They are a range of medications that are used for some types of mental distress or disorder – mainly schizophrenia and manic depression (bipolar disorder). They can also be used to help severe anxiety or depression.
Antipsychotics are drugs that are used to treat symptoms of psychosis such as delusions (for example, hearing voices), hallucinations, paranoia, or confused thoughts. They are used in the treatment of schizophrenia, severe depression. and severe anxiety. Antipsychotics are also useful at stabilizing episodes of mania in people with Bipolar Disorder.
Their main action is on dopamine receptors, reducing levels of excess dopamine. They may also affect levels of other neurotransmitters, namely acetylcholine, noradrenaline, and serotonin.
Older antipsychotics tend to be called typical antipsychotics, and antipsychotics that have been developed more recently are called atypical antipsychotics. Atypical antipsychotics are less likely to produce extrapyramidal side effects (such as tremor and Parkinson’s-like symptoms) and tardive dyskinesia (abnormal, repetitive facial movements).
Atypical antipsychotics are also more likely to improve cognitive function. Clozapine (classed as an atypical antipsychotic even though it is quite an old drug) also improves delusions and hallucinations and reduces the risk of suicide.
Antipsychotic medications can reduce or relieve symptoms of psychosis, such as delusions (false beliefs) and hallucinations (seeing or hearing something that is not there). Formerly known as major tranquilizers and neuroleptics, antipsychotic medications are the main class of drugs used to treat people with schizophrenia.
They are also used to treat people with psychosis that occurs in bipolar disorder, depression and Alzheimer’s disease. Other uses of antipsychotics include stabilizing moods in bipolar disorder, reducing anxiety in anxiety disorders and reducing tics in Tourette’s syndrome.
Antipsychotic medications can help to calm and clear confusion in a person with acute psychosis within hours or days, but can take up to four or six weeks to reach their full effect. These medications can help to control symptoms, but they do not cure the underlying condition. When taken over a longer term, antipsychotics can help to prevent further episodes of psychosis.
While antipsychotic medications can help some people with psychosis and mood disorders, at the same time these drugs can have serious side-effects. The aim of medication treatment is to reduce and control symptoms while keeping side-effects at a minimum.
Combining antipsychotic medication with other therapy and support can help people to manage symptoms and improve quality of life. Family therapy, peer support, school and job counselling and housing and employment supports can all be helpful. Some therapists now offer cognitive-behavioural therapy to help people cope with voices
Taking care of your physical health is especially important if you take antipsychotic medication. Both schizophrenia and the medications used to treat it can increase the risk of diabetes and other serious health problems. Getting regular checkups and medical care can help you to have good physical health. Eating a nutritious diet, exercising regularly and getting enough sleep can also help you to get and stay well.
How do they work?
They all affect the action of a number of chemicals in the brain called neurotransmitters – chemicals which brain cells need to communicate with each other. Dopamine is the main neurotransmitter affected by these medications. It is involved in how we feel:
- that something is significant, important or interesting;
It is also involved in the control of muscle movements.
If parts of the dopamine system become overactive, they seem to play a part in producing hallucinations, delusions and thought disorder.
Although these medications were known as ‘major tranquillisers’ in the past, they are not designed to make you calmer or sleepy – so they are not the same as medications like Valium or sleeping tablets.
The basic aim is to help you feel better, without making you feel slowed down or drowsy. However, high doses may well make you feel too sleepy or ‘drugged up’. They can be used in higher doses if you become very overactive, agitated or distressed – but this should usually only be for a short time.
Antipsychotics change the levels of chemicals in your brain called neurotransmitters — the chemicals that carry messages around your brain. The neurotransmitter most targeted by antipsychotics is called dopamine.
Changing the levels of these chemicals reduces, in almost all cases, the hallucinations and delusions of psychosis. In some cases, they also improve your mood and reduce anxiety.
Psychosis is believed to be caused, at least in part, by overactivity of a brain chemical called dopamine, and antipsychotics are thought to work by blocking this dopamine effect. This blocking helps to make the symptoms of psychosis—such as voices and delusions—less commanding and preoccupying, but it does not always make them go away completely. People may still hear voices and have delusions, but they are more able to recognize what isn’t real and to focus on other things, such as work, school or family.
Antipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine, serotonin, noradrenaline and acetylcholine. These chemicals have the effect of changing your behaviour, mood and emotions. Dopamine is the main chemical that these medicines have an effect on.
By altering the effects of these chemicals in the brain they can suppress or prevent you from experiencing:
- Hallucinations (such as hearing voices).
- Delusions (having ideas not based on reality).
- Thought disorder.
- Extreme mood swings that are associated with bipolar disorder.
Antipsychotics affect the action of chemicals in the brain called neurotransmitters. These are chemicals which brain cells need to communicate with each other.
