231. Guidelines In Psychiatry

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231. Guidelines In Psychiatry

231. Guidelines In Psychiatry



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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
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
Clozapine – dosing regimen 147
Optimising clozapine treatment 149
Alternatives to clozapine 153
Re‐starting clozapine after a break in treatment 159
Initiation of clozapine for community‐based patients 160
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
SSRIs 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 (CYP) 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



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