l PRESCRIBING AND DISPENSING INFORMATION Limited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
Medicines for Children leaflet: Imipramine for various conditions
www.medicinesforchildren.org.uk/imipramine-variousconditions
Driving and skilled tasks Drowsiness may affect the
performance of skilled tasks (e.g. driving).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Imipramine hydrochloride (Non-proprietary)
Imipramine hydrochloride 5 mg per 1 ml Imipramine 25mg/5ml
oral solution sugar free sugar-free | 150 ml P £45.00 DT = £45.00
CAUTIONARY AND ADVISORY LABELS 2
▶ Imipramine hydrochloride (Non-proprietary)
Imipramine hydrochloride 10 mg Imipramine 10mg tablets | 28 tablet P £0.81 DT = £0.80
Imipramine hydrochloride 25 mg Imipramine 25mg tablets |
▶ Adult: 140–210 mg daily in divided doses
▶ Elderly: May respond to lower doses
CAUTIONS, FURTHER INFORMATION Treatment should be
stopped if the patient enters a manic phase.
Elderly patients are particularly susceptible to many of
the side-effects of tricyclic antidepressants; low initial
doses should be used, with close monitoring, particularly
for psychiatric and cardiac side-effects.
l INTERACTIONS → Appendix 1: tricyclic antidepressants
effective dose (every 2–3 days). Consider using a lower
starting dose in elderly patients.
Overdose Tricyclic and related antidepressants cause dry
mouth, coma of varying degree, hypotension,
hypothermia, hyperreflexia, extensor plantar responses,
convulsions, respiratory failure, cardiac conduction
defects, and arrhythmias. Dilated pupils and urinary
retention also occur. Lofepramine is associated with the
lowest risk of fatality in overdosage, in comparison with
other tricyclic antidepressant drugs. For details on the
management of poisoning see Tricyclic and related
antidepressants under Emergency treatment of poisoning
l PREGNANCY Neonatal withdrawal symptoms and
respiratory depression reported if used during third
l BREAST FEEDING The amount secreted into breast milk is
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild to moderate impairment; avoid in severe impairment.
l RENAL IMPAIRMENT Avoid in severe impairment.
l TREATMENT CESSATION Withdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge (6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
l PRESCRIBING AND DISPENSING INFORMATION Limited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
Driving and skilled tasks Drowsiness may affect the
performance of skilled tasks (e.g. driving). Effects of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Lofepramine (Non-proprietary)
Lofepramine (as Lofepramine hydrochloride) 14 mg per
1 ml Lofepramine 70mg/5ml oral suspension sugar free sugar-free | 150 ml P £30.00 DT = £30.00
CAUTIONARY AND ADVISORY LABELS 2
▶ Lofepramine (Non-proprietary)
Lofepramine (as Lofepramine hydrochloride) 70 mg Lofepramine
70mg tablets | 56 tablet P £59.97 DT = £17.21
▶ Adult: To be initiated at a low dose, then increased if
necessary to 75–100 mg daily in divided doses,
alternatively increased if necessary to 75–100 mg once
▶ Elderly: To be initiated at a low dose, then increased if
necessary to 30–50 mg daily in divided doses
▶ Adult: Initially 10 mg once daily, to be taken at night,
increased if necessary to 75 mg daily, dose to be
increased gradually; higher doses to be given under
l UNLICENSED USE Not licensed for use in neuropathic pain.
l CONTRA-INDICATIONS Arrhythmias . during the manic
phase of bipolar disorder. heart block . immediate recovery
period after myocardial infarction
CAUTIONS, FURTHER INFORMATION Treatment should be
stopped if the patient enters a manic phase.
Elderly patients are particularly susceptible to many of
the side-effects of tricyclic antidepressants; low initial
doses should be used, with close monitoring, particularly
for psychiatric and cardiac side-effects.
l INTERACTIONS → Appendix 1: tricyclic antidepressants
effective dose (every 2–3 days). Consider using a lower
starting dose in elderly patients.
Overdose Tricyclic and related antidepressants cause dry
mouth, coma of varying degree, hypotension,
hypothermia, hyperreflexia, extensor plantar responses,
convulsions, respiratory failure, cardiac conduction
defects, and arrhythmias. Dilated pupils and urinary
retention also occur. For details on the management of
poisoning see Tricyclic and related antidepressants under
Emergency treatment of poisoning p. 1359.
l PREGNANCY Use only if potential benefit outweighs risk.
