4.2 Mental health disorders

4.2.1 Anxiety

Hypnotics and Sedatives (Benzodiazepines)

See Central Nervous System Guidelines for BNSSG Benzodiazepine and Z-drug Prescribing (including withdrawal) Support Document

Recommended:

Diazepam (TLS Green)

• Benzodiazepines should be prescribed at the lowest possible dose for the shortest possible time due to the risk of dependence.
• Diazepam should be used with caution in the elderly. Low dose Lorazepam is preferred in these patients, but should be used with caution.

Alternative:

Lorazepam (TLS Blue)

Specific indication:

Propranolol (TLS Blue)

4.2.2 Attention deficit hyperactivity disorder

There are supply disruptions affecting a wide range of medicines used in the treatment of attention deficit hyperactivity disorder (ADHD).  Local guidance and patient information leaflet has been published to support clinicians with these supply disruptions and patient reviews and is available via the Management of Stock Shortages page.

Methylphenidate, atomoxetine and dexamfetamine are available as treatment options in severe ADHD within NICE NG87

CNS Stimulants

Methylphenidate modified-release and immediate-release (TLS Amber 3 months)

For GP Practices participating in the ADHD LES (SCP Click here)

For GP Practices not participating in the ADHD LES (SCP Click here)

• October 2023 supply issue update: During the current period of supply issues with lisdexamfetamine, it has been agreed that GPs or appropriate prescribers in Primary Care may switch existing patients prescribed lisdexamfetamine onto methylphenidate in line with locally agreed guidance. Patients do not need to be referred back to the specialist team to initiate methylphenidate and provide the first three months of treatment. Clinicians should follow the locally agreed interim guidance by Avon and Wiltshire Mental Health Partnership to support switching and management of patients during this time.
• Treatment in new patients should continue to be initiated and the first 3 months supplied by the specialist team
• Please also refer to information in SCP.

• Other formulations of Methylphenidate and in the treatment of narcolepsy (TLS Red)

Lisdexamfetamine (TLS Amber 3 months)

For GP Practices participating in the ADHD LES (SCP click here)

For GP Practices not participating in the ADHD LES (SCP Click here)

• October 2023 Supply issue update: please refer to locally agreed interim guidance on stock shortage page

Dexamfetamine (TLS Amber 3 months) (SCP click here)

• ADHD
• October 2023 supply issue update: During the current period of supply issues with lisdexamfetamine, it has been agreed that GPs or appropriate prescribers in Primary Care may switch existing patients prescribed lisdexamfetamine onto dexamfetamine in line with locally agreed guidance. Patients do not need to be referred back to the specialist team to initiate dexamfetamine and provide the first three months of treatment. Clinicians should follow the locally agreed interim guidance on stock shortages page by AWP to support switching and management of patients during this time.
• Treatment in new patients should continue to be initiated and the first 3 months supplied by the specialist team
• Please also refer to information in SCP.

Dexamfetamine (TLS Amber 3 months) (SCP click here)

• Narcolepsy

Other 

Atomoxetine (TLS Amber 3 months) 

For GP Practices participating in the ADHD LES (SCP click here)

For GP Practices not participating in the ADHD LES (SCP Click here)

Guanfacine modified release tablets (TLS Amber 3 months)

• For treatment of ADHD in adults where stimulants are not suitable, not tolerated or ineffective.
• 4th line option after two stimulants (methylphenidate and lisdexamphetamine) and atomoxetine. Use outside local pathway is considered non-formulary.
• NICE NG87 advises not to offer guanfacine for adults without advice from a tertiary ADHD service.
• See SCP

4.2.3 Bipolar disorder & mania

Antiepileptics

AWP 'Prescribing Guidance for Mental Health Prescribers and GPs in Perinatal Mental Health' can be found under the ‘Medication Information for Professionals’ tab on the Pharmacy Service page of the AWP website

Sodium valproate / Valproic acid (Depakote) (TLS Amber 3 months)

• Shared Care Protocol
• Valproate must only be considered for bipolar disorder where there is no suitable alternative treatment. 
• Not for routine use in women of childbearing potential - use in exceptional circumstances only - see MHRA Drug Safety Update and MHRA guidance 
• See NHSE Decision support tool: is valproate the right epilepsy treatment for me?
• Very easy read (VERA) leaflets for valproate are available
• Original pack dispensing of valproate exceptions risk assessment form
• Valproic acid must be prescribed by brand - Depakote^®

Carbamazepine (TLS Amber Specialist Initiated)

Lamotrigine (TLS Amber Specialist Recommended)

Lithium Salts

Lithium carbonate modified-release (TLS Amber 3 months) (SCP click here)

Lithium citrate liquid (TLS Amber 3 months) (SCP click here)

• Lithium preparations must be prescribed by brand name and the patient maintained on the same brand

