Schizophrenia medication types and side effects

Schizophrenia is a distressing psychiatric disorder for both those who experience it and their family members. Fortunately, schizophrenia medications are available to help manage symptoms.  

The treatment of schizophrenia primarily involves the use of antipsychotics. When combined with psychotherapy, these medications can help treat hallucinations and delusions. These effects improve a person’s ability to function in social and work situations. While not without their risks, antipsychotics are an essential aspect of schizophrenia treatment.

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Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. Patients with schizophrenia cycle through periods of psychosis, where they experience a disconnect from reality. Psychotic symptoms (also called positive symptoms) include hallucinations, delusions, and disorganized thinking (Hany, 2020). 

Hallucinations can affect any of the five senses, but auditory hallucinations, such as hearing voices, are the most common. Delusions describe firmly held, false beliefs despite evidence proving otherwise. Patients with delusions, for example, might believe that someone is controlling their thoughts or actions. Disorganized thinking causes the person to speak in a way that does not make sense or is difficult to follow (Picchioni, 2007). 

People with schizophrenia can also experience underlying negative symptoms, including social withdrawal, decreased emotional response, loss of motivation, and self-neglect (Picchioni, 2007). They may have difficulty making decisions, trouble with memory and attention, and poor performance at work or school (Bowie, 2016). 

Schizophrenia is diagnosed based on your symptoms. A psychiatrist or other mental health professional will examine your history and mental state. 

No test can tell you if you have schizophrenia. However, your healthcare provider will perform blood work and scans (such as an MRI or CT scan). These tests can rule out any other medical conditions that could be causing your symptoms (Hany, 2020).

The American Psychiatric Association recommends all patients with schizophrenia be treated with an antipsychotic (APA, 2021). Antipsychotic medications work, in part, by affecting dopamine levels in the brain. Researchers believe patients with schizophrenia have altered dopamine levels (Patel, 2014).

Antipsychotic medications are divided into two main groups: first-generation antipsychotics or “typical antipsychotics” and second-generation antipsychotics or “atypical antipsychotics.”  

Healthcare providers generally prefer to prescribe second-generation antipsychotics since they cause fewer side effects (Patel, 2014). 

First-generation antipsychotics include:

• Chlorpromazine

• Fluphenazine 

• Haloperidol (Haldol)

• Loxapine

• Molindone

• Perphenazine

• Pimozide

• Thioridazine

• Thiothixene

• Trifluoperazine 

Second-generation antipsychotics include:

• Aripiprazole (Abilify) 

• Asenapine (Saphris)

• Brexpiprazole (Rexulti)

• Cariprazine (Vraylar)

• Clozapine (Clozaril, Versacloz, FazaClo) 

• Iloperidone (Fanapt) 

• Lumateperone (Caplyta) 

• Lurasidone (Latuda) 

• Olanzapine (Zyprexa) 

• Paliperidone (Invega)

• Pimavanserin (Nuplazid) 

• Quetiapine (Seroquel)

• Risperidone (Perseris, Risperdal)

• Ziprasidone (Geodon) 

People with schizophrenia can have a hard time taking their medication each day. The symptoms of schizophrenia can make it hard to remember or make you feel like you don’t need treatment. Studies show that up to 37–74% of patients with schizophrenia don’t take their medication as prescribed (Patel, 2014). Fortunately, many antipsychotics are available in long-acting injectable form. A healthcare provider administers the injectable antipsychotic every 2–12 weeks, depending on the medicine (APA, 2021). 

If you’re starting treatment with an antipsychotic, you may be worried about all the side effects listed on the package. Depending on the antipsychotic, certain side effects are more likely to occur than others. You and your healthcare provider will work together to pick a medication that’s best for you. 

Let’s take a look at some of the more common side effects.  

Movement disorders

One of the most significant differences between first-generation and second-generation antipsychotics is their ability to cause side effects that impact how your body moves. While all antipsychotics can cause movement disorders, first-generation antipsychotics pose a greater risk. These reactions usually occur within a few weeks of starting treatment or after increasing the dose (APA, 2021). 

Movement disorders related to antipsychotic use are categorized into three types (APA, 2021):

• Akathisia (restlessness):Antipsychotics may cause you to feel restless or unable to sit or stand still. You may fidget your legs, pace back and forth, or rock from side to side. These reactions make some people feel very uncomfortable. 

• Parkinsonism: Antipsychotics can cause side effects that resemble symptoms of Parkinson’s disease. These include tremors, stiff muscles, difficulty moving, or slowed movements. 

• Dystonia (involuntary muscle contractions): People taking antipsychotics can experience involuntary and prolonged muscle contractions. These reactions typically involve the face and neck, but other body parts can be affected as well. Your head may tilt back or twist to one side. Sometimes your body can arch backward. These effects occur sooner than the other movement disorders, usually within a few days of starting the medication. They can come on suddenly and can be painful. 

If you experience any movement disorders while taking your antipsychotic, talk with your healthcare provider. They may recommend lowering your dose or switching to a different medication less likely to cause these effects. Your healthcare provider can also prescribe a medication to help treat or prevent movement side effects (APA, 2021).  

Metabolic side effects 

Antipsychotics, particularly second-generation, can cause weight gain, increase cholesterol levels, and can increase the risk of developing diabetes. These metabolic effects increase your risk of getting and possibly dying of cardiovascular disease. When starting an antipsychotic, you and your healthcare provider will develop an exercise and diet plan to help keep your weight in check (Patel, 2014). 

