To know more about mental health conditions and their treatment, and to obtain printable patient information leaflets go to: www.choiceandmedication.org/nhs24/
3.1 Anxiety
Acute anxiety state
- Diazepam tablets 2mg ✓ First Choice - short term treatment only of acute crises (ensure appropriate review)
Treatment of anxiety and related disorders
- First line – Individualised self help (CBT based) / Psychoeducation
- Second line – High intensity psychological intervention / CBT etc
For adults whose anxiety disorder symptoms only partially respond to psychological interventions consider adding medication:
Benzodiazepines are associated with poorer outcomes in the long term and should not be prescribed for the treatment of anxiety except as a short-term measure during crises.
Pharmacological treatment of anxiety
(Note: different antidepressants have differing product licenses for the anxiety disorders, see product literature for details)
Prescribing notes:
Take into account (and discuss with the individual) the following factors:
• tendency to produce a withdrawal syndrome (especially Paroxetine and Venlafaxine)
• side-effect profile and the potential for drug interactions
• risk of suicide (especially in under 30 year olds) and likelihood of toxicity in overdose particularly during dose titration
• the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping
• Person’s prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, experience of withdrawal syndrome and the person's preference).
• Increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointestinal mucosa or interfere with clotting (for example, NSAIDS or aspirin). Consider prescribing a gastroprotective drug in these circumstances.
Second line pharmacological treatment of anxiety
- Pregabalin: Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence. Discontinue, gradually, if ineffective at 3 months. Propranolol is not recommended by NICE guidance for management of anxiety.
- Propranolol can only help symptoms of anxiety such as palpitations and sweating, it does not mitigate the anxiety itself and has significant potential for sleep disorders and depression. If used it should be used only as needed for these symptoms and reviewed for effectiveness and adverse effects, with consideration of discontinuation once a treatment for the underlying condition is in place. Evidence does not support its use in panic disorder. Avoid use in those with Asthma, and COPD using beta-agonists.
Specialist advice only:
- Antipsychotics
- Sedating antihistamines
- Imipramine / Clomipramine for OCD / BDD
- MAOIs e.g. Phenelzine / Moclobemide
- Lisdexamfetamine in binge eating disorder
Drug treatment of PTSD for adults (Specialist advice only)
Consider antipsychotics such as Risperidone ✓ Specialist Initiation Only, in addition to psychological therapies to manage symptoms for adults with a diagnosis of PTSD if:
- they have disabling symptoms and behaviours, for example severe hyperarousal or psychotic symptoms and
- their symptoms have not responded to other drug or psychological treatments.
Nightmares in PTSD can respond to Prazosin ✓ Specialist Initiation Only or Doxazosin ✓ Specialist Initiation Only given at bedtime.
References
Generalised anxiety disorder and panic disorder: www.nice.org.uk/guidance/cg113
Social Anxiety disorder: www.nice.org.uk/guidance/cg159
Obsessional-compulsive disorder and body dysmorphic disorder: www.nice.org.uk/guidance/cg31
Post-traumatic stress disorder: www.nice.org.uk/guidance/ng116
Eating disorders: www.nice.org.uk/guidance/ng69
3.2 Attention Deficit Hyperactivity Disorder (ADHD) - Specialist initiation only
Medication choice – children aged 5 years and over and young people
(Note: use of medicines for treating ADHD is off-label in children aged < 5).
- Methylphenidate short or long acting. Prescribe methylphenidate XL as recommended by specialist team. Supplies of particular brands of methylphenidate XL may be unpredictable, where possible please maintain patient on a bioequivalent brand if usual brand is not available.
- Lisdexamfetamine if methylphenidate insufficiently effective
- Dexamfetamine if symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.
- Atomoxetine or Guanfacine if:
- they cannot tolerate methylphenidate or lisdexamfetamine or
- their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses
- Consider tertiary referral
Medication choice – adults
(Note: product licenses vary for adults between preparations and if pre-existing or new diagnosis)
- Lisdexamfetamine, or methylphenidate short or long acting (or combination). Prescribe methylphenidate XL as recommended by specialist team. Supplies of particular brands of methylphenidate XL may be unpredictable, where possible please maintain patient on a bioequivalent brand if usual brand is not available.
- Switch to alternative from above if 6-week trial produces insufficient symptom control.
- Atomoxetine if:
- they cannot tolerate lisdexamfetamine or methylphenidate or
- symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.
ONLY on advice of tertiary specialist ADHD service:
- guanfacine for adults
- clonidine for children with ADHD and sleep disturbance, rages or tics
- atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages or irritability
Medication choice – people with coexisting conditions
Offer the same medication choices to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people without ADHD.
