Treatment

Antipsychotics

also known as neuroleptics

Medically reviewed by the Shrinkopedia editorial team, led by Shariq Refai, MD, MBA, FAPA.

8 min read · 1,768 words

Medically reviewed . Reviewed by a board-certified psychiatrist before publication.
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Quick answer

Antipsychotics are a class of medication used mainly to treat psychosis, the symptoms that affect a person's grip on reality, such as hallucinations and delusions. They're a core, evidence-based treatment for schizophrenia, and they're also used in bipolar disorder. They have real side effects that vary by drug, so treatment includes monitoring with a prescriber. This is an overview, and decisions belong with a prescriber.

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Definition

Antipsychotics, sometimes called neuroleptics, are a class of medication used to treat psychosis and several related conditions.

They're most central to the treatment of schizophrenia, where they're a core, evidence-based part of care. They're also used in bipolar disorder, for episodes of mania and as ongoing maintenance treatment, and sometimes as an add-on in depression and for other specific uses. They're commonly grouped into "first-generation" antipsychotics, the older drugs, also called "typical," and "second-generation" or "atypical" antipsychotics. The second-generation drugs are more commonly chosen first today. This entry is a general overview; for drug-by-drug detail and dosing, see PsychiatryRx.org.

### Common second-generation antipsychotics at a glance

Agent	Typical adult dose	D2 profile	Metabolic risk	Notable features
aripiprazole	10-30 mg	partial agonist	low	activating in some; akathisia common; approved for MDD augmentation
brexpiprazole	1-4 mg	partial agonist	low-moderate	approved for MDD augmentation and schizophrenia
cariprazine	1.5-6 mg	D3-preferring partial agonist	low-moderate	evidence in bipolar depression; long half-life
risperidone	1-8 mg	full antagonist	moderate	hyperprolactinemia common at higher doses; long-acting injectable options
paliperidone	3-12 mg	full antagonist	moderate	active metabolite of risperidone; multiple long-acting injectables (monthly to every 6 months)
olanzapine	5-20 mg	full antagonist	high	strong efficacy; substantial weight gain, metabolic syndrome risk
quetiapine	150-800 mg	full antagonist	high	sedating; approved for bipolar depression; XR formulation for MDD augmentation
ziprasidone	40-160 mg	full antagonist	low	must be taken with ≥500 kcal food; QT prolongation
lurasidone	40-160 mg	full antagonist	low	must be taken with ≥350 kcal food; approved for bipolar depression
clozapine	300-600 mg	full antagonist	high	most effective for treatment-resistant schizophrenia; requires REMS enrollment (agranulocytosis, myocarditis)

What it looks like

A person starting an antipsychotic after a first episode of psychosis, as a central part of their care.
A prescriber choosing a second-generation drug and scheduling regular check-ins to track effects.
Routine monitoring of weight, blood sugar, and other measures, because some drugs affect metabolism.
Continuing a medication during stable periods to reduce the chance of a relapse.

What people often confuse this with

Sedatives or "chemical straitjackets." This is a stigmatizing misconception. Antipsychotics aren't simply sedatives, and the "chemical straitjacket" image is inaccurate. They act on the symptoms of psychosis. Some can cause drowsiness, but that isn't their purpose or their mechanism.

Addictive drugs. Antipsychotics aren't addictive in the usual sense. They don't produce the craving and compulsive use seen with addictive substances. Stopping them suddenly can still cause problems, including relapse, so changes are made gradually with a prescriber.

A cure. Antipsychotics treat symptoms and reduce the risk of relapse. They don't cure schizophrenia or bipolar disorder. They're an ongoing part of managing the condition, often alongside therapy and support.

Reality check

Myth: Antipsychotics are just chemical restraints that dull people out.

This idea is stigma, not fact. Antipsychotics work on the symptoms of psychosis, and the goal is to help a person think more clearly and function better, not to flatten them. They're a core, evidence-based treatment for schizophrenia.

Myth: The side effects mean these drugs do more harm than good.

Side effects are real and they matter, and they vary by drug. The older drugs carry more risk of movement-related effects, including, rarely, tardive dyskinesia. Many newer drugs can cause weight gain and metabolic changes. None of that erases the benefit. For psychosis, the evidence that antipsychotics help is strong, and monitoring with a prescriber is how the risks are managed.

