Management of common adverse effects of antipsychotic medications

Stroup, T. Scott; Gray, Neil

doi:10.1002/wps.20567

Cited by 572Schizophrenia research and treatmentBipolar Disorder and TreatmentElectroconvulsive Therapy Studies

Management of common adverse effects of antipsychotic medications

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Stroup, T. Scott, Gray, Neil·2018·World Psychiatry

DOI 10.1002/wps.20567PMC PMC6127750

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Abstract

The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.

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The limited clinical investigation of antipsychotics in AD may be related to their adverse effects.
“The limited clinical investigation of antipsychotics in AD may be related to their adverse effects, which include increased risk of cardiovascular and cerebrovascular events,”
From Drug repurposing for Alzheimer’s disease from 2012–2022—a 10-year literature review (2023) · cites this paper as Stroup and Gray, 2018
The Abstract says antipsychotics are prescribed off-label for dementia syndromes including Alzheimer’s disease and that adverse effects hamper their utility in those conditions. It does not say that clinical investigation in Alzheimer’s disease is limited or that adverse effects explain a lack of investigation. (LLM, conf=0.82)
Experimental — accuracy not yet measured
Antipsychotics' adverse effects include increased risk of cardiovascular and cerebrovascular events, metabolic syndrome, extrapyramidal symptoms, and for clozapine specifically, agranulocytosis, and may be more severe in older adults.
“which include increased risk of cardiovascular and cerebrovascular events, metabolic syndrome, extrapyramidal symptoms, and for clozapine specifically, agranulocytosis, and may be more severe in older adults.(Stroup and Gray, 2018).”
From Drug repurposing for Alzheimer’s disease from 2012–2022—a 10-year literature review (2023) · cites this paper as Stroup and Gray, 2018
Adverse effects of antipsychotic medication are not always reversible upon discontinuation, as exemplified by tardive dyskinesia.
“Many may expect adverse effects to be reversible upon discontinuation, but this is not always the case with antipsychotic medication, as exemplified by tardive dyskinesia (7).”
From Reversibility of Antipsychotic-Induced Weight Gain: A Systematic Review and Meta-Analysis (2021) · cites this paper as [7]
There is international agreement that primary care is the optimal setting for addressing and coordinating management of multimorbidity.
“There is international agreement that primary care is the optimal setting for addressing and coordinating management of multimorbity.298,299”
From The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness (2019) · cites this paper as [298]

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Authors: Stroup, T. S., & Gray, N.
Affiliations: New York State Psychiatric Institute (US)
University of Hawaiʻi at Mānoa (US)
ORCID: Stroup, T. Scott
Venue: World Psychiatry
Publisher: Wiley
Published: 2018-09-07
Volume: 17
Issue: 3
Pages: 341-356
ISSN: 1723-8617 (ISSN-L)
2051-5545
DOI: 10.1002/wps.20567
PMC: PMC6127750
OpenAlex: W2892142575
Cited by: 572
References: 266
Citations by year: 2026: 60 · 2025: 91 · 2024: 111 · 2023: 85 · 2022: 72 · 2021: 76 · 2020: 53 · 2019: 23 · 2018: 1
FWCI: 29.89
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations: World Psychiatry (publishedVersion)
Europe PMC (PubMed Central) (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: Columbia University
Topics: Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
Health Sciences › Medicine › Psychiatry and Mental health › Electroconvulsive Therapy Studies
Keywords: antipsychotic adverse effects, akathisia, tardive dyskinesia, anticholinergic agents, parkinsonism, dystonia, beta-blockers, metformin, weight gain, drooling, constipation, sexual dysfunction, agranulocytosis, myocarditis, dose adjustment, concomitant medications, valbenazine, deutetrabenazine, behavioral interventions

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