Informed Consent for Antipsychotic Medication
MEDICATIONS INCLUDED: Haldol (haloperidol), Orap (pimozide), Navane (thiothixene), Stelazine (trifluoperazine), Prolixin (fluphenazine), Risperdal (risperidone), Moban (molindone), Trilafon (perphenazine), Mellaril (thioridazine), Thorazine (chlorpormazine), Zyprexa (olanzapine), Seroquel (quetiapine).

BENEFITS: Antipsychotic medications can be helpful in the treatment of disorganized thinking, hallucinations (false visual or auditory perceptions), and delusions (false believes). They are some times helpful in reducing violent behaviors. Some antipsychotic medications can help reduce neuro-muscular tics. The FDA has approved Haldol, Orap, Stelazine, Mellaril, and Thorazine for use with children. Other medications are also used with children if the benefits outweigh the potential for adverse effects.

COMMON SIDE EFFECTS: Episodes of severe muscle stiffness (dystonia), ongoing moderate muscle stiffness, wanting to move or pace (akesthesia), blurry vision, constipation, stomach ache, sedation, lowered blood pressure, dizziness, lightheadedness, fainting, breast enlargement, breast milk production, menstrual irregularities, dry mouth, blurred vision, urinary retention. Note that these side effects do not occur in every one.

SERIOUS ADVERSE EFFECTS: There is a low possibility for the following adverse effects (incomplete list): Agitation, confusion, seizures, pneumonia, heart failure, eye damage. A rare side effect, neuroleptic malignant syndrome involves high fever and muscle stiffness, and can cause death. Therefore, if high fever and muscle stiffness occur, seek help in an emergency room immediately. A potentially common severe effect is tardive dyskinesia, which is a movement disorder involving rhythmic movements of the tongue, face, mouth or jaw, which can begin at any time, including after the medication dose is lowered or discontinued. Tardive dyskinesia can become permanent in some people. Antipsychotic medications have not been tested for safety in pregnancy.

ALTERNATIVES: If hallucinations or delusions are caused by depression or bipolar disorder, then medications specific for those illness may be helpful in reducing those symptoms. Otherwise, antipsychotic medication is considered a primary treatment for thought disorganization, hallucinations, or delusions. Intensive treatment without medication is generally less effective than treatment with medication.

OTHER ISSUES: Zyprexa, Risperdol, Seroquel and other new antipsychotic medications have statistically been shown to have lower rate of side effects, including tardive dyskinesia.

GENERAL WARNINGS: Florida law prohibits the use of prescription medication without ongoing physician supervision. Florida law prohibits the use of prescription medication in those for whom it has not been specifically prescribed. Failure to take medication as prescribed may result in a resumption of the symptoms for which this medication was prescribed. However, if this medication is found to cause severe adverse effects, it would be better to discontinue the medication and seek medical attention as soon as possible. Any medication can cause an allergic reaction, which may show any of these symptoms: rash on the chest, abdomen and back; difficulty breathing; choking. This medication can cause serious harm, permanent injury or death if not taken as prescribed or if taken in an overdose. This medication must be kept in a secured location so that children or teenagers do not have access to it. To avoid problems of medication interactions, check with the pharmacist or the physician prescribing additional medication. Notify physician prescribing the medication if you become pregnant or are sexually active without birth control. These medications can cause sensitivity to sunlight; use a sun-blocking lotion when out in the sun for over an 30 minutes. Do not drive, use complex or hazardous machinery, or engage in potentially hazardous physical activity unless certain that the medication does not affect performance in these activities. ( 9710)

I have read and discussed the above information and all of my questions have been answered.

Patient name (print): ________________________________________________

Signature of person giving consent: ____________________________________

Date: __________________  Location: _________________________________

Name of guardian giving consent if not patient (print): ______________________

Signature of professional providing information: ___________________________


Copyright 2001, Psychological Associates, P.A., All rights reserved.

Usage Agreement

August, 2001