Kevin Leehey, M.D.
1980 E. Ft. Lowell Road, Suite 150 Tucson, Arizona 85719 (520) 296-4280 Fax: (520) 296-3835
ANTIPSYCHOTIC MEDICATIONS ("Atypicals" Page 1)
Used for Psychosis, Schizophrenia, Bipolar Disorder, Severe Impulsive Aggression, Tourette's, Paranoia

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Medication
Brand/Generic
Form Dose Schedule Dose Range Most Common Side Effects for Group Pros for Group Cautions for Group

Risperdal
(risperidone)

tablets
.25mg, .50mg, 1mg, 2mg, 3mg, 4mg

M tabs
0.5, 1, 2mg

liquid
1mg/1ml
Consta IM Depot
1-3 times daily, often evening only

one quarter to 16mg/day depending on age, size, diagnosis, and severity.

Youth and adults

Sedation, weight gain or appetite increase. Extrapyramidal symptoms (EPS) less common than with "Typicals." Prolactin increase also less common than typicals but also can occur especially with higher doses. Sun sensitivity, heat intolerance, sexual side effects can occur but are uncommon. Rarely negative effects on liver or blood count.

Fanapt shows no to little EPS and moderate QTc, orthostasis, weight gain. Dizzy, dry mouth , sleepy, increased heartrate, nasal congestion are most common but mild and dose related.

Zyprexa, Clozaril, and Seroquel have lowest risks of EPS. 

Zyprexa, Clozaril, Risperdal, and Seroquel cause the most sedation and weight gain. Abilify and Saphris are in the middle. Geodon is lowest. Directly or indirectly weight gain can lead to diabetes, hypertension, and high cholesterol and triglycerides. Latuda looks good so far.

Seroquel has very low risks of EPS. This includes a very low risk of Tardive Dyskinesia (TD) and Neuroleptic Malignant Syndrome (NMS).

Sedation and weight gain occur often.

Seroquel is not very potent. Thus higher doses are often needed.

Geodon and Seroquel have shorter action and are thus sometimes advised to be given a.m. and evenings.

The "Atypical" antipsychotics are often preferred over the "typicals" as first line treatments for the above conditions.

The "Atypicals" have benefit for mood disorders and may work as mood stabilizers. Generic risperidone, Seroquel, Zyprexa, Abilify, and Geodon are available.


Invega is an extended smoother release cousin of risperidone (OROS).

Risperdal and Zyprexa have been available longest, studied the most, have the best track records, are very effective (often rapidly) and have been used enough with kids and the elderly to have shown benefit and safety. But side effects may be less in newer options.

No routine blood tests for any of the group except clozapine.


Seroquel is effective for bipolar mania, bipolar depression, depression booster, and borderline personality disorder..

In certain situations improved appetite and improved sleep are desired side effects. Side effects are often less at lower doses. Side effects can often be avoided completely. Sedation is most common.

Geodon rarely, if ever, causes weight gain.

Clozaril not only does not cause EPS, especially Tardive Dyskinesia (TD), it actually can treat TD. "Miraculous" benefits have occurred with some cases of schizophrenia.

All Atypicals help psychosis, mania, and impulsive aggression.

FDA approved for schizophrenia and bipolar. 

Prolactin increase and breast discharge happens more with Risperdal than other atypicals. Also Fanapt, olanzapine, Latuda and Invega, but less so.

Appetite increase or sedation are often more of a concern than EPS or TD.

Weight gain and related metabolic health effects occur most often with Zyprexa and Risperdal but least with Geodon.

Invega has a small chance of heart rhythm side effect. Fanapt has no EPS, akathisia or tremor and similar QTc effect to Geodon.

All antipsychotics block the dopamine (D2) receptor. The atypicals also somewhat block serotonin (5HT). The atypicals also boost antidepressant adn anti-anxiety meds (good).

Seroquel, Risperdal, Zyprexa, Geodon, and Clozaril are now available in a generic.

Cataract risk may be increased slightly by all antipsychotics as well as by some other medicines and health conditions.

Geodon is now available in a generic.

Geodon may worsen or bring out abnormal heart rhythm. Certain patients may thus be best off with one of the others. Checking an EKG may be worthwhile in some cases.

I generally do not use Clozaril because of side effects although it may be the most effective.

Abilify, as with most atypicals, is often helpful as a "booster" to improve benefit when added to an antidepressant or antianxiety med. Atypicals often help as mood stabilizers, especially mania, but also depression and anxiety.

Youth studies and experience is just beginning for most atypicals. Zyprexa, Risperdal, Abilify, Seroquel, Invega are FDA approved for youth.

