These drugs are usually used to help treat illnesses or conditions such as:

• Psychiatric emergency
• Psychosis
• Schizophrenia
• Mania

They can also be used to help manage

• ADHD (Attention Deficit Hyperactivity Disorder)
• Bipolar depression
• Bipolar mood disorder
• Dementia
• Depression
• Insomnia
• OCD (Obsessive Compulsive Disorder)
• Panic disorder
• PTSD (Post-Traumatic Stress Disorder
• Seasonal Affective Disorder
• Social anxiety

They are often known as 'neuroleptics', 'anti-psychotic drugs' or wrongly as 'major tranquillisers'. They may also be used in smaller doses to help treat tension and agitation. Some of them are used to treat dizziness, nausea and vomiting.

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There is a naturally occurring chemical ("neurotransmitter") in the brain called dopamine. Dopamine is the chemical messenger in the brain mainly involved with thinking, emotions, behaviour and perception. In some illnesses, this dopamine may be overactive and upsets the normal balance of chemicals in the brain. This excess dopamine helps to produce some of the symptoms of the illness. The main effect that these drugs have is to block some dopamine receptors in the brain, reducing the effect of having too much dopamine and correcting the imbalance. This reduces the symptoms caused by having too much dopamine.

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Tablets and capsules:
Tablets and capsules should be swallowed with at least half a glass of water whilst sitting or standing. This is to make sure that they reach the stomach and do not stick in your throat.

Liquids:
Your pharmacist should give you a medicine spoon, dropper or oral syringe. Use it carefully to make sure you measure the correct amount. Ask your pharmacist for a medicine spoon if you do not have one. Shake the bottle well before use as the drug can settle to the bottom and cause you to receive a lower dose at the start and too high a dose at the end of the bottle.
"Stelazine" syrup (trifluoperazine) may be diluted in a drink of water or orange juice if necessary.

Suppositories
Chlorpromazine ("Largactil") is available as suppositories. Suppositories are specially shaped to be inserted into the anus (the rectum or "back passage"). After removing a suppository from its wrapping you should insert it as deeply as possible into your anus. You may find it easier to insert if you put one foot on a chair or lie on your side with one leg drawn up as high as possible under the chin. Do not swallow them. If you have any problems using your suppositories ask your pharmacist or doctor for advice.

Injections
It is sometimes necessary or helpful for these drugs to be given as 'depot' injections. A 'depot' injection is a long acting injection usually given into a buttock. The injection releases drug over several weeks and so you will not have to remember to take tablets at regular times each day. Depot injections are otherwise no more or less effective than tablets or capsules. If you are in hospital it will be given to you by a nurse. Outside hospital it may be given to you by a Community Psychiatric Nurse, as a day patient or by your G.P. or community nurse. You may need to have this injection every few weeks for some time. To start with you will be given a 'test dose' to make sure the drug suits you. Then, if there are no problems, 5 to 10 days later you will be given your first full dose injection which will then be repeated every one to four weeks. They are usually given into the buttock although some may be able to be given into the thigh.

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Take your medication as directed on the medicine label. Try to take it at regular times each day. Taking it at mealtimes may make it easier for you to remember as there is no problem about taking any of these drugs with or after food. If the instructions say to take them ONCE a day this is usually best at bedtime as they may make you drowsy at first. They are not sleeping tablets as such.

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Some of the effects of these drugs appear soon after taking them, for example the drowsiness. The most important action, however, to help the symptoms of your illness may take weeks or even months of regular medication to become fully effective. In the same way if your dose or treatment is changed it may take an equally long period of time before you notice the effects of such a change.

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This should be discussed with your doctor as different people respond differently. You will probably, however, need to continue your treatment for a long time, possibly several years after your symptoms have gone to make sure you are fully over your illness. Long term treatment should be reviewed at regular intervals, for example every 3 to 6 months, or even sooner if there are problems.

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Antipsychotics are not addictive as such but if you have taken them for a long time you may get some effects if you stop them suddenly. So-called "cholinergic rebound" can occur with the phenothiazines (such as chlorpromazine, trifluoperazine, pericyazine) if stopped suddenly e.g. feeling sick, tiredness, sweating, anxiety and insomnia. It usually mild and only last a few days. Sometimes muscle stiffness and restlessness can occur. It is best to stop any antipsychotic slowly to let your brain get used to the change. The other main problem could be your symptoms coming back.

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It is unwise to stop taking them suddenly, even if you feel better. Your symptoms can return if treatment is stopped too early. This may occur some weeks or even many months after the drug has been stopped and you may feel well before this happens. You could also experience some mild withdrawal symptoms (as explained above). When the time comes your doctor will usually withdraw the drug by a gradual reduction in the dose taken over a period of several weeks. You should discuss this fully with your doctor.

