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How do benzodiazepines work?

When you are anxious, your brain becomes more active. It may then produce a chemical messenger (or ‘neurotransmitter’) called GABA (short for gamma-aminobutyric acid) that makes you feel calmer. GABA is the brain’s naturally occurring ‘calmer’. The benzodiazepines make the action of GABA more powerful and this helps to calm people down.

Benzodiazepines are recommended as an emergency treatment that should not be used for more than 1 month. Benzodiazepines should not be used for panic disorder. They should not be used as a routine treatment for generalised anxiety disorder, except as a short-term measure during a crisis.

These drugs are not usually helpful for conditions like schizophrenia or bipolar disorder but may be used in emergency situations needing rapid calming.

What different types of benzodiazepines are there?

Types of benzodiazepines are normally grouped by the length of time over which they act (called a half-life), with shorter acting benzodiazepines called ‘hypnotics’ and longer acting benzodiazepines called ‘anxiolytics’.

Hypnotics are used for those experiencing difficulties sleeping (insomnia). Anxiolytic type benzodiazepines help to reduce anxiety, agitation and tension. For both of these types of benzodiazepine, using them should only be for the shortest amount of time possible. Drugs that fall into the category of benzodiazepines include:

Benzodiazepines – Hypnotic effects Benzodiazepines – Anxiolytic effects
Flurazepam Alprazolam
Loprazolam Chlordiazepoxide
Lormetazepam Diazepam
Nitrazepam Lorazepam
Temazepam Oxazepam

These drugs can come as tablets, capsules and liquids. They should start to work fairly soon after you take them.

Antipsychotics are medicines that are mainly used to treat schizophrenia or mania caused by bipolar disorder. There are two main types of antipsychotics: atypical antipsychotics and older antipsychotics. Both types are thought to work as well as each other. Side-effects are common with antipsychotics. You will need regular tests to monitor for side-effects while you take theses medicines.

What are antipsychotics?

Antipsychotics are a group of medicines that are mainly used to treat mental health illnesses such as schizophrenia, or mania (where you feel high or elated) caused by bipolar disorder. They can also be used to treat severe depression and severe anxiety. Antipsychotics are sometimes also called major tranquillisers.

There are two main types of antipsychotics:
•Newer or atypical antipsychotics. These are sometimes called second-generation antipsychotics and include: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.
•Older typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide, sulpiride, trifluoperazine, and zuclopenthixol.

Antipsychotics are available as tablets, capsules, liquids, and depot injections (long-acting). They come in various different brand names.

Older antipsychotics have been used since the 1950s and are still prescribed today. Newer antipsychotics were developed in the 1970s onwards. It was originally thought that these medicines would have fewer side-effects than the older type of antipsychotics. However, we now know that they can also cause quite a few side-effects.

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How do antipsychotics work?

Antipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine, serotonin, noradrenaline and acetylcholine. These chemicals have the effect of changing your behaviour, mood and emotions. Dopamine is the main chemical that these medicines have an effect on.

By altering the effects of these chemicals in the brain they can suppress or prevent you from experiencing:
•Hallucinations (such as hearing voices).
•Delusions (having ideas not based on reality).
•Thought disorder.
•Extreme mood swings that are associated with bipolar disorder.

When are antipsychotics usually prescribed?

As discussed above, antipsychotics are usually prescribed to help to ease the symptoms of schizophrenia, mania (caused by bipolar disorder), severe depression or severe anxiety. Normally they are started by a specialist in psychiatry, or your GP will ask a specialist for advice on when to start them.

Also, for many years antipsychotics were used to calm elderly people who had dementia, but this use is no longer recommended. This is because these medicines are thought to increase the risk of stroke and early death – by a small amount. Risperidone is the only antipsychotic recommended for use in these people. Even then, it should only be used for short period of time (less than six weeks) and for severe symptoms.

Which antipsychotic is usually prescribed?

The choice of antipsychotic prescribed depends upon what is being treated, how severe your symptoms are, and if you have any other health problems. There are a number of differences between the various antipsychotic medicines. For example, some are more sedating than others. Therefore, one may be better for one individual than for another. A specialist in psychiatry usually advises on which to use in each case. It is difficult to tell which antipsychotic will work well for you. If one does not work so well, a different one is often tried and may work well. Your doctor will advise.

It is thought that the older and newer types of antipsychotics work as well as each other. The exception to this is clozapine – it is the only antipsychotic that is thought to work better than the others. Unfortunately, clozapine has a number of possible serious side-effects, especially on your blood cells. This means that people who take clozapine have to have regular blood tests.

In some cases, an injection of a long-acting antipsychotic medicine (depot injection) is used once symptoms have eased. The medicine from a depot injection is slowly released into the body and is given every 2-4 weeks. This aims to prevent relapses (recurrences of symptoms). The main advantage of depot injections is that you do not have to remember to take tablets every day.

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Schizophrenia
How well do antipsychotics work?

It is thought that for every 10 people who take these medicines, 8 will experience an improvement in their symptoms. Unfortunately, antipsychotics do not always make the symptoms go away completely, or for ever. A lot people need to take them in the long term even if they feel well. This is in order to stop their symptoms from coming back. Even if you take these medicines on a long-term basis and they are helping, sometimes your symptoms can come back.

Symptoms may take 2-4 weeks to ease after starting medication, and it can take several weeks for full improvement. The dose of the medicine is usually built up gradually to help to prevent side-effects (including weight gain).

What is the usual length of treatment?

This depends on various things. Some people may only need to take them for a few weeks, but others may need to take them long-term (for example, for schizophrenia). Even when symptoms ease, antipsychotic medication is normally continued long-term if you have schizophrenia. This aims to prevent relapses, or to limit the number and severity of relapses. However, if you only have one episode of symptoms of schizophrenia that clears completely with treatment, one option is to try coming off medication after 1-2 years. Your doctor will advise.

Stopping antipsychotics

If you want to stop taking an antipsychotic you should always talk to your doctor first. This is in order to help you decide if stopping is the best thing for you, and how you should stop taking your medicine. These medicines are usually stopped slowly over a number of weeks. If you stop taking an antipsychotic medicine suddenly, you may become unwell quite quickly. Your doctor will usually advise you to reduce the dose slowly to see what effect the lower dose has on your symptoms.

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What about side-effects from antipsychotics?

Side-effects can sometimes be troublesome. There is often a trade-off between easing symptoms and having to put up with some side-effects from treatment. The different antipsychotic medicines can have different types of side-effects. Also, sometimes one medicine causes side-effects in some people and not in others. Therefore, it is not unusual to try two or more different medicines before one is found that is best suited to an individual.

The following are the main side-effects that sometimes occur. However, you should read the information leaflet that comes in each medicine packet for a full list of possible side-effects.

Common side-effects include:
•Dry mouth, blurred vision, flushing and constipation. These may ease off when you get used to the medicine.
•Drowsiness (sedation), which is also common but may be an indication that the dose is too high. A reduced dose may be an option.
•Weight gain which some people develop. Weight gain may increase the risk of developing diabetes and heart problems in the longer term. This appears to be a particular problem with the atypical antipsychotics – notably, clozapine and olanzapine.
•Movement disorders which develop in some cases. These include: •Parkinsonism – this can cause symptoms similar to those that occur in people with Parkinson’s disease – for example, tremor and muscle stiffness.
•Akathisia – this is like a restlessness of the legs.
•Dystonia – this means abnormal movements of the face and body.
•Tardive dyskinesia (TD) – this is a movement disorder that can occur if you take antipsychotics for several years. It causes rhythmical, involuntary movements. These are usually lip-smacking and tongue-rotating movements, although it can affect the arms and legs too. About 1 in 5 people treated with typical antipsychotics eventually develops TD.

Atypical antipsychotic medicines are thought to be less likely to cause movement disorder side-effects than typical antipsychotic medicines. This reduced incidence of movement disorder is the main reason why an atypical antipsychotic is often used first-line. Atypicals do, however, have their own risks – in particular, the risk of weight gain. If movement disorder side-effects occur then other medicines may be used to try to counteract them.

Will I need any tests while taking an antipsychotic?

Your doctor will want to monitor you regularly for side-effects if you take an antipsychotic. The tests needed and how often you will need to have them depend on which antipsychotic you are taking.

In general, your doctor will take a sample of blood for certain tests before you start treatment. The tests look at how many blood cells you have, how well your kidneys and liver are working, how much lipid (fat) is in your blood, and if you have diabetes. These tests may be repeated in the first 3 or 4 months of treatment. After this they are normally done every year. However, your doctor may advise you to have these tests more often.

Your weight and blood pressure are usually measured before you start treatment and every few weeks after this for the first few months. After this they are normally measured every year.

The blood level of prolactin (a hormone) may also be measured before starting treatment and six months later. Usually it is then measured every year after this. The prolactin level is measured because sometimes antipsychotics can make you produce too much of this hormone. If you make too much prolactin it can lead to your breasts growing bigger and breast milk being produced.

Note: people taking clozapine need weekly blood tests for the first six months and two-weekly blood tests after that. This is because it can have a serious effect on how many blood cells you make.

