Antipsychotics, also called neuroleptics or major tranquilizers, are medications that are intended to treat psychosis. Psychosis is a mental health symptom that interferes with the mind’s ability to understand what is real. Psychosis can cause delusions, auditory hallucinations, visual hallucinations, paranoia and confused thoughts.
Antipsychotic drugs are usually effective at treating psychosis and helping with the symptoms that psychotic disorders cause. The main mental health conditions that cause psychosis and make antipsychotic medications necessary are schizophrenia and bipolar disorder, especially the manic phase of bipolar disorder. While psychosis can result from a mental health disorder, there are also several other causes of psychosis, including substance use, medications and physical illnesses.
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What are Antipsychotics?
People studying mental illness may often ask, “What are antipsychotics and what do they do?” The antipsychotic definition can be found by simply breaking down the word. Antipsychotic medications are medications that are anti (against) psychosis (a disconnect from reality), meaning that these drugs help to treat a disconnect from reality.
While these drugs are generally good at treating psychosis, they may not be particularly effective at treating psychosis from certain causes, such as psychosis that is experienced with using illegal substances. Antipsychotics are best used for psychosis that has its origins in mental illness, although it may still be effective when used for psychosis for other causes.
While antipsychotic medications are primarily used to treat psychosis, there are several other conditions that some of these medications can help to treat. These conditions include:
- Hiccups that won’t stop
- Alcohol dependence
While some antipsychotic drugs may treat these conditions, they should only be used to help with these conditions if they have been prescribed by a doctor for that reason. Taking someone else’s antipsychotic medications or taking antipsychotic medications that have been prescribed to you for a reason other than what they were prescribed for can be very dangerous and should be avoided.
Background and History
The history of antipsychotic drugs started with promethazine, which was developed in France starting in 1933. Before promethazine, treatment of psychosis involved several non-medicinal treatments including hydrotherapy, electroconvulsive therapy (using electricity to induce a seizure) and insulin shock therapy (a temporary coma caused by using insulin). None of those techniques helped with psychosis. The development of promethazine was the first time that an effective medication was discovered.
The next advancement in the history of antipsychotics was when promethazine was altered and used to develop a medication called chlorpromazine, which became available in the United States in 1955. Once chlorpromazine was seen to be a success, the government began reducing the number of long-term psychiatric treatment facilities, and pharmaceutical companies began inventing and producing medications that work by similar mechanisms and had similar effects. These medications became known as first-generation antipsychotics.
During the 1960s, clozapine was invented and was used clinically. Clozapine was an antipsychotic drug but worked in a different way than first-generation antipsychotics worked. Clozapine was the first of a new type of antipsychotics, referred to as either atypical antipsychotics or second-generation antipsychotics. In 1975, clozapine was found to lower the number of white blood cells in some people, leading to a — sometimes fatal — suppressed immune system. This discovery helped to spur research into other antipsychotics, leading to the development of more second-generation antipsychotics.
In 2002, an effective antipsychotic called aripiprazole (brand name Abilify) was developed. There is some debate about whether aripiprazole should be considered part of the second generation of antipsychotics or if it is part of a third generation, due to the different type of mechanism it has compared to other second-generation antipsychotics.
Since aripiprazole’s discovery, two new antipsychotics were developed and became available in 2015: brexpiprazole and cariprazine. Both of those antipsychotics have similar mechanisms to aripiprazole. Some scientists believe it is reasonable to assume that medical science has entered into a new era of antipsychotic medications and that brexpiprazole and cariprazine are part of a third generation of antipsychotics.
Use in Treating Mental Illness
People wanting to learn more about antipsychotics often wonder, “What are antipsychotics used for?” Antipsychotic drugs are used to treat psychosis and can help with mental health conditions that cause psychosis. Many people use antipsychotics for schizophrenia and find that the psychosis that is often experienced with schizophrenia may be almost or completely resolved with regular use.