Myth: If you feel better, you can just stop taking them.

Feeling well often means the medication is working. Stopping suddenly can trigger a relapse and other problems. Any change should be made gradually and with a prescriber, who can weigh the options with you.

What research says

Antipsychotics have a strong evidence base. They're recommended as a core treatment for schizophrenia by major clinical guidelines, supported by randomized trials showing they reduce symptoms of psychosis and lower the risk of relapse.

For schizophrenia, antipsychotics are central to both treating acute episodes and preventing relapse.
In bipolar disorder, they're used for mania and as maintenance treatment, and several are approved for these uses.
Some are used as an add-on in depression and for other specific indications.
Side-effect profiles differ between drugs, which is a major reason treatment is individualized and monitored.

The honest, balanced picture is this: antipsychotics clearly help with psychosis and are a well-supported treatment, and they also carry side effects that need ongoing attention. The older and newer drugs differ, with movement-related effects more associated with first-generation drugs and metabolic effects with many second-generation ones. Good care means matching the drug to the person and monitoring over time.

What we know and what we don't know

What we know

Antipsychotics are a core, evidence-based treatment for schizophrenia and reduce the risk of relapse.
They're also used in bipolar disorder and sometimes as an add-on in depression.
They have real side effects that vary by drug, so prescriber monitoring is part of treatment.

What we don't know

We can't reliably predict which antipsychotic will work best, or be best tolerated, for a given person.
Their full long-term effects, and how to balance benefits and risks over many years, are still being studied.
Exactly why response varies so much between people isn't fully explained.

Questions people ask

Are antipsychotics only for schizophrenia?

No. They're used for bipolar disorder (both mania and, for some, depression), schizoaffective disorder, augmentation of antidepressants in treatment-resistant depression, agitation in dementia (carefully), delirium (short-term), and Tourette syndrome. Some have FDA approvals for these specific indications.

What's the difference between typical and atypical antipsychotics?

Typical (first-generation) antipsychotics were developed in the 1950s and 1960s. They block dopamine D2 receptors strongly and are more likely to cause motor side effects. Atypical (second-generation) antipsychotics were developed later and generally have lower risk of motor side effects, though higher risk of metabolic side effects. Both have real utility; choice depends on the picture.

What are the main side effects to know about?

Metabolic effects (weight gain, increased blood sugar, cholesterol changes, particularly with olanzapine and clozapine), motor effects (particularly with first-generation), sedation, and various others depending on the specific agent. Long-term risks include tardive dyskinesia (involuntary movements that can be permanent), which is more common with first-generation.

Is clozapine dangerous?

Clozapine has meaningful risks (agranulocytosis, myocarditis, seizures) that require monitoring, but it also has the strongest evidence of any antipsychotic for treatment-resistant schizophrenia and for reducing suicide risk in schizophrenia. Careful use with monitoring provides real benefit for people who need it.

How long do I need to be on an antipsychotic?

Depends on the condition. For schizophrenia, long-term treatment is standard, particularly after a first episode. For bipolar disorder, may be part of long-term regimen or used only during specific episodes. For treatment-resistant depression augmentation, usually until the depression is stable.

How it works

A few things are worth understanding about how antipsychotics work and how they're used:

they act largely on dopamine signaling in the brain, and the atypicals also act on serotonin (PsychiatryRx lets you see how antipsychotics act on dopamine)
they reduce symptoms of psychosis, such as hallucinations and delusions, and help prevent relapse
they're grouped into first-generation (older, typical) and second-generation (atypical) drugs
second-generation drugs are more commonly used first now, partly because of their side-effect profiles
they're often used alongside other treatment, including psychotherapy and social support
they treat symptoms and lower the risk of relapse, but they aren't a cure

Medications in this class

First-generation ("typical") antipsychotics

Haloperidol

Receptor mechanism. High-affinity D2 antagonist; minimal serotonergic, histaminergic, or muscarinic activity.

Potency. High-potency (dose per mg is small; chlorpromazine-equivalent ≈ 2 mg).