- Dopamine is the main neurotransmitter affected by antipsychotic medication. If parts of the dopamine system become overactive, it is thought that they may cause hallucinations, delusions and thought disorder. Dopamine is also involved in muscle movements.
- Most antipsychotics are known to affect other neurotransmitters such as serotonin and noradrenaline, which are both thought to be involved in regulating mood.
Taking antipsychotic medication will not change your personality and antipsychotic medications are not addictive. When starting an antipsychotic medication, give it time to start working properly.
Choosing an antipsychotic
Most antipsychotics seem to be equally as good at controlling psychotic symptoms – Clozapine is the exception and is described later. Even so, individuals react differently to them, particularly with the side-effects. We cannot predict how well a particular person will respond to a particular drug – even whether a newer, or older drug, will be more helpful. It can often take some time, negotiation and ‘trial and error’ to find the best antipsychotic for a particular person.
The antipsychotic medication you are prescribed will depend on the severity and nature of your illness, other medical conditions you may have, your response to medication and other things – for example if you need your medication in a different form such as an injection instead of pills.
- Different people respond differently to antipsychotic medication, so finding the one that is best for you may be a process of ‘trial and error’, where you may have to try a few before you find the antipsychotic medication that is right for you. It can take time to find the right type and dose of medication to manage your symptoms.
- Also different antipsychotic medication may have different side effects. When deciding on the best medication for you, it is important to discuss with your doctor what the possible side effects are and how they may impact your lifestyle.
The following resource provides more information about things to think about when choosing antipsychotic medication. Be aware that this is from another country and may have information that differs from New Zealand recommendations.
- Sleepiness and slowness
- Weight gain
- Interference with your sex life
- Increased chance of developing diabetes.
- Some can affect your blood pressure and make you feel dizzy.
- In high doses, some have the same Parkinsonian side-effects as the older medications (stiffness of the limbs).
- Long-term use can produce movements of the face (tardive dyskinesia) and, rarely, of the arms or legs.
Compared to the older drugs they seem:
- less likely to cause Parkinsonian side-effects (see above)
- less likely to produce tardive dyskinesia.
- more likely to produce weight gain
- more likely to produce diabetes
- more likely to give you sexual problems.
They may also help ‘negative symptoms’ (poor motivation, lack of interest, poor self-care), on which the older drugs have very little effect. Some people find the side effects less troublesome than those of the older medications.
The main drawback is that it can affect your bone marrow, leading to a shortage of white cells. This makes you vulnerable to infection. If this happens, the medication is stopped at once so that the bone marrow can recover. So, if you take Clozapine you will need weekly blood tests for the first 6 months and 2 weekly blood tests after that. It can also cause weight gain, constipation, over-production of saliva and make epileptic fits more likely.
These problems mean that Clozapine is usually only suggested after at least two other antipsychotics have been tried. It is a difficult drug to monitor and can be difficult to take, but some people find that overall it gives them a much better quality of life.
Certain antipsychotic drugs cause significant weight gain and high cholesterol levels, and they may increase the risk of diabetes. People considering an antipsychotic for bipolar disorder should be screened for their risk of heart disease, stroke, and diabetes, according to a study published in Diabetes Care.
Common side effects of antipsychotic medications include:
- Blurred vision
- Dry mouth
- Muscle spasms or tremors
- Weight gain
Older antipsychotic drugs are also generally not used as a first-line treatment for bipolar disorder, and they are less established for treating depressive symptoms or preventing episodes during long-term use. However, they may be helpful if a person has troublesome side effects or doesn’t respond to the newer drugs.
Older antipsychotics include chlorpromazine (Thorazine), haloperidol (Haldol), and perphenazine (Trilafon). These drugs may cause a serious long-term side effect called tardive dyskinesia, a movement disorder characterized by repetitive, involuntary movement like lip smacking, protruding the tongue, or grimacing. Newer atypical antipsychotics also have the potential to cause this side effect, but are thought to have a relatively lower risk than the older conventional antipsychotics.
The medications deutetrabenazine (Austedo) and valbenazine (Ingrezza) have proven effective in treating adults with tardive dyskinesia.
Antipsychotic medication can cause unpleasant side-effects, especially when the symptoms are severe and a higher dose of medication is used. Side-effects should become mild or at least tolerable when the dose is reduced and as your body adjusts to the presence of the drug.
Most side-effects will go away when you stop taking the drug. There is a risk, however, of a condition that causes people to make involuntary movements, known as tardive dyskinesia, which can be permanent.
Some people accept the side-effects as a trade-off for the relief these drugs can bring. Others find the side-effects distressing and may choose not to take the medication.
Check the information given to you by your doctor or pharmacist to find out the specific side-effects of any drug you have been prescribed. If you are troubled by any of these effects, it is best to continue to take your medication as prescribed and let your doctor know as soon as possible.
