Mental Health

Mental Health (General Adult Psychiatry) Specialist formulary list

**Other indications for particular drugs may be included on completion of further specialist lists**

Formulary medicines generally provide first and second-line treatment options. The following sections of the Tayside Area Formulary (TAF) should be used in conjunction with this specialist formulary list: section 4.2.1 – Antipsychotic drugs, section 4.2.2 – Antipsychotic depot injections, section 4.2.3 – Mood stabilisers (antimanic drugs), and section 4.3 – Antidepressant drugs.

For information on use of unlicensed medicines or medicines used 'off-label' - click here

The following medicines are approved for prescribing by or on the recommendation of a Psychiatrist:

TAF SECTION: 4.2.1 Antipsychotic drugs. See NHS Tayside Guidelines for Management of High Dose Antipsychotic Therapy (NHS Tayside Staffnet intranet link only).

MEDICINE	SUMMARY OF RESTRICTED INDICATION	CATEGORY	PROTOCOL
Second-generation antipsychotic drugs (atypical antipsychotic drugs) Risperidone is the formulary first choice atypical antipsychotic. See formulary section 4.2.1 for further information on antipsychotic drugs.
Olanzapine tablets, orodispersible tablets	Schizophrenia, combination therapy for mania, preventing recurrence in bipolar disorder. Monotherapy for mania.		Algorithm for antipsychotic treatment of schizophrenia Pharmacological Management of Acute Behavioural Disturbance in Adult In-Patients Guidance on the use of Emergency Sedation during the escort of patients to In-Patient psychiatric care in the Tayside Multi-Agency Psychiatric Emergency Plan (NHS Tayside Staffnet intranet links only).
Quetiapine tablets,prolonged- release tablets	Schizophrenia. Treatment of mania in bipolar disorder. Psychosis in patients with Parkinson’s disease (unlicensed use ‘off-label’).
Amisulpiride tablets, oral solution	Schizophrenia.		Algorithm for antipsychotic treatment of schizophrenia
Aripiprazole tablets, orodispersible tablets, oral solution	Schizophrenia (in adults) where patients have experienced unacceptable adverse effects on previous treatment or in patients at increased risk of developing adverse effects.
Clozapine tablets (Zaponex^®)	Schizophrenia in patients unresponsive to, or intolerant of, conventional antipsychotic drugs.
Olanzapine injection 5mg/mL (Zyprexa^®▼)	Control of agitation and disturbed behaviour in schizophrenia or mania when oral therapy is not appropriate. Use is restricted to the Intensive Psychiatric Care Unit (IPCU) or Specialist Mental Health Services.		Pharmacological Management of Acute Behavioural Disturbance in Adult In-Patients
Aripiprazole injection ▼	Control of agitation and disturbed behaviour in schizophrenia when oral therapy is not appropriate. Use is restricted to the Intensive Psychiatric Care Unit (IPCU) or Specialist Mental Health Services.
First-generation antipsychotic drugs (typical antipsychotic drugs) Haloperidol and chlorpromazine are formulary typical antipsychotics. See formulary section 4.2.1 for further information on antipsychotic drugs.
Levomepromazine 25mg tablets	Schizophrenia.		Algorithm for antipsychotic treatment of schizophrenia
Sulpiride tablets, oral solution	Schizophrenia.
Zuclopenthixol tablets	Schizophrenia and other psychoses.
Haloperidol injection 5mg/mL	Schizophrenia and other psychoses, mania, short-term adjunctive management of psychomotor agitation, excitement, and violent or dangerously impulsive behaviour, when oral route not possible.	(may be prescribed by GPs in a Psychiatric Emergency)	Pharmacological Management of Acute Behavioural Disturbance in Adult In-Patients Guidance on the use of Emergency Sedation during the escort of patients to In-Patient psychiatric care in the Tayside Multi-Agency Psychiatric Emergency Plan (NHS Tayside Staffnet intranet links only)
Zuclopenthixol acetate injection (Clopixol Acuphase^®)	Short-term management of acute psychosis, mania, or exacerbations of chronic psychosis.		Pharmacological Management of Acute Behavioural Disturbance in Adult In-Patients
Benzodiazepines for pharmacological management of acute behavioural disturbance See formulary section 4.2.1 for further information on the control of agitation and disturbed behaviours after appropriate psychological and environmental management has failed.
Lorazepam injection	Acute management of violent / disturbed behaviour when oral route not possible (unlicensed use ‘off-label’) Licensed indications include treatment of acute anxiety states, acute excitement or acute mania.	(may be prescribed by GPs in a Psychiatric Emergency)	Pharmacological Management of Acute Behavioural Disturbance in Adult In-Patients Guidance on the use of Emergency Sedation during the escort of patients to In-Patient psychiatric care in the Tayside Multi-Agency Psychiatric Emergency Plan (NHS Tayside Staffnet intranet links only)
Midazolam injection	Acute management of violent / disturbed behaviour (unlicensed use ‘off-label’).		Pharmacological Management of Acute Behavioural Disturbance in Adult In-Patients
Antihistamines for pharmacological management of acute behavioural disturbance See formulary section 4.2.1 for further information on the control of agitation and disturbed behaviours after appropriate psychological and environmental management has failed.
Promethazine hydrochloride tablets, elixir, injection	Emergency sedation (short-term use) in patients with violent / disturbed behaviour.	(may be prescribed by GPs in a Psychiatric Emergency)	Pharmacological Management of Acute Behavioural Disturbance in Adult In-Patients Guidance on the use of Emergency Sedation during the escort of patients to In-Patient psychiatric care in the Tayside Multi-Agency Psychiatric Emergency Plan (NHS Tayside Staffnet intranet links only)
Medication to manage adverse effects of drugs used for pharmacological management of acute behavioural disturbance See formulary section 4.2.1.
Flumazenil injection	In addition to resuscitation equipment and medication if benzodiazepine-induced respiratory depression is suspected.	(may be prescribed by GPs in an Emergency)	Pharmacological Management of Acute Behavioural Disturbance in Adult In-Patients Guidance on the use of Emergency Sedation during the escort of patients to In-Patient psychiatric care in the Tayside Multi-Agency Psychiatric Emergency Plan (NHS Tayside Staffnet intranet links only)
Procyclidine injection	Emergency treatment for acute drug-induced dystonic reactions.	(may be prescribed by GPs in an Emergency)