Typical dosing. Oral 0.5-5 mg/day starting, titrated to 5-20 mg/day for schizophrenia; long-acting decanoate 50-200 mg IM every 4 weeks.

Safety monitoring. Baseline and ongoing: EPS/AIMS every 6 months for tardive dyskinesia, ECG (QTc) before parenteral use and periodically, prolactin if symptomatic, weight, fasting glucose/lipids annually.

Sources. FDA label (Haldol); APA Practice Guideline for the Treatment of Patients with Schizophrenia (3rd ed.); NICE CG178.

Chlorpromazine

Receptor mechanism. D2 antagonist plus significant H1, α1-adrenergic, and muscarinic blockade (explains sedation, hypotension, anticholinergic effects).

Potency. Low-potency (reference drug; 100 mg = 1 CPZ equivalent).

Typical dosing. 25-75 mg/day starting, titrated to 300-800 mg/day for psychosis in divided doses.

Safety monitoring. BP (orthostasis), sedation, weight, lipids/glucose, LFTs (cholestatic jaundice risk), ECG, AIMS.

Sources. FDA label; APA Practice Guideline; Stahl's Essential Psychopharmacology (7th ed., 2025).

Fluphenazine

Receptor mechanism. High-affinity D2 antagonist; low muscarinic/α1 activity.

Potency. High-potency (2 mg = 100 mg CPZ).

Typical dosing. Oral 2.5-10 mg/day; decanoate 12.5-50 mg IM every 2-4 weeks.

Safety monitoring. AIMS every 6 months, prolactin, weight, metabolic labs annually.

Sources. FDA label; APA Practice Guideline.

Second-generation ("atypical") antipsychotics

Risperidone

Receptor mechanism. Potent 5-HT2A and D2 antagonist; also α1, α2, and H1 antagonism at higher doses.

Potency. Moderate-to-high potency; 2 mg ≈ 100 mg CPZ equivalent.

Typical dosing. Oral 1-2 mg/day starting, titrated to 4-8 mg/day (max 16 mg/day); long-acting injectable (Risperdal Consta) 25-50 mg IM every 2 weeks or Perseris subcutaneous monthly.

Safety monitoring. Weight/BMI at baseline, 4, 8, and 12 weeks then quarterly; fasting glucose and lipids at baseline, 3 months, then annually; prolactin if symptomatic (highest prolactin elevation among atypicals); EPS/AIMS every 6 months; BP.

Sources. FDA label (Risperdal); ADA/APA consensus statement on antipsychotics and metabolic risk; APA Guideline (3rd ed.).

Olanzapine

Receptor mechanism. Multi-receptor antagonist across D2, 5-HT2A, 5-HT2C, H1, M1-M5, and α1. H1 and 5-HT2C blockade largely drive weight gain.

Potency. Moderate potency; 5 mg ≈ 100 mg CPZ equivalent.

Typical dosing. Oral 5-10 mg/day starting, titrated to 10-20 mg/day; long-acting injectable (Zyprexa Relprevv) 150-300 mg every 2 weeks (with post-injection observation for delirium/sedation syndrome).

Safety monitoring (metabolic priority). Weight/BMI at baseline, 4, 8, 12 weeks then quarterly; fasting glucose, HbA1c, and lipids at baseline, 3 months, then at minimum annually (many centers now do this every 6 months given metabolic risk); BP; waist circumference. Metformin co-commencement is now guideline-recommended (see below).

Sources. FDA label (Zyprexa); ADA/APA consensus; Carolan et al., Schizophrenia Bulletin, 2024/2025 metformin guideline.

Metformin co-commencement

A clinical guideline led by Aoife Carolan strongly recommends co-commencing metformin alongside high-risk antipsychotics like olanzapine or clozapine. This proactive approach helps mitigate severe metabolic side effects, significantly reducing antipsychotic-induced weight gain and improving insulin resistance. The Schizophrenia Bulletin guideline states that when prescribing olanzapine or clozapine, metformin should be initiated immediately to prevent weight gain and cardiometabolic issues.