l BREAST FEEDING The amount secreted into breast milk is
l HEPATIC IMPAIRMENT Manufacture advises avoid in severe
▶ Manufacturer advises plasma-nortriptyline concentration
monitoring if dose above 100 mg daily, but evidence of
l TREATMENT CESSATION Withdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge (6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
l PRESCRIBING AND DISPENSING INFORMATION Limited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
l PATIENT AND CARER ADVICE Drowsiness may affect the
performance of skilled tasks (e.g. driving). Effects of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Nortriptyline (Non-proprietary)
Nortriptyline (as Nortriptyline hydrochloride) 10 mg Nortriptyline
10mg tablets | 30 tablet P £6.87–£11.79 | 100 tablet P £68.41 DT = £4.29
Nortriptyline (as Nortriptyline hydrochloride) 25 mg Nortriptyline
25mg tablets | 30 tablet P £6.81–£12.43 | 100 tablet P £41.44 DT = £8.77
Nortriptyline (as Nortriptyline hydrochloride) 50 mg Nortriptyline
50mg tablets | 30 tablet P £24.86 DT = £24.86
Depressive illness (particularly where sedation required)
▶ Adult: Initially 50–75 mg daily in divided doses,
alternatively initially 50–75 mg once daily, dose to be
taken at bedtime, increased if necessary to 150–300 mg
▶ Elderly: Initially 10–25 mg 3 times a day, maintenance
378 Mental health disorders BNF 78
heart block . immediate recovery period after myocardial
CAUTIONS, FURTHER INFORMATION Treatment should be
stopped if the patient enters a manic phase.
Elderly patients are particularly susceptible to many of
the side-effects of tricyclic antidepressants; low initial
doses should be used, with close monitoring, particularly
for psychiatric and cardiac side-effects.
l INTERACTIONS → Appendix 1: tricyclic antidepressants
effective dose (every 2–3 days). Consider using a lower
starting dose in elderly patients.
Overdose Tricyclic and related antidepressants cause dry
mouth, coma of varying degree, hypotension,
hypothermia, hyperreflexia, extensor plantar responses,
convulsions, respiratory failure, cardiac conduction
defects, and arrhythmias. Dilated pupils and urinary
retention also occur. For details on the management of
poisoning see Tricyclic and related antidepressants under
Emergency treatment of poisoning p. 1359.
l PREGNANCY Use only if potential benefit outweighs risk.
l BREAST FEEDING The amount secreted into breast milk is
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
l TREATMENT CESSATION Withdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge (6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
l PRESCRIBING AND DISPENSING INFORMATION Limited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
Driving and skilled tasks Drowsiness may affect the
performance of skilled tasks (e.g. driving). Effects of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Trimipramine (Non-proprietary)
Trimipramine (as Trimipramine maleate) 10 mg Trimipramine
10mg tablets | 28 tablet P £197.18 DT = £179.15
Trimipramine (as Trimipramine maleate) 25 mg Trimipramine
25mg tablets | 28 tablet P £205.44 DT = £200.50
CAUTIONARY AND ADVISORY LABELS 2
▶ Trimipramine (Non-proprietary)
Trimipramine (as Trimipramine maleate) 50 mg Trimipramine
50mg capsules | 28 capsule P £217.50 DT = £217.08
l DRUG ACTION Tryptophan is an essential dietary amino
acid, and is a precursor of serotonin; it re-establishes the
inhibitory action of serotonin on the amygdaloid nuclei,
thereby reducing feelings of anxiety and depression.
Treatment-resistant depression (used alone or as adjunct
to other antidepressant drugs) (initiated under direction
▶ Adult: 1 g 3 times a day; maximum 6 g per day
l CONTRA-INDICATIONS History of eosinophilia myalgia
syndrome following use of tryptophan
l INTERACTIONS → Appendix 1: tryptophan
SIDE-EFFECTS, FURTHER INFORMATION If patients
experience any symptoms of eosinophilia myalgia
syndrome (EMS), manufacturer advises to withhold
treatment until possibility of EMS is excluded.
l PREGNANCY Manufacturer advises caution—no
l BREAST FEEDING Manufacturer advises avoid—no
l MONITORING REQUIREMENTS Manufacturer advises close
monitoring for signs of suicidal thoughts, particularly in
patients at high risk and during early treatment and dose
l PATIENT AND CARER ADVICE Manufacturer advises
patients and carers should be advised to seek medical
advice immediately if any clinical worsening, suicidal
thoughts, or unusual behaviour develops.