Many people also use antipsychotics for bipolar disorder, as psychosis can be commonly experienced during the manic phase of bipolar disorder. Using antipsychotics to treat bipolar disorder can help to reduce some of the symptoms of mania and, when combined with mood stabilizers, may be helpful in managing the condition.
While doctors typically do not use antipsychotics for depression initially, some antipsychotics can help with depression and may be used in addition to antidepressants or when antidepressants have not been effective. Doctors may also use antipsychotics in dementia patients, especially for those who have hallucinations or who experience psychosis that causes agitation.
Another potential use for antipsychotics is the use of antipsychotics for schizoaffective disorder. Schizoaffective disorder is difficult to treat, and antipsychotic medication will likely be the first line of treatment for this disorder.
How Do Antipsychotics Work?
Many people considering talking to their doctor about antipsychotics wonder, “How do antipsychotics work?” The way that antipsychotics work is complex and is still being researched. Each generation of antipsychotics works slightly differently, but all three generations of antipsychotics affect chemical interactions in the brain with dopamine.
Dopamine is a neurotransmitter, a chemical that interacts with receptors in the brain to send nerve signals. Multiple types of receptors use dopamine. How each receptor works and interacts with dopamine is an ongoing area of research.
First-generation antipsychotics block certain dopamine receptors in the brain. This function is thought to help decrease nerve signals that are caused by excessive amounts of dopamine and lead to a decrease in the symptoms of psychosis.
Second-generation antipsychotics block dopamine receptors, but not as strongly. They also tend to block receptors for other chemicals in the brain, like serotonin. Second-generation antipsychotics help decrease symptoms of psychosis but creates fewer side effects than first-generation antipsychotics do.
Third-generation antipsychotics block dopamine weakly and help stabilize the levels of dopamine. As the study of antipsychotics is an ongoing area of research, how these medications truly affect the brain is not yet fully understood, although progress is being made toward understanding the complex system fully.
Types of Antipsychotics
There are several types of antipsychotics, and there are differences between each one. Any antipsychotic drugs list will make a clear distinction between typical vs atypical antipsychotics, as these two antipsychotics work differently and have unique side effects.
Typical antipsychotics are known to have more severe side effects than atypical antipsychotics and so they are not as commonly used. Typical antipsychotics fit in the first generation and atypical antipsychotics into the second and sometimes third generations, although the third generation is so new that the terminology is still developing.
First Generation Antipsychotics (Typical Antipsychotics)
First generation antipsychotics, also called typical antipsychotics, are medications that reduce psychosis but have a high risk of creating serious side effects that may lead to permanent disabilities. Medications commonly found in this generation of antipsychotics include:
- Chlorpromazine (Most common brand name Thorazine)
- Haloperidol (Most common brand name Haldol)
- Loxapine (Most common brand name Loxitane)
- Molindone (Most common brand name Moban)
- Perphenazine (Most common brand name Trilafon)
Second Generation Antipsychotics (Atypical Antipsychotics)
The second generation antipsychotics, also called atypical antipsychotics, were developed in response to the severe side effects that were experienced with first-generation antipsychotics. Second generation antipsychotics are also more effective, while also causing fewer symptoms. Common second-generation antipsychotic medications include:
- Clozapine (Most common brand name Clozaril)
- Olanzapine (Most common brand name Zyprexa)
- Risperidone (Most common brand name Risperdal)
- Quetiapine (Most common brand name Seroquel)
Third Generation Antipsychotics
Within the development of new antipsychotics over the last two decades, a new generation of antipsychotic medications has emerged. These medications better regulate dopamine levels than second-generation antipsychotics did and are the result of improved knowledge of the biological causes of psychosis. These new medications help to treat certain types of psychosis or subsets of psychosis much better than previous medications. Third-generation antipsychotics include:
- Aripiprazole (Most common brand name Abilify)
- Brexpiprazole (Most common brand name Rexulti)
- Cariprazine (Most common brand name Vraylar)
Effectiveness of Antipsychotics
People who use antipsychotics or are considering using antipsychotics often wonder, “How effective are antipsychotics?” Because antipsychotics cause subjective changes rather than objective changes, it is harder to measure their effectiveness.
