The atypical antipsychotics (AAP; also known as second generation antipsychotics (SGAs)) are a group of antipsychotic drugs (antipsychotic drugs in general are also known as major tranquilizers and neuroleptics, although the latter is usually reserved for the typical antipsychotics) used to treat psychiatric conditions. Some atypical antipsychotics have received regulatory approval (e.g. by the FDA of the US, the TGA of Australia, the MHRA of the UK) for schizophrenia, bipolar disorder, autism, and as an adjunct in major depressive disorder.
Both generations of medication tend to block receptors in the brain's dopamine pathways. Atypicals are less likely – than the most widely used typical antipsychotic haloperidol – to cause extrapyramidal motor control disabilities in patients such as unsteady Parkinson's disease-type movements, body rigidity, and involuntary tremors. However, only a few of the atypicals have been demonstrated to be superior to lesser-used, low-potency first-generation antipsychotics in this regard.
As experience with these agents has grown, several studies have questioned the utility of broadly characterizing antipsychotic drugs as "atypical/second generation" as opposed to "first generation," noting that each agent has its own efficacy and side-effect profile. It has been argued that a more nuanced view in which the needs of individual patients are matched to the properties of individual drugs is more appropriate. Although atypical antipsychotics are thought to be safer than typical antipsychotics, they still have severe side effects, including tardive dyskinesia (a serious movement disorder), neuroleptic malignant syndrome, and increased risk of stroke, sudden cardiac death, blood clots, and diabetes. Significant weight gain may also occur. Critics have argued that "the time has come to abandon the terms first-generation and second-generation antipsychotics, as they do not merit this distinction."
- 1 Medical uses
- 2 Adverse effects
- 3 Regulatory status
- 4 Pharmacodynamics
- 5 Pharmacokinetics
- 6 History
- 7 See also
- 8 Notes
- 9 References
- 10 External links
Atypical antipsychotics are typically used to treat schizophrenia or bipolar disorder. They are also frequently used to treat agitation associated with dementia, anxiety disorder, Autism Spectrum Disorder, and obsessive-compulsive disorder (an off-label use). In dementia, they should only be considered after other treatments have failed and if the patient is a risk to himself and/or others.
The first-line psychiatric treatment for schizophrenia is antipsychotic medication, which can reduce the positive symptoms of psychosis in about 8–15 days. Antipsychotics, however, fail to significantly improve the negative symptoms and cognitive dysfunction.
The choice of which antipsychotic to use for a specific patient is based on benefits, risks, and costs. It is debatable whether, as a class, typical or atypical antipsychotics are better. Both have equal drop-out and symptom relapse rates when typicals are used at low to moderate dosages. There is a good response in 40–50% of patients, a partial response in 30–40%, and treatment resistance (failure of symptoms to respond satisfactorily after six weeks to two of three different antipsychotics) in the remaining 20%. Clozapine is an effective treatment for those who respond poorly to other drugs, but it has the potentially serious side effect of agranulocytosis (lowered white blood cell count) in 1–4% of patients.
Efficacy in the treatment of schizophrenia
The utility of broadly grouping the antipsychotics into first generation and atypical categories has been challenged. It has been argued that a more nuanced view, matching the properties of individual drugs to the needs of specific patients is preferable. While the atypical (second-generation) antipsychotics were marketed as offering greater efficacy in reducing psychotic symptoms while reducing side effects (and extrapyramidal symptoms in particular) than typical medications, the results showing these effects often lacked robustness, and the assumption was increasingly challenged even as atypical prescriptions were soaring. In 2005 the US government body NIMH published the results of a major independent (not funded by the pharmaceutical companies) multi-site, double-blind study (the CATIE project). This study compared several atypical antipsychotics to an older typical antipsychotic, perphenazine, among 1,493 persons with schizophrenia. The study found that only olanzapine outperformed perphenazine in discontinuation rate (the rate at which people stopped taking it due to its effects). The authors noted an apparent superior efficacy of olanzapine to the other drugs in terms of reduction in psychopathology and rate of hospitalizations, but olanzapine was associated with relatively severe metabolic effects such as a major weight gain problem (averaging 9.4 lbs over 18 months) and increases in glucose, cholesterol, and triglycerides. No other atypical studied (risperidone, quetiapine, and ziprasidone) did better than the typical perphenazine on the measures used, nor did they produce fewer adverse effects than the typical antipsychotic perphenazine (a result supported by a meta-analysis by Leucht et al. published in The Lancet), although more patients discontinued perphenazine owing to extrapyramidal effects compared to the atypical agents (8% vs. 2% to 4%, P=0.002). A phase 2 part of this CATIE study roughly replicated these findings. Compliance has not been shown to be different between the two types. Overall evaluations of the CATIE and other studies have led many researchers to question the first-line prescribing of atypicals over typicals, or even to question the distinction between the two classes.
It has been suggested that there is no validity to the term "second-generation antipsychotic drugs" and that the drugs that currently occupy this category are not identical to each other in mechanism, efficacy, and side-effect profiles. 
In bipolar disorder, SGAs are most commonly used to rapidly control acute mania and mixed episodes, often in conjunction with mood stabilizers (which tend to have a delayed onset of action in such cases) such as lithium and valproate. In milder cases of mania or mixed episodes, mood stabilizer monotherapy may be attempted first. SGAs are also used to treat other aspects of the disorder (such as acute bipolar depression or as a prophylactic treatment) as adjuncts or as a monotherapy, depending on the drug. Both quetiapine and olanzapine have demonstrated significant efficacy in all three treatment phases of bipolar disorder. Lurasidone (trade name Latuda) has demonstrated some efficacy in the acute depressive phase of bipolar disorder.
Major depressive disorder
- Risperidone Not approved for MDD
- Ziprasidone — which has only demonstrated adjunctive benefit in an open-label study.
Only aripiprazole, olanzapine, and quetiapine have specifically been approved for MDD by the FDA in the United States. Quetiapine and lurasidone have been approved for bipolar depression, but as of present, lurasidone has not been approved for MDD.
Both risperidone and aripiprazole have received FDA labelling for autism.