Typical metformin titration used in the guideline. 500 mg once daily → 500 mg twice daily after one week → increase by 500 mg every 2 weeks as tolerated, up to a maximum of 1000 mg twice daily by ~week 6. Contraindicated with eGFR < 30 mL/min/1.73 m²; monitor renal function annually and hold with acute illness/dehydration.

Carolan A, et al. Metformin for the Prevention of Antipsychotic-Induced Weight Gain: Guideline Development and Consensus Validation. Schizophrenia Bulletin. 2025;51(5):1193-1203. Read the guideline →

Clozapine

Receptor mechanism. Broad-spectrum antagonist across D1, D2 (relatively weak D2 blockade), D4, 5-HT2A, 5-HT2C, 5-HT6, 5-HT7, H1, M1 (partial agonist at some subtypes), α1, and α2. Unique efficacy in treatment-resistant schizophrenia not fully explained by receptor profile.

Potency. Moderate potency by mg (50-100 mg = 100 mg CPZ) but unmatched clinical efficacy in treatment-resistant psychosis.

Typical dosing. 12.5-25 mg on day 1, titrated by 25-50 mg/day as tolerated to 300-450 mg/day divided over 2 weeks; therapeutic serum level 350-600 ng/mL. Slow titration essential (orthostasis, sedation, myocarditis risk).

Safety monitoring (ANC and beyond).

ANC (absolute neutrophil count). Baseline ANC ≥ 1.5 × 10⁹/L required to start (≥ 1.0 × 10⁹/L in benign ethnic neutropenia / DARC-null). Weekly ANC for the first 6 months, every 2 weeks for months 6-12, then monthly indefinitely. As of February 24, 2025, the FDA eliminated the mandatory REMS program, but monitoring per the prescribing information remains standard of care. Discontinue for ANC < 1.0 × 10⁹/L (< 0.5 × 10⁹/L in benign ethnic neutropenia). See the FDA Drug Safety Communication: https://www.fda.gov/drugs/drug-safety-communications/fda-removes-risk-evaluation-and-mitigation-strategy-rems-program-antipsychotic-drug-clozapine
Myocarditis/cardiomyopathy. Baseline and week 4 troponin, CRP, ECG; clinical vigilance for tachycardia, fever, chest pain, dyspnea in weeks 1-4.
Metabolic. Same schedule as olanzapine; co-commence metformin per Carolan/Schizophrenia Bulletin guideline.
Seizure risk. Dose-dependent; consider EEG if > 600 mg/day or serum > 600 ng/mL.
Constipation/ileus. Assess bowel function at every visit; scheduled laxatives often indicated.
Sialorrhea, tachycardia, orthostasis. Symptom-based management.

Sources. FDA label (Clozaril); FDA Drug Safety Communication, Feb 24, 2025 (REMS elimination); AAPP Clozapine in Practice guideline (2025); Delphi consensus on international clozapine monitoring (Siskind et al., 2024).

Metformin co-commencement

Quetiapine

Receptor mechanism. D2 and 5-HT2A antagonist; strong H1 and α1 antagonism; active metabolite norquetiapine is a NET inhibitor and 5-HT1A partial agonist (contributes to antidepressant effect).

Potency. Low potency by mg (75-100 mg ≈ 100 mg CPZ).

Typical dosing. Immediate-release 25-50 mg BID starting, titrated to 300-800 mg/day for schizophrenia, 400-800 mg/day for bipolar mania, 300 mg/day for bipolar depression; XR available for once-daily dosing.

Safety monitoring. Metabolic labs (weight, glucose, lipids) baseline, 3 months, annually; sedation; orthostatic BP; cataract screening not required per FDA but historically noted; TSH (rare hypothyroidism).

Sources. FDA label (Seroquel/Seroquel XR); ADA/APA consensus.

Aripiprazole

Receptor mechanism. D2 and 5-HT1A partial agonist ("dopamine system stabilizer"); 5-HT2A antagonist.

Potency. High potency; 7.5 mg ≈ 100 mg CPZ.

Typical dosing. Oral 10-15 mg/day starting, titrated to 15-30 mg/day; LAI options: Abilify Maintena 400 mg IM monthly, Aristada 441-1064 mg IM every 4-8 weeks, Abilify Asimtufii 960 mg every 2 months.

