1. Conventional
Antipsychotics
Concise Review for
Non-Psychiatrists Treating
Developmentally Disabled Population

2. Presenter
S. Christopher Shim, M.D.
Distinguished Fellow
American Psychiatric Association

3. Objectives
Participants will have enhanced knowledge in:
 Different potencies of conventional anti-psychotic
medications
 Safety and tolerability profiles of conventional
anti-psychotic medications
 Cautions of reduction and discontinuation of
conventional anti-psychotic medications

4. Potency
Efficacy

5. Different Potency of Treatment

6. High Potency Antipsychotics
BRAND NAME GENERIC NAME Eq
Haldol Haloperidol 2
Prolixin Fluphenazine 2
Navane Thiothixine 4
Stelazine Trifluoperazine 5
Orap Pimozide 1.5

7. High Potency Antipsychotics
Benefits & Risks
 Higher binding to D2 receptors:
 Higher Efficacy
 More EPS (Extra Pyramidal Symptoms)
 Higher incidence of TD (Tardive Dyskinesia)
 Less Cognitive Problems
 Less Sedation
 Less Anti-cholinergic SE (Side Effects)
 Less Cardiovascular SE

8. Low Potency Antipsychotics
BRAND NAME GENERIC NAME Eq
Mellaril Thioridazine 100
Thorazine Chlorpromazine 100
Serentil Mesoridazine 50

9. Low Potency Antipsychotics
Benefits & Risks
 Lower binding to D2 receptors:
 Lower Efficacy
 Less EPS (Extra Pyramidal Symptoms)
 Lower incidence of TD (Tardive Dyskinesia)
 More Cognitive Problems
 More Sedation
 More Anti-cholinergic SE
 More Cardiovascular SE and Other SE

10. Mid Potency Antipsychotics
BRAND NAME GENERIC NAME Eq
Trilafon Perphenazine 8
Moban Molindone 10
Loxitane Loxapine 10
Compazine Prochlorperazine 15

11. Safety and Tolerability
Side Effect Profiles

12. Safety Profiles
 Many Various Safety and Tolerability Factors
 Individual Differences
 Measure Benefits and Risks
 Preventions and Treatments

13. Extra Pyramidal Symptoms
EPS

14. EPS
(Extra Pyramidal Symptoms)
 EPS include:
 Acute Dystonias: happens within hours
 Parkinsonism: develops gradually (Days – Weeks)
 Tardive Dyskinesia: chronic development
 Tardive Dystonia: chronic development
 Changes in Dopamine Receptor Blockade in the
Certain Areas of Brain (Substantia Niagra and
Caudate Nucleus)

15. Parkinsonian Syndrome
 Parkinsonian Syndrome
 Tremors
 Rigidity
 Cogwheeling
 Bradykinesia
 Akinesia
 May resemble Depression:
 Slowing in thinking
 Decreased initiative
 Masked face

16. Treatment of EPS
BRAND NAME GENERIC NAME Dose
(mg)
Akineton Biperiden 2-6
Artane Trihexyphenidyl 5-15
Cogentin Benztropine 1-4
Kemadrin Procyclidine 7.5-15
Symmetrel Amantadine 100-300

17. Akathisia
Restless Pacing

18. Akathisia
 Akathisia: Inability to sit still
 A feeling of restlessness,
 A need to keep moving,
 An urge to raise the feet high
 Difficult to differentiate from
illness-related behaviors

19. Akathisia
 Appear Anxious:
 May misidentify akathisia as anxiety
 Anxiety can aggravate akathisia
 Treatment:
 Lowering the dosage of the medication
 Anticholinergics: not always effective
 Propranolol: 10 to 80 mg/d
 Clonidine: 0.1 to 0.8 mg/d

20. Neuroleptic Malignant Syndrome
NMS

21. NMS
(Neuroleptic Malignant Syndrome)
 A rare but potentially fatal complication
 Main clinical findings:
 Hyperthermia
 Severe muscular rigidity
 Autonomic instability:
 Pulse/ BP/ Breathing/ Sweating
 Changing levels of consciousness
 Unstable vital signs

22. NMS
(Neuroleptic Malignant Syndrome)
 Most common:
 When high potency antipsychotics are given
high dosages
 When depot forms are used
 When the dosage is escalated rapidly
 In young person than in mature person
 Twice as common in men as in women