Comparison table of efficacy
|Relative efficacy of SGAs|
|Generic Drug Name||Schizophrenia||Mania||Bipolar Maintenance||Bipolar Depression||Adjunct in Major Depressive Disorder|
|Amisulpride||+++||?||?||?||? (+++ as a dysthymia monotherapy, however)|
|Asenapine||++/+||++||++||? (some evidence has suggested efficacy in treating depressive symptoms in mixed/manic episodes)||?|
|Olanzapine||+++||+++||++||++/+ (+++/++ when combined with fluoxetine)||++|
And these are currently under development but are not yet licensed:
The side effects reportedly associated with the various atypical antipsychotics vary and are medication-specific. Generally speaking, atypical antipsychotics are widely believed to have a lower likelihood for the development of tardive dyskinesia than the typical antipsychotics. However, tardive dyskinesia typically develops after long-term (possibly decades) use of antipsychotics. It is not clear, then, if atypical antipsychotics, having been in use for a relatively short time, produce a lower incidence of tardive dyskinesia.
Some of the other side effects that have been suggested is that atypical antipsychotics increase the risk of cardiovascular disease. The research that Kabinoff et al. evaluated found that the increase in cardiovascular disease is seen regardless of the treatment they receive, instead it is caused by many different factors such as lifestyle or diet.
Sexual side effects have also been reported when taking atypical antipsychotics. In males antipsychotics reduce sexual interest, impair sexual performance with the main difficulties being failure to ejaculate. In females there may be abnormal menstrual cycles and infertility. In both males and females the breasts may become enlarged and a fluid will sometimes ooze from the nipples. Sexual adverse effects caused by some anti-psychotics are a result of an increase of prolactin. Sulpiride and Amisulpiride and in less extense Risperdone and paliperidone cause a high increase of prolactin.
In April 2005, the US Food and Drug Administration (FDA) issued an advisory and subsequent black box warning regarding the risks of atypical anti psychotic use among elderly patients with dementia. The FDA advisory was associated with decreases in the use of atypical antipsychotics, especially among elderly patients with dementia. Subsequent research reports confirmed the mortality risks associated with the use of both conventional and atypical antipsychotics to treat patients with dementia. Consequently, in 2008 the FDA issued although a black box warning for classical neuroleptics. Data on treatment efficacies are strongest for atypical antipsychotics. Adverse effects in patients with dementia include an increased risk of mortality and cerebrovascular events, as well as metabolic effects, extrapyramidal symptoms, falls, cognitive worsening, cardiac arrhythmia, and pneumonia. Conventional antipsychotics may pose an even greater safety risk. Moreover, high potential conventional antipsychotics like haloperidol may be associated with the highest risk followed by low potential neuroleptics thereafter risperidone and olanzapine. Quetiapine seemed to have a lower risk. No clear efficacy evidence exists to support the use of alternative psychotropic classes (e.g. antidepressants, anticonvulsants).
All of the atypical antipsychotics warn about the possibility of tardive dyskinesia in their package inserts and in the PDR. It is not possible to truly know the risks of tardive dyskinesia when taking atypicals, because tardive dyskinesia can take many decades to develop and the atypical antipsychotics are not old enough to have been tested over a long enough period of time to determine all of the long-term risks. One hypothesis as to why atypicals have a lower risk of tardive dyskinesia is because they are much less fat-soluble than the typical antipsychotics and because they are readily released from D2 receptor and brain tissue. The typical antipsychotics remain attached to the D2 receptors and accumulate in the brain tissue which may lead to TD.
Recently, metabolic concerns have been of grave concern to clinicians, patients and the FDA. In 2003, the Food and Drug Administration (FDA) required all manufacturers of atypical antipsychotics to change their labeling to include a warning about the risks of hyperglycemia and diabetes with atypical antipsychotics. It must also be pointed out that although all atypicals must carry the warning on their labeling, some evidence shows that atypicals are not equal in their effects on weight and insulin sensitivity. The general consensus is that clozapine and olanzapine are associated with the greatest effects on weight gain and decreased insulin sensitivity, followed by risperidone and quetiapine. Ziprasidone and aripiprazole are thought to have the smallest effects on weight and insulin resistance, but clinical experience with these newer agents is not as developed as that with the older agents. The mechanism of these adverse effects is not completely understood but it is believed to result from a complex interaction between a number of pharmacologic actions of these drugs. Their effects on weight are believed to mostly derive from their actions on the H1 and 5-HT2C receptors, while their effects on insulin sensitivity are believed to be the result of a combination of their effects on body weight (as increased body mass is known to be a risk factor for insulin resistance) and their antagonistic effects on the M3receptor. Some of the newer agents, however, such as risperidone and its metabolite paliperidone, ziprasidone, lurasidone, aripiprazole, asenapine and iloperidone have clinically-insignificant effects on the M3 receptor and appear to carry a lower risk of insulin resistance. Whereas clozapine, olanzapine and quetiapine (indirectly via its active metabolite, norquetiapine) all antagonise the M3 receptor at therapeutic-relevant concentrations.
Recent evidence suggests a role of the α1 adrenoceptor and 5-HT2A receptor in the metabolic effects of atypical antipsychotics. The 5-HT2A receptor, however, is also believed to play a crucial role in the therapeutic advantages of atypical antipsychotics over their predecessors, the typical antipsychotics.
A study by Sernyak and colleagues found that the prevalence of diabetes in atypical antipsychotic treatments was statistically significantly higher than that of conventional treatment. The authors of this study suggest that it is a causal relationship the Kabinoff et al. suggest the findings only suggest a temporal association. Kabinoff et al. suggest that there is insufficient data from large studies to demonstrate a consistent or significant difference in the risk of insulin resistance during treatment with various atypical antipsychotics.