Safety monitoring. Weight, glucose, lipids at baseline, 3 months, annually (metabolic risk lower than olanzapine/clozapine); akathisia (common); impulse-control behaviors (pathologic gambling, hypersexuality; an FDA warning); prolactin (typically normal or low).

Sources. FDA label (Abilify); FDA Safety Communication on impulse control (2016, reaffirmed); APA Guideline.

Ziprasidone

Receptor mechanism. D2 and 5-HT2A antagonist; 5-HT1A partial agonist; moderate SERT and NET inhibition.

Potency. Moderate; 60 mg ≈ 100 mg CPZ.

Typical dosing. 20-40 mg BID starting, titrated to 80-160 mg/day divided; must be taken with ≥ 500 kcal meal for adequate absorption.

Safety monitoring. Baseline and periodic ECG (QTc prolongation risk: avoid if QTc > 500 ms or with other QT-prolonging drugs, uncorrected hypokalemia/hypomagnesemia); metabolic labs (relatively metabolic-friendly); AIMS.

Sources. FDA label (Geodon); APA Guideline.

Paliperidone

Receptor mechanism. 9-hydroxyrisperidone (active metabolite of risperidone); potent 5-HT2A and D2 antagonist.

Potency. Similar to risperidone; 3 mg oral ≈ risperidone 2 mg.

Typical dosing. Oral (Invega) 6 mg/day; LAI options: Invega Sustenna monthly, Invega Trinza every 3 months, Invega Hafyera every 6 months.

Safety monitoring. Same as risperidone: metabolic labs, prolactin if symptomatic, EPS, BP.

Sources. FDA labels; APA Guideline.

Lurasidone

Receptor mechanism. D2, 5-HT2A, 5-HT7 antagonist; 5-HT1A partial agonist.

Potency. Moderate; 40 mg ≈ 100 mg CPZ.

Typical dosing. 40 mg/day for schizophrenia (up to 160 mg/day); 20-120 mg/day for bipolar depression. Take with ≥ 350 kcal meal.

Safety monitoring. Metabolic labs (metabolic-friendly profile); akathisia; renal/hepatic dose adjustment; avoid strong CYP3A4 inhibitors/inducers.

Sources. FDA label (Latuda); APA Guideline.

Cariprazine

Receptor mechanism. D3-preferring D3/D2 partial agonist; 5-HT1A partial agonist; 5-HT2B antagonist.

Potency. High; 1.5-3 mg range.

Typical dosing. Schizophrenia 1.5-6 mg/day; bipolar mania 3-6 mg/day; bipolar depression 1.5-3 mg/day; MDD adjunct 1.5-3 mg/day.

Safety monitoring. Akathisia (dose-related), EPS, metabolic labs; long half-life (active metabolites 1-3 weeks), so steady state and effects lag.

Sources. FDA label (Vraylar); APA Guideline.

Brexpiprazole

Receptor mechanism. D2 and 5-HT1A partial agonist; 5-HT2A and α1B/2C antagonist.

Typical dosing. Schizophrenia 2-4 mg/day; MDD adjunct 1-3 mg/day; agitation in Alzheimer dementia 2-3 mg/day.

Safety monitoring. Metabolic labs; akathisia (lower than aripiprazole); AIMS; boxed warning for elderly dementia mortality.

Sources. FDA label (Rexulti).

Asenapine and iloperidone

Asenapine is sublingual/transdermal and iloperidone is orthostasis-prone; standard second-generation metabolic and EPS monitoring apply. See FDA labels (Saphris, Fanapt).

Long-acting injectable considerations. LAIs require baseline oral tolerability testing (except paliperidone palmitate and aripiprazole lauroxil, which don't need it under specific initiation regimens). Monitoring frequency is unchanged from oral.

Shared safety themes.

