Antipsychotics, Mood Stabilizers and Anxiolytics
Including ADHD medications
First-generation (typical)
haloperidol, chlorpromazine, fluphenazine. Block dopamine (D2) receptors. Best for positive symptoms (hallucinations, delusions).
- Higher risk of extrapyramidal symptoms (EPS), tardive dyskinesia, NMS.
- Haloperidol: QT prolongation. Long-acting depot injections (decanoate) are given IM only.
Second-generation (atypical)
risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, lurasidone, clozapine. Block dopamine and serotonin receptors; treat positive and some negative symptoms.
- Metabolic syndrome: weight gain, high glucose and lipids. Check weight, glucose, lipids at baseline and regularly.
- Clozapine: severe neutropenia (monitor ANC), myocarditis (first weeks), seizures, severe constipation, drooling.
- Ziprasidone and lurasidone: take with food.
- New: xanomeline-trospium (2024) works without blocking dopamine. New
Movement and serious reactions
| Acute dystonia | Hours–days: neck, eye (oculogyric crisis) or tongue spasm → benztropine or diphenhydramine IM/IV |
| Akathisia | Restlessness, can't sit still → lower dose, propranolol, benzodiazepine |
| Parkinsonism | Tremor, rigidity, shuffling → benztropine, amantadine |
| Tardive dyskinesia | Months–years: lip smacking, tongue movements, grimacing; may be permanent. Screen with AIMS. Treat with valbenazine or deutetrabenazine |
| Neuroleptic malignant syndrome | Emergency: high fever, "lead-pipe" rigidity, altered mental status, unstable BP and HR, ↑ CK. Stop the drug, cool, fluids, dantrolene or bromocriptine |
Lithium
- Level 0.6–1.2 mEq/L; toxic >1.5. Draw ~12 h after the last dose.
- Keep sodium intake and fluids normal and steady (2–3 L/day). Low sodium or dehydration (vomiting, sweating, heat) → toxicity.
- Raise levels: NSAIDs, ACE inhibitors/ARBs, thiazides.
- Expected: fine tremor, thirst, frequent urination, weight gain. Long-term: hypothyroidism, kidney effects.
- Toxicity: vomiting, diarrhea, coarse tremor, confusion, ataxia, seizures.
- Teratogenic (heart defect): plan pregnancy with the prescriber.
Other mood stabilizers
- Valproate: liver toxicity, pancreatitis, low platelets, weight gain; major birth defects (avoid in pregnancy).
- Carbamazepine: SJS (HLA-B*1502 testing in Asian ancestry), low blood counts, low sodium; weakens birth control pills.
- Lamotrigine: rash → SJS: must be increased slowly; report any rash.
Anxiolytics
- Benzodiazepines (lorazepam, diazepam, alprazolam, chlordiazepoxide): sedation, falls (avoid in older adults where possible), dependence, withdrawal seizures if stopped suddenly. Boxed warning: with opioids → respiratory depression and death. Antidote: flumazenil. Used for alcohol withdrawal.
- Buspirone: no dependence; takes 2–4 weeks; not for "as needed" use.
ADHD medications
- Stimulants (methylphenidate, amphetamines): appetite and weight loss, insomnia (give early in the day), ↑ HR and BP, growth monitoring, misuse risk (controlled drug).
- Non-stimulants: atomoxetine (suicidal thoughts warning), viloxazine, guanfacine, clonidine (sedation, low BP).