Antipsychotics explained

What antipsychotics are

Antipsychotics are a class of medication used to treat psychosis and several other conditions. The name points to psychosis, but it understates what they do. In psychiatric care they treat schizophrenia and bipolar disorder, and at lower doses several of them are added to antidepressants to help with depression that has been hard to treat.

There are two generations. The older first-generation antipsychotics are also called typical antipsychotics. The newer second-generation antipsychotics are also called atypical antipsychotics. The atypicals are the ones most used today in mood care.

The main atypicals are quetiapine (Seroquel), aripiprazole (Abilify), risperidone (Risperdal), olanzapine (Zyprexa), and lurasidone (Latuda).

How they work

Antipsychotics act on dopamine receptors. Dopamine is a chemical messenger that nerve cells use to pass signals to one another. The atypical antipsychotics also act on serotonin receptors, another chemical messenger system. These actions are thought to explain how the medications ease psychotic and mood symptoms.

What they are used for

Antipsychotics are used for several conditions.

• Schizophrenia and other psychotic conditions.
• Bipolar disorder, including manic episodes, bipolar depression, and ongoing maintenance treatment.
• As an add-on to an antidepressant in depression that has been hard to treat.

It is worth being clear about that last use. When someone sees an antipsychotic prescribed for depression, it is usually as a low-dose add-on to an antidepressant. It does not mean the diagnosis is psychosis.

What they have in common

The medications in this class share a number of features.

• They take time to work for mood and psychotic symptoms.
• They carry an FDA boxed warning about an increased risk of death in older adults with dementia-related psychosis. Antipsychotics are not approved for that use.
• Metabolic effects are a shared concern. This means weight gain and rises in blood sugar and cholesterol, so weight and blood tests are monitored during treatment.
• Tardive dyskinesia, a movement disorder, is a risk with long-term use.
• Neuroleptic malignant syndrome, a rare but serious reaction, can occur.

How they differ from each other

The antipsychotics differ mainly in their side-effect profiles.

Some are quite sedating and more associated with weight gain, such as quetiapine and olanzapine. Others are more activating and lighter on weight, such as aripiprazole. Restlessness, called akathisia, is more associated with some than with others.

Because the medications are broadly similar in what they treat, the choice is often driven by which side effects to avoid in a given person.

The medications in this group

• Quetiapine (Seroquel). An atypical antipsychotic used across schizophrenia, bipolar disorder, and depression as an add-on. It tends to be sedating and is more associated with weight gain.
• Aripiprazole (Abilify). An atypical antipsychotic used in schizophrenia, bipolar disorder, and depression as an add-on. It tends to be more activating and lighter on weight.
• Risperidone (Risperdal). An atypical antipsychotic used in schizophrenia and bipolar disorder.
• Olanzapine (Zyprexa). An atypical antipsychotic used in schizophrenia and bipolar disorder. It is effective but more associated with weight gain and metabolic effects.
• Lurasidone (Latuda). An atypical antipsychotic used in schizophrenia and bipolar depression, often noted for a lighter effect on weight.

PsychiatryRx has dedicated guides for quetiapine and aripiprazole, with more detail on uses, side effects, dosing, and what to expect.

Sources

This guide draws on current prescribing information and public health references. It is reviewed for clinical accuracy and updated as guidance changes.

1. U.S. Food and Drug Administration. Prescribing information.
2. MedlinePlus, U.S. National Library of Medicine.
3. National Institute of Mental Health. Mental health medications.