23. NMS
(Neuroleptic Malignant Syndrome)
 Lab tests:
 Creatine Phosphokinase (CPK)
 Adolase
 Liver Transaminases
 Leukocytosis (increased WBC)
 Increased Myoglobin and Myoglobinuria
 Mortality: 20 – 30 %
 May be higher when depot forms are used

24. NMS
(Neuroleptic Malignant Syndrome)
 Treatments
 Stop the antipsychotics
 Supportive and symptomatic TX
 Medications:
 Dantrolene (Dantrium):
 IV, 0.8 to 2.5 mg/kg, Q 6h
 A maximum IV dosage 10 mg/ kg/ d
 When symptoms subside, PO 100 - 200 mg/ d
 Bromocriptine (Parlodel):
 20 -30 mg/ d in four divided doses
 Amantadine (Symmetrel)

25. Tardive Dyskinesia
TD

26. TD
(Tardive Dyskinesia)
 Involuntary and persistent movement disorder
that may occur later after long-term treatment
 At least 10 – 20% of the patients (pts) treated
with the conventional antipsychotics for more
than a year experience TD
 In chronically institutionalized pts who were
treated with conventional antipsychotics, the
prevalence rate is between 15 and 20 %

27. A task report on TD by APA in 1992:
1. Abnormal movements are reduced by
voluntary movements of the affected parts
and increased by voluntary movements of
the unaffected parts
3. The movements are increased by emotional
arousal and decreased by relaxation and
volitional effort

28. A task report on TD by APA in 1992:
 Some movements are at least moderate in one
body area or mild in at least two body area
 The movements should be present for at least 4
weeks
 The patient should have a history of at least 3
months of total cumulative antipsychotic
exposure

29. Risk Factors of TD
 Children
 Elderly person: especially elderly women
 African Americans
 Patients with mood disorders
 The potency of antipsychotic
 The dosage of antipsychotic
 The amount of time of using antipsychotic
 Patients who are vulnerable to acute EPS

30. Cardiovascular Effects
Heart Effects

31. Cardiovascular Effects
 Prolonged QTc intervals
 Low Potency Conventional Antipsychotics
 Mellaril (Thioridazine)
 Thorazine (Chlorpromazine)
 With QTc intervals exceeding 0.440 seconds, the
risk of sudden cardiac death increases because of
ventricular tachycardia or ventricular fibrillation

32. Cardiovascular Effects
 Malignant Arrhythmias (torsade de pointes)
 In pts with pre-existing prolongation of the QTc intervals
 In pts with increased QTc intervals during the Tx
 Sudden Cardiac Death
 Temperature increase in highly agitated pts, particularly
when restrains are used
 Treatment (Tx)-resistant pts in long-term Tx unit who
show violence and disruptive behaviors may have higher
risk

33. Other Safety Profiles
Various Different Side Effects

34. Eye Effects
 High dosage of Mellaril (Thioridazine), above
1,000 mg/d, can result in retinal pigmentation
that may lead into serious irreversible visual
impairment or blindness
 Early sign may be nocturnal confusion
 Mellaril should not be prescribed at the doses
over 800 mg/d
 Thorazine (Chlorpromazine) may be associated
with granular deposits in the anterior lens and
the posterior cornea

35. Skin Effects
 Low Potency Conventional Antipsychotics,
especially Thorazine (Chlorpromazine), are
associated with an uncommon discoloration
of the skin.
 The skin areas that are exposed to sunlight,
particularly the face and the neck, develop
blue-gray metallic discoloration.

36. Miscellaneous Effects
 Orthostatic BP changes
 More common with the low potency antipsychotics
 Prolactin elevation
 More common with the high potency antipsychotics
 Anti-cholinergic effects
 More common with the low potency antipsychotics

37. Cautions
Reduction or Discontinuation of
Conventional
Antipsychotic Medications

38. Reduction of Conventional
Antipsychotic Medications
 Typically, reduction should be done gradually
 The reason for the medication reduction
should be discussed among the IDT members
and with a psychiatrist
 Prior to the reduction, review the client’s past
history and discuss with the psychiatrist

39. Reduction of Conventional
Antipsychotic Medications
 The required medication reduction by
regulatory reasons does not necessarily mean
that the medication has to be reduced
regardless of the client’s clinical condition.
 It may be very difficult to cut down the
lower dosage of conventional antipsychotic
medications.

40. Discontinuation of Conventional
Antipsychotic Medications
 The benefits and risks of stopping the
medication verse continuation of the
medication need to be reviewed.
 Justifications of continuation of the
medication should be discussed and
documented.

41. Thank you !

42. Q & A