What we’ve said about Antipsychotics

“they're classified as antipsychotics because usually of some kind of a historical or FDA approved use for the psychotic disorders. But the fact is they have such a wide range of receptor functioning across this class that it's almost a misnomer to call them antipsychotics”

“One of the reasons that the neuroleptics help psychotic people is that they are huge anti-anxiety drugs. They reduce terror and sometimes allow for more clear-headedness”

“Histamine, Alpha 1, Muscarinic receptors. So the histamine has to do with the sedation, the weight gain, the Muscarinic has to do with the sedation, all the anti-Muscarinic problems. The Alpha 1 is the orthostatic hypotension”

“The medications that we use to treat psychosis are not fun medications. They are fun. literally anti-addictive medications. They block dopamine. So they're incredibly unrewarding”

“if you use an antipsychotic that causes a lot of metabolic side effects, especially in a young person, you are putting them on a metabolic highway to eventually develop all kinds of morbidity and mortality risk from diabetes and high cholesterol”

“I think it's super important to pick weight sparing medications when possible. Yes, that trades often for risk of akathisia. or maybe sometimes even risk of tardive dyskinesia if you're picking a first generation”

“the pines are, which they were thinking, olanzapine, clozapine, quetiapine, by far the most metabolic medications we have. Then the dones have more variants. Risperidone in the middle”

“After that, Latuda, Geodon are probably the best ones to go to in terms of not having much weight gain. and second generation. Vraylar, relatively new. I have not seen much weight gain on that either”

“if you treat enough schizophrenia and bipolar disorders, you're going to find that everyone is an individual. And one medication that works really, really great in 90% of people may work terribly in one person”

“you just really need to find common ground in what patients find to be a problem. And you need to pick the medications that have the least side effects that you have access to”

“I don't think the newer meds are more effective, but they're certainly better tolerated. I don't think that can be questioned”

“The monitoring requirements basically make it impossible to use. Also, the titration requirements similarly make it extremely hard to use because who has that amount of time to get somebody stable these days? It essentially self-selects for patients who are lower acuity”

“It is perhaps the most effective antipsychotic out of all of these in all of my experiences. And don't be afraid, like Haldol, to dose it lower for milder cases. It comes in a 2.5”

“Now, Risperidone is that Goldilocks, not too hot, not too cold. It's got a little bit, it's got one foot in kind of both camps. So you often see on inpatient, risperidone is the first antipsychotic that's chosen on the algorithm”

“it works. It works really great. Second of all, it has basically no metabolic burden compared to the other ones in the second generations and the first generations”

“If you dose Haldol with his chlorpromazine equivalents like Risperdal, it's a lot more better tolerated. That being said, some people do need high doses”

“You can use it in PTSD, anxiety, depression, all that stuff, but massive weight gain, appetite increase, diabetes risk, and sedation in comparison to the actual antipsychotic benefits you're getting”

“I probably would have put it into A tier when I was younger, but having tried to use it a lot because of its favorable side effect profile, it's simply not efficacious enough”

“I'm putting these in the B tier and that's actually because I kind of think we should encourage them to be used a little bit more because they are more atypical than you think”

“I hate that child psychiatrists are so comfortable around here giving this to children because it's been tested because it's genuinely an awful medication in terms of side profile. Okay. And you don't even get that much D2 blockade until you get to higher doses where it has intolerable side effects”

“A lot of people are trying to use it kind of as a second antipsychotic because it's got a totally different mechanism. First of all, when it's tolerated, I don't see it really making much of a dent. And second of all, when it's making a minor dent, it's completely intolerable”

“A lot of people don't ever learn that after a patient leaves inpatient, the best thing to do is smush it all into, you know. One time a day dosing”

“A big lesson from this podcast, move all your antipsychotic dosing to once a day at nighttime. It makes a huge difference. It improves side effects that you wouldn't even expect it improves”

“The ones you need to take with food tend to end with Doan. So Ziprasidone is another one you really need to take with food”

“it takes anywhere from four to eight weeks to get to full steady state on a single dose of all three active molecules from Raylor. So it can look like it's not working a lot of the time if you simply start it at too low of a dose”

“Simply switching the agent, people can see a response where they didn't on a different agent. I think that's even more true for antipsychotics than it is for, say, antidepressants”

“I will start the new agent first to test tolerability, sometimes not even changing the dose to the existing agent if it's not at maximum. And then I will slowly go down by equivalent chlorpromazine doses”

