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Antipsychotics: A Focus on Indications,
Monitoring, and Counseling

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Antipsychotic therapy improves the lives of millions with severe and persistent mental illnesses like schizophrenia and bipolar disorder. In recent years, FDA-approved use has expanded to other indications including depression and autism spectrum disorder. There has also been an explosion of off-label (unapproved) use as varied as behavioral problems and anxiety.

Antipsychotics are classified as either first-generation (FGA, "typical", or conventional) or second generation (SGA or "atypical"). The SGAs are among the top 5 therapeutic classes undergoing significant growth in medication spending. Aripiprazole (Abilify®) and quetiapine (Seroquel®) rank among the top 10 prescription drugs in terms of sales.

The use of the older FGAs has declined, while the use of SGAs increased nearly 6-fold from 1995 to 2008 among both adults and children. Factors contributing to this increase include expanded indications beyond schizophrenia and better tolerability of SGAs. Aggressive marketing of SGAs, including direct-to-consumer advertising and illegal promotion, also may have contributed to the increase in use. The number of physician office visits at which antipsychotics were prescribed off-label almost doubled between 1995 and 2008. Concerns have been raised about off-label uses that lack sufficient evidence for efficacy and safety. This issue summarizes the current evidence for FDA-approved antipsychotic indications (see Table 1.) as well as nonapproved uses - with a focus on comparative safety and tolerability among the agents. The supplement to this issue addresses the history of antipsychotic use, important antipsychotic interactions, and the SGA clozapine. Additional CE credit is available for the supplement.

Understanding the benefits and risks of antipsychotic use, especially in vulnerable patient populations such as children and elders, is critical for providing quality healthcare. Community practitioners can take an active role in working with patients and caregivers to ensure that antipsychotics are used for appropriate indications, and to provide them with recommended monitoring and education to improve safety.


Publication Date: 07/18/2013
Expiration Date: 07/18/2016
CE Credit: 1.5 (0.15 CEU)
Type of Activity: Knowledge-based

This program was developed by The Rx Consultant and published by Continuing Education Network, Inc. The Rx Consultant accepts no advertising or financial support from the pharmaceutical industry and is funded solely by the purchase of programs. The Rx Consultant is dedicated to providing unbiased, balanced information to health care practitioners.

Programs developed by The Rx Consultant are written by health care providers with expertise in the topic area, peer-reviewed, extensively edited, and fact-checked. This development process was created to insure that every program presents information that is current, accurate, relevant to "real world" health care providers, and written in an easy reading, "plain English" style.


Julie Dopheide, PharmD, BCPP, Tracy Farnen, PharmD, and Pamela Mausner, MD

Disclosure Statement

Dr. Dopheide, Dr. Farnen and Dr. Mausner report no financial or personal relationship with any commercial interest producing, marketing, reselling, or distributing a product or service that appears in this issue.

Target Audience

This accredited program is targeted to pharmacists and nurses.

Goals & Objectives

At the conclusion of this program, participants will be able to:

    1. For commonly prescribed SGAs, state the FDA-approved indications and age ranges. Identify 2 off-label uses of antipsychotics for which there is at least limited evidence for efficacy.
    2. Discuss extrapyramidal symptoms (EPS), metabolic effects, QT prolongation, and hyperprolactinemia associated with antipsychotics; list the agents most likely to cause them.
    3. Provide recommendations to patients, families, and healthcare providers for managing antipsychotic adverse effects; include important monitoring parameters.
    4. Discuss the relative effectiveness of the most commonly used SGAs in treating schizophrenia.

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The Rx Consultant is a publication of Continuing Education Network, Inc.

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ACPE Universal Activity Number: 0428-0000-13-009-H01-P

Exam & Credit Statement Procedures

Upon successful completion of this program and the post test (70%), 1.5 hours of continuing education credit will be awarded. To receive credit and your exam score, please complete the exam questions and program evaluation.

Editorial and Review Board

Chief Editor and CE Administrator

Terry M. Baker, PharmD

Managing Editor

Tracy Farnen, PharmD

Associate Editors

James Chan, PharmD, PhD
Pharmacy Quality and Outcomes Coordinator
Kaiser Permanente
Oakland, CA

Associate Clinical Professor
School of Pharmacy
University of California San Francisco
San Francisco, CA

Richard Ron Finley, B.S. Pharm.,R.Ph.
Clinical Pharmacist (volunteer faculty)
University of California, San Francisco (UCSF) Memory and Aging Center
Lecturer (Emeritus) UCSF, Department of Clinical Pharmacy
Health Sciences Clinical Professor, UCSF School of Pharmacy
San Francisco, CA

Consultant Pharmacist
Ray Dolby Brain Health Center, Sutter Health/CPMC
San Francisco, CA

Consult Pharmacist Aging and Adult Health Services
San Francisco Health Department
San Francisco, CA

Julio R. Lopez, PharmD, FCSHP
Chief of Pharmacy Service
VA Northern California Health Care System

Adjunct Clinical Professor
College of Pharmacy
Touro University
Vallejo, CA

Assistant Clinical Professor
School of Pharmacy
University of California, San Francisco
San Francisco, CA Adjunct Professor
Thomas J. Long School of Pharmacy
University of the Pacific
Stockton, CA

Visiting Associate Professor and Lecturer
Nursing School
Samuel Merritt University
Oakland, CA

Pamela Mausner, MD

Helen Berlie, Pharm.D. CDE, BCACP
Clinical Assistant Professor, Pharmacy Practice
Wayne State University
Detroit, MI

Ambulatory Care Specialist - Diabetes
Health Centers Detroit Medical Group
Detroit, MI

Senior Editorial Advisor

Gerard Hatheway, PharmD, PhD

Editorial Advisors

Belinda M. Danielson, RPh
Christopher M. DeSoto, PharmD
Angie S. Graham, PharmD
Cynthia Chan Huang, PharmD, MBA
Fred Plageman, PharmD

Editorial Advisor and Clinical Practice Consultant for Nurse Practitioners

Emily K.
Meuleman, RN, C, MS

About the Rx Consultant

The Rx Consultant is a monthly publication dedicated to providing health care professionals with the information they need to educate patients about drugs and manage drug therapy. The reader is responsible for confirming the information presented here and interpreting it in relation to each patient's specific situation before utilizing the information.

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