Medicines called antipsychotics are the core of treatment for schizophrenia. If you or a family member have been diagnosed with schizophrenia, you will most likely be prescribed antipsychotic medicines. Many people with schizophrenia need lifelong treatment with medicines to control their symptoms.
Antipsychotic medicines work by helping to restore the brain’s natural chemical balance. While these medicines cannot cure schizophrenia, they can relieve or improve symptoms. Even during periods when there are no symptoms, medicines still usually need to be taken to prevent the symptoms from coming back.
Treatment for schizophrenia works best when medicines are combined with psychological treatments, rehabilitation, education and support from healthcare workers, family and friends.
What symptoms can be helped with antipsychotic medicines?
Antipsychotics work to reduce the ‘psychotic’ symptoms of schizophrenia. These symptoms of psychosis include disorganised thinking, delusions (strange and false beliefs) and hallucinations (seeing or hearing things that are not there). Many people who are diagnosed with schizophrenia have what’s called a first psychotic episode early on in the disease, where they experience psychotic symptoms like these. People having a psychotic episode can have trouble knowing what is real and what isn’t.
Antipsychotic medicines can be given to treat a first psychotic episode, helping people return to normal thinking and to feel like themselves again. Ongoing treatment with antipsychotics reduces the risk of having any more psychotic episodes. Not all people with schizophrenia will need ongoing treatment, but most will.
Antipsychotics can also help with the so-called negative symptoms of schizophrenia - including lack of interest in things, social withdrawal, reduced motivation and lack of emotions. Anxiety, agitation and mood changes can improve with antipsychotics, but additional medicines may also be needed to treat these symptoms.
Types of antipsychotic medicines
Antipsychotic medicines were first developed in the 1950s and revolutionised the treatment of schizophrenia. Antipsychotic medicines available now in Australia can be broadly classified into 2 groups.
First-generation antipsychotic medicines include many of the very first antipsychotic medicines developed, or derivatives of them.
Antipsychotics that have been developed more recently are known as second-generation antipsychotics (also referred to as atypical or novel antipsychotics). These newer medicines are usually recommended over the first-generation antipsychotics because they have fewer troublesome side effects and may be more effective for some symptoms.
|Examples of the different types of antipsychotic medicines|
|First-generation antipsychotics||First-generation antipsychotics|
|chlorpromazine (brand name Largactil)||amisulpride (brand names Solian, Sulprix)|
|flupenthixol (Fluanxol)||aripiprazole (Abilify, Abyraz)|
|fluphenazine (Modecate)||asenapine (Saphris Wafers)|
|haloperidol (Serenace)||clozapine (brand name Clozaril)|
|pericyazine (Neulactil)||lurasidone (Latuda)|
|trifluoperazine (Stelazine)||olanzapine (Zyprexa, Zyprexa Zydis Wafers, Zypine, Lanzek, Lanzek Zydis Wafers)|
|zuclopenthixol (Clopixol)||paliperidone (Invega)|
|quetiapine (e.g. Seroquel)|
|risperidone (e.g. Risperdal, Rixadone)|
|ziprasidone (brand name Zeldox)|
Different preparations are available, including tablets and wafers that dissolve in the mouth. Sometimes antipsychotic injections are given, but medicines taken by mouth are generally preferred.
Side effects of antipsychotic medicines
Most antipsychotic medicines have side effects. However, not everyone who takes a particular medicine will get the same side effects. Second-generation antipsychotics tend to have fewer side effects and are generally better tolerated than the older medicines.
Among the more serious side effects of antipsychotics are problems with nerves and muscles. These include muscle stiffness, trembling, restlessness or unusual movements. Tardive dyskinesia is a side effect that involves abnormal, uncontrollable movements, typically of the mouth, lips, tongue and jaws. These movement side effects are more often seen with first-generation antipsychotics. If you experience them, your doctor will recommend a lower dose or a different medicine.
Side effects of antipsychotics that can lead to physical health problems include weight gain, increased risk of diabetes, raised blood cholesterol and high blood pressure. If weight gain is a problem, your doctor will be able to advise you on diet and exercise which may help. Sometimes a medicine called metformin may be tried to reduce weight gain.
Other side effects include:
- dry mouth;
- dizziness when standing up;
- loss of menstrual periods;
- breast swelling, unusual secretion of breast milk or breast enlargement in men; and
- sexual dysfunction, including impotence.
