Selection of antipsychotics is challenging, and in my experience, you never know for sure which medication will work for each patient.  Here’s a few important clinical pearls regarding the use of antipsychotics.

1. Typical (1^st generation) antipsychotics are generally avoided due to a high incidence of troublesome extrapyramidal side effects (EPS). Haloperidol is the classic example of a 1^st generation antipsychotic that has a high incidence of EPS.
2. Metabolic Syndrome: Antipsychotics can cause metabolic syndrome and weight gain. Some are worse than others.  The classic examples of antipsychotics that have a higher incidence of causing metabolic syndrome include olanzapine and clozapine.
3. Neuroleptic malignant syndrome (NMS) is a classic, rare, and very serious adverse effect that can be caused by antipsychotics.
4. Cost is always a consideration when selecting any medications. Risperidone is generic and relatively cheap and I often see this one trialed first.  Many 1^st generation antipsychotics are obviously cheap as well, but are seldom used due to the above noted EPS.
5. Long acting injectables are another option at our disposal, but there are plenty of concerns with these. Expense and risk of adverse effects that will last for weeks once the injection is given are two significant concerns.  You also better understand what you are doing with long acting injectables like in this case.

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