“Seroquel is the one that if you're switching from it, you should probably just leave it and titrate on the other medication and then pull off. And then another factor to consider is partial agonists have the highest binding affinity”

“I really hate the practice of adding it to Haldol. You're basically making the medications fight each other because it binds so tightly to dopamine receptor that it essentially counteracts a lot of other antipsychotics”

“Well, first of all, they started at 15 milligrams, and then they easily went up to 30 milligrams pretty quickly. And on top of that, they used benzodiazepine. I believe it was lorazepam as a PRN, and it was basically on board”

“we don't use Metformin enough with these medications. Now I'm thinking we don't use GLP-1s enough with these medications”

“for the telehealth people out there you can at least ask the patient to weigh themselves on a regular basis and self-report don't forget to weigh your patients now if you want to be really gold standard you're going to do waist circumference”

“I think that a degree of weight gain that we see on these medications is not fully from the medication effect itself, but is actually from the treatment effect. People, many people, don't eat when they're in emotional distress”

“checker prolactin levels, It's super low threshold to check our prolactin level on these patients”

“Largely, in my experience, outpatient akathisia is subjective. It's something that the patient feels. They can suppress it, especially in the encounter with you”

“You can get abrupt withdrawal dyskinesias that can go away or they can persist. A little scary. and it's definitely more likely to happen in people with mood disorders and have schizophrenia so please use your antipsychotics sparingly and only as needed for the clinical picture”

“schizophrenia has its own rate of movement disorders, okay, without antipsychotic use. If you look at pre-antipsychotic studies, they were already developing tardive dyskinesia anyway”

“some of the antipsychotics can actually worsen OCD. I think clozapine and olanzapine are the most likely”

“a lot of antipsychotics are depressogenic. They can lead patients to depression and long-term aren't great. A lot of these medications come with really bad side effects, really bad metabolic effects. There's risks of... of EPS, tardive dyskinesia, typically not the lower doses”

“regardless of the cause of psychosis, you should continue antipsychotic treatment for six months to a year”

“If you can reasonably identify a classical primary psychotic disorder or a serious bipolar disorder, tapering is actually quite dangerous. Generally speaking, in my opinion, those conditions do require lifetime medications”

“when there are psychotic features of a severe mood disorder, episode, that's probably closer to what we consider psychosis. And that does absolutely warrant treatment with an antipsychotic. But don't neglect the primary treatment of the mood with either SSRI or mood stabilizer”

“your priority is keeping the patient in treatment and monitoring. And in treatment is not on a medication necessarily. In treatment means engaged with monitoring and follow-ups”

“Often you have to go to a high enough dose of antipsychotic that there's intolerable side effects or serious neurolepsis, basically drug-induced negative symptoms. So don't just go, here's the symptom of the voice, I need to get rid of it, right”

“some people, when you give them antipsychotics and they stop having that delusional perception anymore, they go like, well, I remember feeling that way about it, but that just seems strange now”

“My answer to bipolar disorder is mood stabilizer. My answer to bipolar disorder not responding to one mood stabilizer is not antipsychotic. It's two mood stabilizers. So do not neglect the mood stabilizers”

“So don't be afraid to add a mood stabilizer to your existing antipsychotic regimen, maybe even before and probably even before you add a second antipsychotic, if there are prominent mood features”

“if I'm going to give you an antipsychotic, I want it to work for every phase of the bipolar disorder. So naturally, that's Latuda. Unfortunately, Latuda has The most akathisia risk, that's the restlessness of every antipsychotic, probably”

“I usually do a combination treatment. I think of three main things. So the mood stabilizer, I want to solve that and I want to start it. Whatever one we can get on. But I also know that that one's going to take some time to work”

“I want to see them in euthymia for probably two or three months at minimum. And I just go off of patient comfort at that point. But sooner is usually better”

“Then really, unfortunately, the best thing that you can do is go temporarily again to those second generation antipsychotics that have some kind of proven efficacy for bipolar depression. I like those the most for the use”

“But I say to people with bipolar disorder and to the clinicians, please give the mood stabilizers a fighting chance. You may find that things go better for you body health wise, mind health wise in the long term”

“you're not stuck with this antidepressants versus like antipsychotics. You can go antipsychotics versus social rhythm therapy. Oh man, from a risk benefit point of view, that's a no brainer, right? And then you can look at Lamotrigine in the similar light”