Comparison table of adverse effects
|Comparison of side effects for atypical antipsychotics|
|Generic Name||Weight gain||Metabolic Effects||EPS||High
|Sedation||Hypotension / Orthostasis||QTc prolongation||Anti-ACheffects||Other adverse effects|
|Amisulpride||+||+||+||++||-||-||+++||-||Seizures, suicidal ideation|
|Aripiprazole||0-10%||0-10%||10-20%||-||10-20%||0-10%||-||-||Seizures (0.1-0.3%), anxiety, rhabdomyolysis, pancreatitis (<0.1%), agranulocytosis (<1%), leukopenia, neutropenia, suicidal ideation, angioedema (0.1-1%)|
|Asenapine||0-10%||20%||0-10%||0-10%||10-20%||0-10%||+||-||Immune hypersensitivity reaction, angioedema, suicidal ideation|
|Clozapine||20-30%||0-15%||-||-||>30%||20-30%||+||+++||Seizures (3-5%), agranulocytosis (1.3%), leukopenia, pneumonia, respiratory arrest, angle-closure glaucoma, eosinophilia (1%), thrombocytopenia, Stevens-Johnson syndrome, myocarditis, erythema multiforme and abnormal peristalsis|
|Iloperidone||0-10%||0-10%||0-10%||-||10-20%||0-10%||++||-||Suicidal ideation (0.4-1.1%), syncope (0.4%)|
|Lurasidone||-||-||>30%||-||20-30%||-||+||+||Agranulocytosis, seizures (<1%), elevated serum creatinine (2-4%)|
|Melperone||+||+||+/-||-||+/++||+/++||++||-||Agranulocytosis, neutropenia and leukopenia|
|Olanzapine||20-30%||0-15%||20-30%||20-30%||>30%||0-10%||+||+||Acute haemorrhagic pancreatitis, immune hypersensitivity reaction, seizures (0.9%), status epilepticus, suicidal ideation (0.1-1%)|
|Paliperidone||0-10%||-||10-20%||0-10%||20-30%||0-10%||+/- (7%)||-||Agranulocytosis, leukopenia, priapism, dysphagia|
|Perospirone||?||?||>30%||+||+||+||?||-||Insomnia in up to 23%, CPK elevation neuroleptic malignant syndrome|
|Quetiapine||20-30%||0-15%||10-20%||-||>30%||0-10%||++||+||Agranulocytosis, leukopenia, neutropenia (0.3%), anaphylaxis, seizures (0.05-0.5%), priapism, tardive dyskinesia (0.1-5%), suicidal ideation, pancreatitis, syncope (0.3-1%)|
|Remoxipride||+/-||-||-||-||-||+/-||?||-||There is a risk of aplastic anaemia risk which is what lead to its removal from the market.|
|Risperidone||10-20%||0-10%||20-30%||>30%||>30%||0-10%||+||-||Syncope (1%), pancreatitis, hypothermia, agranulocytosis, leukopenia, neutropenia, thrombocytopenia, thrombotic thrombocytopenic purpura, cerebrovascular incident (<5%), tardive dyskinesia (<5%), priapism, neuroleptic malignant syndrome (<1%), Gynecomastia, Galactorrhea|
|Ziprasidone||0-10%||0-10%||0-10%||-||20-30%||0-10%||++||-||Syncope (0.6%), dysphagia (0.1-2%), bone marrow suppression, seizure (0.4%), priapism|
|Regulatory Status of Second-Generation Antipsychotics (SGAs)|
The atypical antipsychotics integrate with the 5ht2-receptors, norepinephrine and dopamine receptors, have important role of schizophrenia. An activated 5HT2A-receptor upregulates the D2-receptor which can cause paranoia and psychosis in humans. Therefore, many antipsychotics block the 5HT2A-receptor. Blockade of 5HT2A receptor release dopamine in the brain just as with 5HT2C. 5HT2C activated blocks dopamine and inhibit norepinephrine release. Blockade of 5ht2C-receptor increases serotonin, releasing norepinephrine and releases dopamine within the brain. But neuronal reuptake of norepinephrine is limited sharply by some antipsychotics, for example Ziprasidone. Increased norepinephrine can cause increased glucose levels, it will say blood sugar levels. Increased blood sugar level by increased norepinephrine gives hunger in many humans, why weight gain occurs with some antipsychotics if the norepinephrine not is inhibited. The affinity for 5ht2A-receptor is often very very much higher compared to the dopamine D2-receptor in many antipsychotics, by blocking 5ht2A the D2-receptor is downregulated but some gives also extra function by its chemical to block the dopamine D2-receptor which is seen in antipsychotics. The 5ht7-receptor is very potent for mitigation of bipolar conditions and antidepressant effect. Also inhibition of norepinephrine stabilize mood in humans, touching of H1D-receptor have its antidepressant effect to. But the H1-receptors are linked to weight gain. Blockade of 5ht7-receptor can make it hard to sleep. Lurasidone, Risperidone and Abilify is very potent for the 5ht7-receptor. To have partial agonism at 5ht1A-receptor can give absence of weight gain for an antipsychotic, this is very relevant for Ziprasidone, but it gives risk for prolonged QTc intervals. On other hand, blockade of the 5ht3-receptor removes the risk for prolonged QTc but then has its bigger risk for weight gain. Relation to the 5ht3-receptor increases calorie uptake and glucose, this is seen in the Clozapine and Olanzapine. Other ways for dopamine resolving is to have agonism at both D2-receptor and 5ht1A-receptor will normalize the dopamine level in the brain, this occurs with Haldol and Abilify.
Note: Unless otherwise specified, the drugs below serve as antagonists/inverse agonists at the receptors listed.
|Aripiprazole||+||++++ (PA)||+++ (PA)||+ (PA)||+++ (PA)||+||+++||++ (PA)||+||+++ (PA)||++/+||+||-||-||++/+|
|Blonanserin||-||++++||++++||+||-||?||+++||+||+||+/-||+ (RC)||+ (RC)||+||?||-|
|Ziprasidone||+++/++||+++||+++||+++/++||+++ (PA)||+++ (PA)||++++||+++(PA)||++||+++||+++/++||++||-||-||++|
|Zotepine||+++/++||+++||++++/+++||+++||++ (PA)||+++||++++||++++ (RC)||++++||++++/+++||+++||+++/++||++ (RC)||++ (RC)||++++|
|RC||Cloned rat receptor|
Atypical antipsychotics are most commonly administered orally. Antipsychotics can also be injected, but this method is not as common. They are lipid-soluble, are readily absorbed from the digestive tract, and can easily pass the blood–brain barrier and placental barriers. Once in the brain, the antipsychotics work at the synapse by binding to the receptor. Antipsychotics are completely metabolized in the body and the metabolites are excreted in urine. These drugs have relatively long half-lives. Each drug has a different half-life, but the occupancy of the D2 receptor falls off within 24 hours with atypical antipsychotics, while lasting over 24 hours for the typical antipsychotics. This may explain why relapse into psychosis happens quicker with atypical antipsychotics than with typical antipsychotics, as the drug is excreted faster and is no longer working in the brain. Physical dependence with these drugs is very rare. However, if the drug is abruptly discontinued, psychotic symptoms, movement disorders, and sleep difficulty may be observed. It is possible that withdrawal is rarely seen because the AAP are stored in body fat tissues and slowly released.
