"Why Have I Been Prescribed an Antipsychotic?" Understanding What These Medications Are Used For
One of the medication conversations that can understandably make people nervous is being told that they have been prescribed an antipsychotic.
The reaction I sometimes hear is immediate:
"Does that mean you think I'm psychotic?"
Often, the answer is no.
The term antipsychotic describes a group of medications rather than the diagnosis of everyone who takes them. Although these medicines play an important role in treating psychosis, they are also used in several other mental health conditions.
Understanding why a particular medication has been recommended is therefore much more useful than focusing on the name of the medication group.
What Are Antipsychotic Medications?
Antipsychotics are a group of medications that influence several neurotransmitter systems within the brain. Their effects vary between individual medications, although dopamine signalling is particularly important for many of them.
Examples include Aripiprazole, Olanzapine, Quetiapine and Risperidone, although there are many others.
They are commonly divided into older or "first-generation" antipsychotics and newer or "second-generation" antipsychotics. In practice, choosing between them involves considering the condition being treated, previous response, physical health, potential side effects and the individual's preferences.
There isn't one antipsychotic that is automatically best for everybody.
They Aren't Only Used for Psychosis
Antipsychotic medication is an important treatment for conditions involving psychosis, where someone may experience symptoms such as hallucinations or delusional beliefs.
However, this is only one reason these medications may be prescribed.
Some antipsychotics are used in the treatment of bipolar disorder, particularly during episodes of mania. Certain medications may also be used alongside antidepressants in some people with depression that has not responded sufficiently to antidepressant treatment alone.
There are other circumstances in which particular antipsychotic medications may be considered depending on someone's diagnosis and clinical needs.
If you have been prescribed one, it is therefore reasonable to ask:
"What symptom or condition are we actually trying to treat?"
That question is often much more informative than the medication's classification.
What Should the Medication Actually Do?
The expected benefit depends on why the medication has been prescribed.
For someone experiencing psychosis, treatment may reduce the intensity or frequency of hallucinations, unusual beliefs and associated distress.
During mania, medication may help reduce excessive activation, agitation and changes in thinking and behaviour while helping sleep return towards normal.
When an antipsychotic is being used for another reason, the treatment goal will be different again.
This is why I think every psychiatric prescription should have a clear purpose.
Rather than simply asking whether medication is "working", it is helpful to agree what improvement would actually look like.
Will It Change My Personality?
This is another concern people sometimes raise.
The aim of treatment is not to change someone's personality or make them emotionally detached.
When somebody is acutely unwell, their illness itself may have significantly changed the way they are behaving, sleeping, thinking and interacting with other people. Effective treatment should ideally help them return towards their usual level of functioning.
That said, antipsychotics can sometimes cause sedation or a sense of feeling slowed down. If someone feels excessively sleepy, emotionally dulled or unlike themselves after starting medication, this deserves discussion.
Sometimes the dose can be adjusted. Sometimes the timing of medication can be changed. In other circumstances, an alternative medication may be more appropriate.
Treatment should balance symptom improvement against side effects rather than assuming that feeling heavily medicated is an unavoidable part of getting better.
Why Do Side Effects Differ Between Medications?
This is an important consideration when choosing an antipsychotic.
Some medications are more likely to cause sedation. Some are more strongly associated with increased appetite, weight gain and changes in blood glucose or cholesterol. Others may be more likely to cause movement-related side effects or an uncomfortable feeling of inner restlessness known as akathisia.
Hormonal effects can also occur with certain medications.
The fact that these medicines belong to the same broad group does not mean their side-effect profiles are identical.
This is why a medication that works very well for one person may not be the best option for another.
Why Do I Need Physical Health Checks?
If you are prescribed certain antipsychotic medications, your healthcare team may recommend monitoring things such as your weight, blood pressure, blood glucose and cholesterol.
Depending on the medication and circumstances, other monitoring may also be required.
Patients sometimes find this surprising because they are taking the medication for their mental rather than physical health.
The reason is that some antipsychotics can affect metabolism and other aspects of physical health. Monitoring allows potential problems to be identified early and helps clinicians make informed decisions about whether treatment remains appropriate.
Mental and physical health should not be treated as completely separate things.
Good psychiatric prescribing considers both.
What If I'm Gaining Weight?
Weight gain is a particularly important concern for some people taking antipsychotics.
It should not simply be dismissed.
If appetite or weight changes significantly after starting treatment, it is worth raising this with the prescribing team early rather than waiting until it becomes a much larger problem.
The options depend on the circumstances. They may include reviewing the dose, considering lifestyle support, looking at whether another medication would offer a better balance of benefits and risks or considering other appropriate interventions.
The psychiatric benefits of medication may be extremely important, particularly when treating a serious illness, but that does not mean physical side effects should be ignored.
Can I Stop Taking It Once I Feel Better?
This depends very much on why the medication was prescribed.
Feeling well can sometimes create the understandable impression that medication is no longer necessary.
However, in conditions such as psychotic illnesses or bipolar disorder, continuing treatment after recovery may substantially reduce the risk of another episode.
Stopping medication suddenly can also cause difficulties and, depending on the condition, may increase the risk of symptoms returning.
This does not mean that everyone prescribed an antipsychotic will need to take it indefinitely.
It means that decisions about reducing or stopping treatment should usually be made carefully with the prescribing clinician, taking into account the diagnosis, previous episodes, current stability and the individual's circumstances.
A Final Thought
The word "antipsychotic" can carry a great deal of meaning for someone who has just been handed a prescription.
It can lead people to make assumptions about their diagnosis, the severity of their condition or what their clinician thinks about them.
The medication name alone tells you surprisingly little.
What matters is why the medication has been recommended for you.
What are we treating?
What improvement are we hoping to see?
What side effects should we monitor?
How will we decide whether the benefits outweigh the disadvantages?
And how long are we expecting treatment to continue?
Those are the conversations that make psychiatric prescribing collaborative rather than mysterious.
Medication should never simply be a label attached to a diagnosis.
It should have a clear purpose, a sensible monitoring plan and an ongoing discussion about whether it is helping the person taking it.
Dr James Glass
MBChB MRCPsych
Medical Director, WMI Psychiatry