Pregnancy and breastfeeding. Every entry should link to condition-specific perinatal considerations and reference LactMed/NICE/APA perinatal guidance.
Drug interactions. SSRIs/SNRIs + MAOIs (14-day washout, 5 weeks for fluoxetine); lithium + NSAIDs/ACEi/thiazides; carbamazepine broad CYP induction; clozapine + fluvoxamine, ciprofloxacin.
Discontinuation. Taper SSRIs, SNRIs, benzodiazepines, and antipsychotics gradually. Fastest tapers (paroxetine, venlafaxine, short-acting benzos) carry the most discontinuation symptoms.
Metabolic monitoring standard. Per the ADA/APA consensus, still the standard framework in 2026: baseline, 4, 8, 12 weeks, then quarterly: weight/BMI, waist. Baseline, 3 months, then annually: fasting glucose or HbA1c, fasting lipids, BP.
QTc considerations. Baseline ECG for citalopram > 20 mg (age > 60), ziprasidone, IV haloperidol, thioridazine, and any combination of QT-prolonging agents.

Sources

American Psychiatric Association (APA). Practice guidelines for the treatment of schizophrenia and bipolar disorder.
National Institute for Health and Care Excellence (NICE). Guidance on psychosis, schizophrenia, and bipolar disorder.
US Food and Drug Administration (FDA). Approved labeling for antipsychotic medications.
National Institute of Mental Health (NIMH). Mental health medications.
FDA prescribing information (label) for each drug, accessed via DailyMed.
APA Practice Guidelines (Schizophrenia 3rd ed.; MDD; Bipolar Disorder; OCD).
NICE Guidelines: NG222 (Depression 2022), CG185 (Bipolar 2014, updated), CG178 (Psychosis and schizophrenia 2014, updated), NG215 (Medicines associated with dependence).
ADA/APA Consensus on Antipsychotic Drugs and Obesity/Diabetes (2004, still foundational; updates via ISBD/EPA metabolic monitoring statements).
Carolan A, et al. Metformin for the Prevention of Antipsychotic-Induced Weight Gain: Guideline Development and Consensus Validation. Schizophrenia Bulletin. 2025;51(5):1193-1203.
FDA Drug Safety Communication: Clozapine REMS elimination (February 24, 2025).
AAPP Clozapine in Practice guideline (2025 updates).
International Society for Bipolar Disorders (ISBD) lithium and mood-stabilizer consensus statements.
APA/ASKP Consensus on Ketamine and Esketamine (2017 base; 2023-2025 updates).
Beers Criteria (AGS 2023) and STOPP/START v3 (2023) for prescribing in older adults.
Cochrane systematic reviews for individual class efficacy and safety.

Review panel

Reviewer: the Shrinkopedia editorial team, led by Shariq Refai, MD, MBA
Evidence strength: Strong What this rating means
Evidence type: Clinical practice guidelines, randomized controlled trials, large epidemiological surveys
Published: May 24, 2026
Medically reviewed: June 8, 2026
Sources checked: July 14, 2026
Last updated: June 8, 2026
Review status: Reviewed and published
Verify the reviewer: ORCID Wikidata NPI Registry All verification links

Every entry is rechecked against current guidance in our quarterly review.

Guidelines and prescribing information reviewed and current as of June 8, 2026. This entry will be revisited when major guidelines change or the FDA/EMA update a label. Nothing here is medical advice. Individual decisions belong with a licensed prescriber.

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How to cite this page

Short: Antipsychotics. Shrinkopedia, medically reviewed by Shariq Refai, MD, MBA. https://shrinkopedia.com/treatments/antipsychotics/
APA: Shrinkopedia. (2026, June 8). Antipsychotics. Medically reviewed by Shariq Refai, MD, MBA. https://shrinkopedia.com/treatments/antipsychotics/
MLA: "Antipsychotics." Shrinkopedia, 8 June 2026, https://shrinkopedia.com/treatments/antipsychotics/.

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Medical disclaimer

Shrinkopedia is for education, not medical advice. It can't tell you whether an antipsychotic is right for you, and it isn't a substitute for care from a licensed clinician. Decisions about antipsychotic medication belong with a prescriber, who can weigh the benefits, the side effects, and your situation with you.

If you're in crisis or thinking about harming yourself, call or text 988 in the US to reach the Suicide and Crisis Lifeline, or call 911.

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1 TREATMENT Antipsychotics (current)
2 CONDITION Schizophrenia
3 SYMPTOM Hopelessness
4 MEDICATION Antipsychotics explained
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