Antipsychotics

What are antipsychotics?

Antipsychotics are prescription medications originally developed to treat psychosis — symptoms such as hallucinations and delusions. Today they are used for a broader range of conditions.

What they’re used for

• Schizophrenia and other psychotic disorders
• Bipolar disorder — for mania, depression (some medications) and maintenance
• As an add-on treatment for depression (some medications)
• Other uses a specialist may consider

How they work

Most antipsychotics block or modulate dopamine receptors; many second-generation medications also affect serotonin receptors.

How they’re taken

Usually by mouth daily. Some are available as long-acting injections given every few weeks or months. This page does not provide dosing guidance.

Common side effects

• Drowsiness
• Weight gain and increased appetite
• Changes in blood sugar and cholesterol
• Restlessness (akathisia) or stiffness
• Dizziness when standing
• Increased prolactin levels with some medications

Serious side effects

Seek urgent care for high fever with muscle rigidity and confusion (possible neuroleptic malignant syndrome), fainting, or fast or irregular heartbeat. Report any involuntary movements of the face, tongue or body (tardive dyskinesia) to your prescriber.

Warnings

• Regular monitoring of weight, blood sugar, cholesterol and sometimes heart rhythm is recommended.
• Increased risk of death in older adults with dementia-related psychosis.
• Don’t stop suddenly without medical advice.

Interactions

Antipsychotics can interact with other sedating medications, alcohol, some antidepressants, and medications that affect heart rhythm. Check with a pharmacist.

A wider range of uses than the name suggests

Despite the name, antipsychotics are used for more than psychosis. They are used for schizophrenia and related disorders, for manic or mixed episodes in bipolar disorder, and, at the prescriber’s discretion, as add-on treatment for depression that hasn’t responded to an antidepressant alone, for irritability associated with autism in children and for other conditions. Some are used in short courses, others long term. What is prescribed depends on the diagnosis, the symptoms and medical factors.

First- and second-generation medicines

First-generation (typical) antipsychotics, such as haloperidol, have been used for decades and are effective, but are more likely to cause movement-related side effects. Second-generation (atypical) antipsychotics, such as aripiprazole, quetiapine, risperidone, olanzapine and lurasidone, are more commonly used now and tend to cause fewer movement problems but can affect weight, blood sugar and cholesterol. Differences between individual medicines are significant, so a prescriber chooses based on your symptoms, history and risk profile.

Side effects to know about

• Metabolic changes: weight gain, higher blood sugar and cholesterol. Healthy eating, activity and regular checks help.
• Movement-related effects: restlessness (akathisia), stiffness, tremor, and, with long-term use, a risk of involuntary movements (tardive dyskinesia). Tell your prescriber about any new movement symptoms.
• Sedation and dizziness, particularly when starting.
• Hormonal effects, including changes in periods, breast changes or sexual side effects with some medicines.
• Heart rhythm effects with some medicines.

Many side effects can be reduced by adjusting the medicine or schedule, so speak up rather than stopping.

Monitoring and follow-up

Regular monitoring is a normal part of care. It typically includes tracking weight and waist measurement, blood pressure, blood sugar and cholesterol, and checks for movement symptoms. Some medicines need additional blood tests. Keep appointments, and bring a list of everything you take, including supplements and substances such as alcohol and cannabis.

Taking antipsychotics well

• Take them as prescribed, even when you feel well, because stopping can lead to relapse.
• Don’t stop suddenly without medical advice; some people experience withdrawal effects or a return of symptoms.
• Ask about long-acting injectable forms if remembering daily doses is difficult.
• Avoid alcohol and other sedatives, which can increase drowsiness.
• Plan for pregnancy or breastfeeding with your care team.

Antipsychotics in older adults

Antipsychotics carry an FDA boxed warning about increased risk of death in older adults with dementia-related psychosis, so they are not approved for that use and any use in dementia needs careful medical judgment. Older adults are also more sensitive to side effects such as falls and confusion.

Recovery involves more than medication

Medication reduces symptoms, but recovery usually involves therapy, family support, help with work or school, peer support and a stable routine. Approaches such as CBT, family psychoeducation and supported employment have good evidence. See psychotherapy for an overview. If you or someone you care about is experiencing a crisis, such as hearing voices that urge harm, severe confusion or thoughts of suicide, call your local emergency number or see Get Help Now.

Questions to ask your healthcare professional

• Why are you recommending this medication for me?
• What monitoring will I need?
• Which side effects are most likely, and what can we do about them?
• How long might I need to take it?

Antipsychotics are usually started by a psychiatrist who can monitor you closely. Some online psychiatry services, such as Sesame, list antipsychotics such as aripiprazole among medications their psychiatric clinicians may prescribe or refill.

Talking with your prescriber about side effects

Side effects are one of the main reasons people stop antipsychotics, so it helps to raise them early and specifically. Mention changes in weight, appetite, sleep, energy, movement, restlessness, periods or sexual function. Your prescriber may adjust the schedule, switch to a different medicine, or add steps such as a dietitian referral or exercise plan. Never stop abruptly: doing so can bring symptoms back and may cause unpleasant effects.