Antipsychotic medications are used as a short-term treatment for bipolar disorder to control psychotic symptoms such as hallucinations, delusions, or mania symptoms. In people with bipolar disorder, antipsychotics are also used "off label" as sedatives, for insomnia, for anxiety. Antipsychotics, also known as neuroleptics or major tranquilizers, are a class of medication primarily used to manage psychosis principally in schizophrenia and . Antipsychotic drugs can also be called neuroleptics. Some people prefer this term because it means 'seizing hold of the nerves', which describes their action.
Contraindications Hypersensitivity to the active substance or adjuvants Acute intoxication with alcohol, sleeping pills, analgesics , opioid , or psychotherapeutic drugs; comatose patients Parkinson syndromes, lesions in the basal ganglia , EPS Dose adjustment in renal impairment Dose adjustment is not necessary.
Haloperidol is not recommended during the lactation period. Active ingredient Levomepromazine e. Contraindications Hypersensitivity to the active substance or adjuvants Angle-closure glaucoma Micturition disorders with residual urine History of agranulocytosis Porphyria Leukopenia Neurological disorders, e.
Substance not recommended during lactation period. Active ingredient Pipamperone e. Contraindications Hypersensitivity to the active substance or adjuvants CNS depression e. Levomepromazine is not recommended during the lactation period. Active ingredient Clozapine e. Indications Treatment of refractory schizophrenia Long-term reduction of suicidal behavior associated with schizophrenia and schizoaffective disorders Psychosis in patients with Parkinson's disease Special considerations Doses have to be assessed individually.
The goal is to determine the lowest effective dose for each patient. Cautious dose titration and splitting of the daily dose into several individual doses are necessary to minimize the risk of hypertonia, seizures , and sedative effects. Treatment should be continued for at least 6 months after onset of the antipsychotic effect. Clozapine is not recommended during the lactation period. Active ingredient Olanzapine e. Olanzapine is not recommended during the lactation period. Active ingredient Risperidone e.
Contraindications Patients with dementia and symptoms of Parkinson's disease such as rigor, bradykinesia , and postural abnormalities Patients with dementia most probably caused by dementia with Lewy bodies Dose adjustment in renal impairment Begin with half the recommended dose, then cautiously increase it.
Dose adjustment in hepatic impairment Begin with half the recommended dose, then cautiously increase it. Risperidone is not recommended during pregnancy.
Risperidone is not recommended during the lactation period. First-generation antipsychotics FGA Mechanism of action: Low- potency antipsychotics are antidopaminergic, antihistaminergic , and anticholinergic primarily sedative.
In comparison to butyrophenones e. However, no difference was detected regarding secondary negative symptoms e. Therefore, dopamine antagonists increase the effects of prolactin , which may lead to galactorrhea.
First-generation high- potency antipsychotics: Treatment In case of EPS or in case of patient wish if longterm antipsyochotic therapy is likely , a typical antipsychotic can be replaced with an atypical 2 nd generation antipsychotic In case of severe dyskinesia , tetrabenazine can be given EPS subtype Onset Symptoms Treatment Acute dystonia see also the learning card on dystonia Hours to days Painful and lasting muscle spasms predominantly affecting the head, neck , and tongue Oculogyric crisis Tongue protrusion or twisting Facial grimacing, torticollis Opisthotonus of the back Acute treatment: Pseudoparkinsonism Week 1 Cogwheel rigidity , stiff gait, tremor Anticholinergic e.
Neuroleptic malignant syndrome NMS Description: A connection between NMS and the duration of therapy or therapeutic dose has not been established. Central D2 receptor blockade in the nigrostriatal pathway Clinical features: Rarely, this may present as diabetic ketoacidosis. The atypical medications Table 1 have become widely used because of their lower rate of extrapyramidal adverse effects compared to older classes of medication such as the phenothiazines and the butyrophenones.
However, while some of the atypical drugs are better tolerated, they also increase the incidence of diabetes. In patients younger than 40 years of age, the odds ratio for developing diabetes is 1. Classification of antipsychotic medications available in Australia a. Not all antipsychotics increase the risk of diabetes to the same extent. The mechanisms responsible for the elevated risk of diabetes associated with some antipsychotics are not fully understood.
