Haloperidol works really well and has basically no metabolic burden, at the price of more tardive dyskinesia and akathisia. It is not first line, but it is worth trying in seriously ill patients who failed a couple of drugs and want to avoid weight gain and sedation, and it should be dosed like risperidone (they are milligram for milligram equivalent), not started at 5 mg out of habit.
When we reach for it
It works really well, and it has basically no metabolic burden compared with the other first- and second-generation drugs.
“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”
6:39Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 Not first line. But if a patient has failed a couple of antipsychotics, is very ill and suffering, and really does not want weight gain and sedation, try haloperidol, and treat it like risperidone.
“I don't use it first line, but if patients have failed a couple ones and they have a very serious mental illness, very symptomatic suffering, and on top of that, they really don't want weight gain and sedation, try the Haldol, but treat it like Risperdal”
11:16Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 It has a long-acting injectable, the decanoate, and it is a very good one with a wide range of efficacy and doses.
“one of the reasons why I love Haldol is because it has a decanoid. It has a long acting injectable and it's a pretty dang good one with a wide range of efficacy and doses”
34:16Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026
Dosing and titration
Haloperidol and risperidone are one to one in chlorpromazine equivalents for D2 blockade. Nobody starts risperidone at 5 mg or takes it past 8, yet haloperidol is routinely started at 5 mg and pushed to very high doses.
“Haldol and Risperdal have the same chlorpromazine equivalents in terms of milligram dose. Okay. One milligram of Haldol is roughly equivalent for a D2 blockade to one milligram of Risperdal. But for some reason, no one ever starts on 5 milligrams of Risperdal. But they routinely start Haldol on 5 milligrams”
9:36Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 Also said in 1 more episode
“The chlorpromazine equivalent of Haldol in Risperdal is one to one, okay? We only dose Risperdal up to eight milligrams and we take Haldol up to very high heights”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025 Most patients respond below 8 mg, just like risperidone, and it is much better tolerated dosed that way. Some people do need high doses: do not be afraid of 10 to 15 mg in very rare cases.
“Don't be afraid to go up to, you know, 10, 15 milligrams in very rare cases, but most of the time they will respond below eight milligrams, just like Risperdal”
11:32Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 Also said in 1 more episode
“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”
33:26Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and PsychosisFeb 2026
Side effects and safety
The trade-off is plain: sleepy, heavier and full of metabolic syndrome on other drugs, or more tardive dyskinesia and akathisia on this one.
“You ask yourself, Do I want to be sleepy, fat, and full of metabolic syndrome? Or do I want to be developing more targeted dyskinesia and having more akathisia”
7:05Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 Like any strong dopamine blocker, it can cause neurolepsis: some apathy, emotional blunting and low motivation.
“any major dopamine blockade medication can at least cause neurolepsis, you know, some apathy, emotional blunting and low motivation”
10:37Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 It is among the antipsychotics generally accepted in pregnancy, along with olanzapine and quetiapine.
“there's at least one study showing relative safety in pregnancy. So that's a nice thing to have with trazodone. While we're on it, I believe other ones that are generally accepted in pregnancy that you can see here on the board include Haldol, Olanzapine, and Quetiapine”
47:56Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026
Compared with others
Fluphenazine is not really any better, and its long-acting injectable lasts only one to two weeks, so it is harder to dose and give than haloperidol's.
“The long-acting injectable for fluphenazine is really only supposed to last one to two weeks and is not very practical. So it's harder to dose and administer than haloperidol and it's not really any better”
1:10:27Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026
Pitfalls and myths
The old tale that it causes depression is overblown. We have used it successfully in many patients with mood features, and their depression improved.
“I also think that the old tale of it causing depression is overblown because I have successfully used it in many cases with mood features now, and they have improved in terms of depression”
10:23Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 Do not add aripiprazole to haloperidol. Aripiprazole binds the dopamine receptor so tightly that it counteracts the other drug, so the two just fight each other.
“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”
39:31Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026
It also comes up on
- PerphenazineCompared with haloperidol or fluphenazine, the high-potency first-generation drugs, you get less EPS and akathisia, though still a moderate EPS risk. It is a little cleaner metabolically with minimal weight gain, and surprisingly decent for negative symptoms.
- Negative symptomsPerphenazine is surprisingly decent at negative symptoms, with less EPS and akathisia than haloperidol or fluphenazine, a cleaner metabolic profile and minimal weight gain, though still a moderate EPS risk.
- SchizophreniaTelling the patient they have schizophrenia and should take Haldol does not work. Ask what is a problem for them, and tie the medication to that.
- Therapeutic allianceLack of insight is the most common symptom of schizophrenia in some frameworks, so explaining the diagnosis and the antipsychotic will not make anyone say they should take Haldol. Ask instead what is a problem for them.
From these episodes
- Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 · 11 points
- Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and PsychosisFeb 2026 · 1 point
- Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.