Many medications will change a chemical in the blood that can be measured or change vital signs, such as blood pressure, measurably. Antipsychotics do not have the same measurable changes. Changes from antipsychotics must largely be reported by the individuals taking them, which complicates how the effectiveness of the medicine can be measured.
While it is true that the effect of antipsychotics is hard to measure, there are still many subjective reports of improvement and many noticeable changes in behaviors that are reported with antipsychotic use.
One study found that the risk of death or hospitalization decreased for individuals who used antipsychotics to treat their psychosis. Many psychiatrists reported cases of patients who were homeless and unable to interact with others who became functioning and successful members of society after using antipsychotic medications to treat their mental health conditions.
There are several side effects of antipsychotics that may be experienced by those who take them. The more common side effects of antipsychotics are not severe. However, some rare side effects can lead to lifelong disabilities. Newer antipsychotic medications have reduced the incidence of severe side effects, but these side effects may still occur.
The side effects that are possible to experience with antipsychotic medications include:
- Sedation – This is a common side effect of antipsychotics, but can be managed by altering the dose or the time of day at which the medication is used.
- Low blood pressure – This effect may be more common in older adults or those who are on blood pressure medications. While medications may need to be switched, people who experience this side effect may gradually adjust over time.
- Anticholinergic effects – Antipsychotics may create something called anticholinergic effects, leading to dry mouth, constipation, urinary retention and blurred vision. This problem can be treated by changing doses or altering how frequently the medication is taken.
- Pseudoparkinsonism – This is a reversible condition that can lead to tremors, social withdrawal and a shuffling gait. This condition can be treated with medication or by changing the dose of the medication.
- Akathisia – This is a feeling of inner restlessness and can be very unpleasant. Treatment for akathisia can involve using other medications or changing the strength of the antipsychotic.
- Dystonic reactions – This causes spasming of muscles all over the body and can be irreversible or life-threatening in some circumstances. Someone who may have this side effect should go to the nearest emergency room or call 911. Dystonic reactions can be treated, but treatment must be started as soon as possible.
- Tardive dyskinesia – This side effect causes involuntary movements that normally affect the face and mouth, but may affect all parts of the body. While there may be some treatments that could help with tardive dyskinesia if it is detected early, this condition is typically permanent. Someone who is developing tardive dyskinesia should have their doctor discontinue their antipsychotic and find another medication to avoid worsening the symptoms.
- Sexual dysfunction – This is a common side effect and may require treatment using a different antipsychotic.
- Agranulocytosis – This is a decrease in the white blood cells and causes an increased risk of infection. People who are at risk for this side effect should be closely monitored by their doctor.
- Cardiac arrhythmias – Antipsychotic medications can lead to an abnormal heartbeat. Anyone who feels palpitations or chest pain should consult with their doctor.
- Seizures – This is more rare but possible. Those who experience a seizure while on antipsychotics should consult with their doctor about the best course of action to take.
- Weight gain – Weight gain may be an acceptable side effect, depending upon its severity.
While this is a general overview of possible side effects of antipsychotics, specific side effects will be different for each medication and individual. Someone wanting more additional information about the side effects of a specific antipsychotic and how it could affect them should discuss their concerns with their doctor.
Antipsychotic drug interactions can occur when antipsychotics are mixed with other drugs or substances. Antipsychotic medications should not be mixed with other medications that can lead to similar side effects. For example, when mixing antidepressants and antipsychotics, interactions between these drugs may cause excessive sedation, as both types of medications can cause sedation.
There is a known interaction between smoking and antipsychotics, as some of the chemicals in tobacco smoke can make antipsychotics more active in the bloodstream.