|Pharmacokinetic parameters of available atypical antipsychotics|
|Drug||Route(s) of Administration[Note 1]||Half-life (t1/2 in hours)||Volume of distribution (Vd in L/kg)||Protein binding||Excretion||Enzymes involved in metabolism||Bioavailability||Peak plasma time (h)||Cmax (ng/mL)|
|Amisulpride||Oral||12||5.8||16%||Urine (50%), faeces (20%; 70% of this is as unchanged drug)[Note 2]||?||48%||Two peaks: 1 hr & 3-4 hrs post-oral dosing||39±3 (1 hr), 54±4 (3-4 hrs)|
|Aripiprazole||Oral, intramuscular (including depot)||75 (94 for active metabolite)||4.9||99%||Faeces (55%), urine (25%)||CYP2D6 & CYP3A4||87% (Oral), 100% (IM)||3-5||?|
|Asenapine||Sublingual||24||20-25||95%||Urine (50%), faeces (40%)||CYP1A2 & UGT1A4||35% (sublingual), <2% (Oral)||0.5-1.5||4|
|Blonanserin||Oral||10.7 (single 4 mg dose), 12 (single 8 mg dose), 16.2 (single 12 mg dose), 67.9 (repeated bid dosing)||?||>99.7%||Urine (59%), faeces (30%)||CYP3A4||84% (Oral)||<2||0.14 (single 4 mg dose), 0.45 (single 8 mg dose), 0.76 (single 12 mg dose), 0.57 (bid dosing)|
|Clozapine||Oral||8 hours (single dosing), 12 (twice daily dosing)||4.67||97%||Urine (50%), faeces (30%)||CYP1A2, CYP3A4, CYP2D6||50-60%||1.5-2.5||102-771|
|Iloperidone||Oral||?||1340-2800||95%||Urine (45-58%), faeces (20-22%)||CYP2D6 & CYP3A4||96%||2-4||?|
|Lurasidone||Oral||18||6173||99%||Faeces (80%), urine (9%)||CYP3A4||9-19%||1-3||?|
|Melperone||Oral, intramuscular||3-4 (Oral), 6 (IM)||7-9.9||50%||Urine (70% as metabolites; 5-10.4% unchanged drug)||?||65% (tablet), 87% (IM), 54% (oral syrup)||0.5-3||75-324 (repeated dosing)|
|Olanzapine||Oral, intramuscular (including depot)||30||1000||93%||Urine (57%), faeces (30%)||CYP1A2, CYP2D6||>60%||6 (Oral)||?|
|Paliperidone||Oral, intramuscular (including depot)||23 (Oral)||390-487||74%||Urine (80%), faeces (11%)||CYP2D6, CYP3A4||28%||24 (Oral)||?|
|Perospirone||Oral||?||?||92%||Urine (0.4% as unchanged drug)||?||?||1.5||1.9-5.7|
|Quetiapine||Oral||6 (IR), 7 (XR)||6-14||83%||Urine (73%), faeces (20%)||CYP3A4||100%||1.5 (IR), 6 (XR)||?|
|Risperidone||Oral, intramuscular (including depot)||3 (EM) (oral), 20 (PM) (oral)||1-2||90%, 77% (metabolite)||Urine (70%), faeces (14%)||CYP2D6||70%||3 (EM), 17 (PM)||?|
|Sertindole||Oral||72 (55-90)||20||99.5%||Urine (4%), faeces (46-56%)||CYP2D6||74%||10||?|
|Ziprasidone||Oral, intramuscular||7 (oral)||1.5||99%||Faeces (66%), urine (20%)||CYP3A4 & CYP1A2||60% (Oral), 100% (IM)||6-8||?|
The first major tranquilizer or antipsychotic medication, chlorpromazine (Thorazine), a typical antipsychotic, was discovered in 1951 and introduced into clinical practice shortly thereafter. Clozapine (Clozaril), an atypical antipsychotic, fell out of favor due to concerns over drug-induced agranulocytosis. Following research indicating its effectiveness in treatment-resistant schizophrenia and the development of an adverse event monitoring system, clozapine re-emerged as a viable antipsychotic. According to Barker (2003), the three most-accepted atypical drugs are clozapine, risperidone, and olanzapine. However, he goes on to explain that clozapine is usually the last resort when other drugs fail. Clozapine can cause agranulocytosis (a decreased number of white blood cells), requiring blood monitoring for the patient. Despite the effectiveness of clozapine for treatment-resistant schizophrenia, agents with a more favorable side-effect profile were sought-after for widespread use. During the 1990s, olanzapine, risperidone, and quetiapine were introduced, with ziprasidone and aripiprazole following in the early 2000s. The atypical anti-psychotic paliperidone was approved by the FDA in late 2006.
The atypical antipsychotics have found favor among clinicians and are now considered to be first-line treatments for schizophrenia and are gradually replacing the typical antipsychotics. In the past, most researchers have agreed that the defining characteristics of atypical antipsychotics are the decreased incidence of extrapyramidal side effects (EPS) and an absence of sustained prolactin elevation.
The terminology can still be imprecise. The definition of "atypicality" was based upon the absence of extrapyramidal side effects, but there is now a clear understanding that atypical antipsychotics can still induce these effects (though to a lesser degree than typical antipsychotics). Recent literature focuses more upon specific pharmacological actions and less upon categorization of an agent as "typical" or "atypical". There is no clear dividing line between the typical and atypical antipsychotics therefore categorization based on the action is difficult.