It is known that the atypical antipsychotics and some of the low potency conventional antipsychotics cause weight gain 6 and that, at least for olanzapine and clozapine, the magnitude of this weight gain correlates with the magnitude of the therapeutic response. Clozapine and olanzapine cause the greatest gain, risperidone and quetiapine moderate gain, and aripiprazole and amisulpride the least gain.
Obesity can precipitate diabetes in susceptible people so weight gain is one mechanism for the increased incidence in diabetes. However, the fact that hyperglycaemia improves quickly after stopping the antipsychotic medication and that diabetes can appear in some patients who do not put on weight, suggests that other mechanisms must be involved. Antipsychotics , also known as neuroleptics or major tranquilizers ,  are a class of medication primarily used to manage psychosis including delusions , hallucinations , paranoia or disordered thought , principally in schizophrenia and bipolar disorder.
They are increasingly being used in the management of non-psychotic disorders but with serious side effects. Antipsychotics are usually effective in relieving symptoms of psychosis in the short term. The long-term use of antipsychotics is associated with side effects such as involuntary movement disorders , gynecomastia , impotence , weight gain and metabolic syndrome.
First-generation antipsychotics, known as typical antipsychotics , were discovered in the s. Most second-generation drugs, known as atypical antipsychotics , have been developed more recently, although the first atypical antipsychotic, clozapine , was discovered in the s and introduced clinically in the s. Neuroleptic , originating from Greek: They are not recommended for dementia or insomnia unless other treatments have not worked.
The World Health Organization provides a description of recommendations for the prescription of antipsychotics for the purposes of the treatment of psychosis. There is mixed evidence to support a significant impact of antipsychotic use on negative symptoms such as apathy, lack of emotional affect, and lack of interest in social interactions or on the cognitive symptoms disordered thinking, reduced ability to plan and execute tasks of schizophrenia.
Applications of antipsychotic drugs in the treatment of schizophrenia include prophylaxis in those showing symptoms that suggest that they are at high risk of developing psychosis, treatment of first episode psychosis, maintenance therapy, and treatment of recurrent episodes of acute psychosis.
Test batteries such as the PACE Personal Assessment and Crisis Evaluation Clinic and COPS Criteria of Prodromal Syndromes , which measure low level psychotic symptoms, and others focused on cognitive disturbances Basic symptoms" , are used to evaluate people with early, low level symptoms of psychosis.
While generally useful for reducing symptoms, the clinical trials performed to date provide little evidence that early use of antipsychotics, alone or in combination with cognitive-behavioral therapy, provides improved long term outcomes in those with prodromal symptoms.
NICE recommends that all persons presenting with a first episode of frank psychosis be treated with both an antipsychotic drug and cognitive-behavioral therapy CBT. NICE further recommends that those expressing a preference for CBT alone be informed that combination treatment is more efficacious.
The goals of treatment of these patients include reducing symptoms and potentially improving long-term treatment outcomes. Randomized clinical trials have provided evidence for the efficacy of antipsychotic drugs in achieving the former goal, with first-generation and second generation antipsychotics showing about equal efficacy.
Evidence that early treatment has a favorable effect on long term outcomes is equivocal. Placebo-controlled trials of both first and second generation antipsychotic drugs consistently demonstrate the superiority of active drug to placebo in suppressing psychotic symptoms.
Few patients achieve complete resolution of symptoms. Response rates, calculated using various cutoff values for symptom reduction, are low and their interpretation is complicated by high placebo response rates and selective publication of clinical trial results.
The majority of patients treated with an antipsychotic drug will experience a response within 4 weeks. The goals of continuing treatment are to maintain suppression of symptoms, prevent relapse, improve quality of life, and support engagement in psychosocial therapy. Maintenance therapy with antipsychotic drugs is clearly superior to placebo in preventing relapse, but is associated with weight gain, movement disorders, and high dropout rates.
The effect of relapse prevention on long term outcomes is uncertain, as historical studies show little difference in long term outcomes before and after the introduction of antipsychotic drugs. A significant challenge in the use of antipsychotic drugs for the prevention of relapse is the poor rate of compliance. In spite of the relatively high rates of adverse effects associated with these drugs, some evidence, including higher dropout rates in placebo arms compared to treatment arms in randomized clinical trials, suggest that most patients who discontinue treatment do so because of suboptimal efficacy.