Taking Antipsychotics While Pregnant
People who use antipsychotics and are considering getting pregnant may wonder, “Can you take antipsychotics while pregnant?” Stopping antipsychotic use suddenly can cause psychosis to return and greatly affect someone’s life. However, the effect the antipsychotic could have on the baby’s development should be considered.
According to the Royal College of Psychiatrists, antipsychotics have not been proven to be safe during pregnancy, but have also not been shown to be harmful to the developing baby — with the exception of Risperidone. Someone who is pregnant, or is trying to become pregnant, should speak with their doctor about the risks and benefits of using antipsychotics while pregnant and make the decision that is best for their situation.
Women may also wonder how to approach antipsychotics and breastfeeding. Those with psychosis are more at risk of developing worsening psychosis immediately after childbirth, a condition called postpartum psychosis. Because of this increased risk, antipsychotics should normally be taken during this time. Antipsychotics will pass into breast milk, but only in small amounts. Someone who is on antipsychotics and is considering breastfeeding should speak with their doctor about the risks and benefits that are unique to their situation.
Stopping antipsychotics abruptly can be dangerous. It can often lead to a sudden return of the psychosis and may increase the risk of injury or suicide. Even when tapering antipsychotics, these negative effects may be experienced. Someone who is discontinuing or decreasing the dose of an antipsychotic should only do so under the supervision of a doctor. One of the biggest dangers in stopping antipsychotic medications is that people are not aware that they are beginning to experience psychosis again, and they are at risk of experiencing serious negative mental health symptoms.
What to Do In Case of Overdose
Overdoses on antipsychotic medications are common. An overdose on antipsychotics can lead to permanent problems and may lead to death under some circumstances. Some antipsychotic overdose symptoms include:
- High heart rate
- Flushed skin
- Dry mouth
- Urinary retention
- Muscle rigidity
- Involuntary muscle movements
- Severe sedation
- Low blood pressure
- Severely high or low body temperature
- Decreased breathing
If you or someone you know is taking an antipsychotic and is experiencing any of these symptoms, they may have overdosed on an antipsychotic. Immediately call 911 or go to the nearest emergency room. Antipsychotic overdose treatment will depend upon the amount of antipsychotic taken and the type of antipsychotic used. If you have this information available you should bring it to the hospital with you to help the medical team to provide the best treatment possible.
Get More Information on Antipsychotics
You can find more information on antipsychotics by studying resources about the individual antipsychotics and the different generations of antipsychotics that have been developed using the following resources:
- The National Alliance on Mental Illness has several good resources about mental illnesses that cause psychosis, as well as the antipsychotic medications used to treat them.
- Medscape is a good resource for learning information about medications, including their individual side effects, doses, common uses and miscellaneous information particular to medications.
- Merck Manuals is another reliable, scientific resource for information about antipsychotic medications.
