Antipsychotics

Antipsychotic medication refers to a category of psychotropic medications aimed at treating psychosis, the mechanism by which this effect is achieved is dependent on the specific medication within the category. These medications can treat psychosis as an isolated symptom, mental illnesses characterized by the presence of psychotic symptomology such as schizophrenia or schizoaffective disorder, or as a feature of another primary psychiatric diagnosis such as depression or mania.

The first generation of antipsychotic medications were first developed in the 1950s. These medications revolutionized the treatment of psychoses and schizophrenia. Chlorpromazine was the first contemporary, laboratory medication developed able to successfully alleviate psychotic symptoms. It has a nonspecific tranquilization effect and more specific antipsychotic effects. Chlorpromazine was a significant contributing factor in the movement to de-institutionalize chronic psychotic patients, something that had largely never been considered a possibility.

There are two major groupings of antipsychotic medications: first-generation antipsychotics (FGAs), also known as typical antipsychotic drugs, and second-generation antipsychotics (SGAs), also known as atypical antipsychotic drugs. Some examples of FGAs are Chlorpromazine (Thorazine) Thioridazine (Mellaril), Perphenazine (Trilafon), Fluphenazine (Prolixin), and Haloperidol (Haldol). FGAs act on the dopaminergic system. It blocks dopamine type 2 (D2) receptors. FGAs often have neurological side effects. FGAs are classified as high-potency, mid-potency, and low-potency on D2 receptors. Low potency antipsychotics have less risk of extrapyramidal side effects (EPS) but more antihistaminic effects. Mid- and high-potency FGAs can lead to the development of acute dystonia, akathisia and tardive dyskinesia (TD).  Dystonia refers to muscle spasms that can begin a few minutes after administration of the antipsychotic medication and can be extremely uncomfortable. Common examples of dystonia are spasms of the neck and back muscles pulling an affected patient's head to one side, their eyes rolling back, or their throat closing. Akathisia can be described as an inner sense of restlessness, and it is poorly understood.  Both FGAs and SGAs can cause akathisia. Akathisia can be manifested in a patient feeling a need to walk or to move, most frequently accompanied by difficulty in articulating how they feel.  Tardive dyskinesia is a potentially irreversible side effect. It has a late onset of involuntary movements, mostly if antipsychotics are used for long periods and at high doses. Some examples of tardive dyskinesia are tongue thrusting, facial grimacing, jerking of the head, mouth puckering, finger, movement, blinking, rolling the tongue around the mouth, twitching hands, tapping feet, twisting the trunk. Hyperprolactinemia is the increase in breast tenderness and lactation for both males and females. It is often seen in FGAs and Risperidone (Risperdal) as SGA. Neuroleptic Malignant Syndrome is often a medical emergency and can happen early in treatment. A few examples are autonomic instability: elevated heart rate, high blood pressure, very high fever), lead-pipe rigidity, delirium, white blood cells increased, creatine phosphokinase.

SGAs were developed in the late 80s and early 90s. The hope for SGAs was to have fewer neurological side effects than FGAs and a possible therapeutic effect on negative symptoms. Some examples of SGAs are Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon),and Aripiprazole (Abilify). The main concern with FGAs is metabolic side effects. Severe weight gain, high blood sugar, and high lipids are often seen. Compared to FGAs, SGAs still bring one set of long-term worries. Risperidone (Risperdal), Olanzapine (Zyprexa), and Clozapine (Clozaril) are the SGAs with the most evidence supporting better efficacy. Clozapine (Clozaril) is the most efficacious antipsychotic but has severe side effects. It should only be used in patients who have failed two or more other antipsychotics. Clozapine can lower white blood cells so patients need weekly blood testing as they start taking Clozapine. The blood test then tapers into every 2 weeks then monthly. Clozapine can cause severely low blood pressure so it needed to start in a low dose and increase slowly to accommodate. If the patient stops it for 48 hours or longer then he/she must go back to starting does.  It is important to not insist a patient return to taking the full dose if a patient has been non-adherent.

**The Uses of Antipsychotics in Treatment**

Antipsychotics were initially primarily only utilized in order to help reduce the symptoms schizophrenia. To date antipsychotics are still used in the treatment of schizophrenia. The use of antipsychotics are important for treatment because they are able to manage positive symptoms because they block the receptors in the brain that account for disorganization and presences of hallucinations or delusions. Furthermore, antipsychotics can help patients with schizophrenia to improve their attention.In addition, antipsychotics play an essential role in the prevention of relapse of schizophrenia which can help to improve the quality of life of patients. While antipsychotics are beneficial in the treatment of schizophrenia they are the most effective when properly prescribes to the needs of the individual and used in addition to psychosocial treatments.

Throughout the years and with additional research, antipsychotics have been proven effective for more disorders than only schizophrenia. In addition antipsychotics are utilized in the treatment of mood disorders such as bipolar. The use of antipsychotics is to help clients to stabilize their moods. Atypical antipsychotics or second generation are found to be effective in the treatment of both the manic and depressive phases of bipolar. In a clinical trial by Derry et al. (2007) they found anti psychotics to be more effective than the placebo group and additionally proved to be as effective as previously established drug therapies in treatment. This study additional presented the need for further research between effectiveness within the class of antipsychotics in order to determine which antipsychotic is most effective in the treatment of bipolar disorder.

Lastly, second generation or atypical psychotics are now being utilized in the treatment of Autism Spectrum Disorder (ASD) in severe cases. Antipsychotics can be used to help manage many symptoms that impact the quality of life in a client with ASD.The use of this class of drugs is seen most commonly in mitigating the adverse behavioral symptoms like motor restlessness, sensory response, irritability, and self-injurious behavior. All of these symptoms can present challenges for clients in daily life and with the reduction of them with the use of antipsychotics they are able to participate better in life.

**References**

1. ↑ Kapur, S., Agid, O., Mizrahi, R., & Li, M. (2006). How antipsychotics work—from receptors to reality. *NeuroRx*, *3*(1), 10-21.
2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Ansari A, Osser DN, Psychopharmacology, A Concise Overview for Students and Clinicians, 2nd Edition, North Charleston, SC, CreateSpace, 2015.
3. ↑ Ban T. A. (2007). Fifty years chlorpromazine: a historical perspective. *Neuropsychiatric disease and treatment*, *3*(4), 495–500.
4. ↑ https://pubmed.ncbi.nlm.nih.gov/15702141/
5. ↑ https://www.goodtherapy.org/drugs/anti-psychotics.html
6. ↑ 6.0 6.1 6.2 6.3 https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/antipsychotic-medication#:~:text=Formerly%20known%20as%20major%20tranquilizers,disorder%2C%20depression%20and%20Alzheimer's%20disease.
7. ↑ 7.0 7.1 7.2 7.3 7.4 Tandon R. (2011). Antipsychotics in the treatment of schizophrenia: an overview. *The Journal of clinical psychiatry*, *72 Suppl 1*, 4–8.
8. ↑ 8.0 8.1 8.2 Derry, S., & Moore, R. A. (2007). Atypical antipsychotics in bipolar disorder: systematic review of randomised trials. *BMC psychiatry*, *7*, 40. https://doi.org/10.1186/1471-244X-7-40
9. ↑ 9.0 9.1 9.2 9.3 Posey, D. J., Stigler, K. A., Erickson, C. A., & McDougle, C. J. (2008). Antipsychotics in the treatment of autism. *The Journal of clinical investigation*, *118*(1), 6–14. https://doi.org/10.1172/JCI32483