Sohn M, Moga DC, Blumenschein K, Talbert J. National trends in off-label use of atypical antipsychotics in children and adolescents in the United States. Medicine (Baltimore). 2016 Jun. 95 (23):e3784. [QxMD MEDLINE Link]. [Full Text].
Haddad PM, Dursun SM. Neurological complications of psychiatric drugs: clinical features and management. Hum Psychopharmacol. 2008 Jan. 23 Suppl 1:15-26. [QxMD MEDLINE Link].
Jeon SW, Kim YK. Unresolved Issues for Utilization of Atypical Antipsychotics in Schizophrenia: Antipsychotic Polypharmacy and Metabolic Syndrome. Int J Mol Sci. 2017 Oct 18. 18 (10):[QxMD MEDLINE Link]. [Full Text].
Levine M, Ruha AM. Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management. CNS Drugs. 2012 Jul 1. 26(7):601-11. [QxMD MEDLINE Link].
Park Y, Bateman BT, Kim DH, Hernandez-Diaz S, Patorno E, Glynn RJ, et al. Use of haloperidol versus atypical antipsychotics and risk of in-hospital death in patients with acute myocardial infarction: cohort study. BMJ. 2018 Mar 28. 360:k1218. [QxMD MEDLINE Link]. [Full Text].
Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Bronstein AC, Rivers LJ, et al. 2020 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021 Dec. 59 (12):1282-1501. [QxMD MEDLINE Link]. [Full Text].
Huybrechts KF, Gerhard T, Crystal S, Olfson M, Avorn J, Levin R, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012 Feb 23. 344:e977. [QxMD MEDLINE Link]. [Full Text].
Laugharne J, Waterreus AJ, Castle DJ, Dragovic M. Screening for the metabolic syndrome in Australia: a national survey of psychiatrists' attitudes and reported practice in patients prescribed antipsychotic drugs. Australas Psychiatry. 2015 Dec 3. [QxMD MEDLINE Link].
Berling I, Isbister GK. Prolonged QT Risk Assessment in Antipsychotic Overdose Using the QT Nomogram. Ann Emerg Med. 2015 Aug. 66 (2):154-64. [QxMD MEDLINE Link].
Collins A, Davies D, Menon S. Atypical neuroleptic malignant syndrome. BMJ Case Rep. 2016 Jun 13. 2016:[QxMD MEDLINE Link]. [Full Text].
Mizumura N, Uematsu M, Ito A, Okumura S, Maehira H, Ogawa M, et al. "Brief" Aripiprazole-induced Neuroleptic Malignant Syndrome with Symptoms that Only Lasted a Few Hours. Intern Med. 2017 Nov 15. 56 (22):3089-3092. [QxMD MEDLINE Link]. [Full Text].
American Psychiatric Association. Medication-Induced Movement Disorders and other Adverse Effects of Medication. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th Edition. Washington, DC: American Psychiatric Publishing; 2013. 709-714.
Drotts DL, Vinson DR. Prochlorperazine induces akathisia in emergency patients. Ann Emerg Med. 1999 Oct. 34(4 Pt 1):469-75. [QxMD MEDLINE Link].
Dilsaver SC, Alessi NE. Antipsychotic withdrawal symptoms: phenomenology and pathophysiology. Acta Psychiatr Scand. 1988 Mar. 77(3):241-6. [QxMD MEDLINE Link].
DE Hert M, Schreurs V, Vancampfort D, VAN Winkel R. Metabolic syndrome in people with schizophrenia: a review. World Psychiatry. 2009 Feb. 8(1):15-22. [QxMD MEDLINE Link]. [Full Text].
Shirzadi AA, Ghaemi SN. Side effects of atypical antipsychotics: extrapyramidal symptoms and the metabolic syndrome. Harv Rev Psychiatry. 2006 May-Jun. 14(3):152-64. [QxMD MEDLINE Link].
McKnight RF, Adida M, Budge K, Stockton S, Goodwin GM, Geddes JR. Lithium toxicity profile: a systematic review and meta-analysis. Lancet. 2012 Feb 25. 379(9817):721-8. [QxMD MEDLINE Link].
Krause T, Gerbershagen MU, Fiege M, et al. Dantrolene--a review of its pharmacology, therapeutic use and new developments. Anaesthesia. 2004 Apr. 59(4):364-73. [QxMD MEDLINE Link].
Reulbach U, Dutsch C, Biermann T, Sperling W, Thuerauf N, Kornhuber J, et al. Managing an effective treatment for neuroleptic malignant syndrome. Crit Care. 2007. 11(1):R4. [QxMD MEDLINE Link].
Borg L, Julkunen A, Rørbaek Madsen K, Strøm T, Toft P. Antidepressant or Antipsychotic Overdose in the Intensive Care Unit - Identification of Patients at Risk. Basic Clin Pharmacol Toxicol. 2016 Jul. 119 (1):110-4. [QxMD MEDLINE Link].