More recent research is questioning the notion that second-generation antipsychotics are superior to first generation typical anti-psychotics. Using a number of parameters to assess quality of life, Manchester University researchers found that typical antipsychotics were no worse than atypical antipsychotics. The research was funded by the National Health Service (NHS) of the UK. Because each medication (whether first or second generation) has its own profile of desirable and adverse effects, a neuropsychopharmacologist may recommend one of the older ("typical" or first generation) or newer ("atypical" or second generation) antipsychotics alone or in combination with other medications, based on the symptom profile, response pattern, and adverse effects history of the individual patient.
- The route of administration in this category refers to the standard means of administration when the drug is being used in its capacity as an atypical antipsychotic, not for other purposes. For example, amisulpride can be administered intravenously as an antiemetic drug but this is not its standard route of administration when being used as an antipsychotic
- Note these values are from a study in of which amisulpride was intravenously administered
- Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM (January 2009). "Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis". Lancet. 373 (9657): 31–41. doi:10.1016/S0140-6736(08)61764-X. PMID 19058842.
- Leucht S, Cipriani A, Spineli L, et al. (September 2013). "Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis". Lancet. 382 (9896): 951–62. doi:10.1016/S0140-6736(13)60733-3. PMID 23810019.
- "A roadmap to key pharmacologic principles in using antipsychotics". Primary care companion to the Journal of clinical psychiatry. 9 (6): 444–54. 2007. doi:10.4088/PCC.v09n0607. PMC . PMID 18185824.
- Leucht, Stefan; Corves, Caroline; Arbter, Dieter; Engel, Rolf R; Li, Chunbo; Davis, John M (2009). "Second-generation versus first-generation antipsychotic drugs for schizophrenia: A meta-analysis". The Lancet. 373 (9657): 31–41. doi:10.1016/S0140-6736(08)61764-X. PMID 19058842.
- Tyrer, Peter; Kendall, Tim (2009). "The spurious advance of antipsychotic drug therapy". The Lancet. 373 (9657): 4–5. doi:10.1016/S0140-6736(08)61765-1. PMID 19058841.
- "Respiridone". The American Society of Health-System Pharmacists. Retrieved April 3, 2011.
- Maher, Alicia Ruelaz; Maglione, M; Bagley, S; Suttorp, M; Hu, JH; Ewing, B; Wang, Z; Timmer, M; Sultzer, D; Shekelle, PG (2011). "Efficacy and Comparative Effectiveness of Atypical Antipsychotic Medications for Off-Label Uses in Adults - A Systematic Review and Meta-analysis". JAMA. 306 (12): 1359–69. doi:10.1001/jama.2011.1360. PMID 21954480.
- American Geriatrics Society 2012 Beers Criteria Update Expert Panel (2012). "American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults". Journal of the American Geriatrics Society. 60 (4): 616–31. doi:10.1111/j.1532-5415.2012.03923.x. PMC . PMID 22376048.
- National Collaborating Centre for Mental Health. Gaskell and the British Psychological Society. Schizophrenia: Full national clinical guideline on core interventions in primary and secondary care [PDF]; 2009-03-25 [Retrieved 2009-11-25].
- Smith, T; Weston, C; Lieberman, J (2010). "Schizophrenia (maintenance treatment)". American Family Physician. 82 (4): 338–9. PMID 20704164.
- Tandon, Rajiv; Keshavan, Matcheri S.; Nasrallah, Henry A. (2008). "Schizophrenia, "Just the Facts": What we know in 2008". Schizophrenia Research. 100 (1–3): 4–19. doi:10.1016/j.schres.2008.01.022. PMID 18291627.
- van Os, Jim; Kapur, Shitij (2009). "Schizophrenia". The Lancet. 374 (9690): 635–45. doi:10.1016/S0140-6736(09)60995-8. PMID 19700006.
- Kane, JM; Correll, CU (2010). "Pharmacologic treatment of schizophrenia". Dialogues in Clinical Neuroscience. 12 (3): 345–57. PMC . PMID 20954430.
- Schultz, SH; North, SW; Shields, CG (2007). "Schizophrenia: A review". American Family Physician. 75 (12): 1821–9. PMID 17619525.
- Picchioni, M. M; Murray, R. M (2007). "Schizophrenia". BMJ. 335 (7610): 91–5. doi:10.1136/bmj.39227.616447.BE. PMC . PMID 17626963.
- Essali A, Al-Haj Haasan N, Li C, Rathbone J (2009). "Clozapine versus typical neuroleptic medication for schizophrenia". The Cochrane Database of Systematic Reviews (1): CD000059. doi:10.1002/14651858.CD000059.pub2. PMID 19160174.
- Alexander, G. C.; Gallagher, S. A.; Mascola, A.; Moloney, R. M.; Stafford, R. S. (2011). "Increasing off-label use of antipsychotic medications in the United States, 1995-2008". Pharmacoepidemiology and Drug Safety. 20 (2): 177–84. doi:10.1002/pds.2082. PMC . PMID 21254289.
- Geddes, J.; Freemantle, N.; Harrison, P.; Bebbington, P. (2000). "Atypical antipsychotics in the treatment of schizophrenia: Systematic overview and meta-regression analysis". BMJ. 321 (7273): 1371–6. doi:10.1136/bmj.321.7273.1371. PMC . PMID 11099280.
- Lieberman, Jeffrey A.; Stroup, T. Scott; McEvoy, Joseph P.; Swartz, Marvin S.; Rosenheck, Robert A.; Perkins, Diana O.; Keefe, Richard S.E.; Davis, Sonia M.; Davis, Clarence E.; Lebowitz, Barry D.; Severe, Joanne; Hsiao, John K.; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators (2005). "Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia". New England Journal of Medicine. 353 (12): 1209–23. doi:10.1056/NEJMoa051688. PMID 16172203.
- Stroup, T.; Lieberman, JA; McEvoy, JP; Swartz, MS; Davis, SM; Rosenheck, RA; Perkins, DO; Keefe, RS; Davis, CE; Severe, J; Hsiao, JK; Catie, Investigators (2006). "Effectiveness of Olanzapine, Quetiapine, Risperidone, and Ziprasidone in Patients with Chronic Schizophrenia Following Discontinuation of a Previous Atypical Antipsychotic". American Journal of Psychiatry. 163 (4): 611–22. doi:10.1176/appi.ajp.163.4.611. PMID 16585435.