For person with ADHD experiencing an acute psychotic or manic episode:
- stop any medication for ADHD
- Consider restarting or starting new ADHD medication after the episode has resolved, considering the individual circumstances, risks and benefits of the ADHD medication.
Be cautious about prescribing stimulants for ADHD if there is a risk of diversion for cognitive enhancement, appetite suppression or a risk of stimulant misuse or diversion.
After titration and dose stabilisation, prescribing and monitoring of ADHD medication can be carried out within primary care.
When methylphenidate medication is not available due to ongoing supply issues please maintain patients on a similar formulation to avoid destabilisation.
3.3 Bipolar disorder and mania
Sodium valproate should never be started in any woman or girl unless alternative treatments are not suitable. If it is prescribed a Pregnancy Prevent Programme must be in place. Follow latest advice for contraceptive use for men prescribed sodium valproate to avoid exposure pre and post conception.
NICE CG185: Bipolar disorder: assessment and management
*MHRA Drug Safety Update April 2018 Valproate medicines (Epilim▼, Depakote▼): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met
MHRA Drug Safety update: Valproate medicines (Epilim, Depakote): Pregnancy Prevention Programme materials online
https://www.gov.uk/government/news/mhra-advises-men-taking-valproate-and-their-partners-to-use-effective-contraception
Pharmacological interventions for mania/hypomania
Seek specialist service advice, (Acute Mania would generally be managed in hospital, hypomania may be managed at home with support).
- If taking an antidepressant consider stopping this
- Offer an antipsychotic (haloperidol, olanzapine, quetiapine or risperidone) if not already taking one. If already taking one consider if the dose should be increased or the medication switched.
- If poorly tolerated switch to an alternative antipsychotic within the list above.
- Consider adding lithium (prescribe by brand) if appropriate, optimise treatment using lithium blood level monitoring.
- Consider adding sodium valproate (and not woman of CBP)
Insomnia is both a symptoms and trigger for mania, consider if a hypnotic is indicated.
Lamotrigine is not helpful in managing mania
Pharmacological treatment of bipolar depression
(with specialist advice) consider:
- Fluoxetine +/- (olanzapine or quetiapine)
- Olanzapine monotherapy
- Lamotrigine monotherapy
- If already taking lithium, optimise treatment using lithium blood level monitoring.
If not already taking lithium and still unwell, consider adding lithium and optimising treatment using lithium blood levels.
If already taking sodium valproate* (and not a woman of CBP) consider increasing the dose within the therapeutic range
Pharmacological prophylaxis of relapse in Bipolar disorder
(with specialist advice): Consider, with the individual, the medication that has been helpful during episodes of mania or bipolar depression and if to continue this longer term.
If not already taking offer lithium as a first-line, long-term pharmacological treatment for bipolar disorder and:
- if lithium is ineffective, consider adding valproate* (if not woman of CBP)
- If lithium is poorly tolerated, or is not suitable (for example, because the person does not agree to routine blood monitoring), consider valproate* (if not woman of CBP) or olanzapine, or quetiapine.
Consider the long term adverse effects of the medication and plan for physical health monitoring appropriate to the medication, including blood level monitoring for lithium.
3.4 Depression
Mild to moderate depression
Pharmacological treatment of moderate to severe depression
First line:
Second line:
- Alternative SSRI
- Duloxetine
- Mirtazapine
- Venlafaxine standard release tablets, (XL preparations are less cost-effective and should only be considered where standard release is not suitable).
Recurrence of depression:
- previously successful anti-depressant
Antidepressants for treatment of anxiety disorders see 3.1
Formulary note: Fluvoxamine is NOT recommended for use in NHS D&G
3.6 Psychoses and schizophrenia
NICE Psychosis and schizophrenia in adults: prevention and management: [CG178] Published Feb 2014 Last update March 2014 https://www.nice.org.uk/guidance/cg178
Treatment of psychosis (specialist initiation only)
- An antipsychotic appropriate to the patient’s needs and characteristics
MHRA Drug safety update - Clozapine and other antipsychotics: monitoring blood concentrations for toxicity –
Antipsychotics and dementia (on specialist advice only)
Before prescribing consider Stress and Distress and contacting the IDEAS team unless prescribing on specific advice of specialist services. Review regularly to consider dose reduction/discontinuation
- Risperidone - only licensed for a maximum of 6 weeks use in the management of Behavioural and Psychological Symptoms of Dementia (BPSD)
- Antipsychotic depot injections (specialist initiation only)
Formulary note: Where quetiapine is used it should be prescribed as standard release tablets
DGRefHelp - NHS Dumfries & Galloway