Your doctor may:
- adjust your dose
- prescribe other medications to help control side-effects
- change your medication.
- Side-effects vary depending on the type of medication. More information on side-effects is included with each type of antipsychotic.
How do I stop taking it?
if you decide you want to stop taking an antipsychotic, talk it over with your psychiatrist. You and the psychiatrist may disagree about this, but there is a way that can help both sides to feel happier. You can:
- make a list of feelings/thoughts/behaviours that might warn you that your symptoms are returning. The pattern of symptoms is often very similar from one episode to another.
- make a similar list – with someone you trust and who knows you well – of what other people might notice if your symptoms start to return.
Antipsychotics are not addictive, but your body does get used to having them in its system and stopping them suddenly may make you feel physically and/or mentally unwell. If you decide to stop, reduce the medication gradually, giving each reduction a few weeks to take effect.
This means that your symptoms are not likely to suddenly return. If they do start to get worse again, you can think about what to do next while you are still well.
If you do stop medication completely, keep in touch with your psychiatrist or mental health worker, even if you have been well for a few months without medication.
Your doctor will want to monitor you regularly for side-effects if you take an antipsychotic. The tests needed and how often you will need to have them depend on which antipsychotic you are taking.
In general, your doctor will take a sample of blood for certain tests before you start treatment. The tests look at:
- How many blood cells you have.
- How well your kidneys and liver are working.
- How much lipid (fat) is in your blood.
- Whether you have diabetes.
When you take clozapine your white blood cell (leukocyte) and differential blood counts must be normal before treatment is started. After beginning treatment, a full blood count should be taken every week for 18 weeks then at least every two weeks after that. If clozapine is continued, and the blood count is stable after one year, then monitoring should occur at least every four weeks, and for four weeks after finishing. These tests may be repeated in the first three or four months of treatment. After this they are normally done every year. However, your doctor may advise you to have these tests more often.
Your weight and blood pressure are usually measured before you start treatment and every few weeks after this for the first few months. After this they are normally measured every year.
The blood level of prolactin (a hormone) may also be measured before starting treatment and six months later. Usually it is then measured every year after this. The prolactin level is measured because sometimes antipsychotics can make you produce too much of this hormone. If you make too much prolactin it can lead to your breasts growing bigger and breast milk being produced.
What alternatives are there?
The evidence is very clear that nothing else works as well as antipsychotic medications in the treatment of the more troublesome symptoms of psychotic illnesses. For many people, antipsychotics alone are not enough to get them back to a full and active life. Other ways of helping will usually be added to antipsychotic treatment rather than replacing it. These include:
Cognitive behaviour therapy (CBT)
This is a talking treatment which can be helpful if you have distressing psychotic symptoms. It can help you to control them and to feel less distressed by them. It can also be used to help you identify if your symptoms are returning again.
This helps you to find out more about your disorder, how to manage it and the treatments available. The purpose is to help everyone (including families) understand the illness better so that they can cope better and be more supportive.
- Professionals will meet with the whole family. The aims are:
- to reduce tensions between the person with a psychiatric illness and those who care for them;
- to give the family practical ways of coping with everyday problems.
- We know that these tensions can make it more likely that the symptoms will get worse.
- Hearing voices groups
- People who have similar experiences of hearing voices get together to discuss their experiences and how they cope with them.
- Not all of these are available in all areas, and they may not be helpful for everybody – if you feel that one of these might be helpful for you, talk it over with your psychiatrist or mental health worker.
Which antipsychotic is right for me?
There are no antipsychotics that are clearly ‘better’ than any others. Clozapine is more effective, but has potentially dangerous side-effects and means that you have to have regular blood tests.
NICE guidelines (England and Wales) suggest that one of the newer antipsychotics should be tried first and then one of the older ones, depending on how well the medication works for you, and any side-effects they give you.
The best thing is to weigh up the benefits and risks of the different medications with your psychiatrist. Write down the things you are worried about before the appointment so that you don’t forget anything important.
Safety with medication
There are a few things you can do to make sure your experience with medication is safe:
Tell your doctor everything: your allergies, other medication you take, your alcohol, smoking and recreational drug habits, if you’re pregnant or breastfeeding, and anything else they ask. It all helps with finding the right medication plan for you.
Store your medication carefully: medicine doesn’t like heat or damp, so keep your medication out of bathrooms and cars. Keep it in a container in a cool, dry place. Store it high to make sure children can’t reach it.
Don’t share medication: your medication is designed for you and no one else. Don’t take anyone else’s medication and don’t let anyone take yours. It can do real harm.
Take the right dose: taking too little or too much reduces how effective your medicine is, and can do harm. Stick to the instructions on the packet.
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