Basic Knowledge of Antipsychotics: The Five Atypicals
“I encouraged Henry to talk to me about his medications, and he is now asking me questions about his Risperidone. What do I need to know?” Cindy asked Dawn.
“You are showing a sense of accomplishment, Cindy. You have remained curious and want more for your patients and clients and your career. Let us now start talking about the atypical antipsychotics,” responded Dawn.
In the first article of this series, Basic Psychopharmacology Knowledge for Non-Medical Staff: 5 Reasons Why, I outlined that:
minimized overwhelming feelings, and
feeling empowered are crucial reasons why non-medical staff need to have basic knowledge in psychopharmacology.
I also mentioned (4) enhanced communication, as well as (5) maintained stability and decreased waste, as the other essential reasons to learn the basics of psychopharmacology.
In two subsequent articles entitled, Basic Knowledge of Antipsychotics: The How and the First Two and Basic Knowledge of Antipsychotics: The How and The Next Five, I provided an overview of pharmacology, psychopharmacology, and I described seven of the most commonly used typical antipsychotics.
Henry has been taking Risperidone, a medication classified as an atypical antipsychotic. Atypical antipsychotics have been slowly replacing the first generation antipsychotics.
What are the atypical antipsychotics; how do they differ from the typical antipsychotics; and what do I need to know to assist my patients and clients? Below is the response to these three key questions and an overview of 5 of the most commonly used atypical antipsychotics.
Also known as second-generation antipsychotics, are similar to the typical antipsychotic medications in that they are also known as major tranquilizers or neuroleptics and are used for the treatment of Schizophrenia. Atypical antipsychotics have also been extended to the treatment of Bipolar Disorder, as adjunct treatment of Major Depressive Disorder, and, for a few of them, as part of treatment of the aggressive behavior in Autism. These extended indications can be explained by the fact that, while the first-generation antipsychotics primarily act on dopamine (a chemical in the brain that plays a major role in the mechanism of Schizophrenia and psychosis), the atypical antipsychotics also act on other chemicals in the brain—in addition to dopamine—including, epinephrine, norepinephrine, and serotonin (also known as neurotransmitters). The atypical medications generally have a less potent action on dopamine, which also mean they are less likely to cause extrapyramidal symptoms compared to the first generation antipsychotics. Nonetheless, it is worth keeping in mind that atypical antipsychotics do cause extrapyramidal symptoms, in addition to causing side effects related to extreme weight gain, including diabetes and hypercholesterolemia, and that also involve the heart. Cindy will next need to start a conversation with Henry about lifestyle modification, including regular exercise, healthy dieting and appetite management.
Five of the most commonly used atypical antipsychotics are:
Its trade or brand name is Risperdal, and it is commonly used in the treatment of Schizophrenia, Bipolar Disorder, aggressive behavior in individuals with severe Personality Disorder, and aggressive behavior in individuals with Autism. Another use is in the treatment of Obsessive Compulsive Disorder that fails to respond to usual treatment.
Like Haloperidol and Fluphenazine, Risperidone comes in an oral and long acting, injectable form, Risperidone Consta. Like Fluphenazine, Risperidone Consta is administered every two weeks, but it is unlike Haloperidol, with long lasting injectable administered every four weeks. Risperidone is one of the only two atypical antipsychotics that has made it on the World Health Organization’s (WHO) List of Essential Medicines (the other atypical being Clozapine or Clozaril) and one of the 5 antipsychotics on that list (Haloperidol, Fluphenazine, Chlorpromazine, Risperidone, and Clozapine).
Aripiprazole is also known by its trade or brand name, Abilify, and, unlike Risperidone, it is also used as an adjunct treatment for Major Depressive Disorder. Other indicated use includes the treatment of Schizophrenia and Bipolar Disorder. Like Risperidone, it is also used in the treatment of aggressive behavior in Autism, and treatment-resistant Obsessive Compulsive Disorder. The side effects are typically the same as the other atypical antipsychotics. It was thought to be less likely to cause weight gain compared to some of the other atypical antipsychotics, but this has failed to translate into practice, as the results have been rather mixed.
