood ADHD (Feb 2015) 

 

CNS Stimulants (Amfetamine isomers)

Dexamfetamine sulfate (Amber 3) CD 

  • Tablets 5mg 

 

Lisdexamfetamine dimesylate (Amber 3) CD

  • Elvanse® Capsules 30mg, 50mg, 70mg 

Notes: 

 

CNS Stimulants (Noradrenaline reuptake inhibitors)

Atomoxetine (2nd line to methylphenidate) (Amber 3)

  • Capsules 10mg, 18mg, 25mg, 40mg, 60mg, 80mg, 100mg  

Notes: 

 

 

CNS Stimulants (Sympathomimetics, centrally acting)

Methylphenidate hydrochloride (Amber 3) CD

  • Tablet 5mg, 10mg, 20mg
  • Xaggitin®XL Modified release tablet 18mg, 27mg, 36mg, 54mg 

Notes: 

 

 

Non-Stimulants (Sympathomimetics, alpha-adrenoceptor agonists)

 

Guanfacine hydrochloride

  • Intuniv® Tablets prolonged-release, 1mg, 2mg, 3mg, 4mg 

 

 

 

 

4.2.3 Bipolar disorder and mania 

National Guidelines:

 

 

Antiepileptics

 

Valproate

Valproic acid (as Valproate semisodium) Amber 2

  • Depakote® Tablets 250mg, 500mg

 

Notes:

 

 

 

 

 

 

 

 

Lithium Salts (Shared care guideline)

Lithium carbonate (Amber SCG)

  • Priadel® Modified Release tablet 200mg, 400mg  

 

Lithium citrate (Amber SCG)

  • Priadel®  Sugar Free Liquid 520mg (equivalent to 5.5mmol Li+) in 5mL

Notes: 

  • Safer Lithium Therapy (Signs of Lithium Toxicity) May 2017
  • Dose equivalence and conversion: Lithium citrate tetrahydrate 520mg is equivalent to lithium carbonate 204mg
  • Priadel® should be preferred for all new patients.
  • It is not intended that patients stabilised on Camcolit® should be changed to Priadel®.
  • Please specify the brand when prescribing lithium to ensure that the patient receives the same preparation. Different brands of lithium are not equivalent.

 

 

4.2.4 Depression 

 

National Guideline

NICE CG90: Depression in adults: recognition and management (October 2009)

 

Monoamine-oxidase A inhibitors (reversible)

Moclobemide (Amber 2)

  • Tablets 150mg, 300mg

Notes:

  • Patients should avoid consuming large amounts of tyramine-rich food (such as mature cheddar, yeast extracts, red wine and fermented soya bean products) and sympathomimetics (such as ephedrine, pseudoephedrine and phenylpropanolamine).
  • Please refer the patient to the patient information leaflet (PIL) supplied with the product for dietary restrictions.  

 

 

Selective Serotonin Re-uptake Inhibitors (SSRIs)

Citalopram 

  • Tablets 10mg, 20mg, 40mg
  • Oral drops Sugar Free 40mg in 1mL

Note:

 

Escitalopram (Amber 3)

  • Tablet 5mg, 10mg, 20mg

Notes:

  • Only for initialtion by consultant psychiatrist where other treatments have failed

 

Advice for healthcare professionals:

Maximum daily dose schedule is as follows:

  Adults Adults >65 years Adults with hepatic impairment
Citalopram 40 mg* 20 mg* 20 mg*
Escitalopram 20 mg 10 mg* 10 mg

*New (restricted) maximum daily dose.

Contraindications in patients at greatest risk of QT interval prolongation:

  • Citalopram and escitalopram should not be used:
    • in patients with congenital long QT syndrome or known pre-existing QT interval prolongation
    • in combination with other medicines known to prolong the QT interval (see link)
  •  

 

Fluoxetine  

  • Capsules 20mg
  • Liquid 20mg in 5ml

 

Paroxetine

  • Tablet 20mg, 30mg
  • Liquid 10mg in 5mL

 

Sertraline

  • Tablets 50mg, 100mg   

 

 

Serotonin transporter inhibitor

Vortioxetine (Amber 3)

  • Brintellix® Tablets film-coated 5mg, 10mg, 20mg

Notes:

 

 

Serotonin and Noradrenaline re-uptake inhibitors 

Venlafaxine

  • Tablets 37.5mg, 75mg
  • Modified Release tablets 37.5mg, 75mg, 150mg, 225mg  

 

