Antipsychotics, clozapine and long-acting injectables

Domain IX · Biomedical, neuro & digital

What it is

Antipsychotics, including clozapine and long-acting injectable (depot) formulations, are prescriber-delivered medicines. This guide is written for the psychotherapist working alongside the prescriber and the mental health team, not for prescribing. It contains no doses, titration, schedules,…

Format

• United States: clozapine carries a boxed warning (see 4.A2). The clozapine REMS was removed effective 13 June 2025. Prescribers, pharmacies and patients no longer enrol in a REMS, and ANC results are no longer reported to one. ANC monitoring is still recommended according to the prescribing…

Who practises it, and how they are trained or regulated

• Psychotherapy dose and format (per NICE CG178): CBTp one-to-one, following a manual, at least 16 planned sessions, offered starting in the acute phase or later (including inpatients). Family intervention for families in close contact: 3 months to 1 year, at least 10 planned sessions, including the client where practical. Consider arts therapies, especially for negative symptoms, preferably in groups. NICE does not…
• Version followed: US Clozaril prescribing information (revised June 2025) and FDA Drug Safety Communication of 27 August 2025 (clozapine REMS removed, effective 13 June 2025); UK clozapine SmPC (Clozapine Viatris orodispersible, revised February 2026); NICE CG178 Psychosis and schizophrenia in adults (2014, minor updates to December 2021) with NICE QS80; APA Practice Guideline for the Treatment of Patients With…
• Who delivers it and regulatory status. Prescribing: psychiatrists or other prescribers in secondary care, with physical-health monitoring shared with primary care. NICE keeps monitoring in secondary care for at least 12 months or until the person is stable, whichever is longer.

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Is it a group, retreat or community? How do they respond if someone wants to leave or raises a concern?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• eating-disorder history or distress about weight. Flag it to the team.
• early relapse signs. Act on the crisis plan (B9) and contact the team.
• plans that exist only in the therapy file. The team and carers need a copy.
• constipation being embarrassing to mention. Normalise asking about it directly.
• the client feeling talked about. Share copies of letters with them where possible.

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.