Medications for Schizophrenia

The first line of pharmacological treatment for schizophrenia is antipsychotic medication.

These medications come in three forms:

• Second-generation antipsychotics
• First-generation antipsychotics
• Long-acting injectable antipsychotics

With the exception of long-acting injectables, antipsychotic medication is usually taken in pill form, but some are available in dissolving tablets, suppository, or liquid form.

How They Work

Antipsychotic medications help control the symptoms of psychosis—a state in which a person loses touch with reality and believes, hears, or sees things that are not real.

They are the first line of treatment for schizophrenia, but can also be used to treat other conditions such as:

• Alzheimer's disease
• Bipolar disorder
• Depression
• Anxiety
• Tourette's syndrome

While antipsychotics do not cure illness, they help control symptoms and, when taken long-term, can help prevent future episodes of psychosis.

Antipsychotics work by blocking dopamine in the brain. Dopamine is a brain chemical that, when overactive, is thought to play a part in psychosis.

Second-Generation Antipsychotics

Second-generation antipsychotics (sometimes called atypical antipsychotics) are the first treatment choice for most professionals treating schizophrenia.

In addition to blocking dopamine, second-generation antipsychotics also affect another brain chemical called serotonin.

Types 

Types of second-generation antipsychotics include:

• Abilify (aripiprazole)
• Fanapt (iloperidone)
• Geodon (ziprasidone)
• Invega (paliperidone)
• Latuda (lurasidone)
• Risperdal (risperidone)
• Rexulti (brexpiprazole)
• Saphris (asenapine)
• Seroquel (quetiapine)
• Vraylar (cariprazine)
• Zyprexa (olanzapine)

Clorazil (clozapine) is a second-generation antipsychotic, but it is typically only used when other antipsychotics are ineffective or when a person has suicidal ideation. It has an increased risk of lowered white blood cells, so people taking Clorazil will usually have their white blood cell count monitored.

Side Effects

Side effects for second-generation antipsychotics include:

• Dry mouth
• Dizziness
• Blurred vision
• Seizures (rarely)
• Weight gain
• Movement effects (such as tremor, agitation, stiffness)
• Sedation (sleepiness, low energy)
• Decreased sex drive and function
• Missed periods
• Discharge from breasts
• Higher risk of diabetes

First-Generation Antipsychotics

First-generation antipsychotics (sometimes called typical antipsychotics) are older medications, first starting to be developed in the 1950s.

While they can work well, they carry a higher risk of side-effects, including a serious long-term side effect, tardive dyskinesia (TD), an involuntary movement disorder in which people may experience random movements in their muscles, eyes, tongue, jaw, and lips.

For this reason, first-generation antipsychotics are usually only prescribed when second-generation antipsychotics have not been effective or cannot be used.

Types

Types of first-generation antipsychotics include:

• Haldol (haloperidol)
• Loxitane (loxapine)
• Navane (thiothixene)
• Prolixin (fluphenazine)
• Thorazine (chlorpromazine)
• Trilafon (perphenazine)
• Stelazine (trifluoperazine)

Side Effects

Side effects of first-generation antipsychotics vary depending on the drug, but can include:

• Drowsiness
• Agitation
• Dry mouth
• Constipation
• Blurred vision
• Emotional blunting
• Dizziness
• Stuffy nose
• Weight gain
• Breast tenderness
• Liquid discharge from breasts
• Missed periods
• Muscle stiffness or spasms
• Tardive dyskinesia (TD)

A new medication, Caplyta (lumateperone), has recently been given FDA approval for use in the treatment of schizophrenia. According to the manufacturers, it interacts with the brain chemicals dopamine, serotonin, and glutamate.

Note: it is not approved for use for people with dementia-related psychosis.

Long-Acting Injectable Antipsychotics

Long-acting injectable antipsychotics are an option for people who struggle with taking pills or sticking to a regular medication schedule.

These medications can help reduce:

• Relapses
• Hospitalizations
• Emergency room visits
• Intentional or accidental overdose

Dosage (including how often it is administered) varies by drug. They are typically administered every two to four weeks but can be given every six or eight weeks, depending on the drug and the individual.

