Schizophrenia - atypical antipsychotics

Summary

NICE has made the following recommendations:

Doctors should discuss with the individual which antipsychotic drug to take. The decision about which drugs are prescribed should be made jointly, after the doctor has explained the benefits and side effects of the drugs. The individual’s advocate or carer should be consulted if appropriate.

For a person who has been newly diagnosed with schizophrenia, doctors should consider prescribing one of the following atypical (newer) oral antipsychotic drugs: amisulpride, olanzapine, quetiapine, risperidone or zotepine.

For people who are currently taking typical (older) antipsychotic drugs that are controlling their symptoms of schizophrenia but are causing side effects that and the individual and doctor agree are unacceptable, the doctor should consider prescribing an oral atypical antipsychotic (amisulpride, olanzapine, quetiapine, risperidone, sertindole or zotepine).

NICE does not recommend that people with schizophrenia should change to one of the atypical (newer) antipsychotic drugs if they are currently taking typical (older) antipsychotics that are controlling the symptoms of schizophrenia and are not causing unacceptable side effects.

If there is evidence that someone has what is known as treatment-resistant schizophrenia or TRS (where the drugs they are taking are not controlling the symptoms of schizophrenia), then the doctor should prescribe clozapine.

It is important to take antipsychotic drugs regularly at the doses that have been prescribed. Some people with schizophrenia have problems keeping to a regular dosing regimen and may be prescribed a depot preparation - that is an injection of an antipsychotic in a form that allows it be released slowly into the body over a few weeks. Doctors and other professionals responsible for the person’s care should assess and discuss with the person whether a depot preparation would be appropriate.

If more than one of the atypical antipsychotic drugs is suitable, doctors should prescribe the least expensive drug.

If it is not possible for the person with schizophrenia to have a full discussion with their doctor about which drug should be prescribed, for example because they are having a relapse or acute schizophrenic episode, then the doctor may prescribe an atypical antipsychotic because of the lower risk of side effects. In these circumstances, the doctor should discuss the drug treatment with a carer or advocate if possible and appropriate.

It is recommended that "advanced directives" are developed and kept in the person’s care programme. Advanced directives are instructions written by the person with schizophrenia and the healthcare team, that describe what the person would like to happen if they are not able to be involved in a discussion with their doctor at a time when they require treatment (for example, during a relapse of acute schizophrenic episode).

Treatment with antipsychotic drugs should be part of an overall package of care that addresses the person’s medical, emotional and social needs. The doctor and key worker should monitor progress, how well the drugs are working, and any side effects on an ongoing basis. This is particularly important for people who have just changed from one antipsychotic to another.

Atypical and typical antipsychotic drugs should not be prescribed at the same time except for short periods if patients are changing drugs.

Documents

For healthcare professionals

• TA43 Schizophrenia - atypical antipsychotics: Summary
• TA43 Schizophrenia - atypical antipsychotics: Guidance (HTML version)
• TA43 Schizophrenia - atypical antipsychotics: Guidance

For patients, carers and the public

• TA43 Schizophrenia - atypical antipsychotics: Information for patients (Welsh version)
• TA43 Schizophrenia - atypical antipsychotics: Information for the public

Background information

• Review decision
• Review proposal
• Assessment Report on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia
• 2002/030 NICE recommends newer antipsychotic drugs as one of the first line options for schizophrenia

Implementing this guidance

Any further information NICE has produced to help the NHS implement this guideline locally is linked to below:

• None found