- Voruganti, Lakshmi P; Baker, Laura K; Awad, A George (2008). "New generation antipsychotic drugs and compliance behaviour". Current Opinion in Psychiatry. 21 (2): 133–9. doi:10.1097/YCO.0b013e3282f52851. PMID 18332660.
- Paczynski, Richard P.; Alexander, G. Caleb; Chinchilli, Vernon M.; Kruszewski, Stefan P. (2012). "Quality of evidence in drug compendia supporting off-label use of typical and atypical antipsychotic medications". The International Journal of Risk and Safety in Medicine. 24 (3): 137–46. doi:10.3233/JRS-2012-0567 (inactive 2017-01-31). PMID 22936056.
- Owens, D. C. (2008). "How CATIE brought us back to Kansas: A critical re-evaluation of the concept of atypical antipsychotics and their place in the treatment of schizophrenia". Advances in Psychiatric Treatment. 14: 17–28. doi:10.1192/apt.bp.107.003970.
- Fischer-Barnicol, David; Lanquillon, Stefan; Haen, Ekkehard; Zofel, Peter; Koch, Horst J.; Dose, Matthias; Klein, Helmfried E.; Working Group 'Drugs in Psychiatry' (2008). "Typical and Atypical Antipsychotics – the Misleading Dichotomy". Neuropsychobiology. 57 (1–2): 80–7. doi:10.1159/000135641. PMID 18515977.
- Robert Whitaker (2010). Anatomy of an Epidemic. Crown. p. 303.
- Taylor, D; Paton, C; Kapur, S (2012). The Maudsley Prescribing Guidelines (12th ed.). Informa Healthcare. pp. 12–152, 173–196, 222–235.
- Soreff, S; McInnes, LA; Ahmed, I; Talavera, F (5 August 2013). "Bipolar Affective Disorder Treatment & Management". Medscape Reference. WebMD. Retrieved 10 October 2013.
- Post, RM; Keck, P (30 July 2013). "Bipolar Disorder in adults: Maintenance treatment". UpToDate®. Wolters Kluwer Health. Retrieved 10 October 2013.
- Komossa K, Depping AM, Gaudchau A, Kissling W, Leucht S (2010). "Second-generation antipsychotics for major depressive disorder and dysthymia". The Cochrane Database of Systematic Reviews (12): CD008121. doi:10.1002/14651858.CD008121.pub2. PMID 21154393.
- Spielmans GI, Berman MI, Linardatos E, Rosenlicht NZ, Perry A, Tsai AC (2013). "Adjunctive atypical antipsychotic treatment for major depressive disorder: a meta-analysis of depression, quality of life, and safety outcomes". PLoS Medicine. 10 (3): e1001403. doi:10.1371/journal.pmed.1001403. PMC . PMID 23554581.
- Nelson, JC; Papakostas, GI (September 2009). "Atypical Antipsychotic Augmentation in Major Depressive Disorder: A Meta-Analysis of Placebo-Controlled Randomized Trials". The American Journal of Psychiatry. 166 (9): 980–991. doi:10.1176/appi.ajp.2009.09030312. PMID 19687129.
- Dunner, DL; Amsterdam, JD; Shelton, RC; Loebel, A; Romano, SJ (July 2007). "Efficacy and tolerability of adjunctive ziprasidone in treatment-resistant depression: a randomized, open-label, pilot study". The Journal of Clinical Psychiatry. 68 (7): 1071–1077. doi:10.4088/jcp.v68n0714. PMID 17685744.
- Maneeton N, Maneeton B, Srisurapanont M, Martin SD (2012). "Quetiapine monotherapy in acute phase for major depressive disorder: a meta-analysis of randomized, placebo-controlled trials". BMC Psychiatry. 12: 160. doi:10.1186/1471-244X-12-160. PMC . PMID 23017200.
- Truven Health Analytics, Inc. DRUGDEX® System (Internet) [cited 2013 Oct 10]. Greenwood Village, CO: Thomsen Healthcare; 2013.
- Rothschild, AJ; Williamson, DJ; Tohen, MF; Schatzberg, A; Andersen, SW; Van Campen, LE; Sanger, TM; Tollefson, GD (August 2004). "A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features". Journal of Clinical Psychopharmacology. 24 (4): 365–373. doi:10.1097/01.jcp.0000130557.08996.7a. PMID 15232326.
- Roberts RJ, Lohano KK, El-Mallakh RS (2016). "Antipsychotics as antidepressants". Asia-Pacific Psychiatry. 8 (3): 179–88. doi:10.1111/appy.12186. PMID 25963405.
- Cipriani, A; Barbui, C; Salanti, G; Rendell, J; Brown, R; Stockton, S; Purgato, M; Spineli, LM; Goodwin, GM; Geddes, JR (October 2011). "Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis". Lancet. 378 (9799): 1306–1315. doi:10.1016/S0140-6736(11)60873-8. PMID 21851976.
- Leucht, Stefan; Cipriani, Andrea; Spineli, Loukia; Mavridis, Dimitris; Örey, Deniz; Richter, Franziska; Samara, Myrto; Barbui, Corrado; Engel, Rolf R; Geddes, John R; Kissling, Werner; Stapf, Marko Paul; Lässig, Bettina; Salanti, Georgia; Davis, John M (2013). "Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: A multiple-treatments meta-analysis". The Lancet. 382 (9896): 951–62. doi:10.1016/S0140-6736(13)60733-3. PMID 23810019.
- Szegedi, A; Zhao, J; van Willigenburg, A; Nations, KR; Mackle, M; Panagides, J (June 2011). "Effects of asenapine on depressive symptoms in patients with bipolar I disorder experiencing acute manic or mixed episodes: a post hoc analysis of two 3-week clinical trials" (PDF). BMC Psychiatry. 11: 101. doi:10.1186/1471-244X-11-101. PMC . PMID 21689438.
- Tohen, M; Katagiri, H; Fujikoshi, S; Kanba, S (July 2013). "Efficacy of olanzapine monotherapy in acute bipolar depression: a pooled analysis of controlled studies". Journal of Affective Disorder. 149 (1–3): 196–201. doi:10.1016/j.jad.2013.01.022. PMID 23485111.
