Summary of Maudsley Prescribing Guidelines

I have created this compact summary of prescribing guidelines on the request of one my teachers. I really
benefitted from the process and still find these notes very useful. I am sharing these notes with you and I hope
it will help all my colleagues. I recommend to take a print copy of these.
Dr Waleed Ahmad
Twitter: @DoctorPKMC
Condition Antipsychotic Mood stabilizer Sedative Antidepressant Other

Renal Failure Haloperidol 2-6mg a day Valproate Zopiclone Citalopram Rivastigmine for dementia
Olanzapine 5mg a day Carbamezapine Lorazepam Sertraline
Lamotrigine
Liver failure Haloperidol Lithium Lorazepam Imipramine
Amisulpiride Oxazepam Citalopram
Palliperidone deot Temazepam Paroxetine
Zopiclone
Epilepsy Haloperidol Moclobemide
Trifluperazine SSRIs except citalopram
Sulpiride mirtazapine
Amisulpiride
Dementia Risperidone (licensed) Use may be justified where Avoid benzodiazepines, SSRIs Ginkgo Biloba may be
Olanzapine other treatments are Effect is modest at best. effective for symptoms like
Effect is modest at best contraindicated or ineffective Supporting evidence is weak apathy, anxiety, depression.
Valproate best avoided 240mg per day
Parkinson’s Disease 1. Rule out organicity SSRIs 1st choice Depression:
2. Optimize environment SNRIs but venlafaxine ay Rule our organicity as a 1st
3. Less severe, do not treat worsen modestly the motor step, Consider CBT as 2nd
4. Reduce anticholinergics and symptoms step in addition to
DA agonists TCAs at low doses more antidepressants,
5. Quetiapine effective than SSRIs but poorly Augmentation with
6. AChE inhibitor tolerated. pramipexole or other DA
7. Clozapine agonists/releasers as 3rd Step
8. ECT ECT as a 4th step
Multiple Sclerosis Recommended Olanzapine for Steroid SSRIs (start at half the usual Amantadine or modafinil for
Risperidone induced mania dose) 1st choice fatigue
Clozapine Valproate for bipolar mania Moclobemide 2nd choice
Other Avoid lithium Venlafaxine No symptomatic treatment
Olanzapine Mirtazapine for cognitive impairment
Aripiprazole Duloxetine
Quetiapine
Condition Antipsychotic Mood stabilizer Sedative Antidepressant Other

Pregnancy If already using one, obtain Antipsychotics preferred first
the most up-to-date advise line, if ineffective use ECT.
about its it, New patients: Lithium should be avoided if
Chlorpromazine possible. If patient is already
Trifluperazine using it, weigh the risks and
Haloperidol benefits of stopping it.
Olanzapine Valproate and Carbamezapine
Quetiapine most teratogenic, if deemed
Clozapine essential add folic acid 5mg
per day one month before
conception and Vitamin K to
mother and baby post
delivery in case of
Carbamezapine use in last
trimester
Breast feeding Olanzapine Antipsychotic or
Valproate + protection against
pregnancy
Learning Disability Risperidone (0.5 to 2mg) for Only Lithium is licensed for
aggression and instability of aggression and self injurious
mood behavior
Aripiprazole licensed by FDA Valproate for mood lability
for behavioral disturbance in and aggression
young people with autism Carbamezapine
Haloperidol for autism
Zuclupenthixol for behavioral
disturbance
Olanzapine
For anxiety CBT is first line Nortriptyline SGAs should be avoided in
while sleep hygiene for Amitriptyline gestational diabetes
insomnia. Imipramine Avoid depot preparations and
Benzodiazepines ( avoid in Sertraline 50-200mg anticholinergics
late pregnancy) fluoxetine To avoid SSRI discontinuation
Promethazine For resistant depression use symptoms in neonates,
ECT rather than polyphamacy continue the drug in breast
NICE (NICE) feeding, wean off slowly.
(in low dose for Sedation) Consider Omega 3 fatty acids CBT for moderate bipolar
Chlorpromazine SSRI, combination of SSRI and depression.
Amitriptyline Olanzapine or Lamotrigine for
severe bipolar depression,
Lorazepam Sertraline (preferred)
Paroxetine
Nortriptyline
Imipramine
SSRIs for severe anxiety and Naltrexone for severe and
obsessionality in autistic intractable cases of severe
spectrum disorder self-injurious behavior
1st line alternative to
antipsychotics in case of
aggression and impulsivity
Condition Antipsychotic Mood stabilizer Sedative Antidepressant Other

