Appropriate use of psychotropic medicines in adult social care

Psychotropic medicines work in the brain. They affect behaviour, mood, consciousness, thoughts or perception. They are used to treat mental illness. Sometimes they are given to people to restrain or to control behaviour seen as challenging by others.

Examples of psychotropic medicines include:

• antipsychotics
• antidepressants
• mood stabilisers
• anxiolytics (benzodiazepines)
• sedatives
• antiepileptics.

You must make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines. Read S4.5 of our key lines of enquiry for adult social care:

• S4.5 How does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?

People with dementia

Behavioural and psychological symptoms are often experienced by people living with dementia. These symptoms can include agitation, aggression, hallucinations and delusions.

Good practice recommendations recommend psychosocial and environmental interventions to 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 four to six week period. Read NICE NG97 Dementia: assessment, management and support for people living with dementia and their carers.

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

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

Risperidone is the only antipsychotic medicine licensed in the UK for treating behavioural and psychological symptoms in dementia for up to six weeks. Risperidone may be used for longer than six weeks, or other antipsychotics may be prescribed for people with behavioural and psychological symptoms in dementia. This is prescribing outside of the UK marketing authorisation. It is known as unlicensed or ‘off-label’ use. 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, harm and death for people living with dementia.

People with a learning disability and autistic people

Psychotropic medicines are more likely to be taken by people with a learning disability and autistic people. These medicines may need regular monitoring. 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 to meet their needs to maintain a good quality of life. Psychotropic medicines should only be used as the least restrictive option. They must be included in a person-centred care plan.

STOMP stands for stopping overmedication 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.

Psychotropic medicines should only be considered 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 very severe. Read 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.
• 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. Using a medicine should be 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, make sure you have clear, person-centred guidance for staff. 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. Healthcare advice should be sought if needed.
• Work collaboratively with healthcare staff and share information. Support people to access medicines reviews, physical health checks and therapeutic medicine monitoring.
• Report the numbers of people who have had their behaviour was controlled or restrained by medicines. Use the adult social care provider information return.