Who cannot take antipsychotics?

Antipsychotics are usually not prescribed for people who are comatose (in a coma), have depression of their central nervous system, and who have phaeochromocytoma (tumour on the adrenal gland).

Can I buy antipsychotics?

No – they are only available from your pharmacist, with a doctor’s prescription.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines, you can report this on the Yellow Card Scheme. You can do this online at the following web address: http://www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that your medicines may have caused. If you wish to report a side-effect, you will need to provide basic information about:
•The side-effect.
•The name of the medicine which you think caused it.
•Information about the person who had the side-effect.
•Your contact details as the reporter of the side-effect.

It is helpful if you have your medication and/or the leaflet that came with it with you while you fill out the report.

Education and Recovery
An important aspect of recovery involves not only getting better, but also achieving a full and satisfying life. Education can accelerate your recovery process in that it broadens your intellectual, social and emotional horizons. When you go to classes, you not only have an opportunity to expand your knowledge on a wide variety of topics that interest you, but you also have a chance to meet new people. Completing tasks and graduating from courses can give you a sense of pride in your accomplishments. Education can also further your goals in other areas of your life as well – it can help you get a job, and it can help you understand more about things that impact your life such as finances or health.
Education and Mental Illness
Seeking Accommodations
Learning and Career Choices
College and Mental Illness
Education-Related Issues

Education and Mental Illness
Having a mental illness can impact and affect the trajectory of your education in many ways. However, there are alternate academic opportunities at every stage of education that can enable you to continue to learn when you are well enough to do so:
•Special education and alternative secondary schools
•GED and high school equivalency
•Supported education

Special Education and Alternative Schools
If you are still in high school and have had a problem with traditional public schools, alternative schools offer another option. Alternative schools differ from public schools in a variety of ways, depending on the institution. There may be shorter or longer classes or more flexibility on assignments. You may be able to work and go to school at the same time. One type of alternative school is a continuation school. Continuation schools are non-traditional high schools that offer programs to students who have been expelled, are on probation, or have disciplinary or attendance problems.

General Equivalency Degree (GED)
If you haven’t received a high school diploma, you can take a test to receive your GED, which is the same as a high school diploma. The cost for this test may be up to $100, but the tests are frequently less. GED tests are administered at local community colleges or adult education centers. You don’t have to take any coursework to take the test and receive your GED; however, there are limits as to who can take it, and most test takers have completed at least through the 10th grade. If you don’t feel prepared to take your GED, you can take a GED preparation course.

Certificate of Attendance
If you do not meet all the requirements to graduate, such as hours taken or passing grades, you may still receive a Certificate of Attendance from a secondary school. Many schools will offer a plan of action to finish your coursework within a period of time after receiving a Certificate of Attendance.

Supported Education
Supported education is generally geared toward post-secondary college education. You will work with either a supported education specialist or a supported education team, although they may have different titles. Supported education services can include placement services, which help you find a learning path that fits your needs, assistance with admissions, and assistance finding financial aid. You might also receive help with problem-solving skills, test-taking skills, or studying tactics. A supported education specialist may, at your request, serve as an advocate for you and intervene on your behalf in school settings.

Seeking Accommodations
Teachers and professors vary in how accommodating they are to student problems – some may be willing to give you extra time if you ask, and some may tie up your request or deny it. Your academic advisor or student-counseling center may be able to help you if you run into problems.
Like employers, educators are required by law to make school a place that is open to people with and without disability. You may have a disability if your mental health condition prevents you from doing one or more major life activities. Many people with mental health conditions have disabilities. There are a number of federal government acts that cover education issues. Many private schools willingly comply with these.
Primary and secondary education, K-12, are required to provide free and appropriate education by law. Post-secondary educational institutions are not required to provide free and appropriate education, but they are required to take other actions. Schools may not stop your enrollment because of your disability; they must make reasonable accommodations or academic adjustments to your learning; if housing is available to non-disabled students, you must receive housing.
Academic adjustments can vary by the nature and severity of your disability and the school. Common examples include asking for longer time to take tests or asking for help with a student note-taker. You may be able to ask for a reduced course load or for oral tests instead of written ones; however, the more your request changes the class, the less likely it is covered by law. Still, some schools and teachers are voluntarily compliant and may even exceed the legal requirements. If you know other people with mental health conditions who have flourished in a school environment, you should ask them how their schools and teachers helped them.
You should never have to pay more to receive academic adjustments. Each school will have a process for handling academic adjustments; you can usually find this on the website, and if you can’t, you can ask any admissions counselor for assistance.
You will often have to provide documentation to schools about your disability. The burden of proof may be different for a post-secondary school than for a secondary school or an employer. You may need a detailed note from a doctor or a new evaluation.
If you think you have been unfairly discriminated against, you should follow your school’s reporting and grievance procedure. They should have a staff member who is required to ensure compliance with disability and education.

Consider your Learning and Career Choices
You have many choices in higher education beyond high school. Different careers will require very different paths of learning. If you want to be a doctor, you will need an undergraduate degree, you’ll need to pass a test to get into medical school, and you’ll need to spend another several years in medical school, internships and residencies. If you love fixing cars and want to be a mechanic, you’ll have to take a different path; a four-year degree may not be a good investment in time and money. If you want to be a bartender, you might not want to go to school at all; you will want to wait tables and tend bar during a day shift to get more experience to work at night.

Vocational School
Where a community college is more likely to offer courses that are academic in nature, vocational schools focus on specific occupations. Sometimes, community colleges will offer vocational tracks in addition to academic ones. Technical or vocational schools may be very broadly oriented – a large technical school, for example, might offer several degree programs for web design, graphic design, mechanical engineering and auto repair. Some technical or vocational schools, however, are highly specialized. Such schools may only offer training in a single field such as cosmetics for hairdressers and make-up artists, or the culinary arts for future chefs. When you graduate from a technical or vocational school, you will have a two-year degree or a certification.

Going to College with a Mental Illness
Having a mental health condition can affect your ability to study and learn. Because mental illnesses often manifest themselves during teenage years or early adulthood, it is not uncommon for symptoms to appear during the college years. If you become acutely ill while in college, you might need to take time out to seek treatment and stability. Chances are you will be able to continue your education once the condition is well controlled. While the onset of a mental illness can be dismaying, don’t feel ashamed; seek help. Mental illnesses are treatable and recovery is the norm.
You may want to seek a college or university that offers supportive services for students with mental or physical disabilities. Another way to get help is to team up with a mentor or fellow consumer for extra support. You may also find or start a support group for people with mental health problems on your campus.
If you feel that your mental health condition will affect your performance, you may need to reduce your schedule or ask for a reasonable accommodation. Work with an enrollment specialist to make sure that you aren’t jeopardizing your status as a full-time student.
Another option to consider if a mental health condition has prevented you from starting college or caused you to leave college is starting slowly as a non-degree student to figure out how much of a course load you can handle.

Community College
A community college is a public school that offers some college courses and certain certificates, diplomas or 2-year degrees. Students may attend community college to pursue a 2-year degree or a specific certificate to go straight to work afterwards. They may also attend to complete initial coursework before transitioning to another (usually more expensive) school, or take remedial coursework or specific courses as part of joint program. Typically a public community college has lower tuition than four-year colleges, lacks on-campus housing, is accessible by public transportation and offers a variety of enrollment options, from a few hours a semester to night school. Community colleges may be called junior colleges; however, a junior college can be a private institution (not a public one) and therefore typically is more expensive.

Four-Year Colleges and Universities
College most frequently refers to a liberal arts college that offers a four-year undergraduate degree such as a Bachelor of Arts or a Bachelor of Science. A university is generally a school that has an undergraduate college as well as graduate schools that offer advanced degrees like a Masters or PhD. While colleges and universities can be expensive, you can apply for financial aid and outside scholarships.

Distance Education
Correspondence schools allow you to get a degree through the mail. Correspondence schools may offer high school or college-level courses. While there is usually a set finish date, work in correspondence schools can usually be done at your own pace. It is very important for you to understand, however, that if you are someone who needs external structure and discipline to excel, correspondence schools may not provide that structure. You also may not have an instructor that you work closely with; however, instructors will frequently be available by e-mail or telephone. A correspondence school is usually highly affordable.
Telecourse learning might be sponsored by your local college or university. Instead of attending classes in a classroom, you receive your education manual and watch either a live television feed or prerecorded video of a lecture. The instructor is available by e-mail or phone. Like correspondence school, telecourse learning can be done more at your own pace than a traditional school. However, you may have to go to your campus or a pre-designated satellite site to take tests, turn in assignments or study for exams with a group. Telecourses may be more expensive than correspondence courses because they typically have the same cost per credit hour as the university that sponsors them. You will likely need access to a television with a video player, a computer with Internet access, or both.
E-learning or online degree programs have made distance learning more popular and accessible than ever. Many traditional colleges and universities have offered some courses or degree programs online, but recently, schools that specialize in all distance learning have sprung up. In fact, an online college has the highest enrollment of any U.S. university. E-learning can take a variety of forms. In some programs, you may work entirely on your own, reading your textbook and watching lectures online but working largely at your own pace as long as you finish by the end of your semester. Other online degree programs will be highly involved, requiring you to attend regularly scheduled meetings with classmates through technology that lets you see and talk to each other and submit paperwork. You should pick a style of learning that best fits your schedule. You will need a computer and regular Internet access to attend online degree courses.