“I do think they work, and I don't think it's just that it's people misdiagnosed with bipolar disorder or something like that. I suspect it's just that the second-generation antipsychotics have a lot of different receptor effects, unique ones, that are not present if you have a selective serotonin reuptake inhibitor”

“Make sure you have the right diagnosis, people. Treatment-resistant depression is where personality disorders go to hide”

“people reach for antipsychotic first because they're so used to it now right we're all primed to using the antipsychotic as augmentation depression anxiety even”

“start with an SSRI. If that doesn't work, switch to another SSRI. And I'm talking about without any nuance involved in these, you know, like your clean cut patients. SSRI, if that doesn't work, switch to another SSRI. If that doesn't work, you can add a second-gen antipsychotic”

“if you see something that looks like MDV with psychotic features alongside the PTSD, don't be afraid to consider the agents for bipolar depression efficacy as well”

“that is not for the treatment of quasi-psychotic symptoms, and it is not for general functional improvement so much as it is for the control of quote-unquote unwanted or disruptive behaviors. You should not Give those to high-functioning people who don't have severe disruptive behaviors”

“I'm open to the possibility that the very severe borderline personality disorder is comorbidity, that it's some kind of a crossover of both a severe personality syndrome and some kind of genetic vulnerability”

“I think people have to understand that the main effect in giving a PRN for agitation, I think, is the social component and the sedative, not the antipsychotic”

“if you control the sleep wake cycle, In the ICU or nursing home patient using something else like a trazodone, mirtazapine, or even a melatonin or ramelteon, you may get a lot of the same effect without the same problems”

“clinicians are underestimating the risk of antipsychotic treatment because antipsychotic treatment is so easy. You don't have to draw labs and it works really fast, especially inpatient. So everyone gets antipsychotic. But they have side effects. And the risk of tardive dyskinesia is higher in people who don't have a primary psychotic disorder”

“unless you're sure, reasonably sure of what you're treating, I don't think you should throw on random medications. You're going to cause side effects. You're going to cause problems”

“Those are really just parts of the self that have been split off in terms of an experience, experienced as different or at least separate from the core self. And that does not, in my experience, and I think in the research, actually respond to dopamine blockade”

“if you take an example of people with a lot less experience with rare psychotic disorders and severe psychotic disorders, and you tell them to use the same rules, they might end up prescribing a lot of unnecessary antipsychotics to people”

“First is you have the wrong diagnosis. There's so many times that I'm supervising someone and they say, what medication should I add? And I go, what's their diagnosis? And they're like, I'm not really sure”

“If you're going to augment your antipsychotic treatment, I would first go back to the diagnosis and try to see if there are any what we might call mixed features or just additional psychopathological features and then psychosis”

“you kind of pick how conservative of a practitioner you want to be. And if you're conservative, then you're going to have more patients on unnecessary medications, but more stable patients”

“the biggest difficulty in treating psychotic disorder, the meds work. The meds work really well. The problem is that they're not fun and they have really bad side effects. And the challenge in treating psychotic illness is to develop a relationship with the patient that they trust you and that they trust your recommendations”

“we know medically that these medications are going to help with things like fear stress level sleep and thinking process okay the thinking process will be more organized and less disrupted and therefore you'll be able to concentrate better and live your life better”

“I tell them it's antipsychotic, but I also tell them the truth. And the truth is that second generation and first generation antipsychotics are indicated and used in a variety of different conditions, right”

“Sometimes some people are OK with having more hallucinations. if they're less sedated. And it doesn't mean that they're going to get hospitalized. You have to assess the patient”

“you can say, listen, I know you disagree, but we've talked about the risks and benefits of this medication, and I think it's indicated. It'll be there at the pharmacy waiting for you”

“I'd rather a patient safely taper off and safely be monitored than tell a patient they need to be on a medication and have them not follow up. Autonomy is one of our guiding principles”

“You're basically kind of doing a synthetic second generation style receptor profile by adding buspirone to something that has D2 blockade. And then by pushing the dose, it's almost a second antipsychotic”

“The people who wore the amber lenses, in addition to the rest of treatments that happened on this inpatient unit routine, had half the number of antipsychotics that the group with the control lens got and got out of the hospital earlier”

“Do you really want to treat that with a mood stabilizer or an antipsychotic? Probably not, but there is a risk in some patients with mood temperaments that they actually do develop full-blown mood disorders”