Antipsychotic Medications List and Management Guide
Psychosis is a medical condition that affects the way the brain processes information. Common conditions involving psychosis include:
- Schizophrenia
- Bipolar Disorder
- Borderline Personality Disorder
- Mania
- Dementia
- Major Depressive Disorder
Psychosis affects people’s ability to discern between what is real and what isn’t.
Since the 1950s, healthcare providers have used antipsychotics to treat psychosis, but the specific medications used to treat psychosis have changed over the years. Today, antipsychotic medications break down into two different groups: first-generation antipsychotics (FGAs), also called typical antipsychotics, and second-generation antipsychotics (SGAs), or atypical antipsychotics.
As the names imply, first-generation antipsychotics include some of the first medications used to treat psychosis. However, many of them have fallen out of favor over the years. While many of these medications are still used today, second-generation antipsychotics avoid some of the most acute and significant side effects of first-generation medications.
Continue reading to learn more about our antipsychotic medications list in this management guide.
Types of Antipsychotics
Before modern anesthetics, doctors noted that a drug they administered to treat shock, promethazine, had a calming effect on some patients. It wasn’t until the development of the chlorinated version of promethazine (chlorpromazine, sold today under the name brand Thorazine) that prescribers started using what is now known as antipsychotics as a treatment for psychosis.
First-Generation Antipsychotics
The first generation of antipsychotics (FGAs) are also called typical antipsychotics. FGAs include this list of antipsychotic medications:
- Haldol (haloperidol)
- Serentil (mesoridazine)
- Loxitane (loxapine)
- Thorazine (chlorpromazine)
These medications primarily work by reducing dopamine activity in the brain. Excess dopamine is thought to increase excitability and other symptoms of psychosis, so FGAs target dopamine receptors to relieve these symptoms.
However, FGAs also carry the risk of extrapyramidal side effects like dystonia, akathisia, and parkinsonism — all drug-induced movement disorders. Because of these side effects, FGAs have fallen out of favor with prescribers as a new generation of antipsychotics has risen in prevalence. However, FGAs are still used today, primarily in patients who don’t respond to other antipsychotics, in conjunction with s, and for off-label use in treating non-specific conditions such as stress and insomnia.
Second-Generation Antipsychotics
Second-generation (or atypical) antipsychotics are newer than their first-generation counterparts. Popular SGAs include this antipsychotic medication list:
- Abilify (aripiprazole)
- Latuda (lurasidone)
- Seroquel (quetiapine)
- Rexulti (brexpiprazole)
- Risperdal (risperdone)
Like FGAs, SGAs target dopamine in the brain but also regulate levels of serotonin, another neurotransmitter that affects feelings of satisfaction and contentment. They have a broader focus than FGAs and importantly avoid some of the extrapyramidal side effects (involuntary movement disorders) that made FGAs challenging for some patients. When it comes to typical vs atypical antipsychotics, it often comes down to side effects.
Prescribing Antipsychotics
Today, most prescribers prefer SGAs — they cover a broader range of symptoms and avoid some of the most troubling side effects of antipsychotic medication.
However, treatment for psychosis can be highly individualized, depending on the specifics of each patient’s needs.
For some patients, FGAs are more effective, so healthcare providers may switch medications or types of medications for patients whose symptoms don’t respond to treatment.
Each medication on the antipsychotic drug list has a different optimal dose where it is most effective. Going over this dosage typically yields diminishing returns, plateauing, or even reducing the effectiveness of the medication.
Since higher doses can contribute to more severe side effects, prescribers should start small, gradually increasing the dosage over time. This is especially true when treating conditions where psychosis is not the primary symptom, such as major depression.
Side Effects Management
The side effects of antipsychotic medication vary based on the patient and the specific medication. Some of the general side effects of antipsychotics include:
- Lightheadedness
- Constipation
- Weight gain
- Involuntary movements
- Dry mouth
- Seizures
However, each medication may have its own side effects. For example, seizures and neutropenia (an abnormally low concentration of white blood cells) are virtually unique to clozapine — an SGA.
Minimizing and Monitoring Side Effects
The first line of defense against adverse side effects is dosage. Licensed prescribers should start with low doses that gradually increase to find the minimum dosages that are effective at relieving symptoms because higher dosages can result in more severe side effects.
Patients can partially manage some of the most common side effects — weight gain and constipation — through lifestyle changes like exercise and a healthy, high-fiber diet.
However, some side effects of antipsychotics are irreversible, so prescribers should exercise caution in prescribing medications when the benefits fail to outweigh the risks.
Role in Treatment Plans
Antipsychotic medications are the first line of defense against psychosis, but healthcare providers often use antipsychotic medication as part of a larger treatment plan rather than on its own. While antipsychotics are effective at treating the immediate symptoms of psychosis, they’re less effective at providing long-term relief.
Cognitive behavioral therapy (CBT) doesn’t seek to address the immediate symptoms of psychosis, but it can help address their underlying causes. For some patients, psychosis is the result of an underlying mental health condition that CBT can effectively treat.