Other Types of Learning
Tests and Certifications
Depending on your job, a specific certification may be the most reputable thing you can have. You can achieve certifications by taking tests or performing jobs. Some tests will require that you have existing working experience; others do not. For example, human resources professionals may want to have the Professional of Human Resources (PHR) title. To take the test to get PHR certified, you need to prove you have a combination of a degree and certain years of experience. If you want to repair computers, you may need certifications in some computer courses. These certifications may not require experience in the field; you can be self-taught.
Short Courses
Some employment fields have short courses or on-the-job training that can prepare you for what to do. These on-the-job courses, such as ones that train you to work at a crisis hotline, for example, may be sponsored by your employer.
Continuing Education
Even if you already have a degree, the world is constantly changing and it requires you to stay on top. Social workers and other professionals in human services frequently need to keep continuing education ongoing in their careers. Many conferences or seminars may be certified to offer “continuing education” credits if you need this more formally; otherwise, you will want to keep abreast of current topics.
Adult Education
Many community centers or community colleges will offer adult education. These courses are not specific to degree programs or paths of learning but may offer valuable information, such as courses in running a small business or speaking Spanish. These are usually held at night or on the weekends.
Internships
When most people think of internships, they think of college students working without pay in order to earn academic credit. Internships aren’t actually student specific; they are a blend of education and work. An internship usually involves a close relationship with other staff at a business working on specific projects and tasks to refine old skills or learn new ones. Where a volunteer might answer phones or bring food to homeless people, an intern might help a program staff member develop strategies to bring the food to the homeless. Sometimes the line between intern and volunteer can be blurred. Some internships offer an hourly wage or a paid stipend. If you are interested in an internship, make sure you talk to your employer at the interview. Ask about the specific tasks and projects you will work on. You should expect to spend some of your time doing administrative work like filing, but you should also get a sense of a real opportunity to learn on the job.

Common Education-Related Issues
While managing your mental illness and pursuing your education may be difficult at times, making you feel isolated, you are not alone. Many people, including some highly successful people, have found themselves in similar circumstances. Read on to learn more about questions frequently asked by students and prospective students just like you.
What if I’m uncomfortable in school?
Despite efforts to educate the public about mental health and mental health conditions, you may still encounter stigma from people who don’t know or understand what you are going through. If you think that any school official has illegally discriminated against you or violated your privacy rights because of your mental health condition, you should report your concerns to the Office of Civil Rights.
However, you might feel uncomfortable in school even if your teachers and the staff haven’t done anything illegal. Maybe your fellow students are judgmental; maybe your school doesn’t offer enough academic adjustments. Remember, switching schools may be a lot easier than switching work. You should always ask in advance what kind of accommodations a school is willing to make for someone with disabilities.
When would I need an advocate?
Despite efforts to educate people about mental illness, some people still harbor prejudices. Your teachers may not understand your condition, or believe that no one needs adjustments or accommodations. If you encounter problems asking for adjustments like longer test times or student note-takers, it may be helpful to involve an advocate to speak to your educator on your behalf.
How will going to school affect government benefits?
While government benefits such as SSI, SSDI or Food Stamps are generally impacted by wages and employment, attending school may have little or no impact on government benefits you receive. In fact, full-time students often have more benefits available to them. If your campus is large enough, you may have access to a health center or a teaching hospital. You can read more about attending school at http://www.disability.gov/education/.
What are some things to watch out for?
You should always make sure that your school is accredited by proper authorities. Regional and national organizations accredit institutions of learning to make sure they adhere to certain standards. Accreditation validates your degree. If you get a law degree, but your school isn’t accredited, you will not be able to practice law in most areas. It gets tricky because there are both recognized accreditation and unrecognized accreditation organizations. The Department of Education runs a database on accredited postsecondary institutions that can be found at http://ope.ed.gov/accreditation/.
Additionally, you should be aware of the fact that some schools or courses may be run by organizations or persons that have their own agenda and interests other than your education. You should always research the mission of any school you pick.
What are some other things I might need while attending school?
A permanent address – If you’re moving around frequently or staying with friends, you will still want a permanent address so you can receive important school documents. If you visit family and friends and trust them, ask if you can use their address temporarily. Otherwise, you might want to consider getting a P.O. Box from a local post office.
Important Documents – When you apply to a formal school, you may need to have proof of legal U.S. residency. Resident ID cards, passports, birth certificates, social security cards and driver’s licenses may help you with this. Schools are generally less strict about verifying legal status than employers. If you are pursuing adult education, you may need to have proof of address, as many locations offer discounts or require that you live in a certain area. Additionally, you may want to have something that verifies a diagnosis of a mental health condition in the event you need to request accommodations. Schools may ask for an updated diagnosis if you request an adjustment.
Transportation – If you do not have a car, research the schools you are interested in attending to see if they are accessible by public transportation. Generally, most schools and education centers are accessible by public transportation in areas where transportation is readily available. If not, your school might have its own bus system or a way to transport someone with a disability.

Introduction

This leaflet is aimed at:
•The carers of people with alcohol and drug problems (substance misuse) who provide continuing help and support, without payment, to a relative, partner or friend.
•The addiction specialists and other professionals involved in the care and treatment of the person with these problems.

It suggests ways of improving communication and partnerships when the person has first been diagnosed with a substance misuse or dependence disorder.

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For the carer

About substance misuse and dependence

Substance misuse harms a person’s health. Dependence occurs when there is physical and/or psychological addiction, and the person will have withdrawal symptoms if they do not use the substance. Their lives are dominated by getting and using the substance. People use many sorts of substances. These can be legal (alcohol, tobacco, and solvents), or illegal (cannabis, heroin and cocaine). Some prescribed drugs are addictive (eg, diazepam). Substance misuse and dependence is increasing in the UK, especially among the young.

Changes in the person’s behaviour

As a carer you may notice that the person is:
•More concerned with getting their substance than dealing with other things.
•Angry if confronted about their substance use.
•Secretive and evasive.
•More often intoxicated, or appears to be under the influence of something.
•Tired, irritable and looks less well.
•Less interested in everyday things.
•Unable to say ‘no’ and has a strong desire for the substance.
•Using more and more of the substance to get the same effect.
•Involved in criminal activity.
•Anxious, depressed or shows symptoms of other mental health problems.

Making a diagnosis

A diagnosis is made by talking to the person about their substance use, looking for signs of withdrawal, examining the person and asking them to perform certain tests. These can include urine-screening tests for drugs and, in the case of alcohol abuse, liver function tests.

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Treatments

The goal of treatment ranges from controlling consumption, to detox and giving up drinking or drugs completely. Psychological treatments are common for all forms of substance misuse, and for opiate (drug) addiction methadone and buprenorphine treatment. Medication is also available for both drug and alcohol addiction to help prevent relapse.

As the carer you may feel
•Frustrated and hurt.
•Unsure how to help.
•Concerned for the person’s safety and well-being.
•Worried about what will happen in the future.
•Angry if your help and advice are not accepted.
•Afraid the police will be involved.
•Frightened by the person’s behaviour.
•Feel that the person is beyond help.
•Worried about the effects on the rest of the family.
•Worried about financial consequences.

Tips for carers

(In partnership with your addiction specialist and other professionals.)

Good communication between all those involved in the person’s care is important, but takes time and effort. Forming a positive relationship with all those involved is important in helping to control or stop the substance use. You may be invited to become involved in treatment plans and in supporting the person. The professionals you may come across are:
•Psychiatrists
•GPs and other specialist doctors
•Addiction therapists
•Counsellors
•Nurses
•Drug workers
•Social workers
•Staff from various non-statutory services

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Questions to ask the doctor
•What does the diagnosis mean?
•Can you explain it in a way that I will understand?
•Are there any treatments?
•Where can I get information about medication and possible side-effects?
•Are there other things we can do to help ourselves?
•What can we expect in the near future and over time?
•Will the person be able to continue to work or in education?
•Is it safe for the person to drive?
•Will the person I care for get better?
•Is an addiction for life?
•How often should I come and see you?
•How can I best support the person?
•What are the risks of accidental overdose?
•Can you give me an ‘out-of-hours’ emergency telephone number?
•Do you have any written material on this disorder? If not, who does?
•Is there anything that we can change at home to make things easier or safer?
•Are there any organisations or community services that can help?
•Which health service worker is my main contact for guidance and advice?

Remember to arrange your next appointment before you leave.

Advice which will help you prepare for follow-up visits

Before your visit
•Keep track of changes in behaviour and reactions to medication in a notebook, along with any concerns or questions since your last visit.
•Look at the information you have collected and write down your top three concerns. This will make sure that you remember to talk about the things that matter. Your concerns may include questions about:
•changes in symptoms and behaviour
•side-effects of medication
•general health of the patient
•your own health
•additional help needed

During your visit
•If you do not understand something, ask questions. Don’t be afraid to speak up.
•Take notes during the visit. At the end, look over your notes and tell the healthcare professional what you understood. This gives them a chance to correct any information or repeat something that was missed.

