What’s an Antipsychotic?

(updated 12/2014)

Big Picture

Careful now, don’t throw these off your list right away because of that name. Antipsychotic” refers to a class of medications that have been around for a long time. Many people worry when they hear this term, because these medications have been used for people with very serious mental health problems (and have been misused as well, in part because for a long time they were the only tool available). There’s a “new generation” of these medications that don’t completely deserve this label, because they have strengths the old ones didn’t have and do not have some of the problems the old ones had. They really ought to have a different name entirely.

So far most of this new generation of antipsychoticshave been used as “antimanic” tools, but several clearly have antidepressant effects as well (as of the 2007 revision, three out of the five have clear evidence for such effects). Their strength, as a group, is to help when a person’s thoughts are out of control, whether that’s “racing thoughts” as in bipolar manic symptoms; or delusional thinking such as paranoia; or severely disorganized thought as can occur in either bipolar disorder or schizophrenia. But even in low doses they can have powerful “mood stabilizing” effects that are equal to and in some cases better than what we can get from the “good old” mood stabilizers like lithium and Depakote.

This new group does not cause some of the effects of the old ones, that often made people want to stop their medications. The old ones sometimes made people feel as if they were too “shut down”, as if they couldn’t think freely or even act freely (an “emotional straightjacket”, you may have heard people say).

Tardive Dyskinesia

In addition, there was a severe side effect called “tardive dyskinesia” (TD). Tardive, like tardy, means this comes on late, usually after people have taken these medications for months and often years. Dyskinesia, another Greek word, means a bad (dys-) motion (kinesia, like kinetic). TD can cause people’s tongue to move in their mouth when they’re not trying to move it. Or cause their lips to smack, also involuntarily. Or more rarely, TD can cause motions of their shoulders, or neck or even their trunk or whole body. And these effects can persist even when the antipsychotic that caused them has been stopped, although in many cases if it’s stopped soon enough, these motions will go away. Here is more information on TD.

Names and generations

So, when it was found that the “new generation” of antipsychotics caused this TD problem at a lower rate, this was very exciting. One of the oldest and worst problems of the antipsychotics had been dramatically reduced. It is still there as a risk, though. And most of the new group can cause serious weight gain. As one of my psychiatry colleagues joked in 2001: in the 90’s, they hated us for tardive dyskinesia; in the 00’s, they’re going to hate us for weight gain”.

Here’s a list of some of the names you’ll see:

Common “Old-Generation” Antipsychotics “New Generation” Antipsychotics
Thorazine clozapine (Clozaril)
Mellaril Zyprexa (olanzapine)
Stelazine risperidone (Risperdal)
Haldol (haloperidol) Seroquel (quetiapine)
Trilafon (perphenazine) Geodon (ziprasidone)
(a.k.a Abilify)
Let’s all try to avoid using that name, hey? it’s just too smarmy
lurasidone/Latuda (good antidepressant but still too new, I’m still avoiding it, but almost there, as of 12/2014)
asenapine/Saphris (no role in bipolar so far)
iloperidone/Fanapt (no data in bipolar so far)
  • olanazapine is clearly a “mood stabilizer” like divalproex and lithium.
  • risperidone has substantial antidepressant effects, particularly in low doses in older folks. ha
  • quetiapine hass strong anti-anxiety effects in many people, and probably the best evidence for antidepressant effects.
  • ziprasidone is tricky to predict as far as how it’s going to affect people, but there are some folks who do well on it and it appears not to cause weight gain, or at least much less (many people lose weight they’ve gained on the others when they switch to it).
  • aripiprazole: its anti-manic effects are quite clear. But compared to quetiapine (and now the newcomer lurasidone), it lacks a sustained antidepressant effect. At low doses it does something antidepressant, granted; but that seems not to stick. And it’s harder to stop, like some sort of withdrawal thing from the low doses, as with antidepressants? (there is no literature on that question to my knowledge as of 12/2014; my suspicion).

Back to the Mood Stabilizer Options Page

Update 7/2013: 63% of people newly started on an antipsychotic stop it, most within 2 months. Most of them do not go back on it or another after that.Chen