Three atypical antipsychotics lurasidone ,  olanzapine  and quetiapine  have also been found to possess efficacy in the treatment of bipolar depression as a monotherapy. Whereas only olanzapine  and quetiapine   have been proven to be effective broad-spectrum i. The American Psychiatric Association and the UK National Institute for Health and Care Excellence recommend antipsychotics for managing acute psychotic episodes in schizophrenia or bipolar disorder, and as a longer-term maintenance treatment for reducing the likelihood of further episodes.
A number of studies have looked at levels of "compliance" or "adherence" with antipsychotic regimes and found that discontinuation stopping taking them by patients is associated with higher rates of relapse, including hospitalization. An assessment for an underlying cause of behavior is needed before prescribing antipsychotic medication for symptoms of dementia.
Thus, antipsychotics should not be used routinely to treat dementia with aggression or psychosis, but may be an option in a few cases where there is severe distress or risk of physical harm to others. A number of atypical antipsychotics have some benefits when used in addition to other treatments in major depressive disorder. Besides the above uses antipsychotics may be used for obsessive—compulsive disorder , posttraumatic stress disorder , personality disorders , Tourette syndrome , autism and agitation in those with dementia.
In children they may be used in those with disruptive behavior disorders , mood disorders and pervasive developmental disorders or intellectual disability. Risperidone has been approved by the US FDA for the treatment of irritability in autistic children and adolescents. Aggressive challenging behavior in adults with intellectual disability is often treated with antipsychotic drugs despite lack of an evidence base.
A recent randomized controlled trial , however, found no benefit over placebo and recommended that the use of antipsychotics in this way should no longer be regarded as an acceptable routine treatment. It is unclear whether the atypical second-generation antipsychotics offer advantages over older, first generation antipsychotics. Due to bias in the research the accuracy of comparisons of atypical antipsychotics is a concern.
Compliance has not been shown to be different between the two types. Many researchers question the first-line prescribing of atypicals over typicals, and some even question the distinction between the two classes.
The re-evaluation of the evidence has not necessarily slowed the bias toward prescribing the atypicals. Generally, more than one antipsychotic drug should not be used at a time because of increased adverse effects.
Very rarely antipsychotics may cause tardive psychosis. Some studies have found decreased life expectancy associated with the use of antipsychotics, and argued that more studies are needed.
Loss of grey matter and other brain structural changes over time are observed in schizophrenia. Meta-analyses of the effects of antipsychotic treatment on the course of grey matter loss and structural changes have reached conflicting conclusions. A meta-analysis concluded that grey matter loss is greater in patients treated with first generation antipsychotics relative to those treated with atypicals, and hypothesized a protective effect of atypicals as one possible explanation.
Subtle, long-lasting forms of akathisia are often overlooked or confused with post-psychotic depression, in particular when they lack the extra pyramidal aspect that psychiatrists have been taught to expect when looking for signs of akathisia. Withdrawal symptoms from antipsychotics may emerge during dosage reduction and discontinuation.
Withdrawal symptoms can include nausea , emesis , anorexia , diarrhea , rhinorrhea , diaphoresis , myalgia , paresthesia , anxiety , dysphoria or depression, cognitive dysfunction, worsening of negative symptoms, agitation, restlessness, and insomnia.
The psychological withdrawal symptoms can be mistaken for a relapse of the underlying disorder. Better management of the withdrawal syndrome may improve the ability of individuals to discontinue antipsychotics. Unexpected psychotic episodes have been observed in patients withdrawing from clozapine. This is referred to as supersensitivity psychosis, not to be equated with tardive psychosis. Tardive dyskinesia may abate during withdrawal from the antipsychotic agent, or it may persist.
Withdrawal effects may also occur when switching a person from one antipsychotic to another, it is presumed due to variations of potency and receptor activity. Such withdrawal effects can include cholinergic rebound, an activation syndrome, and motor syndromes including dyskinesias. These adverse effects are more likely during rapid changes between antipsychotic agents, so making a gradual change between antipsychotics minimises these withdrawal effects.
Clinically used antipsychotic medications are listed below by drug group. Trade names appear in parentheses. A review has stated that the division of antipsychotics into first and second generation is perhaps not accurate. Some antipsychotics are not firmly placed in either first-generation or second-generation classes. This category is for drugs that have been called both first and second-generation, depending on the literature being used.