Further tips for carers when dealing with healthcare professionals

Healthcare professionals can be reluctant to discuss a person’s diagnosis with the carer, as there is a duty of confidentiality between the professional and the patient. However, they will usually want to hear what you have to say. If the person is under 18, there is a balance between confidentiality and the need to share information.

If the healthcare professional is unwilling to involve you as a carer, there are a number of things you can do
•Ask the person you are caring for if you can stay with them during the visit. If the person agrees, the doctor is less likely to refuse.
•Talk with other carers as they may have some helpful suggestions.
•Try to talk to other members of the team involved in the person’s care.
•If you are not satisfied, use the Trust’s complaints’ procedure.

Don’t forget to look after yourself as well
•Share your worries with trusted friends and family members.
•Don’t bottle your feelings up – there is nothing wrong with a good cry.
•Try to keep in touch with friends.
•Go to see your own doctor if you cannot sleep, are exhausted, anxious or depressed.
•Make sure that you find time for yourself and do some simple exercise.

For the professional

As a professional working with people with substance misuse problems and dependence and their carers, we hope that the following is a helpful guide to good practice.

When doing an assessment, do you:
•Try to see the person with the substance problem and the carer separately, as well as seeing them together?
•Consider doing a home visit?

Do you allow yourself enough time to:
•Listen, ask, listen?
•Obtain a life history?
•Leave time for questions and discussion?
•Explain how you arrived at the diagnosis and the need for change?
•Talk about the prognosis?
•Assess the safety of children, carers and others?

In the management of the illness, do you:
•Discuss possible treatments?
•Talk about the possible side-effects of medication?
•Spend time asking about the carer’s health – physical and emotional?
•Discuss how to meet the care needs of both the person with the substance problem and the carer?

Points to remember
•Carers have their own needs and may need respite.
•Communication with everyone involved is important.
•Give easy to understand verbal and written information.
•Give contact telephone numbers.
•Remember issues relating to consent and confidentiality.

What is chronic tension-type headache and whom does it affect?

Chronic tension-type headache is a condition where you have a tension-type headache on at least 15 days every month.Tension-type headache is the common type of headache that most people have at some time. One study found that, on average:
•About half of adults have a tension-type headache every now and then – less than 1 a month. This is called infrequent episodic tension-type headache.
•About a third of adults have two or more tension-type headaches per month, but fewer than 15 a month. This is called frequent episodic tension-type headache.
•About 3 in 100 adults have a tension-type headache 15 or more times per month – that is, on most days. This is called chronic tension-type headache.

Chronic tension-type headache is sometimes called chronic daily headache, as many people have a headache every day. Chronic means persistent. It does not mean severe as some people think. The severity of the headaches can vary from mild to severe. Because of the persistent nature of the headaches, this condition can be quite disabling and distressing.

What causes chronic tension-type headache?

This condition tends to evolve in people who start off with having tension-type headaches more often than usual, until they occur on most days.

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What causes tension-type headaches?

The cause is not clear. Some, but probably not most, may be due to tension. This is why the term tension-type headache is now used rather than tension headache. Many tension-type headaches develop for no apparent reason. Some may be triggered by things such as:
•Emotional tension, anxiety, tiredness or stress.
•Physical tension in the muscles of the scalp and neck. For example, poor posture at a desk may cause the neck and scalp muscles to tense. If you squint to read because you cannot see well, this may tense your scalp muscles too.
•Physical factors such as bright sunlight, cold, heat, noise, etc.

Some research suggests that your genetic make-up may be a factor. So, some people may inherit a tendency to be more prone to develop tension-type headaches more easily than others when stressed or anxious.

By definition, tension-type headache is not caused by other conditions. So, if you have a tension-type headache, a doctor’s examination will be normal apart from the muscles around the head perhaps being a little tender when a doctor presses on them. Also, any tests that may be done will be normal.

Note – medication-overuse headache can be similar to chronic tension-type headache

Medication-overuse headache is caused by taking painkillers (or triptan medicines) too often for tension-type headaches or migraine attacks. For example, you may take a lot of painkillers for a bad spell of headaches. You may end up taking painkillers every day, or on most days. Your body then becomes used to painkillers. A withdrawal headache then develops if you do not take painkillers each day. You think this is just another tension-type headache, and so you take a further dose of painkiller. When the effect of each dose of painkiller wears off, a further withdrawal headache develops, and so on. This is how medication-overuse headache develops. It is a common cause of headaches that occur daily, or on most days. If you find that you are getting headaches on most days then this may be a cause. See a doctor for advice. A separate leaflet called ‘Headache – Medication Overuse’ gives more details.

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Headaches – causes and cures

What are the symptoms of each tension-type headache?
•Typically, the pain is like a tightness around the hat-band area. Some people feel a squeezing or pressure on their head. It usually occurs on both sides of your head, and often spreads down your neck, or seems to come from your neck. Sometimes it is just on one side. The pain is usually moderate or mild, but sometimes it is severe.
•A tension-type headache can last from 30 minutes to 7 days. Most last a few hours.
•The headache usually comes on during the day, and gets worse as the day goes on.
•There are usually no other symptoms. Some people don’t like bright lights or loud noises, and don’t feel like eating much when they have a tension-type headache.

The headaches you have with chronic tension-type headache are the same as described above, but occur frequently. In some cases, the headache seems to be permanent, and hardly ever goes, or only eases off but never goes completely.

Many people with chronic tension-type headache put up with their headaches without seeing a doctor. In one study, two-thirds of people diagnosed with chronic tension-type headache had had daily or near daily headache for an average of seven years before consulting a doctor. Most continued to function at work or school, but their performance was often not as good as it could be. Almost half had anxiety or depression, possibly as a result of coping with their frequent headaches.

If you think you have chronic tension-type headache, it is best to see a doctor, as treatment can often help.

How can I be sure it is not a more serious type of headache?

With tension-type headaches, you are normally well between headaches, and have no other ongoing symptoms. A doctor diagnoses tension-type headaches by their description. Also, there is nothing abnormal to find if a doctor examines you (apart from some tenderness of muscles around the head when a headache is present). Tests are not needed unless you have unusual symptoms, or something other than chronic tension-type headache is suspected. Of particular note, medication-overuse headache should be ruled out (described earlier) as this can often be mistaken for chronic tension-type headache.

Compared to migraine (the other common type of headache that comes and goes), a tension-type headache is usually less severe, and is constant rather than throbbing. Also, migraine attacks usually cause a one-sided headache, and many people with a migraine attack feel sick or vomit. In general, unlike migraine, you are usually able to continue with normal activities if you have a tension-type headache. Some people have both migraine attacks and tension-type headaches at different times.

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Painkillers

You may well be used to taking painkillers such as paracetamol, aspirin, ibuprofen, etc. But note: you should not take painkillers for headache for more than a couple of days at a time. Also, on average, do not take them for more than two days in any week for headaches. If you take them more often, you may develop medication-overuse headache (see above). Do not take painkillers all the time to prevent headaches. Take each day as it comes. Perhaps reserve painkillers for days which are particularly bad.

Opiate painkillers such as codeine, dihydrocodeine and morphine are not normally recommended for tension-type headaches. This includes combination tablets that contain paracetamol and codeine, such as co-codamol. The reason is because opiate painkillers can make you drowsy. They are also the most likely type of painkiller to cause medication-overuse headache if used regularly (described earlier).

Diary

It may help to keep a diary if you have frequent headaches. Note when, where, and how bad each headache is, and how long each headache lasts. Also note anything that may have caused it. A pattern may emerge and you may find a trigger to avoid. For example, hunger, eye strain, bad posture, stress, anger, etc.

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Stress and depression

Stress is a trigger for some people who develop tension-type headaches. Avoid stressful situations whenever possible. Sometimes a stressful job or situation cannot be avoided. Learning to cope with stress and to relax may help. Breathing and relaxation exercises, or coping strategies, may ease anxiety in stressful situations and prevent a possible headache. There are books and tapes which can teach you how to relax. Sometimes a referral to a counsellor or psychologist may be advised.

Regular exercise

Some people with frequent headaches say that they have fewer headaches if they exercise regularly. If you do not do much exercise, it may be worth trying some regular activities like brisk walking, jogging, cycling, swimming, etc. (This will have other health benefits too.) It is not clear how exercise may help. It may be that exercise helps to ease stress and tension, which can have a knock-on effect of reducing tension-type headaches.

Medication

Amitriptyline is the medicine most commonly used to treat chronic tension-type headaches. This is not a painkiller and so does not take away a headache if a headache develops. It is an antidepressant medicine and you have to take it every day with the aim of preventing headaches. (One effect of some antidepressants is to ease pain and prevent headaches even in people who are not depressed. So, although amitriptyline is classed as an antidepressant it is not used here to treat depression.) A low dose is started at first and may need to be increased over time. Once the headaches have been reduced for 4-6 months, the amitriptyline can be stopped. Treatment can be resumed if headaches recur. Other medicines are sometimes tried if amitriptyline is not suitable or does not help.