Clozapine is a very effective antipsychotic, but it can occasionally cause serious side effects, such as a blood disorder called agranulocytosis (see below). For this reason, clozapine is usually reserved for people who have not been helped by other antipsychotic medicines. Also, in rare cases, it can cause inflammation of the heart muscle (myocarditis) and cardiomyopathy.
Always let your doctor know about any side effects you are experiencing.
Monitoring for side effects
Regular blood tests and physical check-ups are needed to check for side effects during treatment with antipsychotic medicines. Your doctor will regularly check your blood pressure and weight, and test your blood sugar and cholesterol levels.
People taking clozapine also need monitoring to check for agranulocytosis, a condition where the number of white blood cells decreases. As white blood cells fight infection, any drop in their numbers may make a person more likely to get serious infections they would normally be able to resist. To detect this problem early, people taking clozapine need to have regular blood tests checking their white cell count.
Which antipsychotic medicine will be best for me?
People respond differently to different antipsychotic medicines - some work well for one person but not so well for another. Or side effects may be a problem with one medicine but less so with another. So, treatment for schizophrenia is tailored specifically for each individual.
In Australia, antipsychotics are available only on prescription. The medicine that your doctor or psychiatrist (doctor specialising in mental health conditions) prescribes will depend on:
- your symptoms and how long you have had them;
- likely side effects of medicines;
- your age and sex; and
- whether you have any other conditions or take other regular medicines.
Sometimes the first antipsychotic medicine you try won’t be effective or will cause troublesome side effects, so you may need to change medicines. Your doctor will work with you to find the best medicine for you and the right dose.
A second-generation antipsychotic is usually the first choice for people who are having a psychotic episode for the first time. If the first medicine tried is not effective in controlling symptoms, a different second-generation or a first-generation antipsychotic may need to be tried.
It’s usually recommended that people take antipsychotic medicines for 2 to 5 years after a psychotic episode. After a certain period of time (usually at least 2 years after full recovery from a psychotic episode), some people may be able to have a trial of no medicines under their doctor’s supervision. If they remain symptom free, they may not need to take long-term medicines.
For those who do need ongoing medication, first- or second-generation antipsychotic medicines can be used. Some second-generation antipsychotic medicines may be more effective than first-generation antipsychotics against the 'negative' symptoms of schizophrenia, such as social withdrawal, loss of motivation and lack of emotional expression.
Taking your medicine as prescribed is important to give yourself the best chance of avoiding further psychotic episodes. Medicines are usually taken by mouth every day. If you have trouble remembering to take your medication, you may find it helps to use a special container that contains a dose for each day (sometimes called a dosette box), or to use a reminder or an app on your mobile phone.
Alternatively, antipsychotic medicines can be given as injections once every 2 to 4 weeks. The injection, called a depot injection, is given into a muscle, and the medicine is slowly released into the body over several weeks. Depot injections are useful in people who find it difficult to manage their medication.
Schizophrenia medicines and other drugs
Using drugs such as marijuana or stimulants such as cocaine and methamphetamine (including ice) can make symptoms worse and interfere with the treatment of schizophrenia. Alcohol can also affect your mental health and affect some medicines. Smoking can affect the blood concentration of some medicines and stop them working properly, so your dose may need to be adjusted if you stop (or start) smoking.
Antipsychotics and pregnancy
It’s not yet known whether many antipsychotics are safe to use during pregnancy or while breast feeding. Talk to your doctor if you become pregnant while taking antipsychotic medicines, or are planning a pregnancy. Your doctor can work with you to make sure your schizophrenia is adequately treated during your pregnancy, while reducing any risks to your baby that may be related to your medicines.
2. Schizophrenia and related psychoses (Published March 2013. Amended February 2014). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2017 Jul. https://tgldcdp.tg.org.au/etgcomplete (accessed Oct 2017).
3. SANE Australia. Schizophrenia (updated 11 May 2017). https://www.sane.org/mental-health-and-illness/facts-and-guides/schizophrenia (accessed Oct 2017).
4. Royal Australian and New Zealand College of Psychiatrists. Schizophrenia - your guide (published 2017). https://www.yourhealthinmind.org/getmedia/50afd990-a2aa-4bde-afe3-87a0e37a25ee/Schizophrenia-YHIM.pdf.aspx?ext=.pdf (accessed Oct 2017).