Fanapt
(iloperidone)
1, 2, 4, 6, 8, 10, 12mg tablets twice daily or evening 6-12 mg twice daily
Invega
(paliperidone)
Sustenna IM Depot
3, 6, 9 mg caplets
Once a day or monthly 3 to 12 mg/d  (6 average)
Zyprexa
(olanzapine)
tablets
2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20 mg

zydis
5mg, 10mg, 15 mg, 20 mg

Injection
Once to twice a day, often evening only 1.25mg to 20mg/day

Youth and adults
Seroquel
(quetiapine)
tablets
25, 50, 100, 200, 300, 400mg

XR 50, 150, 200, 300, 400 mg

Twice daily, sometimes only evening 25mg to 800mg/day total

Youth and adults
Geodon
(ziprasidone)
capsules
20mg, 40mg, 60mg, 80mg

injection
20mg/ml

Twice a day, sometimes once 20 to 160mg/day total, usually

Youth and adults
Clozaril
(clozapine)
tablets, scored
25mg
100mg
Once or twice daily 300 to 900mg a day, usually
Adults
A wide range of nuisance and moderate side effects render Clozaril a hassle often. Blood count suppression can be dangerous so that weekly blood tests are advised at least at first. Clozaril not only does not cause EPS, especially Tardive Dyskinesia (TD), it actually can treat TD. "Miraculous" benefits have occurred with some cases of schizophrenia.


All Atypicals help psychosis, mania, and impulsive aggression.








Long duration form of Abilify improves compliance, convenience, and may improve benefit.






FDA approved for schizophrenia and bipolar including adolescents.
I generally do not use Clozaril because of side effects although it may be the most effective.



Abilify, as with most atypicals, is often helpful as a "booster" to improve  benefit when added to an antidepressant or antianxiety med. Atypicals often help as mood stabilizers, especially mania, but also depression and anxiety.



Abilify may problematically increase some pleasure urges like dopamine agonists for parkinson's or RLS can occasionally.  Not common.



May still require daily oral med to adjust or fine tune. Requires an IM injection. Once given, it lasts a month.



Zyprexa, Risperdal, Abilify, Seroquel, Invega, Saphris, Geodon are FDA approved for youth.
Abilify
(aripiprazole)










Aristada
(Aripiprazole lauroxil)
tablets
2, 5, 10, 15, 20, 30mg

Discmelt
10, 15mg

Oral solution liquid
1mg/1ml

Injection (IM)
9.75mg/1.3 ml vial


441, 662, 882mg
Extended release IM
Once or twice daily











Monthly
882mg lasts 4 to 6 weeks
Child: 1 - 10mg
Adoles: 1 - 20mg
Adult: 2 - 30mg









441 to 882mg
Adults
Sleepy, dizzy, weight gain, nausea, EPS can happen with most atypicals.










Same as Abilify
Saphris
(asenapine)
sublingual tablets
5, 10 mg

Let dissolve under tongue
Once to often twice a day Wait 2 to 10 minutes to eat or drink after taking dose.
Youth and adults
5 to 30 mg a day usually 5 to 10mg twice a day
Brief occasional tongue numbness after dosing (under tongue). Moderate weight gain and metabolic changes. Sedation, EPS, akathisia, dizzy. No prolactin, orthostasis or QTc effects.
Latuda
(lurasidone)
tablets
20, 40, 60, 80, 120mg
evening with food Adults
Start 20-40mg
max 160mg/day
Sedation, nausea, EPS, akathisia, though Latuda causes less.
Take with food to prevent nausea and help absorb.
Less weight and EPS and heart (Qtc, orthostasis) with Latuda. Latuda is approved by FDA in 2011.
Is often a good option, especially for Bipolar depression or major depression as a booster.
Rexulti
(brexpiprazole)
Tablets
0.25, 0.5, 1, 2, 3, 4mg
not scored
Once a day
usually evening
Adults
Start 0.5 to 1mg

For depression booster
1-3mg

For schizophrenia
2-4mg
Sedation, weight gain, EPS (akathisia, tremor) like other atypicals but at similar to lower frequencies. Another option to add to antidepressants to boost effectiveness.

Chemically related to Abilify, both are D2 partial agonists.
New, FDA approved 2015. Brand only.

Remember, all antipsychotics both typical and atypical can cause a range of EPS and metabolic side effects. See my Medical Education memo regarding "Antipsychotic" medicines.
Vraylar
(cariprazine)
Capsules
1.5, 3, 4.5, 6mg
Once daily
AM or evening
Adults

Start 1.5mg
Depression 1.5mg
Mania 3-6mg

Schizophrenia
1.5 - 6mg
EPS/akathisia, weight gain. Less often sedation, nausea, constipation, insomnia D3 preferring partial agonist which makes it different from other antipsychotics.

Only Vraylar and quetiapine have been proven effective in all phases of bipolar disorder.
New, FDA approved 2016. Brand only

Steady state 2-4 days for cariprazine but 1-3 weeks for DDCAR.


Simultaneous use of alcohol or cigarettes and especially street drugs should be avoided. All medications should be avoided, if possible, in pregnancy.
This chart is intended to be a summary guide, not a full and complete list.

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