Olanzapine has its trade or brand name Zyprexa. It is considered an effective medication but with the setback that it’s the atypical antipsychotic with the highest potential to cause weight gain, leading to Metabolic Syndrome.
In a series entitled, Basic Integrated Care Skills for the Non-medical Staff, in the second article, Likelihood of Death: The 10 Reasons Why, I provided an overview on the most common reasons patients and clients are more likely to die. Cardiovascular disease is the number one reason and a significant contributing factor is Metabolic Syndrome, which is a combination of any three of the following: high blood sugar, high blood pressure, obesity, or high levels of two particular fats in the blood, known as triglycerides and LDL (Lower Density Lipoprotein) cholesterol. I also mentioned that our patients and clients diagnosed with Schizophrenia are likely to die on average twenty years earlier than the general population. Unfortunately, some of the medications used to help them manage their symptoms do also contribute to the risk factors leading to their premature death. Nonetheless, you can do something, as a clinician. As I mentioned in previous articles, you can educate, encourage, and work with your patients and clients to slowly adapt some behavior changes for a generally healthy lifestyle, even when they are not taking medications that increase their risk factors for Metabolic Syndrome.
Quetiapine has its trade or brand name as Seroquel, and it is indicated in the treatment of Schizophrenia, Bipolar Disorder, and Major Depressive Disorder. While the risk of extrapyramidal symptoms side effects can be less likely with Quetiapine, weight gain is more likely when compared to the other atypical antipsychotics (except Olanzapine); it is also less effective when generally compared to the other atypicals. Because of its high sedating properties, it is used at times as a sleeping aid, and this is something you can help encourage against for your patient and client, given the related high risk to benefit ratio.
Its trade or brand name is Geodon, and its indication is essentially the same as the other atypical antipsychotics. The overall side effects are also similar to the other atypical antipsychotics, except that Ziprazidone is less likely to cause weight gain, but it is more likely to cause serious and fatal cardiac arrhythmias (abnormal and life threatening heart rhythms). It also has been shown to be less effective when compared to many of the other antipsychotics and has, therefore, not been considered a first line choice as an antipsychotic.
“I encouraged Henry to talk to me about his medications, and he is now asking questions about his Risperidone. What do I need to know?” Cindy articulated these words, seeking more and more opportunities to learn.
With this series of 5 articles, you now have a foundational knowledge of antipsychotics.
Now, it is up to you to build on this, support your colleagues, and continue learning more to make a difference in the lives of your patients or clients.
As usual, please share your stories and experiences. Thank you for this opportunity to accompany you on your journey, and until later.
Your friend and colleague,
Dr. Sidor is quadruple board certified in psychiatry, with board certification in General adult, Child and adolescent, Addiction, and Forensic, psychiatry. He also has additional training in public psychiatry, in several treatment modalities, in addition to his teaching, supervision, mentorship, and management, experience. Some of his passions are public speaking, leadership, business, and research, in addition to program development and project management. His overall goal is to empower all health care professionals throughout the United States and globally, towards ensuring the continuity of excellent patient care, while balancing the need to take care of themselves. Dr. Sidor is the main instructor for the SWEET Institute, and he is currently an Assistant Professor of Psychiatry at Columbia University. He is also the Medical Director and Chief Medical Officer for CASES (Center for Alternative Sentencing and employment Services), and he speaks and writes fluently in six (4) languages—French, English, Spanish, Creole, and has intermediate proficiency in Portuguese and Italian.
Leach S, Corves C, Arbter D, Engel RR, Li C, Davis JM (January 2009). "Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis". Lancet. 373 (9657): 31–41.
Leucht S, Cipriani A, Spineli L, et al. (September 2013). "Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis". Lancet. 382 (9896): 951–62
Tyrer, Peter; Kendall, Tim (2009). "The spurious advance of antipsychotic drug therapy". The Lancet. 373 (9657): 4–5.
Maher, Alicia Ruelaz; Maglione, M; Bagley, S; Suttorp, M; Hu, JH; Ewing, B; Wang, Z; Timmer, M; Sultzer, D; Shekelle, PG (2011). "Efficacy and Comparative Effectiveness of Atypical Antipsychotic Medications for Off-Label Uses in Adults - A Systematic Review and Meta-analysis". JAMA. 306 (12): 1359–69.