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Start again as soon as you remember unless it is nearly time for your next dose then take the next dose as normal. Do not try to catch up by taking two or more doses at once as you may get more side-effects. You should tell your doctor about this next time you meet. If you have problems remembering your doses (as very many people do) ask you pharmacist, doctor or nurse about this. There are some special packs, boxes and devices which can be used to help you remember.

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Use the information in the table below to find out about side effects associated with specific medication used to treat psychosis.

Table adapted from UK Psychiatric Pharmacy Group leaflets, with kind permission www.ukppg.org.uk

Do not be worried by this list of side effects. You may get none at all. There are other rare side-effects. If you develop any unusual symptoms ask your doctor about them next time you meet.

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These drugs may make you feel drowsy or sleepy. You should not drive (see below) or operate machinery until you know how they affect you. You should be careful as they may affect your reaction times or reflexes. They are not, however, sleeping tablets, although if you take them at night they may help you get to sleep.

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Weight gain with the phenothiazines is quite possible. Of the people who gain weight, most is gained during the first 6 to 12 months of treatment. It then tends to level out. It is thought that these drugs cause an increase in appetite which causes you to eat more and therefore put on weight. It is not possible to say what the effect on your own weight may be because each person will be affected differently. All the phenothiazines seem to have the same soft of effect, but some other the other drugs seem to have less effect. If you do start to put on weight or have problems with your weight, you should tell your doctor. He or she may be able to adjust your drug or the dose of your drug to reduce this effect. Your doctor can also arrange for you to see a dietician for advice. If you do gain weight it is possible to lose it while you are still taking this medication, with expert advice about diet. In some people this can be a serious problem. If it causes you distress make sure your doctor knows about this. There is not thought that the other drugs cause major changes in weight. A small weight change is possible.

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Drugs can affect desire (libido), arousal (erection) and orgasmic ability. Phenothiazines have been reported to have an adverse effect on all these three stages, partly through causing drowsiness and partly by other means. Thioridazine may be the worse drug for this. Generally, the other drugs in this section have lesser effects eg. The butyrophenones and thioxanthenes. If this happens, you should discuss this with your doctor, as a change in dose or drug may help minimise the problem.

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If you drink alcohol while taking an antipsychotic it may make you feel more sleepy. If this happens, you must take extra care if you need to drive or operate machinery. You must seek advice on this.

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You should have no problem with any foods or drinks, other than alcohol (see separate question).

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Antipsychotics have many side effects. If antipsychotics are taken with other medicines with the same side effects, then a combined effect can occur.

Antipsychotics (especially the phenothiazines such as pericyazine or chlorpromazine) have anticholinergic effects so be careful if taken with tricyclics (e.g. dosulepin, imipramine, lofepramine), or anticholinergics (e.g. procyclidine) as this may cause dry mouth, blurred vision, constipation and difficulty passing urine. Antipsychotics can also effect the heart (so be careful with amiodarone, disopyramide, clarithromycin), and can be quite sedative, so be careful with sleeping tablets, tricyclics (e.g. dosulepin, imipramine, lofepramine), older antihistamines (e.g. promethazine), benzodiazepines (e.g. diazepam, lorazepam, temazepam), phenobarbital, melatonin or alcohol.

Antipsychotics have a few other drug interactions:

• The effects of antipsychotics can sometimes be increased by beta-blockers, fluoxetine, itraconazole or venlafaxine
• The effect of antipsychotics can be decreased by antacids (sometimes), carbamazepine, phenytoin, phenobarbital, rifampicin or smoking
• Antipsychotics can increase the effect of some tricyclics (e.g. dosulepin, imipramine, lofepramine)

This does not necessarily mean that this will happen in everyone or that some of these medicines can not be used together. It just that you may need to follow your doctor's instructions very carefully. There are many other possible drug interactions.

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It is not thought that "The Pill" is affected by any of these medicines.

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It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs.

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine.

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press.

It may be helpful to know that in the USA, the FDA (Federal Drug Administration) classifies medicines in pregnancy in five groups:
# A = Studies show no risk, so harm to the unborn child appears only a remote possibility
B = Animal and human studies indicate a lack of risk but are not fully conclusive
C = Animal studies indicate a risk but there is no safety data in humans
D = a definite risk exists but the benefit may outweigh the risk in some people
X = the risk outweighs any possible benefit

The phenothiazines available in the USA are all classified as "C". There has been some research on the use of phenothiazines in pregnancy, but mostly only with low doses. This research showed a risk of problems that was about twice that of women not taking such drugs (one in 30 with problems, one in 60 without). Occasional problems of sleepiness and drowsiness in the newborn have been reported. At 2 and 7 years old, the children's development was normal one study of women who took phenothiazines during pregnancy. You should, however, still seek personal advice from your GP, who may then if necessary seek further specialist advice.

