Antipsychotics are considered the mainstay of treatment for psychotic disorders such as schizophrenia and schizoaffective disorders. While the first generation antipsychotics (typical antipsychotics) are effective for treating psychosis, the second generation antipsychotics (atypical antipsychotics) have largely supplanted their older cousins as the “go to” medications for this indication. The main reason for the switch to newer agents is not because of increased efficacy, but because of reduced adverse effect burden. The reduced propensity of the second generation antipsychotics to cause neurological adverse effects such as extrapyramidal symptoms and tardive dyskinesia has been established. However, these agents have a different adverse effect profile that may carry as much “baggage” as the older agents. Adverse effects such as weight gain, hyperglycemia, hyper- or dyslipidemia, and hyperprolactinemia are all fairly common occurrences with these agents. Other serious adverse effects, including neuroleptic malignant syndrome (NMS) or pulmonary embolism, may also occur. This issue of the Mental Health Clinician (MHC) will explore these non-neurologic adverse effects caused by second generation antipsychotics.

First, an article reviewing management and prevention of clozapine-induced agranulocytosis describes some of the challenges when using this “last-resort” second generation antipsychotic. Case reports describing aripiprazole induced hiccups and a pulmonary embolism related to risperidone and paliperidone are included in this issue. Another case report examines treating hyperprolactinemia with bromocriptine. Also, original research on the link between osteoporosis and the use of antipsychotics is presented to further explore the concept of second generation antipsychotic induced hyperprolactinemia. In addition to a review article examining the clinical characteristics of NMS and serotonin syndrome, a case is presented describing a neurotoxic adverse event that illustrates the difficulty in differentiating NMS and serotonin syndrome.

One of the most challenging aspects of using second generation antipsychotics is monitoring, preventing, and treating metabolic adverse effects. This issue includes a Toolbox describing the average weight gain and changes in other metabolic parameters seen with second generation antipsychotics to aid clinicians in determining the most appropriate medication for their patient. A review article discussing prevention and treatment strategies for metabolic adverse effects as well as original research detailing a pharmacist-driven intervention for baseline monitoring of these effects are contained within this issue.

When using second generation antipsychotics in our psychiatric patients, adverse effects are likely to occur. Hopefully, this issue of the MHC will educate the CPNP membership and assist clinicians in providing better care for patients receiving these medications.