Cardiovascular effects 

Some antipsychotic drugs can affect the electrical activity in the heart and lead to arrhythmias, or abnormal heart rhythms. Your healthcare provider may recommend additional monitoring if you have heart problems (Patel, 2014).

Antipsychotics can cause low blood pressure, particularly when you stand up from a seated or lying position. Low blood pressure can make you feel dizzy and can cause you to fall. It’s important to stand up slowly and pause for a moment before walking. When getting up in the morning, it helps to sit on the edge of the bed for a minute before rising (APA, 2021).  

Other side effects

Several other side effects are possible, depending on which antipsychotic you take. These include (Hany, 2020; Patel, 2014):

• Allergic reactions

• Blurred vision 

• Constipation 

• Decreased white blood cells

• Difficulty regulating body temperature 

• Difficulty urinating 

• Dry mouth 

• Fast heart rate 

• Glaucoma and other eye problems

• Increased risk of seizures 

• Liver problems 

• Sensitivity to the sun (increased risk of sunburn)

• Sexual dysfunction 

• Tiredness (very common)

Special considerations for clozapine

Clozapine (brand name Clozaril) is used to treat resistant cases of schizophrenia that haven’t responded to other antipsychotics (APA, 2021). Healthcare providers don’t prescribe this medication initially because it can cause serious side effects. The U.S. Food and Drug Administration (FDA) has issued several boxed warnings—their strongest warnings—regarding clozapine’s risks. Here’s what you should know about these warnings if you take clozapine:

• Infections: Clozapine can decrease white blood cells in your body, putting you at increased risk of infections. These infections can be serious and can even lead to death if not caught early enough. For this reason, the FDA requires routine blood monitoring for all patients taking clozapine (Novartis, 2014). 

• Low blood pressure: All antipsychotics can cause low blood pressure when standing, but clozapine’s effects can be severe. A drop in blood pressure is most common when first starting clozapine or when increasing the dose. In addition, clozapine can slow your heart rate and cause fainting. In some severe cases, it has even led to death. Clozapine should be used with caution if you have a history of heart problems or stroke, or if you currently take blood pressure-lowering medications. If you forget to take your clozapine for two or more days, speak with your healthcare provider—you will need to restart at a lower dose to prevent your blood pressure from dropping too much (Novartis, 2014). 

• Seizures: Clozapine can cause seizures, especially in patients with a history or risk of seizures. Seizures are more likely to occur at high doses of clozapine or when the dose is being increased (Novartis, 2014). It is important not to drive or engage in other potentially dangerous activities (i.e., operating machinery, swimming, climbing) during these times (APA, 2021). 

• Heart effects: Clozapine can cause inflammation of the heart or changes in the heart structure. This can increase your chance of developing heart failure or arrhythmias (abnormal heart rhythms). When taking clozapine, be sure to let your healthcare provider know if you experience any chest pain, difficulty breathing, rapid heart rate, dizziness, fever, or flu-like symptoms (Novartis, 2014).

Antipsychotics have several risks to be aware of. Speak with your healthcare provider about any concerns you have regarding these. 

Tardive dyskinesia 

Tardive dyskinesia (TD) is a movement disorder that occurs after prolonged use of antipsychotics but can start as early as 1–6 months into treatment. Sometimes these effects can be permanent, even after stopping the medication. Tardive dyskinesia causes irregular movements, most commonly affecting the face (Ricciardi, 2019). Symptoms include lip-smacking, chewing movements, puffing of the cheeks, and sticking out the tongue. Other parts of the body may be affected as well. Patients may spread their fingers or toes, rock back and forth, or have unusual postures such as arching backward (Ricciardi, 2019; Vasan, 2021). Some people may be unaware of these movements, but others may find them uncomfortable and embarrassing (Ricciardi, 2019). 

Studies estimate that at least 20% of patients taking first-generation antipsychotics will experience TD, but second-generation antipsychotics can also cause this syndrome. The risk of TD increases with age, the duration of antipsychotic use, and if you’ve experienced any movement side effects in the past (Vasan, 2021). 

If TD occurs, your healthcare provider may recommend decreasing your dose or switching to a different antipsychotic with a lower risk. For more severe cases, medications can be used to treat tardive dyskinesia (APA, 2021). 

Neuroleptic malignant syndrome 

Rarely, a life-threatening condition called neuroleptic malignant syndrome can occur. Any antipsychotic can cause this condition, but it is more common with first-generation antipsychotics. Symptoms develop over 1–3 days and include fever, stiff muscles, confusion, fast heart rate, increased blood pressure, and sweating. Hospitalization is required to treat this condition and involves stopping the antipsychotic, giving fluids, and lowering the fever (Simon, 2021). 

If you’ve been diagnosed with schizophrenia, it can be difficult to manage day-to-day activities. Fortunately, antipsychotic medications, combined with psychotherapy, such as cognitive-behavioral therapy, can help get your symptoms under control.Talk with your healthcare provider about any concerns you have regarding your treatment. Together you can develop a plan to minimize side effects while optimizing your therapy and improving your quality of life.

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Current version

June 07, 2021

Written by

Christina Varvatsis, PharmD

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.