Appropriate use of psychotropic medicines in adult social care

Psychotropic medicines work in the brain. They affect behaviour, mood, consciousness, thoughts or perception. 

Psychotropic medicines are used to treat mental illness. Sometimes, they are given to people to restrain or to control behaviour that others may see as challenging.

Examples of psychotropic medicines include:

• antipsychotics
• antidepressants
• mood stabilisers
• anxiolytics (benzodiazepines)
• sedatives/hypnotics
• anti-epileptics.

The quality statement for Medicines optimisation is that, ‘People’s behaviour is not inappropriately controlled by medicines’.  

People with dementia

People living with dementia often experience behavioural and psychological symptoms. These can include:

• agitation
• aggression
• hallucinations
• delusions.

Good practice recommendations state that psychosocial and environmental interventions can reduce distress. For example, checking for and addressing pain, delirium or inappropriate care.

Many people will experience an improvement in behavioural and psychological symptoms over a 4 to 6 week period.

See NICE NG97 Dementia: assessment, management and support for people living with dementia and their carers.

Antipsychotic medicines should only be used if people with dementia are either:

• at risk of harming themselves or others, or
• experiencing agitation, hallucinations or delusions that are causing them severe distress.

Risperidone and haloperidol are the only antipsychotic medicines licensed in the UK for treating behavioural and psychological symptoms in dementia (for up to 6 weeks use). Due to the adverse effects of haloperidol, risperidone is the preferred choice.

Risperidone may be used for longer than 6 weeks, or other antipsychotics may be prescribed for people with behavioural and psychological symptoms in dementia. This is known as ‘off-label’ or unlicensed prescribing because it goes outside of the UK marketing authorisation.

The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The person (or those with authority to give consent on their behalf) should provide informed consent. This should be documented.

• Read the General Medical Council's Good practice in prescribing and managing medicines and devices for more information.

Antipsychotic medicines are more likely to cause side effects in people with dementia. These include an increased risk of stroke and death.

People with a learning disability and autistic people

People with a learning disability and autistic people are more likely to take psychotropic medicines. These medicines may need to be monitored regularly. They can cause side effects that affect people's physical health.

Psychotropic medicines are sometimes used to control how a person behaves or to restrain them. This could be because staff do not know how to communicate with a person or meet their needs to maintain a good quality of life. Staff should only use psychotropic medicines as the least restrictive option. They must include them in a person-centred care plan.

STOMP stands for stopping over medication of people with a learning disability and autistic people. STOMP is a national project to reduce prescribing and administration of psychotropic medicines. It is about helping people to stay well and have a good quality of life.

Only consider psychotropic medicines if:

• psychological or other interventions, such as treatment for any coexisting mental or physical health problem, have not helped to improve the person’s quality of life, or
• the risk of harm to the person or others is severe. See NICE NG11 Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges.

Considerations for providers

• Follow best practice recommendations and national guidelines. For example, NICE NG10 Violence and aggression: short-term management in mental health, health and community settings.
• Assess people’s capacity to make decisions about their medicines. This includes use of medicines outside of the UK marketing authorisation. Follow the principles of the Mental Capacity Act 2005 if necessary.
• Act in a way that is proportionate, pragmatic and safe. Focus on the best interests of individuals.
• When considering psychotropic medicines, ensure you:
  • include when medicines might be used in person-centred behavioural care planning
  • keep clear records of behaviour that staff find difficult to manage
  • identify themes and triggers
  • put environmental and psychological support in place to reduce distress, improve communication and quality of life
  • use medicines only as the least restrictive option.
• Provide accessible medicines information. Explain the risks and benefits of taking a psychotropic medicine. This supports shared decision-making.
• If medicines are prescribed to be administered 'when required' (PRN medicine):
  • make sure you have clear, person-centred guidance for staff, and explain when it might be needed and the expected outcome.
  • evaluate and record the outcome of giving a when required medicine to make sure it is having the required effect.
• Make sure staff are knowledgeable about psychotropic medicines. Staff should be able to identify potential side effects from taking a medicine. Seek healthcare advice if needed.
• Work collaboratively with healthcare staff and share information. Support people to access:
  • medicines reviews
  • physical health checks
  • therapeutic medicine
• Report the numbers of people who have had their behaviour controlled or restrained by medicines. Use the adult social care provider information return.
• Consider reporting issues involving controlled drugs (for example, pregabalin, gabapentin and benzodiazepines) to the NHS England controlled drugs local intelligence network.