Some injectables require oral supplementation initially when treatment begins.

Some injectables need to be refrigerated, others do not.

Types

The long-acting injectable antipsychotics approved for use in the United States include:

• Risperdal Consta (risperidone microspheres)
• Invega Sustenna (paliperidone palmitate)
• Invega Trinza (paliperidone palmitate)
• Zyprexa Relprevv (olanzapine pamoate)
• Abilify Maintena (aripiprazole monohydrate)
• Aristada (aripiprazole lauroxil)

Side Effects

Side effects for long-acting injectable antipsychotics may include:

• Injection-site redness, pain, or swelling
• Headache
• Weight gain
• Dizziness
• Fast heart rate
• Sleepiness or drowsiness
• Restlessness
• Stuffy nose, sore throat

Precautions and Contraindications

In addition to side effects, there are some things that affect the use of antipsychotics.

Other Medications

Some medications can cause side effects when taken with antipsychotics, while others, like antacids, can affect absorption.

Smoking

Smoking can make the body break down antipsychotics faster. People who smoke heavily may require more medication.

Tell your healthcare provider if the amount you smoke changes.

Coffee

Coffee can slow down how long it takes the body to break down antipsychotics.

Tell your healthcare provider if the amount of coffee you drink changes.

Alcohol

Antipsychotics can increase the effects of alcohol, making one drink have the effects of two or three drinks.

While having an occasional drink or two is probably okay, care should be taken.

Street/Illicit Drugs

Drugs such as marijuana, cocaine, and amphetamines can cause symptoms to reoccur or worsen. They can also interfere with medication and worsen side effects.

Driving

For some people, antipsychotics can cause sleepiness or sedation. It is best to avoid driving—or anything else that requires alertness—until you know how the medication affects you.

Pregnancy and Breastfeeding

Antipsychotics may cause irregular periods and/or false pregnancy tests.

Antipsychotics are considered relatively safe during pregnancy and breastfeeding but may cause the baby to have temporary breathing difficulties and/or withdrawal symptoms (e.g., restlessness, feeding problems) if taken in high doses close to delivery.

These risks and side-effects are often manageable and may be a better choice than living with unmedicated schizophrenia/psychosis.

People who are or are planning to be pregnant or breastfeeding should discuss the benefits versus risks with their care provider.

Age

Age can play a role in the use of antipsychotics.

Children and teens are more likely to experience side effects from these medications, as are people older than 60.

People older than 60 may also be more sensitive to the medication and require lower doses. Older adults are more likely to be taking other medications, which may cause interactions with antipsychotics.

Antipsychotics may also create a higher risk of falls.

Antipsychotic use in older adults has been associated with an increased risk of stroke, and should only be used if other treatments are not an option.

Diet

Some antipsychotics come in forms that contain substances known to affect people with allergies or dietary restrictions, such as:

• Lactose
• Gelatin
• Coconut oil
• Sesame oil
• Vegetable oil

Tell your healthcare provider if you have any allergies at all, not just medication allergies.

Effectiveness

The effectiveness of antipsychotics in the treatment of schizophrenia depends on a number of factors and varies among people.

The most effective treatment for schizophrenia is a multidisciplinary approach including:

• Medication
• Psychological treatment
• Social support

People with schizophrenia who are taking antipsychotics report a higher quality of life than those who are not, but also experience side effects. For those who report symptom relief and manageable side effects, longer-term maintenance therapy using antipsychotics is suggested.

While it may take months for antipsychotics to reach maximum effect, how a person responds within the first few weeks is considered highly predictive of how they will respond long-term.

It takes at least four weeks at a therapeutic dose to determine the effectiveness of a treatment, and unless a person is experiencing an unmanageable adverse reaction or side effects, healthcare providers usually give a trial of four weeks or longer before suggesting a different medication or treatment.

Sometimes a combination of medications is used to treat schizophrenia.

Treatment for schizophrenia works best when started as early as possible and is approached as a team effort between the person with schizophrenia, medical and therapeutic specialists, and support people.

Adherence to treatment (including taking medication as prescribed) can be difficult for people with schizophrenia. It is important to work with your healthcare provider to find strategies for treatments that work for you and ways to make them successful.