Driving and skilled tasks Manufacturer advises patients
should be counselled on the effects on driving and
performance of skilled tasks—increased risk of drowsiness.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule
▶ Optimax (Intrapharm Laboratories Ltd)
Tryptophan 500 mg Optimax 500mg capsules | 84 capsule P £42.00
l DRUG ACTION Vortioxetine inhibits the re-uptake of
serotonin (5-HT) and is an antagonist at 5-HT3 and an
agonist at 5-HT1A receptors. This multimodal activity
appears to be associated with antidepressant and
▶ Adult: Initially 10 mg once daily; adjusted according to
response to 5–20 mg once daily
▶ Elderly: Initially 5 mg once daily; increased if necessary
l CAUTIONS Bleeding disorders . cirrhosis of the liver (risk of
hyponatraemia). elderly (risk of hyponatraemia) . history
of mania (discontinue if patient entering manic phase). history of seizures . unstable epilepsy
▶ Seizures Discontinue treatment in patients who develop
seizures or if there is an increase in seizure frequency.
▶ Elderly Manufacturer advises caution when treating elderly
patients with doses over 10 mg daily—limited information.
l INTERACTIONS → Appendix 1: vortioxetine
▶ Uncommon Flushing . night sweats
▶ Frequency not known Hyponatraemia . neuroleptic
malignant syndrome (discontinue—potentially fatal). serotonin syndrome
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—toxicity in animal studies. If used
during the later stages of pregnancy, there is a risk of
neonatal withdrawal symptoms and persistent pulmonary
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (no information available).
l RENAL IMPAIRMENT Manufacturer advises caution in
severe impairment—limited information available.
l TREATMENT CESSATION Manufacturer advises treatment
can be stopped abruptly, without need for gradual dose
Driving and skilled tasks Manufacturer advises patients and
carers should be counselled on the effects on driving and
performance of skilled tasks, especially when starting
treatment or changing the dose.
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Vortioxetine for treating major depressive episodes
Vortioxetine (Brintellix ®) is recommended as an option for
treating major depressive episodes in adults whose
condition has responded inadequately to 2
antidepressants within the current episode.
Patients currently receiving vortioxetine whose disease
does not meet the above criteria should be able to
continue treatment until they and their NHS clinician
consider it appropriate to stop.
www.nice.org.uk/guidance/ta367
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Vortioxetine (as Vortioxetine hydrobromide) 5 mg Brintellix 5mg
tablets | 28 tablet P £27.72 DT = £27.72
Vortioxetine (as Vortioxetine hydrobromide) 10 mg Brintellix
10mg tablets | 28 tablet P £27.72 DT = £27.72
Vortioxetine (as Vortioxetine hydrobromide) 20 mg Brintellix
20mg tablets | 28 tablet P £27.72 DT = £27.72
ANTIPSYCHOTICS › FIRST-GENERATION
Control of deviant antisocial sexual behaviour
▶ Adult: 0.25–1.5 mg daily in divided doses, adjusted
according to response, for debilitated patients, use
▶ Elderly: Initially 0.125–0.75 mg daily in divided doses,
adjusted according to response
l CONTRA-INDICATIONS CNS depression . comatose states . phaeochromocytoma
l CAUTIONS Risk factors for stroke
l INTERACTIONS → Appendix 1: benperidol
l SIDE-EFFECTS Appetite decreased . blood disorder. cardiac
l PREGNANCY Extrapyramidal effects and withdrawal
syndrome have been reported occasionally in the neonate
when antipsychotic drugs are taken during the third
trimester of pregnancy. Following maternal use of
antipsychotic drugs in the third trimester, neonates should
be monitored for symptoms including agitation,
hypertonia, hypotonia, tremor, drowsiness, feeding
problems, and respiratory distress.
l BREAST FEEDING There is limited information available on
the short- and long-term effects of antipsychotic drugs on
the breast-fed infant. Animal studies indicate possible
adverse effects of antipsychotic medicines on the
developing nervous system. Chronic treatment with
antipsychotic drugs whilst breast-feeding should be
avoided unless absolutely necessary.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments Start with small doses in severe renal
impairment because of increased cerebral sensitivity.
l MONITORING REQUIREMENTS Manufacturer advises
regular blood counts and liver function tests during longterm treatment.
l PRESCRIBING AND DISPENSING INFORMATION The
proprietary name Benquil ® has been used for benperidol
380 Mental health disorders BNF 78
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension
CAUTIONARY AND ADVISORY LABELS 2
Benperidol 250 microgram Anquil 250microgram tablets |
112 tablet P £117.31 DT = £117.31
3.6 Psychoses and schizophrenia
Psychoses and related disorders
Advice of Royal College of Psychiatrists on doses of
antipsychotic drugs above BNF upper limit
Unless otherwise stated, doses in the BNF are licensed
doses—any higher dose is therefore unlicensed
. Consider alternative approaches including adjuvant
therapy and newer or second-generation antipsychotic
. Bear in mind risk factors, including obesity; particular
caution is indicated in older patients, especially those over
. Consider potential for drug interactions—see interactions:
. Carry out ECG to exclude untoward abnormalities such as
prolonged QT interval; repeat ECG periodically and reduce
dose if prolonged QT interval or other adverse cardiac
. Increase dose slowly and not more often than once weekly.
