Basic Knowledge of Antipsychotics: The How and the First Two

“My work with Henry has been a good lesson for me; and now I know I need to learn about Antipsychotics, but how do I even start?”

Lily articulated these words to Dawn, during clinical team meeting with the HOPE ACT team.  Dawn paused, knowing exactly what Lily was alluding to, looked at her and said, “Your request is inspiring, and I am going to carve out some time with you and the rest of the team, each week, for an overview of the basics on psychopharmacology.”

Pharmacology is the study of drugs (pharmaceuticals), their actions and effects, and it is further divided into several branches, depending on the part of the body or the physiologic system a class of drugs has major active or target effects.  For example, cardiovascular pharmacology, neuropharmacology, and psychopharmacology are of special interest in the respective fields of cardiology, neurology, and psychiatry. Each drug class has target effects within the respective physiologic systems of the body.  Psychopharmacology is, therefore, the study of the action and effects of drugs on the thinking (cognition), emotions, behavior, and sensation of an individual.

The main classes of medications of interest in psychopharmacology are: Antidepressants, Mood Stabilizers, Depressants, Anxiolytics, Stimulants, and Antipsychotics.  Henry was taking Risperidone, an antipsychotic, and Dawn promised to start working with Lily and the rest of the team to provide guidance and an overview.  This article gives an overview on the basics of antipsychotics, starting with a special group—the typical antipsychotics.

Antipsychotics are primarily used in the treatment of psychosis (See previous article, Psychosis: Symptom Contextualization, for an understanding of psychosis), and they are also referred to as major tranquilizers or neuroleptics (they have the property of reducing nerve tension).  The antipsychotic medications can be further divided into typical and atypical antipsychotics.  While I caution this is merely an oversimplification, this division will help you with the basic knowledge of antipsychotics.

Also known as first generation antipsychotics, the typical antipsychotics were the first developed in the 1950’s.  Based on their basic chemical composition (formulation), they are further classified into Phenothiazines and Butyrophenones; and regarding effectiveness, they are divided into low, medium, or high potency agent.  Below is a basic description of the two most commonly used typical antipsychotics.

 Haloperidol

Generally, medications have a brand or trade name and a generic or scientific or chemical name.  Haldol is the brand name for Haloperidol, an example of a high potency, typical or first generation antipsychotic, and, as you may have already deduced from your daily practice, it is the most commonly used typical antipsychotics.

While the primary indication of Haloperidol use is Schizophrenia, it has also been used in the treatment of Tourette syndrome associated tics, acute psychosis, alcohol withdrawal induced psychosis, and as a chemical restraint (use of medication to restrain someone), particularly in acute, escalating agitation and aggressive behavior.  These additional uses are also true, for the most part, of the other typical antipsychotics.

Haloperidol is generally a safe medication; the World Health Organization (WHO) has listed it as an Essential Medicine—a list recognizing the most effective and safest medications required in any health system.  The main side effect is a form of abnormal movements, known as extrapyramidal symptoms.  Elaborating on this type of side effect is beyond the scope of this article.  However, explaining to your patients and clients that starting at a low dose and slowly increasing the dose and closely monitoring for these types of motor side effects are the main steps in helping them benefit from this effective medication, while preventing the extrapyramidal symptoms that can be distressful, and that may have long lasting effects at times.

Haloperidol is one of the only five antipsychotic medications that have made it to the list of Essential Medicines by the WHO.  Most of its other adverse effects occur in less than 1% of the patients and clients using it.  Special cautions are required if the patients or clients carry a diagnosis of Parkinson’s disease or are also taking Lithium.  Its use while the patient or client is severely intoxicated with alcohol should also be discouraged.  Lastly, bear in mind that heavy smoking can lead to a requirement of a higher dose of Haloperidol and of some other antipsychotics, while smoking cessation may warrant lower doses to prevent the side effects mentioned above.

Fluphenazine

Fluphenazine, another high potency, typical or first generation antipsychotic, like Haloperidol, is primarily used in the treatment of Schizophrenia.  Its brand or trade name is Prolixin, and it can also lead to the extrapyramidal symptom side effects I mentioned above, but less so than Haloperidol.  However, more than with Haloperidol, some patients and clients can complain of sedation (sleepiness) and weight gain; and like Haloperidol, Fluphenazine comes both in oral and long acting injectable (depot) form.  The long acting form, Fluphenazine decanoate, is also one of the only five antipsychotic medications found in the World Health Organization’s List of Essential Medicines.

“My work with Henry has been a good lesson for me; and now I know I need to learn about Antipsychotics, but how do I even start?”  These were Lily’s words as she became convinced that some basic knowledge of psychopharmacology could be an empowering tool.  She, therefore, decided to take Dawn up on her offer for assistance in this noble endeavor.  If you have made it to this 2nd article, it means you, too, are convinced of the need for a basic knowledge of psychopharmacology.  I hope this article has laid the foundation for you, and I look forward to hearing your experiences.  Please feel free to share with your colleagues, and, until soon.

Your friend and colleague,

Mardoche

With this series of 5 articles, you now have a foundational knowledge of antipsychotics.

References: 

1. Vallance P, Smart TG (January 2006). “The future of pharmacology”. British Journal of Pharmacology. 147 Suppl 1 (S1): S304–7. doi:10.1038/sj.bjp.0706454. PMC 1760753 . PMID 16402118

2. Mannfred A. Hollinger (2003).”Introduction to pharmacology”. CRC Press. p.4. ISBN 0-415-28033-8.

3. Nagle, Hinter; Barbara Nagle (2005). Pharmacology: An Introduction. Boston: McGraw Hill. ISBN 0-07-312275-0.

4. Psychopharmacology: Drugs, The Brain, and Behavior. Sunderland, MA: Sinauer Associates. ISBN 0-87893-534-7.

5. Arana, G.W. & Rames, L. (1995). Chapter Three: Psychopharmacology. In K. Mogul & L. Dickstein (Eds.), Career planning for psychiatrists (pp. 25-34). Washington, DC: American Psychiatric Press, Inc.