Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Compare the metabolic, cardiac and motor burdens of antipsychotics, recognise dangerous reactions, and use baseline measurement and shared review to maintain psychiatric benefit with fewer avoidable harms.
Antipsychotics improve psychotic symptoms and help prevent relapse, while receptor actions outside the therapeutic target create adverse effects. A prescription is therefore an individual therapeutic trial with recorded aims, expected benefit, acceptable burden and review points. Previous response matters: a theoretically favourable metabolic profile offers little benefit if a switch produces severe relapse. Conversely, psychiatric improvement does not justify ignoring disabling movement symptoms or rising cardiometabolic risk.
Dopamine blockade in motor pathways can cause dystonia, parkinsonism and akathisia, while prolonged exposure can produce tardive syndromes. Dopamine effects in the pituitary influence prolactin and reproductive symptoms. Histamine and serotonin receptor effects contribute to appetite and weight changes; sedation can reduce activity further. Alpha-adrenergic blockade promotes orthostatic hypotension. Cardiac ion-channel effects and metabolic interactions can delay repolarisation, particularly when more than one risk factor is present.
Look for rapid weight increase, central adiposity, excess thirst or urinary frequency rather than waiting for a scheduled annual check.
Ask about fainting, near-fainting, palpitations, family sudden death and recent additions such as macrolides or QT-prolonging antiemetics.
Observe facial expression, gait, arm swing, tremor, jaw and tongue movements, and the person's ability to remain comfortably seated.
Dizziness on standing, daytime sleepiness and falls may impair independence even when positive psychotic symptoms have improved.
May cause akathisia, insomnia and impulse-control disorders; adjust for strong CYP2D6 or CYP3A4 interactions and do not assume it is free of metabolic risk.
A modest QT effect can become clinically important when combined with hypokalaemia, bradycardia, congenital susceptibility or metabolic inhibition by another prescription.
Stopping a long-acting injection prevents further administration but does not promptly remove existing exposure, so adverse-effect follow-up must account for its duration.
For one person sexual dysfunction determines adherence, while another prioritises alertness for work or avoiding weight gain; ask rather than assume.
New gambling, compulsive shopping, binge eating or sexual urges can be treatment-related and deserve direct, non-judgemental enquiry and dose review.
Treating new pacing as proof of uncontrolled psychosis before asking about inner restlessness and its relation to dose changes.
Continuing a weight chart without offering any response to rapid gain or deteriorating glucose.
Assuming an ECG obtained before treatment removes the need to review later interacting prescriptions.
Adding an anticholinergic indefinitely without identifying whether the movement disorder is parkinsonism, akathisia or tardive dyskinesia.
Changing clozapine solely from an automated QT report without urgent specialist interpretation of both cardiac and psychiatric risks.
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A person has gained 8 kg during twelve weeks of olanzapine and reports thirst. Their hallucinations have substantially improved. What is the best immediate approach?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
An effective review asks about effects people do not always volunteer: constipation, urinary symptoms, salivation, sexual function, restlessness, inner tension, slowed movement, appetite and feeling emotionally flattened. Involve a chosen supporter where appropriate, while maintaining privacy for sensitive questions. Offer practical help with physical activity, food access and appointments. When changing treatment, state the proposed psychiatric benefit, expected adverse-effect improvement and the risk of destabilisation so the decision is genuinely shared.