Section - Video Lectures

02. Managing Antipsychotic-Induced Sedation

Published on March 1, 2025 Certification expiration date: March 1, 2028

Oliver Freudenreich, M.D.

Co-director of the MGH Psychosis Clinical and Research Program Associate Professor of Psychiatry Harvard Medical School - Massachusetts General Hospital

Key Points

All antipsychotics can cause sedation, with olanzapine and quetiapine being particularly sedating. Most can be given once daily at night.
Sedation from antipsychotics may require longer sleep duration. Tachyphylaxis is likely overrated.
Stimulants have limited benefit for antipsychotic-induced sedation. Management focuses on encouraging activity despite fatigue, similar to chronic fatigue syndrome.

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Slides and Transcript

Slide 1 of 7

Section 2: Managing Sedation in Antipsychotic Treatment

Managing Antipsychotic-Induced Sedation Slide 1 of 7

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If you look at the table of side effects and here is one that I made up using published data. It’s not all antipsychotics. It’s a selection and you’ll see weight gain, somnolence and akathisia in this table. Let’s just look at somnolence. Almost all antipsychotics can lead to sedation. And I use what’s called the number needed to harm, NNH, from published reports. The number needed to harm is not available for most side effects but where I could find them I added them. Cariprazine on at least the published data that I had at the time, the number needed to harm was supposed to be 100. Meaning, it really was not supposed to cause somnolence. I believe that patients would beg to differ. So I take this one with a grain of salt. Otherwise, all antipsychotics can lead to sedation, some perhaps worse than others. For example, that olanzapine and quetiapine are listed as particularly sedating.

References:

Huhn, M., Nikolakopoulou, A., Schneider-Thoma, J., Krause, M., Samara, M., Peter, N., Arndt, T., Bäckers, L., Rothe, P., Cipriani, A., Davis, J., Salanti, G., & Leucht, S. (2019). Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. The Lancet, 394(10202), 939-951. https://doi.org/10.1016/S0140-6736(19)31135-3
Citrome, L. (2017). Activating and sedating adverse effects of second-generation antipsychotics in the treatment of schizophrenia and major depressive disorder: Absolute risk increase and number needed to harm. Journal of Clinical Psychopharmacology, 37(2), 138-147. https://doi.org/10.1097/JCP.0000000000000665

Managing Antipsychotic-Induced Sedation Slide 2 of 7

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03. Antipsychotic-Induced Weight Gain: Prevention and Management

Learning Objectives:

After completing this activity, the learner will be able to:

Identify antipsychotic receptor binding profiles and their associated side effects, including H1 receptor blockade causing sedation and weight gain, alpha-1 blockade causing orthostatic hypotension, and muscarinic blockade leading to anticholinergic effects, to make informed medication selections and provide anticipatory guidance to patients.
Implement evidence-based management strategies for antipsychotic-induced metabolic side effects, including appropriate medication selection, early intervention with metformin when weight gain occurs.
Recognize and appropriately manage severe antipsychotic-induced movement disorders, including akathisia, neuroleptic malignant syndrome, and tardive dyskinesia, through early detection, pharmacologic interventions, and antipsychotic selection or adjustment when indicated.

Original Release Date: March 1, 2025

Expiration Date: March 1, 2028

Expert: Oliver Freudenreich, M.D.

Medical Editor: Flavio Guzmán, M.D.

Relevant Financial Disclosures:

Oliver Freudenreich declares the following interests:

- Alkermes: Research grant, consultant honoraria

- Janssen: Research grant, consultant honoraria

- Otsuka: Research grant

- Karuna: Research grant, consultant honoraria

- Neurocrine: Consultant honoraria

- Vida: Consultant honoraria

- American Psychiatric Association: Consultant honoraria

- Medscape: Honoraria

- Elsevier: Honoraria

- Wolters-Kluwer: Royalties

- UpToDate: Royalties, honoraria

All of the relevant financial relationships listed above have been mitigated by Medical Academy and the Psychopharmacology Institute.
None of the other faculty, planners, and reviewers for this educational activity have relevant financial relationships to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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