Table 1. FDA-approved typical antipsychotic medications

Drug	Indication
Droperidol (Dridol)	Agitation
Haloperidol (Haldol)	Schizophrenia Tourette syndrome Hyperactivity Severe childhood behavioral disorders
Loxapine (Loxitane)	Schizophrenia
Pimozide	Tourette syndrome
Thiothixene (Navane)	Schizophrenia
Fluphenazine (Prolixin)	Psychotic disorders
Perphenazine (Trilafon)	Schizophrenia
Thioridazine (Mellaril)	Schizophrenia
Trifluoperazine (Stelazine)	Schizophrenia Generalized nonpsychotic anxiety
Chlorpromazine (Thorazine)	Schizophrenia
Prochlorperazine (Compro)	Schizophrenia Generalized nonpsychotic anxiety

Table 2. FDA-approved atypical antipsychotic medications

Drug	Indications
Clozapine (Clozaril )	Treatment-resistant schizophrenia Reduce the risk of suicidal behavior in younger patients with schizophrenia
Olanzapine (Zyprexa)	Schizophrenia Bipolar disorder Treatment resistant depression
Quetiapine (Seroquel)	Schizophrenia Bipolar disorder Adjunctive therapy for major depressive disorder
Ziprasidone (Geodon)	Schizophrenia Bipolar disorder
Aripiprazole (Abilify)	Schizophrenia Bipolar disorder (manic/mixed) monotherapy or adjunctive to lithium or valproate Adjunctive treatment of major depressive disorder Irritability associated with autistic disorder Acute treatment of agitation
Paliperidone (Invega)	Schizophrenia Schizoaffective disorder
Risperidone (Risperdal)	Schizophrenia Bipolar disorder Irritability associated with autistic disorder
Asenapine (Saphris)	Acute schizophrenia Bipolar disorder type 1 (manic/mixed)
Iloperidone (Fanapt)	Acute schizophrenia

Table 3. Receptor Affinity (Antagonism) of Atypical Antipsychotics ^[4]

Drug	Dopamine D2	Serotonin 5-HT 2A	Muscarinic M1	Histamine H1	Alpha Adrenergic A-1
Aripiprazole	3+	3+	0	2+	2+
Clozapine	2+	3+	3+	3+	3+
Olanzapine	2+	3+	3+	2+	2+
Paliperidone	3+	3+	0	2+	3+
Quetiapine	1+	1+	3+	3+	3+
Risperidone	3+	3+	0	0	2+
Ziprasidone	3+	3+	0	0	3+
0 is no-to-minimal risk; 1+ is low risk; 2+ is moderate risk; 3+ is high risk.

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Author

Jay T Melton, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine and Medical Toxicology, Excela Health System

Fred Harchelroad, MD, FACMT, FAAEM, FACEP is a member of the following medical societies: American College of Medical Toxicology

Disclosure: Nothing to disclose.

Chief Editor

Michael A Miller, MD Clinical Professor of Emergency Medicine, Medical Toxicologist, Department of Emergency Medicine, Texas A&M Health Sciences Center; CHRISTUS Spohn Emergency Medicine Residency Program

Michael A Miller, MD is a member of the following medical societies: American College of Medical Toxicology

Disclosure: Nothing to disclose.

Additional Contributors

Peter MC DeBlieux, MD Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Kathryn Ruth Challoner, MD, MPH, FACEP Clinical Professor of Emergency Medicine, Department of Emergency Medicine, Keck School of Medicine of the University of Southern California

Kathryn Ruth Challoner, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Edward J Newton, MD, FACEP, FRCPC Professor of Clinical Emergency Medicine, Chairman, Department of Emergency Medicine, University of Southern California Keck School of Medicine

Edward J Newton, MD, FACEP, FRCPC is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Royal College of Physicians and Surgeons of Canada, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.