This is a short overview of antipsychotic medication, how they are separated into two classes and some of the possible side effects. We plan to go into more details about antipsychotics later and probably with focus on different medications.
Antipsychotic medications are used to treat psychosis. Many of them also work well to treat manic symptoms. Antipsyhotics are also sometimes used to treat anxiety, sleeping disorders and other mental illnesses. In those cases doctors tend to prescribe lower doses than when treating psychosis or mania.
Antipsychotics are divided into two groups:
First generation (FGA) or typical antipsychotics.
Second generation (SGA) or atypical antipsychotics.
First generation antipsychotics started with chlorpromazine in the 1950s and the second generation emerged in the 1980s.
This table does not include all antipsychotics but all the ones I use in Iceland.
First generation / typical | Second generation / atypical |
|---|---|
Haloperidol | Olanzapine |
Perphenazine | Quetiapine |
Cisordinol | Aripiprazol |
Chlorpromazine | Risperidone |
Fluphentixol | Paliperidone |
Levomepromazine | Amisulpride |
Lurasidone | |
Clozapine |
In general most antipsychotics are considered equally as effective in treating psychosis. Therefore the decision on which medication to use is often based on potential side effects. The exception to this rule on effectiveness is clozapine which is used for treatment resistant psychosis. Some studies also indicate that olanzapine and maybe risperidone are superior to other antipsychotics.
All medications have side effects, even over-the-counter analgesics like paracetamol and ibuprofen which many people take very regularly without thinking twice can have very serious side effects. Antipsychotics are not considered to be dangerous drugs or to have worse side effects than other types of medications. It is also important to remember that even though a side effect is listed as possible for a medication it does not mean that everyone taking that medication will get that side effect. The two different generations of antipsychotics are considered to have very different side effect profiles. Still it is possible to get side effects considered more common with typical from atypical medications and vice versa. We'll now try to explain the possible side effects and tell you from which generation antipsychotic they are more likely.
Some possible side effects of antipsychotics:
Extrapyramidal symptoms (EPS)
Akathisia (restlessness), rigidity (muscle stiffness), bradykinesia (slow movements), tremor (shaking) and acute dystonic reactions (sudden involuntary muscle contractions).
Many of these are also seen in Parkinson's disease and therefore called parkinsonian symptoms.
EPS are considered the defining difference between FGA and SGA, much more common with most FGA but still seen with many SGA. Akathisia is for example in my clinical experince very common with aripiprazole which is a SGA.
Tardive dyskinesia
Involuntary movements of face, mouth, tongue, extremities or trunk.
"Tardive" -> starts after a while on medication, 1 month after starting at the earliest, sometimes after years on the medication.
Increased risk with older age and if longer exposure to medication.
Much more common with FGA than SGA.
Metabolic syndrome
Weight gain, diabetes and dyslipidemia (like cholesterol being too high).
Weight gain not only because of increased appetite but also that the metabolism changes independent of the weight gain and appetite.
Usually considered much more related to SGA but also quite common with some FGA. Olanzapine, clozapine, quetiapine in my opinion the worst drugs regarding metabolism and weight gain. Risperidon and paliperidone can also cause weight gain. Aripiprazole usually with little weight gain, also amisulpride and perphenazine.
Sedation
Many antipsychotics are sedating and then usually taken in the evening before sleep.
This can sometimes be quite useful, especially if patients also have anxiety, agitation and/or sleeping problems. The sedation/tiredness can in some cases last until the next day and then it is troublesome. Sometimes that gets better with time but if not I usually try to switch medications.
Neuroleptic malignant syndrome
Very rare but can be fatal if not recognized and treated.
More likely in the beginning of treatment, if doses are increased fast and in relation to medical illness and dehydration.
Presents with fever, muscle rigidity, mental status change and autonomic instability, which we usually see in unstable vital signs.
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