Current Use of Antipsychotic Medications: A Conversation With Phillip R. Muskin, MD

TALKING WITH TITANS OF PSYCHOPHARMACOLOGY

At the 2025 American Psychiatric Association (APA) Annual Meeting, Psychiatric Times' Editor in Chief, John J. Miller, MD, sat down with leaders in psychopharmacology to discuss the topics they find most important.

Antipsychotics occupy a special place in the mind of psychiatric clinicians and the public. Phillip R. Muskin, MD, MA, DFLAPA, LFACLP, shared how to choose and use second-generation antipsychotics (SGAs), as well as encouraged attendees to evaluate the threshold for prescribing these medications.

"Antipsychotic drugs come with a side effect package that, once started, can be difficult to reverse," said Muskin. This includes metabolic syndrome, weight gain, diabetes, movement disorders like tardive dyskinesia. "Some are rare... some are not so rare."

SGAs work by influencing the activity of neurotransmitters in the brain, specifically dopamine and serotonin. They generally block dopamine D2 receptors and serotonin 5-HT2A receptors and are associated with a lower risk of extrapyramidal symptoms.¹

Muskin encouraged everyone to ask themselves: Are we too quick to prescribes SGAs? Are better, safer alternatives available? Are we too slow to take them away when they have outlived utility? Are we too reluctant to prescribes SGAs when appropriate? How do we view the widespread off-label use?

He stressed that clinicians should work collaboratively with patients to determine the best treatment strategy, "as a team."

"I like patients to know as much as possible," shared Muskin. "I think it makes them a better partner. Patients love learning about this stuff."

Muskin also recommends titrating patients off antipsychotics once they have achieved remission, not leaving patients on antipsychotics perpetually, as the risk of movement disorders, while low, is not zero.²

Dr Miller is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times; Voluntary Consulting Psychiatrist at Seacoast Mental Health Center, Exeter/Portsmouth, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.

Dr Muskin is a professor of psychiatry and senior consultant in consultation-liaison psychiatry at Columbia University Irving Medical Center in New York, New York. He is also a member of the Psychiatric Times Editorial Board.

References

1. Chokhawala K, Stevens L. Antipsychotic medications. StatPearls. 2023 Feb 26.

2. Matthews M, Gratz S, Adetunji B, et al. Antipsychotic-induced movement disorders. Psychiatry (Edgmont). 2005;2(3):36–41.