The goals of preventative treatment are to reduce the frequency and intensity of headaches. So, with treatment, the headaches may not go completely, but they will often develop less often and be less severe. Any headache that does occur whilst taking preventative medication may also be eased better than previously by a painkiller.

It is often difficult in retrospect to say how well a preventative treatment has worked. Therefore, it is best to keep a headache diary for a couple of weeks or so before starting preventative medication. This is to record when and how severe each headache was, and also how well it was eased by a painkiller. Then, keep the diary going as you take the preventative medicine to see how well things improve. The headaches are unlikely to go completely, but the diary may show a marked improvement.

Questions to ask the psychiatrist

Carers need information and psychiatrists are busy. Carers may not always find out what they need to know about the person they are caring for. This checklist is designed to help you get all the information you need about the diagnosis and treatment of the person you care for.

You may be able to get some of this information from other members of the clinical team involved, or from written information that they can provide.

If the person gives you permission, the psychiatrist will be able to give you information about their condition and care.

Although you may not want to ask all the questions listed, you may find that they help you in preparing to meet the psychiatrist and the mental health team. Not everyone will need all the answers to all these questions at the same time. You may have questions that are not covered in this leaflet. Even so, it should provide a helpful framework for deciding what you do need to know.

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About the illness
•What is the diagnosis or problem?
•If a diagnosis has not yet been made, what are the possibilities?
•Why has this happened to them?
•Will they recover?

If a diagnosis has been made
•What symptoms suggest this diagnosis/illness?
•What is known about the causes of this disorder/illness?
•What is likely to happen in the future? Will it get better or worse?
•Where can I get written information about this disorder?

About the assessment
•What assessments have already been done?
•Are there any other assessments that might be needed?
•Are there any physical problems that have been discovered? If so, what will need to be done?
•Have culture and background been considered?

Care Programme Approach (CPA)
•What is the CPA?
•What does the CPA mean?
•Is the person on the CPA? If not, why not?
•Will I be involved in the CPA?

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About care and treatment
•What are the aims of the care and treatment?
•What is a care co-ordinator?
•What part will the care co-ordinator play in the person’s care?
•Who else will be involved in the treatment?
•What is your plan for treatment?
•For how long will they need treatment?
•Would talking treatments (eg, cognitive behavioural therapy, family therapy) be helpful? If so, are they available locally?
•What happens if they refuse treatment?

Sharing of information
•Have you asked them about how much information they are happy to share with me?
•Will I be informed about important meetings concerning their care and treatment?
•Can I see you on my own?
•Would you like to ask me for any other information about them or the family?
•Can I tell you things that will not be shared with the person or other members of staff?
•Are their views on confidentiality clearly marked in their notes?

Care and treatment
•What can I do to help?
•Are there any local self-help or carers’ groups that can help me understand the illness?
•How can I get advice and training in the day-to-day management of the illness?
•Are there any local groups that can provide support?

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Getting help
•How can I get in touch with you?
•How do I arrange to see you?
•Who do I contact if I’m worried about their behaviour?
•What do I do if I’m worried that they are becoming ill again?
•Who do I contact in an emergency?
•What help might be available?
•How can I get a second opinion?

Carers
•What is the difference between a carer, a nearest relative and a nominated person?
•I understand that, as a carer, I am entitled to an assessment and care plan of my own. Who should I speak to?
•If I have specific needs of my own, who should I ask?
•If I need help, to whom should I turn?

Medication
•What medication is to be used, and how?
•Is the lowest effective dose being prescribed?
•Can a low dose be taken at first and increased if necessary?
•How often will the medication be reviewed?
•Will I be involved in future discussions about the dose or type of medication?
•What should the benefits of this medication be? •In the short term
•In the long term

•What are the possible side-effects of this medication? •In the short term
•In the long term

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Managing the medication
•Why have you chosen this particular medication?
•How long will the medication have to be taken for?
•Are there any other medications that could be used if this one does not work?
•What symptoms might mean that the dose should be changed?

What should I do if they experience unpleasant side-effects?
•What will happen if they stop taking the medication?
•Do you have any written information about this medication to give me?

Hospital treatment
•Do they need to be admitted to hospital? If so, for how long?
•If they have to go into hospital, which one will it be?
•Will they be on a locked ward?
•If they get short-term leave from hospital, when and how will I be informed?
•How often will I be able to see them?

Discharge from hospital
•What arrangements will be made for their care and monitoring after discharge from hospital?
•If I am not able to look after the person when they are discharged, what will happen?
•Am I expected to help with anything, especially medication?
•Do you know of any self-help techniques that will help their recovery?

If not admitted to hospital
•Do they need to be admitted to hospital?
•Are there any alternatives to hospital admission?

Content used with permission from the Royal College of Psychiatrists website: A checklist for carers of people with mental health problems. Copyright for this leaflet is with the Royal College of Psychiatrists.

SSRI antidepressants are used to treat depression and some other conditions. They can take 2-4 weeks to build up their effect to work fully. A normal course of antidepressants lasts at least six months after symptoms have eased. Side-effects may occur, but are often minor. At the end of a course of treatment, you should gradually reduce the dose as directed by your doctor before stopping completely.

SSRI antidepressants are not just for depression

SSRI stands for selective serotonin reuptake inhibitor. They are a group of antidepressant medicines that are used to treat depression. They are also used to treat some other conditions such as bulimia nervosa, panic disorder, and obsessive-compulsive disorder.

How do SSRI antidepressants work?

Antidepressants alter the balance of some of the chemicals in the brain (neurotransmitters). SSRI antidepressants mainly affect a neurotransmitter called serotonin.

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How effective are SSRI antidepressants?

About 5-7 in 10 people with moderate or severe depression have an improvement in symptoms within a few weeks of starting treatment with an antidepressant. However, up to 3 in 10 people improve with dummy tablets (placebos), as some people would have improved in this time naturally. So, if you have depression, you are roughly twice as likely to improve with an antidepressant compared with taking no treatment. But, they do not work in everybody. As a rule, the more severe the depression, the greater the chance that an antidepressant will work well.

Note: antidepressants do not necessarily make sad people happy. The word ‘depressed’ is often used when people really mean sad, fed-up, or unhappy. True depression is different to unhappiness and has persistent symptoms (which often include persistent sadness). See separate leaflet called Depression for more information about this condition.

The success rate of SSRI antidepressants can vary when used to treat the other conditions listed above (bulimia, panic disorder and obsessive-compulsive disorder).

How quickly do SSRI antidepressants work?

Some people notice an improvement within a few days of starting treatment. However, an antidepressant often takes 2-4 weeks to build up its effect and work fully. Some people stop treatment after a week or so thinking it is not helping. It is best to wait for 3-4 weeks before deciding if treatment with an SSRI is helping or not.

If you find that the treatment is helpful after 3-4 weeks, it is usual to continue. A normal course of antidepressants lasts at least six months after symptoms have eased. If you stop the medicine too soon, your symptoms may rapidly return. Some people with recurrent depression are advised to take longer courses of treatment (up to two years or longer).

When you are taking SSRI antidepressants

It is important to take the medication each day at the dose prescribed. Do not stop taking an SSRI medicine abruptly. This is because you may develop some withdrawal symptoms. The dose is usually gradually reduced before stopping completely at the end of a course of treatment. But don’t do this yourself – your doctor will advise on dosage reduction when the time comes. It is best not to stop treatment or change the dose without consulting a doctor.

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Are there different types of SSRI antidepressants?

There are several different types. They include citalopram, escitalopram, fluoxetine, paroxetine and sertraline. Each of these comes in different brand names. There is no best type that suits everyone. If the one chosen does not suit, it is sometimes necessary to change the dose, or change the preparation. Your doctor will advise. Also, if SSRI antidepressants do not help then another type of antidepressant may be advised.

What about side-effects and risks?

Most people have either minor, or no, side-effects. Possible side-effects vary between different preparations. The leaflet that comes in the medicine packet gives a full list of possible side-effects. You should read this before you start taking the medicine. It is beyond the scope of this leaflet to list all side-effects, but the following highlights some of the more common or serious ones.

As a rule, tell your doctor if a side-effect persists or is troublesome. Your doctor can advise on the best course of action – for example, to stop the medication, a switch to a different medicine, etc.

The most common side-effects

These include diarrhoea, feeling sick (nauseated), vomiting (being sick), and headaches. It is worth keeping on with treatment if these side-effects are mild at first as they may wear off after a week or so.

A possible sedating effect

SSRIs can cause drowsiness (a sedating effect) in some people. This side-effect is not common, and is not as much of a problem as with some other types of antidepressants. However, you must be aware of the possibility, especially if you are a driver, as it may impair your ability to drive safely. Any sedative effect is likely to be greatest in the first month of starting treatment, or on increasing the dose. The Driver and Vehicle Licensing Agency (DVLA) advises that you should not drive during this time if you feel that you are drowsy or sedated at all.

