A psychiatric revolution began in the late 1950s with the marketing of Thorazine, the first neuroleptic (antipsychotic) medication. Thorazine and similar drugs quelled psychotic agitation and quieted auditory hallucinations (voices). This allowed large numbers of state-hospital patients to be “de-institutionalized,” i.e., released to the community. While the ultimate promise of this revolution was broken in the U.S. by an inadequately funded community mental health system, the medications themselves were a huge leap forward. In contrast to other types of tranquilizers and sedatives, neuroleptics specifically targeted certain psychotic symptoms, apparently due to effects on the brain chemical dopamine.
Unfortunately, the neuroleptics brought many side-effects as well. Stiff, shuffling, drooling patients became a common sight in clinics and on the street. Thinking and reactivity were slowed. Nearly all developed some degree of a chemically-induced form of Parkinson’s Disease, and many suffered an irreversible movement disorder called tardive dyskinesia. A few died of a severe reaction called “neuroleptic malignant syndrome.” These side-effects were well-known, noxious to the patient, and feared by doctors. It took a condition as terrible as psychosis to justify using such harsh and potentially dangerous treatment.
In 1993 another psychiatric revolution was triggered with the marketing of Risperdal, the first widely prescribed “atypical” neuroleptic — atypical in that it did not primarily act on the brain’s dopamine, and seemed to lack many of the movement side-effects of typical neuroleptics. Patients tolerated it more easily, and as a bonus it also seemed to help a wider range of psychotic symptoms (“negative” symptoms as well as the “positive” symptoms that the older drugs affected). Other atypical neuroleptics were released: Zyprexa, Seroquel, and later Geodon and Abilify. Psychiatrists soon switched most chronically psychotic, e.g., schizophrenic, patients to this new class of medication.
However, the atypicals brought problems of their own. The first was price: Atypical neuroleptics cost several times as much as the medications they replaced, although some studies show this cost is offset by decreased hospitalization. Several cause significant weight gain. In recent years a metabolic syndrome has been identified where patients develop high cholesterol, diabetes, and related abnormalities. There are risks of hormonal (prolactin) imbalance and heart arrhythmia. While atypical neuroleptics may be safer than their predecessors, they are not safe medications by a longshot.
Nonetheless, new and expanded uses of the atypicals keep appearing. Typical neuroleptics have long been used in the acute manic phase of bipolar disorder, not only for the psychosis that is sometimes present, but also as a sedative until the mood stabilizer (e.g., lithium) takes effect. But the advent of atypical neuroleptics led to much wider use in bipolar disorder, i.e., ongoing maintenance use. Eventually the FDA approved these medications as single-agent treatments for bipolar disorder. Atypicals are also used widely to treat autism, ADHD, and simple agitation in children as well as adults (particularly demented elderly), as an adjunct to antidepressants (interesting discussion here), and even as simple sleep aids.
Considering the risks associated with atypical neuroleptics, they are being overused — misused — on a wide scale. Indeed, today’s New York Times reported that a panel of federal drug experts roundly criticized the cavalier use of these medications in children. Adults, too, are being over-prescribed these drugs. Useful for severe disorders, they are dangerous and unwarranted in the face of misguided complacency.