HIV Infection Risperidone Valproate Escitalopram

Other atypicals Lamotrigine
Gabapentin
Atrial Fibrillation Aripiprazole or Lurasidone for Valproate Benzodiazepines SSRIS
Paroxysmal or persistent AF Lithium
Use any with Permanent AF
Children and adolescents Allow patient to choose from For mania 1st line is fluoxetine For anxiety
Aripiprazole Aripiprazole 2nd line escitalopram SSRIs first choice
Olanzapine Olanzapine 3rd line sertraline Sertraline,
Risperidone Risperidone 4th line venlafaxine , Fluoxetine
Quetiapine mirtazapine if sedation Fluvoxamine
Clozapine if no response to For Depression needed, Paroxetine
two of the above Lurasidone Or aripiprazole/Quetiapine 2nd choice is venlafaxine
Olanzapine augmentation For OCD
Quetiapine SSRIs
Condition DOC 2nd Line Other Psychotherapy

Mania Sever or behavioral disturbance: Combinations of the above if All patients (Bipolar disorder)
Valproate inadequate response Clonazepam or Lorazepam Advice about lifestyle
Antipsychotics Refractory: Identification and avoidance of
• Aripiprazole Clozapine triggers for relapse
• Olanzapine Identification of early signs of relapse
• Asenapine Psychoeducation
• Quetiapine Psychosocial approaches
• Haloperidol
If Adherence likely
Lithium
Bipolar Depression • Fluoxetine + Olanzapine Lithium Psychotherapies used for Bipolar
• Quetiapine Lamotrigine disorder as above
• Olanzapine
• Lurasidone
• Valproate
Bipolar Affective Prophylaxis Lithium Valproate Carbamezapine
Olanzapine Lamotrigine
Quetiapine
Psychotic Depression Tricyclic with Olanzapine or SSRI or SNRI ECT
Quetiapine
Rapid Cycling Disorder Quetiapine Olanzapine Aripiprazole
Clozapine
Risperidone
Lamotrigine
Post Stroke Depression SSRIs If SSRI is used in combination with
Nortriptyline aspirin or anticoagulants, consider
Patient on warfarin PPIs
Escitalopram
Condition DOC 2nd Line Other Psychotherapy

Depressive Illness SSRIs Generally Other SSRI or SNRI Augment with Supportive psychotherapy
Mirtazapine If Sedation needed Then Bupropion CBT
Individualize patients Switch to Buspirone Interpersonal therapy
mirtazapine T3 Marital therapy
Vortioxetine Lithium Dynamic psychotherapy
Agomelatine Aripiprazole
Quetiapine
Risperidone
Olanzapine
Mianserin
Antidepressant Discontinuation Restart the original drug and taper
Symptoms slowly over at least 4 weeks duration
Post MI Depression Sertraline 50-200mg Fluoxetine
Fluvoxamine
Paroxetine
Mirtazapine
ADHD in children Methylphenidate for severe cases or Dexamfetamine Clonidine
no improvement with psychosocial Lisdxamfetamine Tricyclics
interventions in moderate or lesser Modafinil
degrees Guanafcine
Atomoxetine is a suitable alternative Bupropion
Carbamezapine
Venlafaxine
Behavioral agitation in delirium Haloperidol 0.5-1mg bd IM/Oral Olanzapine • Lorazepam and diazepam used
Oral can be repeated 4 hourly as Risperidone only in alcohol or sedative
needed while IM can be given after Quetiapine withdrawal, Parkinson’s and NMS
30-60 minutes if necessary. Avoid in • Very limited evidence for
LBD and Parkinson’s disease, monitor Ziprasidone, Amisulpiride and
ECG aripiprazole.
Condition DOC 2nd Line Other Psychotherapy