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Bleeding into the gut

Some research has suggested that SSRIs may be associated with a small increased risk of bleeding into the gut, but the evidence is inconclusive. This is especially in older people and in people taking other medicines that have the potential to damage the lining of the gut or interfere with clotting. Therefore, ideally, SSRIs should be avoided if you take aspirin, warfarin, novel anticoagulants (such as dabigatran, apixaban and rivoraxaban) or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. If no suitable alternative to an SSRI can be found and you have an increased risk of bleeding, your doctor may advise that you take an additional medicine. This will help to protect the lining of the gut.

Small increased risk of fractures

Research studies suggest that there is a small increased risk of fractures in people taking an SSRI. However, the reason for this increased risk is not clear.

Nervous system side-effects

Dizziness, agitation, anxiety, difficulty sleeping, and tremor have all been reported as possible side-effects.

Sexual problems

Problems with sexual function are a common symptom of depression. However, in addition to this, all antidepressants may cause some problems with sexual function. For example, problems getting an erection, vaginal dryness and decreased sex drive have been reported as side-effects in some people.

Antidepressants and suicidal behaviour

In recent years there have been some case reports which claim a link between taking antidepressants and feeling suicidal, particularly in teenagers and young adults. This may be more a risk in the first few weeks of starting medication or after a dose increase. It is debatable whether this possible risk is due to the medicine or to the depression. If it is due to the medication then the risk remains very small. And, overall, the most effective way to prevent suicidal thoughts and acts is to treat depression. However, because of this possible link, see your doctor promptly if you become increasingly restless, anxious or agitated, or if you have any suicidal thoughts. In particular, you should speak with your doctor if these develop in the early stages of treatment or following an increase in dose.

Are SSRI antidepressants addictive?

SSRIs are not tranquillisers, and are not thought to be addictive. Most people can stop an SSRI without any problem. At the end of a course of treatment you should reduce the dose gradually over about four weeks before finally stopping. This is because some people develop withdrawal symptoms if the medication is stopped abruptly. If you have withdrawal symptoms it does not mean that you are addicted to the the medicine, as other features of addiction such as cravings for the medicine do not occur.

Withdrawal symptoms that may occur include:
•Dizziness
•Anxiety and agitation
•Sleep disturbance
•Flu-like symptoms
•Diarrhoea
•Tummy (abdominal) cramps
•Pins and needles
•Mood swings
•Feeling sick (nauseated)
•Low mood

These symptoms are unlikely to occur if you reduce the dose gradually. If withdrawal symptoms do occur, they will usually last less than two weeks. An option if they do occur is to restart the drug and reduce the dose even more slowly.

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How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at the following web address: http://www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines may have caused. If you wish to report a side-effect, you will need to provide basic information about:
•The side-effect.
•The name of the medicine which you think caused it.
•Information about the person who had the side-effect.
•Your contact details as the reporter of the side-effect.

It is helpful if you have your medication – and/or the leaflet that came with it – with you while you fill out the report.

Antipsychotics are medicines that are mainly used to treat schizophrenia or mania caused by bipolar disorder. There are two main types of antipsychotics: atypical antipsychotics and older antipsychotics. Both types are thought to work as well as each other. Side-effects are common with antipsychotics. You will need regular tests to monitor for side-effects while you take theses medicines.

What are antipsychotics?

Antipsychotics are a group of medicines that are mainly used to treat mental health illnesses such as schizophrenia, or mania (where you feel high or elated) caused by bipolar disorder. They can also be used to treat severe depression and severe anxiety. Antipsychotics are sometimes also called major tranquillisers.

There are two main types of antipsychotics:
•Newer or atypical antipsychotics. These are sometimes called second-generation antipsychotics and include: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.
•Older typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide, sulpiride, trifluoperazine, and zuclopenthixol.

Antipsychotics are available as tablets, capsules, liquids, and depot injections (long-acting). They come in various different brand names.

Older antipsychotics have been used since the 1950s and are still prescribed today. Newer antipsychotics were developed in the 1970s onwards. It was originally thought that these medicines would have fewer side-effects than the older type of antipsychotics. However, we now know that they can also cause quite a few side-effects.

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How do antipsychotics work?

Antipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine, serotonin, noradrenaline and acetylcholine. These chemicals have the effect of changing your behaviour, mood and emotions. Dopamine is the main chemical that these medicines have an effect on.

By altering the effects of these chemicals in the brain they can suppress or prevent you from experiencing:
•Hallucinations (such as hearing voices).
•Delusions (having ideas not based on reality).
•Thought disorder.
•Extreme mood swings that are associated with bipolar disorder.

When are antipsychotics usually prescribed?

As discussed above, antipsychotics are usually prescribed to help to ease the symptoms of schizophrenia, mania (caused by bipolar disorder), severe depression or severe anxiety. Normally they are started by a specialist in psychiatry, or your GP will ask a specialist for advice on when to start them.

Also, for many years antipsychotics were used to calm elderly people who had dementia, but this use is no longer recommended. This is because these medicines are thought to increase the risk of stroke and early death – by a small amount. Risperidone is the only antipsychotic recommended for use in these people. Even then, it should only be used for short period of time (less than six weeks) and for severe symptoms.

Which antipsychotic is usually prescribed?

The choice of antipsychotic prescribed depends upon what is being treated, how severe your symptoms are, and if you have any other health problems. There are a number of differences between the various antipsychotic medicines. For example, some are more sedating than others. Therefore, one may be better for one individual than for another. A specialist in psychiatry usually advises on which to use in each case. It is difficult to tell which antipsychotic will work well for you. If one does not work so well, a different one is often tried and may work well. Your doctor will advise.

It is thought that the older and newer types of antipsychotics work as well as each other. The exception to this is clozapine – it is the only antipsychotic that is thought to work better than the others. Unfortunately, clozapine has a number of possible serious side-effects, especially on your blood cells. This means that people who take clozapine have to have regular blood tests.

In some cases, an injection of a long-acting antipsychotic medicine (depot injection) is used once symptoms have eased. The medicine from a depot injection is slowly released into the body and is given every 2-4 weeks. This aims to prevent relapses (recurrences of symptoms). The main advantage of depot injections is that you do not have to remember to take tablets every day.

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How well do antipsychotics work?

It is thought that for every 10 people who take these medicines, 8 will experience an improvement in their symptoms. Unfortunately, antipsychotics do not always make the symptoms go away completely, or for ever. A lot people need to take them in the long term even if they feel well. This is in order to stop their symptoms from coming back. Even if you take these medicines on a long-term basis and they are helping, sometimes your symptoms can come back.

Symptoms may take 2-4 weeks to ease after starting medication, and it can take several weeks for full improvement. The dose of the medicine is usually built up gradually to help to prevent side-effects (including weight gain).

What is the usual length of treatment?

This depends on various things. Some people may only need to take them for a few weeks, but others may need to take them long-term (for example, for schizophrenia). Even when symptoms ease, antipsychotic medication is normally continued long-term if you have schizophrenia. This aims to prevent relapses, or to limit the number and severity of relapses. However, if you only have one episode of symptoms of schizophrenia that clears completely with treatment, one option is to try coming off medication after 1-2 years. Your doctor will advise.

Stopping antipsychotics

If you want to stop taking an antipsychotic you should always talk to your doctor first. This is in order to help you decide if stopping is the best thing for you, and how you should stop taking your medicine. These medicines are usually stopped slowly over a number of weeks. If you stop taking an antipsychotic medicine suddenly, you may become unwell quite quickly. Your doctor will usually advise you to reduce the dose slowly to see what effect the lower dose has on your symptoms.

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What about side-effects from antipsychotics?

Side-effects can sometimes be troublesome. There is often a trade-off between easing symptoms and having to put up with some side-effects from treatment. The different antipsychotic medicines can have different types of side-effects. Also, sometimes one medicine causes side-effects in some people and not in others. Therefore, it is not unusual to try two or more different medicines before one is found that is best suited to an individual.

The following are the main side-effects that sometimes occur. However, you should read the information leaflet that comes in each medicine packet for a full list of possible side-effects.

Common side-effects include:
•Dry mouth, blurred vision, flushing and constipation. These may ease off when you get used to the medicine.
•Drowsiness (sedation), which is also common but may be an indication that the dose is too high. A reduced dose may be an option.
•Weight gain which some people develop. Weight gain may increase the risk of developing diabetes and heart problems in the longer term. This appears to be a particular problem with the atypical antipsychotics – notably, clozapine and olanzapine.
•Movement disorders which develop in some cases. These include: •Parkinsonism – this can cause symptoms similar to those that occur in people with Parkinson’s disease – for example, tremor and muscle stiffness.
•Akathisia – this is like a restlessness of the legs.
•Dystonia – this means abnormal movements of the face and body.
•Tardive dyskinesia (TD) – this is a movement disorder that can occur if you take antipsychotics for several years. It causes rhythmical, involuntary movements. These are usually lip-smacking and tongue-rotating movements, although it can affect the arms and legs too. About 1 in 5 people treated with typical antipsychotics eventually develops TD.

Atypical antipsychotic medicines are thought to be less likely to cause movement disorder side-effects than typical antipsychotic medicines. This reduced incidence of movement disorder is the main reason why an atypical antipsychotic is often used first-line. Atypicals do, however, have their own risks – in particular, the risk of weight gain. If movement disorder side-effects occur then other medicines may be used to try to counteract them.