- Kishi, T; Iwata, N (September 2013). "Efﬁcacy and Tolerability of Perospirone in Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials". CNS Drugs. 27 (9): 731–741. doi:10.1007/s40263-013-0085-7. PMID 23812802.
- Young AH, Calabrese JR, Gustafsson U, Berk M, McElroy SL, Thase ME, Suppes T, Earley W (2013). "Quetiapine monotherapy in bipolar II depression: combined data from four large, randomized studies". International Journal of Bipolar Disorders. 1: 10. doi:10.1186/2194-7511-1-10. PMC . PMID 25505677.
- Stroup, TS; Marder, S; Stein, MB (23 October 2013). "Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment". UpToDate®. Wolters Kluwer. Retrieved 10 October 2013.
- Kabinoff, GS; Toalson, PA; Masur Healey, KM; McGuire, HC; Hay, DP (2003). "Metabolic Issues with Atypical Antipsychotics in Primary Care: Dispelling the Myths". Primary Care Companion to the Journal of Clinical Psychiatry. 5 (1): 6–14. doi:10.4088/PCC.v05n0103. PMC . PMID 15156241.
- Uçok, A; Gaebel, W (2008). "Side effects of atypical antipsychotics: A brief overview". World Psychiatry. 7 (1): 58–62. doi:10.1002/j.2051-5545.2008.tb00154.x. PMC . PMID 18458771.
- McKim, W. (2007). Antipsychotics in Drugs and Behavior: An Introduction to Behavioral Pharmacology. Upper Saddle River, NJ.: Pearson Prentice Hall. pp. 241–60.
- McKim, W. (2007). Psychomotor Stimulants in Drugs and Behavior: An Introduction to Behavioral Pharmacology. Upper Saddle River, NJ.: Pearson Prentice Hall. pp. 241–60.
- Dorsey, E. Ray; Rabbani, A; Gallagher, SA; Conti, RM; Alexander, GC (2010). "Impact of FDA Black Box Advisory on Antipsychotic Medication Use". Archives of Internal Medicine. 170 (1): 96–103. doi:10.1001/archinternmed.2009.456. PMID 20065205.
- Seeman, P (2002). "Atypical antipsychotics: mechanism of action". Canadian Journal of Psychiatry. 47 (1): 27–38. PMID 11873706.
- Correll, Christoph U; Schenk, Eva M (2008). "Tardive dyskinesia and new antipsychotics". Current Opinion in Psychiatry. 21 (2): 151–6. doi:10.1097/YCO.0b013e3282f53132. PMID 18332662.
- American Diabetes, Association; American Psychiatric, Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity (2004). "Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes". Diabetes Care. 27 (2): 596–601. doi:10.2337/diacare.27.2.596. PMID 14747245.
- Brunton, L; Chabner, B; Knollman, B (2010). Goodman and Gilman's The Pharmacological Basis of Therapeutics (12th ed.). McGraw Hill Professional. pp. 417–455.
- Guenette, MD; Giacca, A; Hahn, M; Teo, C; Lam, L; Chintoh, A; Arenovich, T; Remington, G (May 2013). "Atypical antipsychotics and effects of adrenergic and serotonergic receptor binding on insulin secretion in-vivo: An animal model". Schizophrenia Research. 146 (1–3): 162–169. doi:10.1016/j.schres.2013.02.023. PMID 23499243.
- "Comparison of Common Side Effects of Second Generation Atypical Antipsychotics". Facts & Comparisons. Wolters Kluwer Health. Retrieved 2012-03-31.
- Onrust, Susan V.; McClellan, Karen (2001). "Perospirone". CNS Drugs. 15 (4): 329–37; discussion 338. doi:10.2165/00023210-200115040-00006. PMID 11463136.
- Holm, AC; Edsman, I; Lundberg, T; Odlind, B (June 1993). "Tolerability of remoxipride in the long term treatment of schizophrenia. An overview". Drug Safety. 8 (6): 445–456. doi:10.2165/00002018-199308060-00005. PMID 8329149.
- "Risperdal, gynecomastia and galactorrhea in adolescent males". Allnurses.com. Retrieved 2016-09-30.
- Stephen M. Stahl (2008-03-27). Antipsychotics and Mood Stabilizers: Stahl's Essential Psychopharmacology .. Books.google.se. p. 105. ISBN 9780521886642. Retrieved 2016-09-30.
- Egerton A, Ahmad R, Hirani E, Grasby PM (2008). "Modulation of striatal dopamine release by 5-HT2A and 5-HT2C receptor antagonists: [11C]raclopride PET studies in the rat". Psychopharmacology. 200 (4): 487–96. doi:10.1007/s00213-008-1226-4. PMID 18597077.
- "Mirtazapine" (PDF). Universitypsychiatry.com. p. 563. Retrieved 2016-09-30.
- "norepinephrine". Cardiosmart.org. 2010-12-15. Retrieved 2016-09-30.
- Veves, Aristidis; Malik, Rayaz A (2008-02-01). Diabetic Neuropathy: Clinical Management. Books.google.se. p. 401. ISBN 9781597453110. Retrieved 2016-09-30.
- "Epinephrine and Norepinephrine". Boundless.com. Retrieved 2016-09-30.
- "Cariprazine - Side Effects, Uses, Dosage, Overdose, Pregnancy, Alcohol". RxWiki.com. Retrieved 2016-09-30.
- "INVEGA® Side Effects - Schizophrenia Treatment – INVEGA® (paliperidone)". Invega.com. 2016-05-17. Retrieved 2016-09-30.
- "Diabetes Update: Hunger is a Symptom". Diabetesupdate.blogspot.se. 2007-08-08. Retrieved 2016-09-30.
- "High & Low Blood Sugar". Healthvermont.gov. Retrieved 2016-09-30.
- "REXULTI® (brexpiprazole) | Important Safety Information". Rexulti.com. Retrieved 2016-09-30.
- Stephen M. Stahl (2008-03-27). Antipsychotics and Mood Stabilizers: Stahl's Essential Psychopharmacology .. Books.google.se. p. 172. ISBN 9780521886642. Retrieved 2016-09-30.
- Margaret Jordan Halter (2014-03-12). Varcarolis' Foundations of Psychiatric Mental Health Nursing: A Clinical .. Books.google.se. p. 61. ISBN 9781455728886. Retrieved 2016-09-30.