Haloperidol is classified as "C". There is no proven evidence of a teratogenic effect, and animal tests show a low risk of danger but some problems have been reported and so you should seek personal advice from your GP, who may then if necessary seek further specialist advice.

Flupenthixol and zuclopenthixol are not classified, as they are not available in the USA. There is no evidence of a teratogenic effect, animal tests show a low risk of danger but some problems have been reported and so you should seek personal advice from your GP, who may then if necessary seek further specialist advice.

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You might sometimes, to check on some possible side effects e.g. prolactin levels, blood sugar etc. Some people who need to take higher doses occasionally need a blood test. You might also need your blood pressure tested.

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These drugs can affect your driving in two ways. Firstly, you may feel drowsy and/or suffer from blurred vision at first when taking any of these drugs. Secondly, the drugs can slow down your reactions or reflexes. This is especially true if you also have a dry mouth, blurred vision, constipation etc. (the so-called "anticholinergic side effects"). Until these wear off, or you know how your drug affects you, do not drive or operate machinery. You should be careful as they may affect your reaction times or reflexes even though you feel well.

Under Section 4 of the Road Traffic Act 1988 anyone driving while unfit to drive, due to illness (e.g. schizophrenia, mania) or any drug, can be prosecuted. Under UK law it does not matter if the drug is a prescribed medicine or an illegal drug. It’s the effect on your driving that is the main thing. If your ability to drive might be reduced due to illness or medicines, under UK law you must let your insurance company know. If you don’t, the insurance might say this is as 'withholding a material fact' (ie not telling them something they ought to know) and might mean that if you have an accident they might not pay up. Your doctor will be able to advise you.

Medical rules for all drivers:
For the full story click here (opens in new window) and go to "Medical standards". Here there is a pdf document (regularly updated) called "At a glance guide to the current medical standards of fitness to drive" that can be downloaded. It is aimed at medical practitioners (GPs).
For the "Customers guide" (ie a guide for the general public) click here (opens in new window) and download the 'Customer service guide for drivers with medical conditions'.

How to tell the UK DVLA:
If you need to tell the DVLA and you already have a license, you need to download the medical questionnaire from the DVLA website. Or you can call the DVLA to ask them to send it to you. You also need to fill out a form to give your consent for doctors from the DVLA doctors to contact your doctor or a specialist. You can either post, fax or email these forms back to:
Drivers Medical Group, DVLA, Swansea, SA99 1TU
Tel: 0870 600 0301
Fax: 0845 850 0095
Email: eftd@dvla.gsi.gov.uk
Web www.direct.gov.uk/motoring (opens in new window)
You should always allow DVLA to contact your doctor, as what your doctor says will help the DVLA decide if you can keep your license. Rarely, the DVLA may ask you to have a (free) medical examination, which will be free. This is called a medical enquiry.

What happens next
If you give the DVLA all the information they need, they can usually sort things out within 15 days. If they need more information from you, your doctor or other sources, they will try to sort it out within 90 days. What they decide will also depend on what you’re doing e.g. driving a bus is different to driving down to the shops. What can happen includes:

• You may be able to keep your license or be issued with a new one.
• If the DVLA’s doctor thinks your fitness to drive needs to be reviewed again, you may be given a license valid for 1, 2 or 3 years.
• Your license may be taken from you (revoked) or your application refused. This will only happen if you do not meet the standards of fitness to drive at the moment. If this happens, you would be told the reasons for the decision. You would also be told when you can apply again.

Driving safely
If you want to carry on driving, you must take sensible steps to reduce any risk:

• Avoid driving when you are tired or ill
• Do not drive after having any alcohol as this can make an drowsiness worse (a third of all fatal road traffic incidents involve alcohol-dependent drivers)
• Avoid driving at night, dusk or in bad weather
• Avoid motorways, dual carriageways and the rush hour
• Give yourself plenty of time. Don’t rush
• Be extra careful if you have not slept well the previous night

As some medicines can affect your driving, be extra careful:

• If starting a new medicine
• After a change in dose (especially an increase)
• If you are on a high dose or seem very sensitive to side effects
• If you are taking any medicines for other symptoms e.g. antihistamines for hay fever or allergies
• If your medicine causes you blurred vision, drowsiness, poor co-ordination, poor attention

If you are driving less than 2000 miles a year, once you consider insurance, tax, MoT, repairs, maintenance and petrol, you may actually find it is cheaper to get taxis and busses, and walk the short journeys.

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