4.2.4 Depression

National and Local Guidance

• See BNSSG Guideline for the Management of Depression Adults
• NICE clinical guidance CG 90 – Depression. The treatment and management of depression in adults
• NICE clinical guidance CG 91 – Depression with a chronic physical health problem
• NICE advice KTT8 - First-choice antidepressant use in adults with depression or generalised anxiety disorder
• AWP 'Prescribing Guidance for Mental Health Prescribers and GPs in Perinatal Mental Health' can be found under the ‘Medication Information for Professionals’ tab on the Pharmacy Service page of the AWP website
• See AWP 'Physical Health and Monitoring: Procedure for monitoring psychotropic medication- a guide to essential tests and investigations Med37' under the ‘Medication Information for Professionals’ tab on the Pharmacy Service page of the AWP website

Monoamine-Oxidase A and B Inhibitors (irreversible)

Specific indications: (TLS Blue)

Phenelzine

• Specialist recommendation

Monoamine-Oxidase A Inhibitors (reversible)

Specific indications: (TLS Blue)

Moclobemide

• Specialist recommendation

Selective Serotonin Re-uptake Inhibitors

Recommended: (TLS Green)

Sertraline

Citalopram

Fluoxetine

Alternative: (TLS Blue)

Escitalopram

Specific Indication: (TLS Blue)

Paroxetine

• For existing patients only

Fluvoxamine

• In young adults (and children) for the treatment of obsessive compulsive disorder, depressive disorder and anxiety disorder

Serotonin and Noradrenaline Re-uptake Inhibitors

Recommended: (TLS Green)

Venlafaxine

Tetracycline Antidepressants

Recommended: (TLS Green)

Mirtazapine

Tricyclic Antidepressants

Recommended: (TLS Green)

Lofepramine

Alternative: (TLS Blue)

Amitriptyline

 No longer recommended for depression in the BNF due to increased risk of fatality in overdose

Other

Trazodone (TLS Blue)

• For treatment of anxiety and depression.
• Consider sodium levels in elderly patients if used in combination with other medicines such as diuretics that increase risk of hyponatraemia.

Vortioxetine (TLS Amber Specialist Recommended)

• As per NICE TA367 Vortioxetine for treating major depressive episodes.

4.2.6 Psychoses and Schizophrenia

See AWP 'Physical Health and Monitoring: Procedure for monitoring psychotropic medication- a guide to essential tests and investigations Med37' under the ‘Medication Information for Professionals’ tab on the Pharmacy Service page of the AWP website

See MHRA guidance on Antipsychotics: use in elderly people with dementia

• There is a clear increased risk of stroke and a small increased risk of death when antipsychotics (typical or atypical) are used in elderly people with dementia

AWP 'Prescribing Guidance for Mental Health Prescribers and GPs in Perinatal Mental Health' can be found under the Perinatal section of AWP website

Antipsychotics First-generation

See AWP 'Physical Health and Monitoring: Procedure for monitoring psychotropic medication- a guide to essential tests and investigations Med37' under the ‘Medication Information for Professionals’ tab on the Pharmacy Service page of the AWP website

Recommended:

Haloperidol (injection- non depot) (TLS Red) 

Haloperidol (oral) (TLS green)

Flupentixol decanoate (TLS Amber 1 month) (SCP Click here)

Fluphenazine decanoate (TLS Amber 1 month) (SCP Click here)

Haloperidol decanoate (TLS Amber 1 month) (SCP Click here)

Zuclopenthixol decanoate (TLS Amber 1 month) (SCP Click here)

Alternatives: (TLS Blue)

Chlorpromazine

Sulpiride

Trifluoperazine

Zuclopenthixol (oral)

Antipsychotics Second-generation

NICE QS 80 - Psychosis and schizophrenia in adults

See AWP 'Physical Health and Monitoring: Procedure for monitoring psychotropic medication- a guide to essential tests and investigations Med37' under the ‘Medication Information for Professionals’ tab on the Pharmacy Service page of the AWP website

Recommended:

Olanzapine (oral) (TLS Blue)

Following advice of Psychiatry

Risperidone (TLS Green)

 Specific indication:

Aripiprazole (oral) (TLS Amber Specialist Recommended)

• For schizophrenia/psychosis and control of associated agitation and disturbed behaviour in adults. 
• The treatment of moderate to severe manic episodes in Bipolar l Disorder and for the prevention of a new manic episode in adults who experienced predominately manic episodes and whose manic episodes responded to aripiprazole treatment. 

Risperidone injection (Consta^®) (TLS Red) 

Specific indication: (TLS Red)

Clozapine 

• Licensed for treatment resistant schizophrenia, that has not responded to at least 2 alternative antipsychotic drugs and prescribed under the supervision of a consultant psychiatrist
• Clozapine may only be initiated by senior medical staff working in psychiatry, or neurology, who are registered with a clozapine patient monitoring service.
• Full blood counts are required prior to and during clozapine treatment.

Paliperidone palmitate injection (Xeplion^®) (TLS Red)

• These preparations may only be initiated on the advice of senior medical staff working in psychiatry.

 Alternatives:

Amisulpride

Quetiapine

4.2.7 Behavioural Disturbance

Behavioural Disturbance in the Emergency Department

Ketamine (TLS Red)

• For management of behavioural disturbance in the Emergency Department

Droperidol (TLS Red)

• For sedation of patients with acute behavioural disturbance in the Emergency Department. Alternative to ketamine. 
• Decision to administer should be made by ED consultant or registrar.

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