Atypical Antipsychotics: The Need-to-Know Series

“I‘m seeing commercials telling me to talk to my doctor about using Abilify or Seroquel with my antidepressant. What are they? And why would I want to?”

Welcome to the world of the antipsychotics atypical, that is. The chipur antidepressant and benzodiazepine need-to-know series continue to be popular.

So let’s do the first in a series on the atypical antipsychotics…

Antipsychotics 101

Formulated and first used in the early 1950s, chlorpromazine (Thorazine) was the first antipsychotic. The calming effects were so dramatic it was referred to as a “chemical lobotomy.”

Chlorpromazine’s influence upon the treatment of the emotional/mental health disorders is profound. And with its arrival began the development of today’s antidepressant and anti-anxiety medications.

Antipsychotics are also known as neuroleptics. From the Greek for “taking hold of one’s nerves.” They’re used primarily to manage psychosis, particularly as it presents in schizophrenia and bipolar disorder. Antipsychotics work within the brain’s dopamine pathways.

Side Effects

The antipsychotics generate a wide variety of very serious and lasting side effects. Primary are…

Extrapyramidal side effects (EPSEs) – akinesia (inability to initiate movement), akathisia (inability to remain motionless), parkinsonism (rigidity and tremor), tardive dyskinesia (repetitive, involuntary, and purposeless movements; such as grimacing, tongue protrusion, lip smacking/puckering/pursing, and rapid eye blinking. onset is much later in treatment).

Also seen are cardiovascular issues, sexual dysfunction, lethargy, seizures, and hyperprolactinaemia (high prolactin levels in the blood leading to breast enlargement and oozing of the nipples in men and women).

The Atypical Antipsychotics

Discovered in the 1950s, and brought to the market in the 70s, clozapine (Clozaril) was the first atypical antipsychotic. The term atypical was assigned to this second generation of antipsychotics because they were touted as having fewer EPSEs.

Time has shown that EPSEs are more of an issue than initially expected. As a matter of fact, the assumed superiority of the atypicals over the first generation antipsychotics is being questioned.

FYI. Recent literature is actually backing away from the typical/atypical terminology, focusing more upon specific pharmacological actions.

Some of the atypicals are FDA approved for use in the treatment of schizophrenia. Some carry FDA approval for acute mania, bipolar depression, psychotic agitation, bipolar maintenance, and other situations.

The more popular atypicals are…

olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), and paliperidone (Invega).

How Do They Work?

Just exactly how the atypicals work is anyone’s guess, though they all work within the dopamine system. But since there are five dopamine receptors, no one really knows how the action goes down.

Side Effects

No, the issue of side effects didn’t go away, so refer to the roster for the original antipsychotics – and you can add hyperglycemia, diabetes, and weight gain. But, remember, the side effects of the atypicals are very med-specific.

Though the development of tardive dyskinesia was hoped to be less of an issue in the atypicals, it still occurs after years of use. But if you think about it, the atypicals haven’t been in existence all that long. So how could anyone really know the whole story?

Cash Cows

It’s important to point out that antipsychotics are highly popular and profitable. Try $22 billion in global sales in 2008 ($14.6 billion in the US alone). And then there’s the atypical factor – their average cost per prescription is some four times higher than the original antipsychotics. Wow!

‘Til Tomorrow

Well, that gets us off to a great start. Be sure to come back tomorrow. We’re going to discuss why the atypicals are being recommended as antidepressant add-ons. And we’ll talk about the future of the antipsychotics.

Be sure to come back…