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Tamminga, C. “Antipsychotic Drugs.” Merck Manuals, October 2018. Accessed June 7, 2019. National Institute of Mental Health. “What is Psychosis?” 2019. Accessed June 7, 2019. Puder, D. “The History and Use of Antipsychotics.” Psychiatry and Psychotherapy Podcast, June 18, 2018. Accessed June 7, 2019. Mailman, B., Vishakantha, M. “Third generation antipsychotic drugs: partial agonism or receptor functional selectivity?” Current Pharmaceutical Design, 2010. Accessed June 7, 2019. Keltner, N. “Are There Really 3 Generations of Antipsychotics?” International Society of Psychiatric-Mental Health Nurses, 2019. Accessed June 7, 2019. Medscape. “Chlorpromazine.” October 2018. Accessed June 7, 2019. Medscape. “Haloperidol.” April 2019. Accessed June 7, 2019. Medscape. “Loxapine.” October 2018. Accessed June 7, 2019. Medscape. “Molindone.” 2019. Accessed June 7, 2019. Medscape. “Perphenazine.” October 2018. Accessed June 7, 2019. Medscape. “Clozapine.” November 2018. Accessed June 7, 2019. Medscape. “Olanzapine.” October 2018. Accessed June 7, 2019. Medscape. “Quetiapine.” October 2018. Accessed June 7, 2019. Medscape. “Aripiprazole.” December 2018. Accessed June 7, 2019. Medscape. “Brexpiprazole.” 2019. Accessed June 7, 2019. Medscape. “Cariprazine.” 2019. Accessed June 7, 2019. Tiihonen, J. “Real‐world effectiveness of antipsychotics.” Acta Psychiatrica Scandinavica, November 2016. Accessed June 7, 2019. Muench, J., Hamer, A. “Adverse Effects of Antipsychotic Medications.” American Family Physician, March 2010. Accessed June 7, 2019. Bleakley, S. “Identifying and reducing the risk of antipsychotic drug interactions.” Progress in Neurology and Psychiatry, April 2012. Accessed June 7, 2019. Royal College of Psychiatrists. “Antipsychotics in pregnancy and breastfeeding.” 2019. Accessed June 7, 2019. Melton, J. “Neuroleptic Agent Toxicity.” Medscape. Dec 29, 2015. Accessed June 7, 2019. National Alliance on Mental Illness. “Mental Health Medications.” August 2017. Accessed June 12, 2019.
Tamminga, C. “Antipsychotic Drugs.” Merck Manuals, October 2018. Accessed June 7, 2019.
National Institute of Mental Health. “What is Psychosis?” 2019. Accessed June 7, 2019.
Puder, D. “The History and Use of Antipsychotics.” Psychiatry and Psychotherapy Podcast, June 18, 2018. Accessed June 7, 2019.
Mailman, B., Vishakantha, M. “Third generation antipsychotic drugs: partial agonism or receptor functional selectivity?” Current Pharmaceutical Design, 2010. Accessed June 7, 2019.
Keltner, N. “Are There Really 3 Generations of Antipsychotics?” International Society of Psychiatric-Mental Health Nurses, 2019. Accessed June 7, 2019.
Medscape. “Chlorpromazine.” October 2018. Accessed June 7, 2019.
Medscape. “Haloperidol.” April 2019. Accessed June 7, 2019.
Medscape. “Loxapine.” October 2018. Accessed June 7, 2019.
Medscape. “Molindone.” 2019. Accessed June 7, 2019.
Medscape. “Perphenazine.” October 2018. Accessed June 7, 2019.
Medscape. “Clozapine.” November 2018. Accessed June 7, 2019.
Medscape. “Olanzapine.” October 2018. Accessed June 7, 2019.
Medscape. “Quetiapine.” October 2018. Accessed June 7, 2019.
Medscape. “Aripiprazole.” December 2018. Accessed June 7, 2019.
Medscape. “Brexpiprazole.” 2019. Accessed June 7, 2019.
Medscape. “Cariprazine.” 2019. Accessed June 7, 2019.
Tiihonen, J. “Real‐world effectiveness of antipsychotics.” Acta Psychiatrica Scandinavica, November 2016. Accessed June 7, 2019.
Muench, J., Hamer, A. “Adverse Effects of Antipsychotic Medications.” American Family Physician, March 2010. Accessed June 7, 2019.
Bleakley, S. “Identifying and reducing the risk of antipsychotic drug interactions.” Progress in Neurology and Psychiatry, April 2012. Accessed June 7, 2019.
Royal College of Psychiatrists. “Antipsychotics in pregnancy and breastfeeding.” 2019. Accessed June 7, 2019.
Melton, J. “Neuroleptic Agent Toxicity.” Medscape. Dec 29, 2015. Accessed June 7, 2019.
National Alliance on Mental Illness. “Mental Health Medications.” August 2017. Accessed June 12, 2019.
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