Will I need any tests while taking an antipsychotic?

Your doctor will want to monitor you regularly for side-effects if you take an antipsychotic. The tests needed and how often you will need to have them depend on which antipsychotic you are taking.

In general, your doctor will take a sample of blood for certain tests before you start treatment. The tests look at how many blood cells you have, how well your kidneys and liver are working, how much lipid (fat) is in your blood, and if you have diabetes. These tests may be repeated in the first 3 or 4 months of treatment. After this they are normally done every year. However, your doctor may advise you to have these tests more often.

Your weight and blood pressure are usually measured before you start treatment and every few weeks after this for the first few months. After this they are normally measured every year.

The blood level of prolactin (a hormone) may also be measured before starting treatment and six months later. Usually it is then measured every year after this. The prolactin level is measured because sometimes antipsychotics can make you produce too much of this hormone. If you make too much prolactin it can lead to your breasts growing bigger and breast milk being produced.

Note: people taking clozapine need weekly blood tests for the first six months and two-weekly blood tests after that. This is because it can have a serious effect on how many blood cells you make.

Who cannot take antipsychotics?

Antipsychotics are usually not prescribed for people who are comatose (in a coma), have depression of their central nervous system, and who have phaeochromocytoma (tumour on the adrenal gland).

Can I buy antipsychotics?

No – they are only available from your pharmacist, with a doctor’s prescription.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines, you can report this on the Yellow Card Scheme. You can do this online at the following web address: http://www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that your medicines may have caused. If you wish to report a side-effect, you will need to provide basic information about:
•The side-effect.
•The name of the medicine which you think caused it.
•Information about the person who had the side-effect.
•Your contact details as the reporter of the side-effect.

It is helpful if you have your medication and/or the leaflet that came with it with you while you fill out the report.

Antipsychotics are medicines that are mainly used to treat schizophrenia or mania caused by bipolar disorder. There are two main types of antipsychotics: atypical antipsychotics and older antipsychotics. Both types are thought to work as well as each other. Side-effects are common with antipsychotics. You will need regular tests to monitor for side-effects while you take theses medicines.

What are antipsychotics?

Antipsychotics are a group of medicines that are mainly used to treat mental health illnesses such as schizophrenia, or mania (where you feel high or elated) caused by bipolar disorder. They can also be used to treat severe depression and severe anxiety. Antipsychotics are sometimes also called major tranquillisers.

There are two main types of antipsychotics:
•Newer or atypical antipsychotics. These are sometimes called second-generation antipsychotics and include: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.
•Older typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide, sulpiride, trifluoperazine, and zuclopenthixol.

Antipsychotics are available as tablets, capsules, liquids, and depot injections (long-acting). They come in various different brand names.

Older antipsychotics have been used since the 1950s and are still prescribed today. Newer antipsychotics were developed in the 1970s onwards. It was originally thought that these medicines would have fewer side-effects than the older type of antipsychotics. However, we now know that they can also cause quite a few side-effects.

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How do antipsychotics work?

Antipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine, serotonin, noradrenaline and acetylcholine. These chemicals have the effect of changing your behaviour, mood and emotions. Dopamine is the main chemical that these medicines have an effect on.

By altering the effects of these chemicals in the brain they can suppress or prevent you from experiencing:
•Hallucinations (such as hearing voices).
•Delusions (having ideas not based on reality).
•Thought disorder.
•Extreme mood swings that are associated with bipolar disorder.

When are antipsychotics usually prescribed?

As discussed above, antipsychotics are usually prescribed to help to ease the symptoms of schizophrenia, mania (caused by bipolar disorder), severe depression or severe anxiety. Normally they are started by a specialist in psychiatry, or your GP will ask a specialist for advice on when to start them.

Also, for many years antipsychotics were used to calm elderly people who had dementia, but this use is no longer recommended. This is because these medicines are thought to increase the risk of stroke and early death – by a small amount. Risperidone is the only antipsychotic recommended for use in these people. Even then, it should only be used for short period of time (less than six weeks) and for severe symptoms.

Which antipsychotic is usually prescribed?

The choice of antipsychotic prescribed depends upon what is being treated, how severe your symptoms are, and if you have any other health problems. There are a number of differences between the various antipsychotic medicines. For example, some are more sedating than others. Therefore, one may be better for one individual than for another. A specialist in psychiatry usually advises on which to use in each case. It is difficult to tell which antipsychotic will work well for you. If one does not work so well, a different one is often tried and may work well. Your doctor will advise.

It is thought that the older and newer types of antipsychotics work as well as each other. The exception to this is clozapine – it is the only antipsychotic that is thought to work better than the others. Unfortunately, clozapine has a number of possible serious side-effects, especially on your blood cells. This means that people who take clozapine have to have regular blood tests.

In some cases, an injection of a long-acting antipsychotic medicine (depot injection) is used once symptoms have eased. The medicine from a depot injection is slowly released into the body and is given every 2-4 weeks. This aims to prevent relapses (recurrences of symptoms). The main advantage of depot injections is that you do not have to remember to take tablets every day.

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Schizophrenia
How well do antipsychotics work?

It is thought that for every 10 people who take these medicines, 8 will experience an improvement in their symptoms. Unfortunately, antipsychotics do not always make the symptoms go away completely, or for ever. A lot people need to take them in the long term even if they feel well. This is in order to stop their symptoms from coming back. Even if you take these medicines on a long-term basis and they are helping, sometimes your symptoms can come back.

Symptoms may take 2-4 weeks to ease after starting medication, and it can take several weeks for full improvement. The dose of the medicine is usually built up gradually to help to prevent side-effects (including weight gain).

What is the usual length of treatment?

This depends on various things. Some people may only need to take them for a few weeks, but others may need to take them long-term (for example, for schizophrenia). Even when symptoms ease, antipsychotic medication is normally continued long-term if you have schizophrenia. This aims to prevent relapses, or to limit the number and severity of relapses. However, if you only have one episode of symptoms of schizophrenia that clears completely with treatment, one option is to try coming off medication after 1-2 years. Your doctor will advise.

Stopping antipsychotics

If you want to stop taking an antipsychotic you should always talk to your doctor first. This is in order to help you decide if stopping is the best thing for you, and how you should stop taking your medicine. These medicines are usually stopped slowly over a number of weeks. If you stop taking an antipsychotic medicine suddenly, you may become unwell quite quickly. Your doctor will usually advise you to reduce the dose slowly to see what effect the lower dose has on your symptoms.

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What about side-effects from antipsychotics?

Side-effects can sometimes be troublesome. There is often a trade-off between easing symptoms and having to put up with some side-effects from treatment. The different antipsychotic medicines can have different types of side-effects. Also, sometimes one medicine causes side-effects in some people and not in others. Therefore, it is not unusual to try two or more different medicines before one is found that is best suited to an individual.

The following are the main side-effects that sometimes occur. However, you should read the information leaflet that comes in each medicine packet for a full list of possible side-effects.

Common side-effects include:
•Dry mouth, blurred vision, flushing and constipation. These may ease off when you get used to the medicine.
•Drowsiness (sedation), which is also common but may be an indication that the dose is too high. A reduced dose may be an option.
•Weight gain which some people develop. Weight gain may increase the risk of developing diabetes and heart problems in the longer term. This appears to be a particular problem with the atypical antipsychotics – notably, clozapine and olanzapine.
•Movement disorders which develop in some cases. These include: •Parkinsonism – this can cause symptoms similar to those that occur in people with Parkinson’s disease – for example, tremor and muscle stiffness.
•Akathisia – this is like a restlessness of the legs.
•Dystonia – this means abnormal movements of the face and body.
•Tardive dyskinesia (TD) – this is a movement disorder that can occur if you take antipsychotics for several years. It causes rhythmical, involuntary movements. These are usually lip-smacking and tongue-rotating movements, although it can affect the arms and legs too. About 1 in 5 people treated with typical antipsychotics eventually develops TD.

Atypical antipsychotic medicines are thought to be less likely to cause movement disorder side-effects than typical antipsychotic medicines. This reduced incidence of movement disorder is the main reason why an atypical antipsychotic is often used first-line. Atypicals do, however, have their own risks – in particular, the risk of weight gain. If movement disorder side-effects occur then other medicines may be used to try to counteract them.

Will I need any tests while taking an antipsychotic?

Your doctor will want to monitor you regularly for side-effects if you take an antipsychotic. The tests needed and how often you will need to have them depend on which antipsychotic you are taking.

In general, your doctor will take a sample of blood for certain tests before you start treatment. The tests look at how many blood cells you have, how well your kidneys and liver are working, how much lipid (fat) is in your blood, and if you have diabetes. These tests may be repeated in the first 3 or 4 months of treatment. After this they are normally done every year. However, your doctor may advise you to have these tests more often.

Your weight and blood pressure are usually measured before you start treatment and every few weeks after this for the first few months. After this they are normally measured every year.