Duloxetine

  • Capsules 30mg, 60mg

Note:

  • Restricted for use by Consultant Psychiatrist only

 

 

Tetracycline Antidepressants

Mirtazapine

  • Tablets 15mg, 30mg, 45mg
  • Orodispersible tablets 15mg, 30mg, 45mg 

 

 

Triazolopyridines

Trazodone hydrochloride

  • Capsules 50mg, 100mg
  • Liquid Sugar free 50mg in 5mL

 

Tricyclic Antidepressants

Amitriptyline hydrochloride

  • Tablets 10mg, 25mg, 50mg
  • Oral solution 25mg in 5mL and 50mg in 5mL

 

Clomipramine hydrochloride

  • Capsules 10mg, 25mg, 50mg

 

Dosulepin hydrochloride (Amber 2)

Note: Classed as a "Low Value Medicine"

  • Capsules 25mg
  • Tablets 75mg

 

Dosulepin Commissioning Statement

Prescribers should not initiate Dosulepin for any new patient.

Dosulepin should be discontinued from primary care prescribing (deprescribed), with support from specialist services if necessary.

If, in exceptional circumstances, (where the prescribing clinician considers no other medicine or intervention is clinically appropriate and available for the individual) there is a clinical need for dosulepin to be prescribed in primary care, this should be undertaken in a cooperation agreement with a multi-disciplinary team and/or other healthcare professional.

Patient Information Leaflet can be found on the formulary website at:  https://www.formularymk.nhs.uk/includes/documents/Patient-information-Changes-to-dosulepin-prescribing.pdf

 

 

Imipramine hydrochloride

  • Tablets 10mg, 25mg

 

Lofepramine

  • Tablets 70mg

 

 

 

4.2.6 Psychoses and Schizophrenia 

Antipsychotics (first-generation)

Chlorpromazine hydrochloride (Amber 1)

  • Tablets 25mg, 50mg, 100mg
  • Oral solution 25mg/5mL, 100mg/5mL
  • Injection 25mg/mL (2-mL amp) 

 

Flupentixol (Amber 1)

  • Depixol® Tablets 3mg
  • Fluanxol® Tablets 500 microgram, 1mg

 

Flupentixol decanoate (Amber 2)

Diluent = Coconut oil

  • Depixol® Injection 20mg/mL - 20mg in 1mL, 40mg in 2mL
  • Depixol® Injection 100mg /mL ("Concentrate") - 50mg in 0.5mL, 100mg in 1mL
  • Depixol® Injection 200mg/mL ("Low-volume") - 200mg in 1mL 

 

Fluphenazine decanoate (Amber 2)

[Permanent discontinuation of Modecate® - end of supply in 2019 and 2020]

Diluent = Sesame oil

  • Injection 25mg/mL - 25mg in 1mL
  • Injection 100mg/mL ("Concentrate") - 50mg in 0.5mL, 100mg in 1mL 

 

Haloperidol

  • Capsules 500 micrograms
  • Tablets 1.5mg, 5mg, 10mg, 20mg
  • Oral liquid - Sugar free 2mg in 1mL,
  • Injection 5mg/1mL 

 

Haloperidol decanoate (Amber 1)

Diluent = Sesame oil

  • Haldol Decanoate®Injection 100mg/mL  

 

Pimozide

  • Tablets 4mg

Note: Consultant psychiatrist request only

 

Prochlorperazine

  • Tablets 5mg
  • Syrup 5mg/5mL
  • Injection 12.5mg/mL 

 

Sulpiride (Amber 2)

  • Tablets 200mg, 400mg
  • Oral solution - Sugar free 200mg/5mL

 

Trifluoperazine (Amber 2)

  • Tablets 1mg, 5mg
  • Oral solution 5mg/5mL 

 

Zuclopenthixol (Amber 3)

  • Tablets 2mg, 10mg, 25mg 

 

Zuclopenthixol acetate

For deep IM injection

  • Injection 50mg/1mL
  • Injection 100mg/2mL  

 

Zuclopenthixol decanoate (Amber 3)

Diluent = Coconut oil

  • Clopixol® injection 200mg/mL
  • Clopixol® injection 500mg/mL ("Concentrate")  

 

Antipsychotics (Second-generation)

