British National Formulary (BNF) recommendations for adults: 75mg daily increasing to 300mg daily in psychosis. To alleviate acute symptoms: deep IM injection 25mg-50mg every 6-8 hours.
Observed in practice: 100mg tds or qds was not at all unusual in “long-stay” patients. Most new admissions where psychosis was suspected were started on 100mgs tds. For some patients who were deemed either dangerous, unpredictable or aggressive, a dose of 200mgs qds (in conjunction with nitrazepam, possibly other neuroleptics and anti-cholinergics), was not that unusual. IM injections were frequently used on anyone who was “disturbed”, but BNF guidelines were rarely observed (see Asylum Years pp. 40-41 for example).
The use of the liquid suspension was always questionable. An empty bottle was sent to the pharmacy on a regular basis to be returned fully replenished with the bright orange liquid – in those days it would have contained approx. half a pint or 250ml. I believe the strength was 100mg/5ml. It was dispensed in a plastic measuring cup. We were told it could cause skin reactions if it made contact, but as nurses, we were never provided with gloves. As patients, it was not unusual for a very generous 5ml to be dispensed, often followed by the measuring cup being topped with water to ensure every last drop of the medication was consumed. The lack of controls over the provision of the medication made it relatively easy for it to be over-used (or abused). For harassed staff it could be a convenient go-to, especially if it was prescribed prn.
The side effects of this medication at these doses were never properly understood or recognised by staff (both nurses and doctors). Over-salivation and the “Largactil shuffle” were obvious to most and Parkinsonian side effects might be eventually picked up, but few could recognise tardive dyskinesia until the symptoms were very apparent and I, personally, can’t recall anyone being tested for blood dyscrasias or other cellular abnormalities. I’m not saying this never happened, it just didn’t happen in front of me for three years!
Anyone able to establish the maximum dose ever dispensed?
6 April 2025