. Carry out regular pulse, blood pressure, and temperature
checks; ensure that patient maintains adequate fluid
. Consider high-dose therapy to be for limited period and
review regularly; abandon if no improvement after
3 months (return to standard dosage).
Important: When prescribing an antipsychotic for
administration on an emergency basis, the intramuscular
dose should be lower than the corresponding oral dose
(owing to absence of first-pass effect), particularly if the
patient is very active (increased blood flow to muscle
considerably increases the rate of absorption). The
prescription should specify the dose for each route and
should not imply that the same dose can be given by mouth
or by intramuscular injection. The dose of antipsychotic for
emergency use should be reviewed at least daily.
Antipsychotic drugs are also known as ‘neuroleptics’ and
(misleadingly) as ‘major tranquillisers’.
In the short term they are used to calm disturbed patients
whatever the underlying psychopathology, which may be
schizophrenia, brain damage, mania, toxic delirium, or
agitated depression. Antipsychotic drugs are used to
alleviate severe anxiety but this too should be a short-term
The aim of treatment is to alleviate the suffering of the
patient (and carer) and to improve social and cognitive
functioning. Many patients require life-long treatment with
antipsychotic medication. Antipsychotic drugs relieve
positive psychotic symptoms such as thought disorder,
hallucinations, and delusions, and prevent relapse; they are
usually less effective on negative symptoms such as apathy
and social withdrawal. In many patients, negative symptoms
persist between episodes of treated positive symptoms, but
earlier treatment of psychotic illness may protect against the
development of negative symptoms over time. Patients with
acute schizophrenia generally respond better than those
Long-term treatment of a patient with a definitive
diagnosis of schizophrenia is usually required after the first
episode of illness in order to prevent relapses. Doses that are
effective in acute episodes should generally be continued as
First-generation antipsychotic drugs
The first-generation antipsychotic drugs act predominantly
the four dopamine pathways in the brain and so can cause a
range of side-effects, particularly extrapyramidal symptoms
and elevated prolactin. The phenothiazine derivatives can
be divided into 3 main groups:
. Group 1: chlorpromazine hydrochloride p. 384,
levomepromazine p. 441, and promazine hydrochloride
p. 406, generally characterised by pronounced sedative
effects and moderate antimuscarinic and extrapyramidal
. Group 2: pericyazine p. 388, generally characterised by
moderate sedative effects, but fewer extrapyramidal sideeffects than groups 1 or 3.
. Group 3: fluphenazine decanoate p. 392, perphenazine,
prochlorperazine p. 389, and trifluoperazine p. 390,
generally characterised by fewer sedative and
antimuscarinic effects, but more pronounced
extrapyramidal side-effects than groups 1 and 2.
Butyrophenones (benperidol p. 380 and haloperidol
p. 386) resemble the group 3 phenothiazines in their clinical
properties. Thioxanthenes (flupentixol p. 385 and
zuclopenthixol p. 391) have moderate sedative,
antimuscarinic effects, and extrapyramidal effects.
Diphenylbutylpiperidines (pimozide p. 388) and the
substituted benzamides (sulpiride p. 390) have reduced
sedative, antimuscarinic, and extrapyramidal effects.
Second-generation antipsychotic drugs
The second-generation antipsychotic drugs (sometimes
referred to as atypical antipsychotic drugs) act on a range of
receptors in comparison to first-generation antipsychotic
drugs and have more distinct clinical profiles, particularly
The balance of risks and benefit should be considered before
prescribing antipsychotic drugs for elderly patients. In
elderly patients with dementia, antipsychotic drugs are
associated with a small increased risk of mortality and an
increased risk of stroke or transient ischaemic attack (see
Dementia p. 300). Furthermore, elderly patients are
particularly susceptible to postural hypotension and to
hyper- and hypothermia in hot or cold weather.
. Antipsychotic drugs should not be used in elderly patients
to treat mild to moderate psychotic symptoms.
. Initial doses of antipsychotic drugs in elderly patients
should be reduced (to half the adult dose or less), taking
into account factors such as the patient’s weight, comorbidity, and concomitant medication.
. Treatment should be reviewed regularly.
Prescribing of antipsychotic drugs in patients with learning
g When prescribing for patients with learning disabilities
who are prescribed antipsychotic drugs and who are not
experiencing psychotic symptoms, the following
considerations should be taken into account:
. a reduction in dose or the discontinuation of long-term
. review of the patient’s condition after dose reduction or
discontinuation of an antipsychotic drug;
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