Much like the symptoms and health conditions they are used to treat, antipsychotic drugs are complicated. Here are nine things you should know about this powerful class of medication.
1. Antipsychotics are used to manage a mental health phenomenon known as psychosis.
A period of psychosis, called a psychotic episode, is a mental state where a person’s thinking has become so distorted that it is detached from reality, according to the National Institute for Mental Health (NIMH). Someone experiencing psychosis has difficulty understanding what is real and usually experiences delusions (false beliefs) and hallucinations (seeing or hearing things that aren’t there). Other symptoms include incoherent speech, inappropriate behavior, and overall difficulty functioning.
Psychosis itself is not a condition but a set of symptoms that can occur in many different scenarios, Dolores Malaspina, M.D., M.S.P.H., a professor and director of the Psychosis Program in the department of psychiatry at the Icahn School of Medicine at Mount Sinai, tells SELF. “Anyone can have a psychotic episode,” she explains. Although it can occur because of mental health conditions that we’ll discuss in a moment, it can also happen due to issues like a substance use disorder or severe sleep deprivation, according to the NIMH.
2. Antipsychotics are often prescribed to people with schizophrenia.
Schizophrenia is a mental illness that distorts the way people think, feel, and behave, according to the NIMH. Persistent psychosis is one of the main symptoms of this condition; someone must experience psychotic symptoms for at least six months before receiving a schizophrenia diagnosis, per the NIMH.
Antipsychotics are the frontline pharmacological treatment for schizophrenia, according to the Mayo Clinic. They are typically used as a maintenance drug, meaning they are taken daily, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), although there are long-acting injections available that can be taken once or twice a month.
3. They are also commonly prescribed to people with bipolar disorder.
Bipolar disorder is characterized by dramatic fluctuations in mood and energy levels. It is during these periods, called mood episodes, that psychosis can occur, according to the NIMH. Unlike schizophrenia, not everyone who has bipolar disorder will experience psychosis—but if someone has a severe enough depressive or manic episode, psychosis may develop.
Sometimes people with bipolar disorder take antipsychotics indefinitely, but more often they are used to treat symptoms on an as-needed basis, Dr. Malaspina says. This is usually in combination with a maintenance medication, like a mood stabilizer, according to the Mayo Clinic. “Later, when they’re better, they can stop taking the antipsychotics—after a couple weeks or a month, maybe,” Descartes Li, M.D., clinical professor in the department of psychiatry and director of the Bipolar Disorder Program at the University of California, San Francisco, tells SELF.
4. Antipsychotics help people manage symptoms by affecting neurotransmitters like dopamine.
These drugs don’t offer a cure for any condition, Dr. Malaspina explains. The goal in taking them is to reduce symptoms and improve a person’s quality of life. They do this mainly by blocking activity of a neurotransmitter called dopamine, which is thought to play a role in psychosis when levels in the brain are too high, Dr. Malaspina says. (Some antipsychotics affect additional neurotransmitters, which we’ll discuss below.)
Antipsychotics begin to treat some symptoms, like hallucinations, within a few days, but it typically takes a few weeks for them to stop the delusions, per the NIMH. (While they stop you from coming up with new delusions relatively quickly, it takes a while for the old ones to fade away, Dr. Malaspina says.) The full effects may not be seen for up to six weeks, according to the NIMH. How long the person remains on the medication depends on their underlying condition and other factors. “It’s pretty individualized in terms of the duration of treatment,” Dr. Malaspina says.
5. There are two general types of antipsychotics.
The newer class, known as atypical antipsychotics (or second-generation antipsychotics), also affect dopamine, but they tend to have a broader spectrum of action, according to the NIMH. “The new ones have various effects on a lot of different neurotransmitters, not just dopamine,” Dr. Li says.
6. Because atypical antipsychotics affect neurotransmitters beyond dopamine, they can be used to help treat things other than psychosis.
In addition to dopamine, atypical antipsychotics can also affect levels of mood-affecting neurotransmitters like serotonin, norepinephrine, and others, Dr. Li explains. This means that various SGAs can actually work pretty differently from one another. “It’s a little more tricky to anticipate what they will do because they’re not as consistent,” Dr. Li says.
While this makes them less predictable than typical antipsychotics, it also makes them more versatile. For example, they can be used to treat depression not fully managed by antidepressants, per the NIMH. “Atypical antipsychotics also have some mood stabilizing properties, too, so some people with bipolar disorder—even though they don’t have psychosis—can do really well on them [as a maintenance treatment],” Dr. Li explains.
Atypical antipsychotics are also sometimes prescribed off-label in combination with other treatments to manage symptoms of a number of other psychiatric and behavioral conditions, Dr. Malaspina says. These include dementia, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, and eating disorders, according to the NIMH.
7. Typical and atypical antipsychotics may cause different side effects.
Both typical and atypical antipsychotics commonly cause side effects like drowsiness, dizziness, blurred vision, constipation, nausea, and vomiting, per the NIMH. These often go away. But the drugs can also cause serious long-term side effects.
Typical antipsychotics tend to cause more neurological side effects that affect physical movement, like muscle rigidity, spasms, tremors, tics, and restlessness, according to the NIMH. The most serious potential complication is a disorder called tardive dyskinesia (TD) that can cause involuntary movement of the eyes, face, and hands, facial grimacing, rapid eye blinking, and piano playing-like finger movement. The longer somebody is on a typical antipsychotic, the more likely they are to develop this, according to the U.S. National Library of Medicine. Sometimes it goes away when the medication dosage drops, but sometimes it remains.
Although tardive dyskinesia can occur with atypical antipsychotics, it is thought to be pretty rare, per the NIMH. Atypical antipsychotics may cause more metabolic side effects than typical antipsychotics, like elevated weight and blood sugar levels, according to the NIMH, therefore potentially increasing the risk of developing health issues like type 2 diabetes. It appears as though atypical antipsychotics do this by affecting things like appetite level and metabolism.
8. If you’re taking these medications, you need to be closely monitored for side effects and persistent symptoms of psychosis.
“It’s not something you start [a patient] on and then leave them on … until they show up again a year later,” Dr. Li says.
If you are taking a typical antipsychotic, your doctor should keep a close watch for signs of TD or other motor issues. “You need to address [TD] as soon as possible because it could become permanent,” Dr. Malaspina says.
If you are taking an atypical antipsychotic, your psychiatrist should order regular blood work to keep an eye on any metabolic issues that may develop, like high blood sugar, per the NIMH. They may also refer you to a medical specialist who can prescribe you treatments to manage those complications (such as drugs to combat insulin resistance), Dr. Malaspina says.
For both typical and atypical antipsychotics, your prescriber will want to keep tabs on how effectively the drug is managing your symptoms, both in the beginning and throughout treatment. It may take some time and experimenting with different antipsychotics to land on which one works best for you, the NIMH says.
9. The safety of antipsychotic use during pregnancy is unclear, so it’s something to discuss with your doctor.
There’s concern that taking antipsychotics during pregnancy can cause birth defects, especially during the first trimester and if taken in addition to other drugs, according to the NIMH. However, this hasn’t been well studied, so the risks and benefits of using the medication during pregnancy should be discussed with your doctor. In many cases, the risks of stopping the medication could be more harmful to a person’s physical and mental health than taking it.
The NIMH notes that most of the research on this revolves around haloperidol, a typical antipsychotic that actually doesn’t appear to cause defects. Scientists are still studying the safety of atypical antipsychotics during pregnancy.
If you’re pregnant or planning to be and would benefit from antipsychotics, you and your doctor should weigh the possible costs and benefits, then tailor your individual treatment plan to match.