Amisulpride (Amber 2)

  • Tablets 50mg, 100mg, 200mg, 400mg

 

Aripiprazole (Amber 3)

  • Tablets 5mg, 10mg, 15mg, 30mg
  • Abilify Maintena® Injection in pre-filled syringe, 400mg powder and solvent for prolonged-release suspension for injection 

Notes:

 

  • Restrictions on the use of Aripiprazole prolonged – release injection
    1) Can only be initiated by a consultant psychiatrist AND
    2) Can only be initiated for a patient who has a diagnosis of schizophrenia AND
    3) Should only be initiated for patients where a “typical” depot has been considered and cannot be used i.e. it is not clinically appropriate or tolerated. One of the typical antipsychotic depots should be considered first due to the significant financial implications. AND
    4) Can only be initiated for patients who have a documented  clinical response to treatment doses of aripiprazole, tolerated it, and would be considered mentally “stable” with this antipsychotic as monotherapy AND
    5) Follow the approval process for initiation (form to be completed acknowledging the above details)

 

 

Clozapine

  • Tablets 25mg, 100mg

Note:

 

 

Olanzapine 

  • Tablets 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg
  • Orodispersible tablets 5mg, 10mg, 15mg, 20mg

Note:

  • Olanzapine has been associated with an increased risk of hyperglycaemia, diabetes mellitus and exacerbations of diabetes.
  •  

Paliperidone Palmitate

  • Trevicta® 175 mg prolonged release suspension for injection　
  • Trevicta® 263 mg prolonged release suspension for injection　
  • Trevicta® 350 mg prolonged release suspension for injection　
  • Trevicta® 525 mg prolonged release suspension for injection

 

Paliperidone (Amber 3)

  • Xeplion®  Injection 50mg, 75mg, 100mg, 150mg prefilled syringe 

Notes:

  • Restrictions on the use of Paliperidone Palmitate prolonged – release injection
    1) Can only be initiated by a consultant psychiatrist. AND
    2) Can only be initiated for a patient who has a diagnosis of schizophrenia. AND
    3) Should only be initiated for patients where:
     a) A “typical” depot has been considered and cannot be used ie it is not clinically appropriate or tolerated. One of the typical antipsychotic depots should be considered first due to the significant financial implications, OR.
     b) The patient is currently on Risperdal Consta which is effective and tolerated well but there are significant compliance issues with the fortnightly dose i.e. regularly being late for injections and frequency of injections insufficient for effective treatment. AND
    4) Can only be initiated for patients who have a documented therapeutic response and tolerated therapeutic doses of risperidone. AND
    5) Follow the approval process for initiation (form to be completed acknowledging the above details).

 

 

Quetiapine (Amber 2)

  • Tablets immediate release (IR) 25mg, 100mg, 150mg, 200mg, 300mg
  • Tablets Modified Release (MR or XL) 50mg, 150mg, 200mg, 300mg, 400mg (restricted use)

Notes:

  • Quetiapine IR is the preferred option.
  • Exceptions include acutely unwell patients in whom the simplified titration and rapid dose escalation of the XL formulation (to achieve a therapeutic dose) can be used for the first three days after which the IR preparation should be used.
  • The XL formulation may be preferred if intolerable side effects develop with the IR formulation, e.g. sedation and hypotension.

 

 

Risperidone (Amber 3)

  • Tablets 500 micrograms, 1mg, 2mg, 3mg, 4mg
  • Orodispersible tablet (Quicklets®) 500 micrograms, 1mg, 2mg (restricted)
  • Liquid 1mg/1mL 
  • Risperdal Consta® Injection, Powder for reconstitution 25mg, 37.5mg, 50mg vials

Notes:

  • Only use orodispersible tablets if the patient has swallowing difficulties, to prevent “cheeking” or for patients with compliance issues.

 

 

General notes on depot injections:

  1. Anyone prescribing or administering depots must refer to the current edition of the MKCHS Depot Antipsychotic Policy.
  2. Depot antipsychotics - Comparative information and prescribing advice (Ref: The Maudsley NHS Trust Prescribing Guidelines 10th edition 2009)
  3. It is important to establish whether the patient has an allergy to sesame oil (nut allergy) or coconut oil before selecting appropriate treatment

  

 

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

Return to Chapter: 4. Nervous System

Last updated by: Sheila Wood on 03-07-2019 13:12