- "Pharmcology Reviews : 200603" (PDF). Accessdata.fda.gov. Retrieved 2016-09-30.
- Ishibashi T, Horisawa T, Tokuda K, Ishiyama T, Ogasa M, Tagashira R, Matsumoto K, Nishikawa H, Ueda Y, Toma S, Oki H, Tanno N, Saji I, Ito A, Ohno Y, Nakamura M (2010). "Pharmacological profile of lurasidone, a novel antipsychotic agent with potent 5-hydroxytryptamine 7 (5-HT7) and 5-HT1A receptor activity". The Journal of Pharmacology and Experimental Therapeutics. 334 (1): 171–81. doi:10.1124/jpet.110.167346. PMID 20404009.
- Hugh C. Hemmings; Talmage D. Egan (2013). Pharmacology and Physiology for Anesthesia: Foundations and Clinical .. Books.google.se. p. 209. ISBN 1437716792. Retrieved 2016-09-30.
- "FDA : Psychopharmacological Drugs Advisory Committee : Briefing Document for ZELDOX CAPSULES (Ziprasidone HCl)" (PDF). Fda.gov. July 19, 2000. Retrieved 2016-09-30.
- Wouters W, Tulp MT, Bevan P (1988). "Flesinoxan lowers blood pressure and heart rate in cats via 5-HT1A receptors". European Journal of Pharmacology. 149 (3): 213–23. doi:10.1016/0014-2999(88)90651-6. PMID 2842163.
- Horiuchi J, McDowall LM, Dampney RA (2008). "Role of 5-HT(1A) receptors in the lower brainstem on the cardiovascular response to dorsomedial hypothalamus activation". Autonomic Neuroscience. 142 (1–2): 71–6. doi:10.1016/j.autneu.2008.06.004. PMID 18667366.
- Weber S, Volynets V, Kanuri G, Bergheim I, Bischoff SC (2009). "Treatment with the 5-HT3 antagonist tropisetron modulates glucose-induced obesity in mice". International Journal of Obesity (2005). 33 (12): 1339–47. doi:10.1038/ijo.2009.191. PMID 19823183.
- Gobbi G, Janiri L (1999). "Clozapine blocks dopamine, 5-HT2 and 5-HT3 responses in the medial prefrontal cortex: an in vivo microiontophoretic study". European Neuropsychopharmacology. 10 (1): 43–9. doi:10.1016/S0924-977X(99)00055-3. PMID 10647096.
- Navari RM (2014). "Olanzapine for the prevention and treatment of chronic nausea and chemotherapy-induced nausea and vomiting". European Journal of Pharmacology. 722: 180–6. doi:10.1016/j.ejphar.2013.08.048. PMID 24157985.
- Roth, BL; Driscol, J. "PDSP Ki Database". Psychoactive Drug Screening Program (PDSP). University of North Carolina. Archived from the original on November 8, 2013. Retrieved 10 October 2013.
- Culpepper, 2007[verification needed]
- McKim, 2007[verification needed]
- "Medscape Multispecialty – Home page". WebMD. Retrieved 27 November 2013.[full citation needed]
- "Therapeutic Goods Administration – Home page". Department of Health (Australia). Retrieved 27 November 2013.[full citation needed]
- "Daily Med – Home page". U.S. National Library of Medicine. Retrieved 27 November 2013.[full citation needed]
- Deeks, ED; Keating, GM (January 2010). "Blonanserin A Review of its Use in the Management of Schizophrenia". CNS Drugs. 24 (1): 65–84. doi:10.2165/11202620-000000000-00000. PMID 20030420.
- Product Information: Eunerpan(R), Melperonhydrochlorid. Knoll Deutschland GmbH, Ludwigshafen, 1995.
- Borgström, L; Larsson, H; Molander, L (1982). "Pharmacokinetics of parenteral and oral melperone in man". European Journal of Clinical Pharmacology. 23 (2): 173–176. doi:10.1007/BF00545974. PMID 7140807.
- Onrust SV, McClellan K (2001). "Perospirone". CNS Drugs. 15 (4): 329–37; discussion 338. doi:10.2165/00023210-200115040-00006. PMID 11463136.
- Product Information: Nipolept(R), zotepine. Klinge Pharma GmbH, Munich, 1996.
- Tanaka, O; Kondo, T; Otani, K; Yasui, N; Tokinaga, N; Kaneko, S (February 1998). "Single oral dose kinetics of zotepine and its relationship to prolactin response and side effects". Therapeutic Drug Monitoring. 20 (1): 117–119. doi:10.1097/00007691-199802000-00021. PMID 9485566.
- Farah, Andrew (2005). "Atypicality of Atypical Antipsychotics". The Primary Care Companion to the Journal of Clinical Psychiatry. 7 (6): 268–74. doi:10.4088/PCC.v07n0602. PMC . PMID 16498489.
- Weiden, Peter J. (2007). "EPS Profiles: The Atypical Antipsychotics". Journal of Psychiatric Practice. 13 (1): 13–24. doi:10.1097/00131746-200701000-00003. PMID 17242588.
- Jones, Peter B.; Barnes, TR; Davies, L; Dunn, G; Lloyd, H; Hayhurst, KP; Murray, RM; Markwick, A; Lewis, SW (2006). "Randomized Controlled Trial of the Effect on Quality of Life of Second- vs First-Generation Antipsychotic Drugs in Schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1)". Archives of General Psychiatry. 63 (10): 1079–87. doi:10.1001/archpsyc.63.10.1079. PMID 17015810.
- New antipsychotic drugs carry risks for children (USA Today 2006)
- Simpson, GM (2005). "Atypical antipsychotics and the burden of disease". The American Journal of Managed Care. 11 (8 Suppl): S235–41. PMID 16180961.
- "NIMH Study to Guide Treatment Choices for Schizophrenia" (Press release). National Institute of Mental Health. September 19, 2005. Archived from the original on September 2, 2013. Retrieved August 18, 2013.
- Elmorsy E, Smith PA (2015). "Bioenergetic disruption of human micro-vascular endothelial cells by antipsychotics". Biochemical and Biophysical Research Communications. 460 (3): 857–62. doi:10.1016/j.bbrc.2015.03.122. PMID 25824037.