Expanding the Possibilities of Antipsychotics: An Interview with Dr. Josephine McNary

Antipsychotics were originally developed in the 1950s to treat symptoms of psychosis associated with schizophrenia, bipolar disorder, and psychotic depression. However, psychiatrists soon discovered that the potential for relief extended far beyond psychosis. “Over the years we have noticed that these medications are helpful for many other things, including anxiety, bipolar disorder, and depression,” she tells me. The therapeutic value of antipsychotics in the treatment of a range of mental health disorders makes them extraordinarily flexible drugs that allow for the creation of tailored medication strategies either alone or in combination with other medications.

Antipsychotics also have an indication for bipolar disorder, which means they’re mood stabilizers. Bipolar disorder is a spectrum disorder, meaning there are different levels of severity. In certain patients, antipsychotics are a first line treatment for bipolar disorder. In more severe cases, antipsychotics are often used in conjunction with more traditional mood stabilizers, like Lithium or Depakote.

Meanwhile, atypical antipsychotics also offer hope for people with depression who have been unable to find relief from standard antidepressants alone.

Atypical antipsychotics can be used to treat people who have treatment-resistant depression as a way to augment the effect of their antidepressant. It’s usually used in addition to the antidepressant that they are taking. In many cases, adding these medications helps improve depressive symptoms.

Part of what makes antipsychotics so versatile is the ability to produce different effects depending on the specific dose administered. The same medication may produce powerful antipsychotic effects at a high dose or mild anti-anxiety treatment at a low dose, allowing them to be used across a wide spectrum of psychiatric illnesses.

While often extraordinarily effective, older antipsychotics like Risperdal, Zyprexa, and Seroquel sometimes also came with undesirable side effects that interfered with tolerability and patient adherence. The introduction of newer medications provides new possibilities for minimizing side effects while still providing relief from symptoms, giving both psychiatrists and clients more options when it comes to balancing efficacy and tolerability.

Newer antipsychotics, like Latuda and Ability, are effective antipsychotics, but are known to not cause as many burdensome side effects as we used to see with more classic antipsychotics.

These new drugs can allow someone who expresses heightened concern about weight gain or sedation to experience the benefits of antipsychotic treatment while avoiding disruptive somatic and cognitive effects. However, in some cases, psychiatrists can use the side effects of older medications to their advantage.

Sometimes it’s actually better to use the older medications because the sedating qualities tend to be more helpful for things like anxiety. If I have a patient who’s incredibly anxious, not sleeping well at all, in a manic episode, I would probably choose a more sedating antipsychotic like Zyprexa or Risperdal. The trick is to use as low of a dose as possible, as most side effects are dose-dependent.

Residential treatment facilities can offer an ideal setting for creating antipsychotic treatment strategies. Within a supportive environment with 24-hour care, medications can be introduced more aggressively and tailored in response to both therapeutic benefit and side effects.

We’re able to keep a much closer eye on the patient. Because they’re under constant supervision and constantly surrounded by staff, information can be passed back to the clinical team as a way to be able to more aggressively treat symptoms in a way that allows you to be at a more optimal dose. It’s a better way to optimize your dosing of a medication. It enables a higher success rate on medications if you’re monitored more carefully.

By giving clinicians and patients the opportunity to work together intensively for 4 weeks or more, a residential setting like Bridges to Recovery allows for monitoring of both initial responses and effects over time to gain a complete picture of therapeutic value and tolerability.

Increasing public awareness of psychotropic medications has gone a long way toward removing the stigma associated with certain classes of drugs. In particular, antidepressants and anti-anxiety medications such as SSRIs, SNRIs, and benzodiazepines now enjoy widespread acceptance. However, the stigma of antipsychotics has been slower to dissipate, and despite the immense therapeutic benefits made possible by these drugs, many clients who would benefit remain wary due to their association with schizophrenia. Dr. McNary believes that educating clients about the history and variety of dosage-specific uses of antipsychotics can alleviate misconceptions and increase acceptance.

It all comes down to what tools we have to most effectively treat people. When people are in distress and have tried other things, and it turns out that they haven’t tried atypical antipsychotics, it really makes sense to allow that person that opportunity if they’re really struggling. A lot of the time it can be the one thing that really makes a big difference for them.

Many people have already heard about newer atypicals like Latuda and Abilify in advertisements for treatment of non-psychotic illnesses, potentially reframing associations and showing antipsychotics in a new light. With the support of compassionate clinicians and an expanding public awareness of antipsychotics, it is possible that we may see this class of drugs enjoy the same level of acceptance as other types of medications.