Depression and bleeding Non-SSRI antidepressants If SSRI can not be avoided, add PPI

Antidepressant Discontinuation Restart the original drug and taper

Symptoms slowly over at least 4 weeks duration
Antidepressant induced Sexual Switch to 1. Add bupropion Sildenafil for erectile dysfunction in
dysfunction Bupropion 2. Add mirtazapine men
Mirtazapine
Agomelatine
Antidepressant induced Switch to mirtazapine Another SSRI
Hyperprolactinaemia
OCD SSRIs Antipsychotic augmentation of SSRI Duloxetine/Venlafaxine Exposure therapy
Clomipramine Clonazepam for shot term use Buspirone CBT
Sertraline as first line by NICE Citalopram augmentation of Granisetron augmentation of SSRI
clomipramine Memantine
Mirtazapine augmentation of SSRI IV Ketamine
(NICE) N-acetylcystein
Lamotrigine or topiramate Antiandrogn treatment
augmentation o SSRI (BAP)
Social Phobia SSRI Benzodiazepine augmentation of Levtiracetam CBT for social phobia
Pregabalin SSRI Self Exposure monotherapy therapy
Gabapentin Moclobemide FDA Approved Drugs: Computer based exposure training
Olanzapine Sertraline Clinician led exposure
Phenelezine Paroxetine
Propranolol or performance anxiety Venlafaxine
only
Venlafaxine
Valproate
Agoraphobia With frequent panic attacks: use the Exposure therapy
drugs used for panic disorder Relaxation training
Breathing retraining
Condition DOC 2nd Line Other Psychotherapy

Pediatric Social Phobia and Selective
mutism
Fluoxetine for both Sertraline Other SSRIs CBT
Monitor all patients on SSRIs for
emergence of suicidality
Use drugs only when there is
significant impact on life
Condition DOC 2nd Line Other Psychotherapy