Antipsychotic drugs such as haloperidol and chlorpromazine tend to block dopamine D 2 receptors in the dopaminergic pathways of the brain. This means that dopamine released in these pathways has less effect. Excess release of dopamine in the mesolimbic pathway has been linked to psychotic experiences. Decreased dopamine release in the prefrontal cortex, and excess dopamine release in other pathways, are associated with psychotic episodes in schizophrenia and bipolar disorder.
Different alleles of the 5-HT 2A receptor have been associated with schizophrenia and other psychoses, including depression. Typical antipsychotics are not particularly selective and also block dopamine receptors in the mesocortical pathway , tuberoinfundibular pathway , and the nigrostriatal pathway. Blocking D 2 receptors in these other pathways is thought to produce some unwanted side effects that the typical antipsychotics can produce see above.
They were commonly classified on a spectrum of low potency to high potency, where potency referred to the ability of the drug to bind to dopamine receptors, and not to the effectiveness of the drug. High-potency antipsychotics such as haloperidol , in general, have doses of a few milligrams and cause less sleepiness and calming effects than low-potency antipsychotics such as chlorpromazine and thioridazine , which have dosages of several hundred milligrams. The latter have a greater degree of anticholinergic and antihistaminergic activity, which can counteract dopamine-related side-effects.
Atypical antipsychotic drugs have a similar blocking effect on D 2 receptors, however, most also act on serotonin receptors, especially 5-HT 2A and 5-HT 2C receptors. Both clozapine and quetiapine appear to bind just long enough to elicit antipsychotic effects but not long enough to induce extrapyramidal side effects and prolactin hypersecretion. For example, clozapine is notorious for its ability to cause agranulocytosis. If data on the propensity of a particular drug to cause a particular AE is unavailable an estimation is substituted based on the pharmacologic profile of the drug.
The original antipsychotic drugs were happened upon largely by chance and then tested for their effectiveness. The first, chlorpromazine , was developed as a surgical anesthetic. It was first used on psychiatric patients because of its powerful calming effect; at the time it was regarded as a non-permanent "pharmacological lobotomy ". However, chlorpromazine proved to reduce the effects of psychosis in a more effective and specific manner than lobotomy, even though it was known to be capable of causing severe sedation.
The underlying neurochemistry involved has since been studied in detail, and subsequent antipsychotic drugs have been discovered by an approach that incorporates this sort of information. The discovery of chlorpromazine's psychoactive effects in led to further research that resulted in the development of antidepressants , anxiolytics , and the majority of other drugs now used in the management of psychiatric conditions.
In , Henri Laborit described chlorpromazine only as inducing indifference towards what was happening around them in nonpsychotic, nonmanic patients, and Jean Delay and Pierre Deniker described it as controlling manic or psychotic agitation. The former claimed to have discovered a treatment for agitation in anyone, and the latter team claimed to have discovered a treatment for psychotic illness.
Until the s there was considerable debate within psychiatry on the most appropriate term to use to describe the new drugs. Yonkman, a chemist at the Swiss-based Cibapharmaceutical company, first used the term tranquilizer to differentiate reserpine from the older sedatives. Thus, the word means taking hold of one's nerves.
It was often taken to refer also to common side effects such as reduced activity in general, as well as lethargy and impaired motor control. Although these effects are unpleasant and in some cases harmful, they were at one time, along with akathisia, considered a reliable sign that the drug was working.
They are being abandoned in favor of "antipsychotic", which refers to the drug's desired effects. Antipsychotics are broadly divided into two groups, the typical or first-generation antipsychotics and the atypical or second-generation antipsychotics. The typical antipsychotics are classified according to their chemical structure while the atypical antipsychotics are classified according to their pharmacological properties.
These include serotonin-dopamine antagonists see dopamine antagonist and serotonin antagonist , multi-acting receptor-targeted antipsychotics MARTA, those targeting several systems , and dopamine partial agonists , which are often categorized as atypicals. The term major tranquilizer was used for older antipsychotic drugs. The term neuroleptic is often used as a synonym for antipsychotic , even though - strictly speaking - the two terms are not interchangeable.
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There are currently 24 antipsychotic drugs licensed in the UK. These are listed alphabetically to the left of this screen. Some of them also come in a depot. Easy to understand and user-friendly information on Antipsychotic medication, produced by the Royal College of Psychiatrists. About Antipsychotic Drugs. Antipsychotics are a group of drugs that are used to treat serious mental health conditions such as psychosis as well as other.