The blood level of prolactin (a hormone) may also be measured before starting treatment and six months later. Usually it is then measured every year after this. The prolactin level is measured because sometimes antipsychotics can make you produce too much of this hormone. If you make too much prolactin it can lead to your breasts growing bigger and breast milk being produced.

Note: people taking clozapine need weekly blood tests for the first six months and two-weekly blood tests after that. This is because it can have a serious effect on how many blood cells you make.

Who cannot take antipsychotics?

Antipsychotics are usually not prescribed for people who are comatose (in a coma), have depression of their central nervous system, and who have phaeochromocytoma (tumour on the adrenal gland).

Can I buy antipsychotics?

No – they are only available from your pharmacist, with a doctor’s prescription.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines, you can report this on the Yellow Card Scheme. You can do this online at the following web address: http://www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that your medicines may have caused. If you wish to report a side-effect, you will need to provide basic information about:
•The side-effect.
•The name of the medicine which you think caused it.
•Information about the person who had the side-effect.
•Your contact details as the reporter of the side-effect.

It is helpful if you have your medication and/or the leaflet that came with it with you while you fill out the report.

What is anorexia nervosa?

Anorexia nervosa (just called anorexia from now on) is an eating disorder. Anorexia is a serious condition which affects all sorts of people. Anorexia is very common – about 1 in 20 teenagers has it. However, it affects people of all ages and has become more common in boys and men in recent years.

People with anorexia often find that they do not allow themselves to feel full after eating. This means that they restrict the amount they eat and drink. People with anorexia are underweight. Sometimes, the weight becomes so low that it is dangerous to health.

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How do I know if I have an eating disorder?

If you answer yes to two or more of these questions then you may have an eating disorder and you should see your doctor:
•Do you make yourself sick because you are uncomfortably full?
•Do you worry that you’ve lost control over how much you eat?
•Have you recently lost more than 6 kg (about one stone) in the past three months?
•Do you believe you’re fat when others think you are thin?
•Would you say that food dominates your life?

What are the symptoms of anorexia nervosa?

Deliberate weight loss

This is the main symptom. You lose weight by avoiding fattening foods or even any foods. People with anorexia limit the amount they eat and drink, in order to control how their body looks. You may often pretend to other people that you are eating far more than you actually are. You may be using other ways of staying thin such as exercising too much. You may also have made yourself vomit, take laxatives, or even take appetite suppressant medicines or diuretics (water tablets).

People with anorexia typically weigh 15% or more below the expected weight for their age, sex and height. The body mass index (BMI) is calculated by your weight (in kilograms) divided by the square of your height (in metres). For example, if you weigh 66 kg and are 1.7 m tall then your BMI would be 66/(1.7 x 1.7) = 22.8. A normal BMI for an adult is 20-25. Above that you are overweight, and below that you are underweight. Adults with anorexia have a BMI below 17.5.

With anorexia, you feel very in control of your bodyweight and shape. However, with time, anorexia can take control of you. After some time it can become very difficult to make healthy, normal choices about the amount and types of food you eat.

A wrong idea of body size

People with anorexia think that they are fat when they are actually very thin. Although other people see you as thin or underweight, it is very difficult for you to see this. You are likely to have a severe dread (like a phobia) of gaining weight. People with anorexia will do their utmost to avoid putting on weight.

Other features

It is common for people with anorexia to:
•Vomit secretly after eating.
•Try hard to hide their thinness – for example, by wearing baggy clothes.
•Tend not to be truthful about how much they eat and everything to do with food.
•Like food and feel hungry. However, it is the consequences of eating that frighten them.

People with anorexia may also become obsessed with what other people are eating.

People with anorexia often restrict themselves to certain types of food. Eating food may even become like a ritual. For example, each time you eat, you have to cut your food into very small pieces. You may think frequently about your weight and even weigh yourself most days or even several times a day. It is also common to feel cold most of the time and to have irregular sleeping patterns. You might also find yourself having poor concentration.

What are the health risks with anorexia nervosa?

Health risks are caused by undereating (starvation) and by the methods used to get rid of eaten food (vomiting, excess laxatives, etc). Problems that may occur include the following:

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Irregular periods

Many women with anorexia have irregular periods, as hormone levels can be affected by poor diet. Their periods may even stop altogether or they may find that their periods have never started, especially if they started having eating problems when they were younger. Some women with anorexia may be infertile (unable to have a baby).

Chemical imbalances in the body

These are caused either by repeated vomiting or by excess use of laxatives – for example, a low potassium level which may cause tiredness, weakness, abnormal heart rhythms, kidney damage and convulsions. Low calcium levels can lead to tetany (muscle spasms).

Thinning of the bones (osteoporosis)

This is caused by a lack of calcium and vitamin D and can lead to easily fractured bones. In addition, the risk of getting osteoporosis increases if you are a woman and your periods have stopped. This is because oestrogen in your body protects your bones from osteoporosis and the levels of oestrogen in your body reduce when your periods stop.

Bowel problems

These may occur if you take a lot of laxatives. Laxatives can damage the bowel muscle and nerve endings. This may eventually result in permanent constipation and also sometimes abdominal pains.

Swelling of hands, feet and face

This is usually due to fluid disturbances in the body.

Teeth problems

These can be caused by the acid from the stomach rotting away the enamel with repeated vomiting.

Anaemia

Having a diet low in iron can lead to anaemia. This can make you feel weaker and more tired than normal. Dizzy spells and feeling faint can also occur.

Depression

It is common to feel low when you have anorexia. Some people develop clinical depression, which can respond well to treatment. It is important to talk to your doctor about any symptoms of depression you may have. Many people find they become more moody or irritable.

Hair and skin problems

You may find you have downy hair on your body and also the hair on your head becomes thinner. Many people with anorexia also have dry, rough skin.

What is the cause of anorexia nervosa?

The exact cause is not fully understood. Part of the cause is a fear of getting fat but it is not just as simple as that. Different causes possibly work together to bring on the condition. These may include the following:
•The pressure from society and the media to be thin is thought to play a part. This is probably why anorexia is much more common in westernised countries.
•Personality and family environment probably play a role too. People with anorexia often have poor self-esteem (not much self-confidence) and commonly feel that they have to be perfectionists. Often there are disturbed family relationships. All sorts of emotions, feelings and attitudes may contribute to causing anorexia.
•There may be some genetic factor. We know this from studies of families with identical twins. If one twin has anorexia then the other has a 1 in 2 chance of getting it. This tells us that the condition may have a genetic part. However, because not every twin gets it, there are other factors too.

Are any tests needed?

Although there is no test to diagnose anorexia, your doctor may wish to do some tests. These may include blood tests to check for complications of anorexia – for example, anaemia, potassium levels, kidney or liver problems or a low glucose level. An ECG hear tracing (electrocardiography) may be advised to check for an irregular heart rhythm.

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Bulimia nervosa
What is the treatment for anorexia nervosa?

The aim of treatment is to:
•Reduce risk of harm (and death) which can be caused by anorexia.
•Encourage weight gain and healthy eating.
•Reduce other related symptoms and problems.
•Help people become both physically and mentally stronger.

You are likely to be referred to a specialist mental health team which includes psychiatrists, psychologists, nurses, dietitians and other professionals. If you have more severe anorexia, you may be referred to a specialist eating disorder unit.

The sort of treatments that may be offered include the following:

Help with eating

Having regular meals is better. Even if you only eat small meals it is beneficial to the body to eat at least three times a day. You should try to be honest (with yourself and other people) about the amount of food you are actually eating. You should reduce the number of times you weigh yourself; try to weigh yourself only once a week. It may be useful to keep an eating diary to write down all the food that you eat.

Psychological (talking) treatments

For example, cognitive behavioural therapy (CBT), cognitive analytic therapy (CAT), interpersonal psychotherapy (IPT) and focal psychodynamic therapy. Talking treatments help to look at the reasons why you may have developed anorexia, and aim to change any false beliefs that you may have about your weight and body, and to help show you how to identify and deal with emotional issues. Talking treatments take time and usually require regular sessions over several months. Treatment may also involve other members of your family going to meetings to discuss any family issues.

Antidepressant medication

This may be advised in addition to talking treatments if you also develop depression. These are not always recommended if you are younger than 18 years old.

Treatment of any physical or teeth problems that may occur

This may include taking potassium supplements, having dental care and trying not to use laxatives or water tablets. You may be recommend to take hormones (for example, the oral contraceptive pill) to increase levels of oestrogen in your body to help strengthen your bones.

Self-help measures may be of benefit

There are a number of self-help books and guides available. These provide methods on how to cope with and overcome anorexia. (Beat – the Eating Disorders Association listed at the end – may be able to suggest current titles.) They are not suitable for everyone, particularly if your anorexia is severe.

Some people with more severe anorexia may need to have a short stay in hospital.

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What is the outlook (prognosis)?

With treatment, anorexia can take weeks or even many months to improve. It can take several years for people with anorexia to become completely better. Many people find they still have issues with food, even after treatment, but they are more in control and can lead happier, more fulfilled lives.

Unfortunately, some people with anorexia die from causes related to anorexia. Causes of death include infections, dehydration, blood chemical imbalances (such as low potassium levels) and even suicide.