Generalized Anxiety Disorder SSRIs (although may initially Agomelatine B-blockers for somatic symptoms Reassurance
exacerbate symptoms. A lower Buspirone Tiagabine Self help and Psychoeducation
starting dose is often required: Hydroxyzine Vortioxetine Pure self help
fluoxetine and sertraline are Quetiapine Riluzole Guided self help
preferred options) imipramine group psychoeducation
Mirtazapine Clomipramine Indications of pharmacotherapy: Relaxation therapy
Venlafaxine MAOIs temporary before psychotherapy can Applied relaxation
Duloxetine show effect, psychotherapy CBT
Pregabalin ineffective Exercise
Sertraline as first choice by NICE psychotherapies not available
Body Dysmorphic Disorder SSRIs Add Buspirone Medications generally added if there CBT is first line
Or antipsychotic is no response to CBT
Panic Disorder SSRIs MAOIs Gabapentin CBT
Sertraline as first line by NICE Mirtazapine Inositol Anxiety management
Imipramine Pindolol as augmentation
Clomipramine
Venlafaxine
PTSD SSRIs Mirtazapine Carbamezapine Debriefing should be available if
Use drugs after TF-CBT is tried antipsychotics for augmentation Clonidine desired
MAOIs Lamotrigine Counselling
Serotonergic TCAs Phenytoin Anxiety management
Duloxetine Tiagabine Trauma focused CBT
Prazosin as augmentation Valproate EMDR
IV ketamine
PTSD in children and adolescents Sertraline 50-200, Trauma focused CBT to be used as
Citalopram 10-400mg first line
Clonidine 0.1-0.2 nocte In preschool children only
Gunafacine 1-3mg nocte recommended treatments are child-
Prazosin 2-4mg nocte parent-psychotherapy or preschool
Propranolol 40-80mg/day divide tds CBT
Risperidone 0.5-1mg od
Quetiapine 50-200mg nocte
Condition DOC
Pediatric OCD Sertraline 25-100mg
Fluvoxamine 25-200mg
(if no response to psychotherapy or
psychotherapy refused)
Comorbid depression
Fluoxetine 5mg-as tolerated
(Start lowest doses and titrate to
maximum tolerated doses checking
efficacy at 12 week intervals)
Tics and Tourette syndrome Clonidine 3-5 microgram/kg, start
minimum, titrate up, avoid stopping
suddenly.
May cause sedation, postural
hypotension, depression.
Childhood Insomnia Melatonin 2mg, if sleep hygiene and
behavioral interventions not
effective
Autism spectrum Disorder For repetitive behaviors:
Try behavioral therapies first then
drugs
SSRIs are most widely used
Suggested: liquid fluoxetine
Week 1 2.5 mg per day
Week 2 0. 3mg/kg/day
Week 3 0.5mg/kg/day
Week 4 0.8mg/kg/day max allowed
Reduce dose if not well tolerated
2nd Line
If no response to maximum dose of
one SSRI:
Try a different SSRI
Clomipramine
Augment with low dose Risperidone
Risperidone 0.25-2mg
Aripiprazole 2-15mg
Pimozide
Haloperidol 0.5-4mg
2nd-gen preferred.
Increase to 5mg
Discontinue if still no response
For hyperactivity symptoms:
Use methylphenidate in lower doses
than usual and monitor for
worsening of symptoms
For sleep problems
Melatonin 1mg to 10mg
Aggression:
Most evidence for Risperidone
Other drugs include olanzapine,
Quetiapine, aripiprazole, clozapine,
lithium, valproate
Other
Other SSRIs may be chosen even as
first line based on individual features,
e.g. escitalopram 5-20mg or
fluoxetine 5mg-as tolerated liquid for
child not able to take tablets.
Guanafcine, topiramate,
metoclopramide, flutamide, Baclofen
Nicotine augmentation of haloperidol
(prn), botulinum toxin, Pergolide
Olanzapine, Sulpiride, ziprasidone,
Quetiapine
Irritability
Risperidone (less thank 20kg, start
with 0.25mg/day, after three days
0.5mg per day, then increase at 2
weekly intervals to a maximum of
1.5mg, similar dose titration for 20kg
and up but start with 0.5mg/day and
maximum is 2.5mg)
Aripiprazole 5-15mg/day
Psychotherapy
Guided self help support and
information for family members for
mild functional impairment is the
first step
If no response to the above or
moderate or sever functional
impairment, offer CBT+ERP
Psychoeducation of patient, family,
and people they interact with, esp
school
Habit reversal
Exposure with response prevention
Try these first before starting
medications
Sleep hygiene
Behavioral Interventions
Condition
First Episode of Schizophrenia
Acute exacerbation of
schizophrenia, or relapse
Acute exacerbation of
schizophrenia, or relapse
Adherence confirmed
Negative symptoms of
schizophrenia
Step 1
Agree choice with the patient or
choose one of the 2nd generation
antipsychotics. Start with minimum
possible dose e.g. olanzapine 5mg,
haloperidol 2mg, aripiprazole 10mg,
Quetiapine 150mg, Risperidone 2mg,
chlorpromazine 200mg,
and titrate up based on tolerability
and efficacy.
Investigate adherence
If adherence is poor, investigate
reasons for poor adherence,
Investigate social or psychosocial
precipitant
Provide appropriate support and/or
therapy
Continue usual drug treatment
Determine the cause of negative
symptoms.
If they are secondary, treat the
underlying cause
2nd Line
If no response 2-3 weeks after
maximum effective dose, or
inadequate response after 4 weeks,
then switch to another drug
preferably Olanzapine or
Risperidone.
If there is lack of insight or support,
discuss with patient and consider
depot antipsychotics
If there is poor tolerance, discuss
with patient, switch to acceptable
drugs.
If acute drug treatment is required,
Add short term sedative or switch to
a different acceptable antipsychotic,
Augment antipsychotic with an
antidepressant(Cochrane concludes
it effective) e.g. an SRRI (meta-
analysis concludes it ineffective)or
mirtazapine(supported by meta
analysis)
For clozapine treated patients,
consider Lamotrigine or another
suitable antipsychotic
Other Psychotherapy
If no response to two antipsychotics,
start clozapine,. Titrate to maximum
dose, if not effective, add
Lamotrigine or another
antipsychotic. Try to use clozapine as
early as possible for refractory
patients.
If patient is confused or disorganized,
Simplify drug regimen
Reduce anticholinergic load
Consider compliance aids
Consider depot
Switch to clozapine if the previous
step is ineffective after 6 weeks of
maximum tolerated dose. Olanzapine
must have been tried.
Possible causes secondary
Associality due to paranoia
Bradykinesia and lack of
facial expression in EPS
Depression causing social
withdrawal
Institutionalization
Condition Step 1
Patients at high risk of EPA 700mg/day
schizophrenia
Akathisia Reduce dose of antipsychotic or
reduce the rate of increase. If this
strategy is ineffective then switch to
Quetiapine or olanzapine lowest
possible dose, or clozapine for
treatment resistant.
Antipsychotic induced weight gain Try non-pharmacological approaches
and Switch to aripiprazole,
Lurasidone or ziprasidone
Specific Phobia Non-pharmacological approaches
Benzodiazepines prn
2nd Line Other NON pharmacological
Consider propranolol 30-80mg/day Antimuscarininc
starting at 10mg tds after excluding Cyproheptadine
contraindications. Benzodiazepine
If the above is not effective consider Clonidine
mirtazapine 15mf or Mianserin 30mg
Evaluate efficacy of each treatment
over at least one month treatment
Metformin is the drug of choice for Orlistat along with diet restriction Calorie restriction
treatment and prevention (low fat diet) is good option for Low glycemic index diet
Or add aripiprazole clozapine induced weight gain. Exercise programs
Reboxetine 4-8mg daily
Topiramate up to 300mg daily
Zonisamide 150-600mg/day
D-cycloserine is an experimental drug Blood Phobia
Exposure in vivo together with use of
muscle tension
Phobia of choking
Desensitization
Phobia of Flying
Desensitization provided by some
airplanes
Benzodiazepines prn
Virtual reality programs
Self help books
Condition Step 1 2nd Line Other NON pharmacological

