What are the main medicines for psychosis?

If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.  

Main medicines

Phenothiazines

• Chlorpromazine

• Fluphenazine (see also depot and long-acting injections)

• Levomepromazine (used to be known as methotrimeprazine)

• Pericyazine

• Perphenazine

• Pipothiazine (see depot and long-acting injections)

• Prochlorperazine

• Promazine

• Thioridazine (discontinued in UK and many other countries)

• Trifluoperazine

Butyrophenones

• Benperidol

• Haloperidol (see also depot and long-acting injections)

Thioxanthenes

• Flupentixol (see also depot and long-acting injections)

• Zuclopenthixol (see also depot and long-acting injections)

Diphenylbutylpiperidines

• Fluspirilene (see depot and long-acting injections, only available as an import in the UK)

• Pimozide (restricted use due to side effects)

Benzamides, substituted

• Amisulpride

• Sulpiride

Newer, atypical or second generation antipsychotics

• Aripiprazole

• Clozapine (schizophrenia only)

• Olanzapine

• Paliperidone 

• Quetiapine

• Risperidone  (see also depot and long-acting injections)

• Sertindole (available in Australia)

• Zotepine (discontinued in many countries, including UK, in 2010)

• Asenapine (Sycrest® or Saphris®) - is licensed in USA for psychosis or schizophrenia, but isn't yet in UK

Depot and long-acting injections

Several of the above medications are available as depot and long-acing injections - these are listed below:

• Flupentixol decanoate (Depixol®)

• Fluphenazine decanoate (Modecate®)

• Fluspirilene (Redeptin®, only available if imported into UK)

• Haloperidol decanoate (Haldol Decanoate®)

• Olanzapine pamoate (Zypadhera®)

• Paliperidone palmitate (Xeplion®)

• Pipotiazine palmitate (Piportil®)

• Zuclopenthixol acetate (Clopixol-Acuphase®)

• Zuclopenthixol decanoate (Clopixol®)

• Risperidone  (Risperdal Consta®)

Quite a choice eh?

It is generally considered that the newer atypical or second-generation antipsychotics (SGA) are overall better than the older ones. However, two large independent studies (no drug companies involved!) published in 2005 and 2006 called CATIE and CUtLASS have shown that the antipsychotics seem to be as effective as each other but with DIFFERENT side effects rather than some of them having LESS (or fewer) side effects. So, the choice should be based on how you do on a medicine and what side effects are important to you.

Clozapine is really the only antipsychotic that has been shown to be better than the others. However, it has lots of side effects (and one rare but potentially nasty one that means people taking it have to have regular blood tests) so isn’t used unless at least two other antipsychotics have been tried and haven't worked.

Sometimes the symptoms of psychosis can become very severe. This can result in the person becoming very distressed and/or too difficult to cope with and might need to be admitted to hospital. This might then become what is called an "acute psychiatric emergency" or crisis. The treatments for this may need to include some other medicines just to calm the person down and prevent harm to that person, or others. If this happens, follow the link to some information that might help explain what might be going on.

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