Other treatments like transcranial magnetic stimulation can also improve the patient’s underlying condition.
Antipsychotics are most useful in patients with acute or chronic symptoms. Patients with mild or short-term symptoms may experience relief from antipsychotic medication, but the side effects aren’t always worth the relief of mild or first-time symptoms.
Prescribers often use antipsychotic medication in combination with other medications — including other antipsychotics, antidepressants, and other psychotropics.
Special Populations
While antipsychotics can be effective in treating children and adolescents, they’re less common. Only 14% of patients prescribed antipsychotics are under 18. There are several reasons for this:
- The symptoms treated by antipsychotics sometimes don’t appear until late adolescence or early adulthood, so children and adolescents are demographically less likely to need antipsychotic medication.
- Due to the side effects (which can be permanent), prescribers are likely to prescribe antipsychotic medication to children and adolescents only when other forms of treatment are ineffective.
Similarly, patients older than 65 only account for 17% of antipsychotic use. Healthcare providers frequently prescribe antipsychotic medication to treat dementia in older patients, but usually only when other forms of treatment are ineffective.
Prescribers may also make special considerations for patients who are pregnant or breastfeeding. Antipsychotics may pose a risk to the development of unborn or breastfeeding children, but these risks should be weighed against the severity of the patient’s symptoms.
SGAs in particular can cause metabolic side effects like weight gain and diabetes. The potential risks associated with these side effects in vulnerable populations should be weighed against the potential risks of unmedicated or under-medicated psychosis.
Tapering and Discontinuation
Psychosis can make life difficult, so antipsychotics can sometimes offer much-needed relief. However, antipsychotics may introduce new challenges, as discontinuing antipsychotics can lead to the resurgence of symptoms — sometimes, even more severe than before.
Healthcare providers recommend an individualized approach to tapering off antipsychotics rather than abrupt discontinuation or “quitting cold turkey.” Safely tapering off antipsychotics may take months or even years, so it’s important to strategize with your healthcare provider to create a safe dosage schedule.
As you taper off antipsychotic medication, closely monitor your symptoms. If you begin experiencing a resurgence of symptoms, inform your healthcare provider immediately as these early warnings can help prevent more pronounced symptoms in the future.
Your healthcare provider may also recommend alternative treatments as you taper off antipsychotic medication. Treatments like CBT or TMS can help supplement your medication as you transition to life without it.
Research and Future Directions
While first-generation (typical) and second-generation (atypical) antipsychotics constitute the range of antipsychotics available today, new treatments are in progress.
One such treatment is a novel medication for treating psychosis called ulotaront. Ulotaront works differently from FGAs and SGAs. Ulotaront stimulates serotonin receptors as well as the trace amine-associated receptor 1 (TAAR1), which in turn blocks the release of presynaptic dopamine. While the net effect is similar — less dopamine to excite areas of the brain associated with psychosis — ulotaront works by a different mechanism and so avoids the motoric and metabolic side effects of other common antipsychotics.
Transcranial magnetic stimulation (TMS) has also been shown to relieve the symptoms of schizophrenia — in particular, auditory hallucinations. TMS is non-invasive, and mild side effects are rare, making it a highly desirable alternative or supplement to traditional medication.
FAQs About Antipsychotics
Antipsychotic medication can help patients with schizophrenia, borderline personality disorder, bipolar disorder, major depression, or other conditions resulting in psychosis. Antipsychotics fall into two categories: first-generation, which has more motoric side effects, and second-generation, which has more metabolic side effects.
While these side effects are often a deterrent, they can be mitigated with treatments like cognitive behavioral therapy (CBT) and transcranial magnetic stimulation (TMS).
TMS is a safe, non-invasive treatment that can treat the underlying causes of psychosis. To learn more, contact us at Pulse TMS.
If you are experiencing any of these symptoms, call 9-1-1 immediately:
•Thoughts of suicide
•Disturbing hallucinations, such as voices telling you to harm yourself or others
•Extreme anxiety, depression, mania, disorientation, or confusion
•Uncontrollable anger
Any of these symptoms constitute a medical emergency.
The 9-8-8 suicide and crisis lifeline is available 24/7, free of charge.
For more information about psychosis, the Schizophrenia and Psychosis Action Alliance has a free helpline that can answer questions and connect you to resources.
Educational materials about psychosis and antipsychotic medication can be found online. You can also find support groups both in-person and online, such as groups hosted by the Schizophrenia and Psychosis Action Alliance and the National Alliance of Mental Illness.
Different types of anti-anxiety medications address different symptoms and affect each person differently. However, anti-anxiety medication generally aims to create a sense of calmness and restfulness.
The National Institute of Mental Health (NIMH) has many free resources for learning more about anxiety. Healthline recommends these support groups for individuals with anxiety disorders. Some groups meet via video calls, while others offer support through chats and discussion forums, so no matter your preference, there is a group that fits your needs.