Catatonia Exclude organic causes In the context of psychotic illness, Risperidone

Alzheimer's disease
Dementia with lewy bodies
Mixed dementia
Dementia with Parkinson's disease
Stupor in the context of
affective/conversion disorder
Start oral Lorazepam 2mg and give
another dose if no effect after three
hours. Sublingual absorption is good
and is tasteless. Use IM route from
then on. If there is no response in 1-2
days, use high dose Lorazepam (8-
24mg/day) or IV diazepam
Donepezil 10mg /day, start with
5mg/day, increase 5mg daily after 4
weeks
Rivastigmine 6mg bd, start with
1.5mg bd increase every 2 weeks by
1.5mg bd
Galantamine 12mg bd, start with
4mg bd increase at 4 weekly intervals
by 4mg bd
As for Alzheimer's
rule out NMS first, and then start on Aripiprazole
SGA e.g. olanzapine, clozapine. Start Ziprasidone
the Benzodiazepine/ECT protocol if
no response in 1-2 days.
In any case, if there is high dangerous
to life, use ECT earlier.
Memantine 10mg bd, start with Sensory stimulation
5mg/day increase by 5mg/day at Behavior management
weekly intervals Social contact
Exercise
Structured activities programs
Environmental modifications
Carer education and support
Combination therapies
none As other dementias

Pathological jealousy
Late Onset Schizophrenia
Recognize the etiology
If secondary to other conditions,
treat those disorders
Use antipsychotics in 10-20% the
normal doses used in early onset
schizophrenia
If the condition is primary, establish
wither the jealousy is delusional in
which case use antipsychotic, or
overvalued idea, in which case use
antidepressant
Pimozide used widely
High potency non sedating
antipsychotics recommended e.g.
Risperidone
Breach confidentiality if there is risk
of violence
If the jealousy appears from
personality problems
Encourage partner to produce
behaviors that may reduce jealousy
Separation advisable for some
Comorbidity with dementia Recommended drugs Comorbidity with dementia Recommended drugs

