What are some strategies for reducing the adverse effects of antipsychotic medications for people with SMI?

There is a robust evidence base that antipsychotic medications can improve symptoms and functioning in people with psychotic illnesses. However, nearly all of these medications may have neurological and/or metabolic side effects. Current guidelines discourage antipsychotic polypharmacy, and doses of psychiatric medications outside of recommended ranges may worsen side effects without improving underlying psychiatric symptoms. Strategies for addressing side effects include:

  1. Switching antipsychotics based on side effects. There is not strong evidence supporting cross-titration versus immediate taper.
  2. Lowering dosages. There is evidence of a dose-dependent effect of antipsychotic medications and many common side effects.
  3. Pharmacological treatment of the side effects. It is important to have regular discussions with patients about current and potential side effects, and to work with patients and families to continuously assess the risk-benefit ratio of psychopharmacological treatments.


Buchanan, R. W., Kreyenbuhl, J., Kelly, D. L., Noel, J. M., Boggs, D. L., Fischer, B. A, Keller, W. (2010). The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophrenia Bulletin, 36(1), 71-93. doi: 10.1093/schbul/sbp116.

Goff, D.C., Falkai, P., Fleischhacker, W.W., Girgis, R.R., Kahn, R.M., Uchida, H., Zhao, J., Lieberman, J.A. (2017). The Long-Term Effects of Antipsychotic Medication on Clinical Course in Schizophrenia. Am J Psychiatry, 174(9), 840-849. doi: 10.1176/appi.ajp.2017.16091016. Epub 2017 May 5.

Takeuchi, H., Kantor, N., Uchida, H., Suzuki, T., Remington, G. (2017). Immediate vs Gradual Discontinuation in Antipsychotic Switching: A Systematic Review and Meta-analysis. Schizophr Bull, 43(4), 862-871. doi: 10.1093/schbul/sbw171. https://www.ncbi.nlm.nih.gov/pubmed/28044008

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