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Antipsychotics: What You Need to Know

torso shot of well-dressed person pouring pills into hand

For decades, clinicians have been prescribing patients antipsychotic medications. Unfortunately, use of these medications has long been associated with myths, stigmas, and stereotypes. As the name implies, conventionally, people believe that anyone taking antipsychotics must have psychosis (which refers to a loss of contact with reality; typically involving delusions and/or hallucinations)1 or schizophrenia. Also among these myths are that antipsychotic medications are addictive, or that the side effects are worse than the disorder the medication is treating.2

Neither of these is true, says Kevin Lazaruk, RPh, a board-certified geriatric pharmacist and an independent long-term care consultant based in Los Angeles. “There’s been some discussion about renaming this class of medications because of the stigma, but nothing is changing on this front.”

Below, learn more about some of the most common misconceptions about antipsychotics and what can be done to debunk them.

What are antipsychotics?

Antipsychotics, also known as neuroleptics, defines a class of psychiatric drugs. These drugs are subdivided into two categories, first-generation and second-generation, based on their mechanism of action.

Antipsychotics may be more widely used than you’d expect. In fact, 1.6% of adults in the U.S. — or 3.8 million people — report taking antipsychotic medications, according to the latest data.3

These medications are used to treat and manage many mental health concerns, including illnesses associated with psychosis, such as schizophrenia. But they’re also used to treat a host of other conditions, among them:

Some of these are through off-label uses (when a clinician uses a drug to treat a condition that is different from the condition the FDA has approved the drug to treat).5

How do antipsychotics work?

Some of the myths likely stem from misconceptions about how these medications work pharmacologically or how they affect the body. In a nutshell, antipsychotic medications affect dopamine levels in the central nervous system.4 The first-generation antipsychotic medications are considered dopamine antagonists — meaning they block dopamine receptors — while second-generation antipsychotics disrupt dopamine signaling and affect serotonin levels, Lazaruk explains.

By preventing excessive dopamine stimulation, antipsychotics can help relieve symptoms of psychosis such as visual or auditory hallucinations. However, dopamine and serotonin levels are key components to other mental health concerns, such as mood swings, impulse control, and executive function issues or impairment. Since antipsychotics help balance the effects of these neurotransmitters, they can treat conditions other than those typically associated with psychotic episodes.6,7,8

“Mental health conditions are complex and involve multiple neurotransmitter systems. These drugs minimize or stop symptoms,” Lazaruk says.

First-generation vs. second-generation antipsychotics

So-called first-generation antipsychotics, which were developed in the 1950s, are often associated with side effects (i.e., adverse drug reactions) such as weight gain, sedation, dry mouth, urinary retention, dizziness, rigidity, tremor, and tardive dyskinesia (a condition marked by repetitive, involuntary movements such as eye blinking, lip-smacking or grimacing).4

Medications in this group include:

  • fluphenazine
  • trifluoperazine
  • haloperidol
  • loxapine
  • pimozide
  • perphenazine
  • thiothixene
  • chlorpromazine
  • thioridazine

Most of these come in oral formulations, though some are also available as injectable intramuscular or intravenous formulations.

Newer, second-generation antipsychotics are also available in oral form, and some (such as olanzapine, risperidone, paliperidone, and aripiprazole) are available as long-acting injectables. This group typically has fewer side effects than the first, “but they’re not necessarily more effective,” Lazaruk says. The second-generation antipsychotics are also associated with weight gain, fatigue, and drowsiness, as well as an increased risk for developing type 2 diabetes and metabolic syndrome.4 (Metabolic syndrome is characterized by combination of impaired glucose tolerance, obesity and hypertension.)

In recent decades, there has been a substantial shift toward using second-generation antipsychotic medications and away from using first-generation antipsychotics.9 However, Lazaruk says caution should be taken and a risk-vs.-benefit evaluation should be considered when any antipsychotic medication is used in older people and in people with liver or kidney disease, coronary artery disease, cerebrovascular disease, parkinsonism, diabetes, high cholesterol, and severe hypotension or hypertension.4

“If you experience any of these adverse effects while taking an antipsychotic medication, be sure to tell your doctor or pharmacist. They may be able to adjust your dosage, switch you to a different medication, or alter the time when you take it,” Lazaruk says.

You can also ask your doctor if they’re familiar with precision health companies like Genomind, whose pharmacogenetic (PGx) testing and gene-drug software can be a valuable tool in dose adjustments and choosing alternative medications for patients’ individualized genetic profiles.

Your doctor or pharmacist also may be able to suggest non-medication measures — such as dietary changes or exercise — that could counteract the adverse effects associated with an antipsychotic medication.10

“Whatever you do, don’t make a change on your own — do it with your doctor’s guidance,” Lazaruk says. It’s a myth that you can stop taking an antipsychotic medication when you feel better. “If you stop one of these medications abruptly on your own,” he says, “you could experience rebound symptoms of the condition or withdrawal symptoms.” On the other hand, your doctor can help you safely and comfortably taper off the medication without having a bad reaction.

Making a change to the name “antipsychotics” itself might be welcomed in the mental healthcare community and help do away with some of the most obvious misconceptions. As the authors of a 2002 study published in the Journal of Psychiatry and Neuroscience note, “many clinicians know that attempts to obtain informed consent for antipsychotic drug therapy from a person with little insight into the nature of his or her illness provokes a predictable response: ‘Why do I need this pill, doctor? I’m not a psychotic!’”11 New name, less stigma? It might be a giant leap in the right direction.

Sources:

  1. Definition of psychosis: Psychosis (2022)
  2. Myths about antipsychotics: Is antipsychotic medication stigmatizing for people with mental illness? (2007)
  3. Latest data on antipsychotic usage: Characteristics of U.S. adults taking prescription antipsychotic medications, National Health and Nutrition Examination Survey 2013-2018 (2020)
  4. Background information on antipsychotics: Neuroleptic Medications (2021)
  5. Definition of off-label prescribing: Off-Label Drugs: What You Need to Know (2015)
  6. Antipsychotics and antidepressants: Antipsychotics as antidepressants (2016)
  7. Antipsychotics and bipolar depression: Efficacy and tolerability of atypical antipsychotics for acute bipolar depression: a network meta-analysis (2021)
  8. Antipsychotics and off-label uses: Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis (2011)
  9. Information on second- and first-generation antipsychotics: Who are the New Users of Antipsychotic Medications? (2008)
  10. How to counteract antipsychotics’ effects: Management of common adverse effects of antipsychotic medications (2018)
  11. Stigma attached to the name “antipsychotics”: What’s in a name? The evolution of the nomenclature of antipsychotic drugs (2002)

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