TAF SECTION: 4.2.2 Antipsychotic depot injections

MEDICINE	SUMMARY OF RESTRICTED INDICATION	CATEGORY	PROTOCOL
Flupentixol decanoate oily injection	Maintenance in schizophrenia and other psychoses.	(Note: in Dundee and Perth & Kinross)	Algorithm for antipsychotic treatment of schizophrenia
Fluphenazine decanoate oily injection	Maintenance in schizophrenia and other psychoses.
Haloperidol decanoate oily injection	Maintenance in schizophrenia and other psychoses.
Pipotiazine palmitate oily injection	Maintenance in schizophrenia and other psychoses.
Zuclopenthixol decanoate oily injection	Maintenance in schizophrenia and other psychoses.
Aripiprazole prolonged release suspension for injection (intramuscular) 400mg (200mg/mL) (Abilify Maintena ^®)	Maintenance treatment of schizophrenia in adult patients who have responded to oral aripiprazole and depot medication is required due to problems with compliance.
Risperidone prolonged-release injection (Risperdal Consta®▼)	Schizophrenia and other psychoses in patients who require an atypical antipsychotic and who are tolerant to risperidone by mouth.
Paliperidone palmitate prolonged-release suspension for injection (Xeplion®▼)	Maintenance treatment of schizophrenia in adult patients stabilised with paliperidone or risperidone. Restricted to use where an atypical antipsychotic is appropriate and depot medication is required due to problems with compliance.		Note: Oral paliperidone is not recommended by SMC. Algorithm for antipsychotic treatment of schizophrenia

TAF SECTION: 4.2.3 Mood stabilisers (antimanic drugs)