Diarrhea Loperamide not known to have effects on Hyperlipidemia All statins safe but atorvastatin and
cognition but is low potency anticholinergic pravastatin safest

Constipation No evidence of laxatives on cognitions Hypersalivation Pirenzepine

Constipation may worsen cognition Atropine sublingual
Asthma/COPD Beta agonists ((remember tremors as a side Hypertension CCBs
effect) ARBs
Inhaled anticholinergics, have not been ACE Inhibitors
reported to affect cognition
theophylline
Allergy Cetrizine Infections Use the most appropriate antibiotics
Loratidine
Fexofenadine
Nausea/vomiting Domeperidone (caution movement Spasmodic GI pain Mebeverine
disorders) Alverine
5-HT3 receptor antagonists eg ondanstron, Buscupan
granisetron Pepperment oil
Pain Paracetamol Urinary frequency Darifenacin
Oxycodone Trospium
Buprenorphine
Topical NSAIDs where appropriate
Urinary retention Alpha blockers are not known to have effects
on cognition
Condition Step 1
Anorexia nervosa • Establish therapeutic relationship
• History of the development of
the disorder, current pattern of
eating and weight control, ideas
about body weight.
• Depressive symptoms on mental
state
• Thorough physical examination
to recognize associated medical
complications
Bulimia Nervosa • Offer guided CBT based self help
Behavioral disturbance • De-escalation, time out,
placement, etc. as appropriate
Step 2
• Educate the patient and family
about the disorder, agree a plan
with them and start the
treatment
• If the weight is dangerously low,
there is comorbid disorder,
outpatient treatment failed or
suicide risk is high, admit to
hospital, otherwise manage on
outpatient basis.
• If no response to step1 in 6
weeks, treat with full CBT. Use
fluoxetine as alternative or in
combination with CBT
• Oral treatment. If the patient is
on a regular antipsychotic,
lorazepam 1-2mg. Repeat after
45-60 minutes. Consider buccal
midazolam. Go to next step if
two doses fail
• If patient is not taking
antipsychotic, start an oral one
e.g. quetiapine 50-100mg,
olanzapine 10mg, risperidone 1-
2mg, haloperidol
5mg+promethazine 25mg
(pretreatment ECG)
Step 3
• Restore the weight at
0.5kg/week. Avoid rigid
programs. Nonpharmacologial
approaches preferred,
olanzapine is the only drug
shown to increase weight.
• Treat the comorbidities, and
prevent complications that may
arise from re-feeding.
• After discharge, continue with
psychological treatment.
• Comprehensive specialist
treatment
• Consider intensive cognitive
therapy
• Consider IM treatment
Lorazepam 2mg, promethazine
50mg, olanzapine 10mg,
aripiprazole 9.75mg, haloperidol
5mg. Repeat after 30-60 min if
insufficient effect.
• If the above step fail, diazepam
10mg over at least 5 minutes
• Repeat after 5-10minutes if
insufficient effect, up to 3 times
have flumazenil at hand
Non-Pharmacological
Cognitive analytic therapy
CBT
Interpersonal therapy
Focal psychodynamic therapy
Family therapy
Dietary counselling
Self Help
CBT
Intensive cognitive therapy
After Parenteral drugs, monitor
vitals every 10 minutes for one
hour, then half hourly until the
patient is ambulatory.
If patient is asleep or unconscious,
continues pulse oximetry is
desirable
ECG monitoring for all who receive
haloperidol
ECG and hematological monitoring
also recommended for those who
receive IV antipsychotics
Condition Step 1 Step 2 Step 3 Non-Pharmacological

Primary Insomnia Education about the problem • If improvement does not occur, • Sleep restriction therapy CBT-I
Sleep hygiene measures do assessment e.g. sleep diary • Add drugs Sleep hygiene
for two weeks then start CBT-I Exercise
Sleep restriction therapy