What are the main medicines for a psychiatric emergency?
In a crisis there may be many reasons why a medicine or group of medicines are chosen. These might include:
- side effects (which ones are important to you)
- local policies or agreements (such as what that GP surgery uses, in your county, country etc)
- national policies (e.g. NICE, SIGN – see last question)
- familiarity (it may be better to get best out of a medicine you are familiar with)
- relative costs for similar medicines
- personal preference
- how bad the symptoms are
- any medicine the person might have done well with in the past (as it’s more likely to work again)
The choice of medication for a psychiatric emergency will be based on:
- Local guidelines
- How long the symptoms have been going on
- Diagnosis, although this is not easy on the first occasion. If a similar crisis has happened before, and a diagnosis made, that may help choice of medicines
- Any medicines the person might have had before e.g. if the person has never had antipsychotics before, lower doses should be used
- How bad the symptoms are e.g. how much danger there is to the person or others
- How reliable the medicines are at having the needed effect
The main medicine choices in UK are listed below (each link should open in a new window). They are divided in “Main medicines” and “Others”:
For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms. They are listed in the British National Formulary (www.bnf.org/bnf/). To be listed in the BNF there needs to be good evidence that the medicine works and that the producers have been given 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. Many of these might be need to be given by injection if the person refuses tablets or syrup.
Main medicinesBNF Listed
Antipsychotics – best to help symptoms such as psychosis, hallucinations and feeling paranoid:
Haloperidol – this can be used for most causes of a crisis. It can be given as tablets, syrup or an injection into the muscles. Usually given with benzodiazepines (see below). It also sometimes needs an anticholinergic such as procyclidine to reduce some side effects. The usual top or maximum dose by mouth is 30mg a day, or 18mg a day by injection. There is usually very little to be gained by having doses higher than this.
Aripiprazole - can be used for schizophrenia or mania. It can be given as tablets, melt-in-the-mouth tablets, syrup or an injection. The usual top or maximum dose is 30mg a day.
Quetiapine - can be used for schizophrenia or mania. It can only be given as tablets. The usual top or maximum dose is around 750mg a day.
Risperidone - can be used for schizophrenia or mania. It can be given as tablets, melt-in-the-mouth tablets or a syrup. The usual top or maximum dose is 6mg a day, although up to 16mg a day can be given.
Zuclopenthixol acetate (Clopixol Acuphase®) – can be used for schizophrenia. It is given as an injection, every 1-2 days. The top or maximum dose is 400mg over two weeks, or up to 3 injections in two weeks.
Trifluoperazine - not often used these days but can be given as tablets or syrup.
Chlorpromazine - not often used these days as it can cause blood pressure to drop quickly but can be given as tablets or syrup.
Benzodiazepines best to help agitation, mania, restlessness:
Antimanics are best used to help if the person is known to have mania (see bipolar mania)
Valproate e.g. Depakote® can be used in higher doses for a crisis. In mania, around 2000mg a day can be given as a starter dose for a few days until symptoms settle.
Carbamazepine - can be used in higher doses for a crisis if due to mania
Combinations– because no single medicine works for everyone, sometimes two are used together. Usually we reckon one medicine is best, but not in this case.
An antipsychotic and a benzodiazepine - it has been shown that an antipsychotic and a benzodiazepine given together are more likely to have a quicker effect. Not only that, but there is then less chance of needed a second injection. The most common pair is haloperidol and lorazepam. Haloperidol 10mg and lorazepam 2mg (sometimes called "ten and two") is often used as it adds an antipsychotic effect to a calming effect without using too high doses of either medicine. Olanzapine and a benzodiazepine should not be given at the same time.
An antipsychotic and promethazine.
Midazolam - this is a very short-acting benzodiazepine. It works very quickly (seconds) but doesn't last long (about 5-10 minutes). It can be given as an injection or mouth spray.
Antihistamines e.g. promethazine. This has a very sedative effect.
Loxapine may become available in 2013 as a spray.
With all these, the doses given in a crisis or psychiatric emergency often need to be higher than usual. So, some of the side effects are different, especially if given by injection. Some of these can include:
Dystonia - when muscles go into a spasm after an antipsychotic injection. It can happen in about 1 in 10 people after an antipsychotic injection.
Heart effects - people given haloperidol by injection should have an ECG (heart monitored) as soon as possible
Disinhibition - with the benzodiazepines some people can lose their inhibitions and become more aggressive, especially if younger or older. This probably doesn’t happen as much as people think it does. It might happen in less than 1 in 100 people.
Akathisia can be caused by some antipsychotics. Akathisia is a restlessness, where the person only feels comfortable when moving around. The trouble is that this can look like agitation and lead to higher doses being given.
Most of these can be helped by an anticholinergic drug such as procyclidine.