MEDICINE	SUMMARY OF RESTRICTED INDICATION	CATEGORY	PROTOCOL
Lithium carbonate tablets (Priadel^®, Camcolit^®) Lithium citrate liquid (Priadel^®)	Treatment and prophylaxis of mania, bipolar disorder, and recurrent depression; aggressive or self-mutilating behaviour.
Valproic acid (as semisodium valproate) (Depakote^®)	Treatment of manic episode in bipolar disorder when lithium is contraindicated or not tolerated. Continuation of treatment after manic episode in patients who have responded to valproic acid for acute mania.
Sodium valproate tablets, oral solution	Treatment of manic episode in bipolar disorder when lithium is contraindicated or not tolerated (unlicensed use ‘off-label’).
Carbamazepine tablets, m/r tablets, liquid	Prophylaxis of bipolar disorder in patients unresponsive to lithium.
Lamotrigine tablets▼, dispersible tablets▼	Monotherapy or adjunctive therapy for prevention of depressive episodes in patients with bipolar disorder who experience predominantly depressive episodes.

TAF SECTION: 4.3 Antidepressant drugs

MEDICINE	SUMMARY OF RESTRICTED INDICATION	CATEGORY	PROTOCOL
Selective serotonin re-uptake inhibitors (SSRIs)
Escitalopram	After other SSRIs have been tried for major depressive episodes, generalised anxiety disorder.		Fluoxetine is the formulary first choice SSRI. See formulary section 4.3 for further information on SSRIs.
Paroxetine	Doses higher than 20mg for depressive illness, social anxiety disorder, or generalised anxiety disorder; doses higher than 40mg for obsessive-compulsive disorder; doses higher than 40mg for panic disorder.
Tricyclic and related antidepressant drugs Lofepramine is a formulary tricyclic antidepressant drug. See formulary section 4.3 for further information on antidepressant drugs.
Amitriptyline	Depressive illness.
Clomipramine	Depressive illness, phobic and obsessional states.
Imipramine	Depressive illness.
Nortriptyline	Depressive illness.
Trazodone	Depressive illness, particularly where sedation is required; anxiety.
Monoamine-oxidase inhibitors (MAOIs) and reversible MAOIs
Moclobemide	Depressive illness refractory to treatment with other antidepressants, social anxiety disorder.
Phenelzine	Depressive illness refractory to treatment with other antidepressants.
Isocarboxazid
Tranylcypromine
Other antidepressant drugs Mirtazapine and venlafaxine are other formulary antidepressant drugs. See formulary section 4.3 for further information on antidepressant drugs.
Duloxetine (Cymbalta^®▼)	Major depressive disorder who have failed to respond to, or are unable to tolerate, initial treatment options.
Augmentation in treatment resistant depression
Tryptophan	Adjunctive therapy for depression resistant to standard antidepressants.
Lithium	To augment antidepressants in treatment-resistant depression (unlicensed use ‘off-label’).

The NHS Tayside Integrated Care Pathways (ICPs) for Bipolar Disorder, Borderline Personality Disorder, Dementia, Depression, and Schizophrenia are in development.

Please refer to the following national guidelines/resources for further information:

NICE Clinical Guideline 25: Violence (Feb 2005) The short-term management of disturbed/violent behaviour in psychiatric in-patient settings
SIGN Guideline 131: Management of Schizophrenia. A National Clinical Guideline (March 2013)
NICE Clinical Guideline 38: Bipolar Disorder (July 2006) The management of bipolar disorder in adults, children and adolescents in primary and secondary care.
SIGN Guideline 82 Bipolar affective disorder. A National Clinical Guideline (May 2005)
Evidence based guidelines for treating bipolar disorder: Revised second edition – recommendations from the British Association for Psychopharmacology March 2009
NICE Clinical Guideline 90 (Oct 2009) Depression: the treatment and management of depression in adults (update)
NICE Clinical Guideline 91 (Oct 2009) The treatment and management of depression in adults with chronic physical health problems (partial update)
NICE Clinical Guideline 113 (Jan 2011) Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults
SIGN Guideline 114 Non-pharmaceutical management of depression in adults. A National Clinical Guideline (Jan 2010)
The Maudsley Prescribing Guidelines 11^th Edition, 2012

	May be prescribed by Hospital Specialists only
	May be prescribed in General Practice under the direction of a Specialist