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Psychiatric Bulletin (2007) 31: 233. doi: 10.1192/pb.31.5.233
© 2007 The Royal College of Psychiatrists
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Correspondence

Dominance of second-generation antipsychotics - time for reflection?

Benjamin R. Underwood, Specialist Registrar in Psychiatry

St Clement’s Hospital, Foxhall Road, Ipswich IP3 8LS, email: brunderwood{at}yahoo.com

Declaration of interest. B.U. has received hospitality from all major drug companies involved in the manufacture of antipsychotics.

Bleakley et al (Psychiatric Bulletin, March 2007, 31, 94–96) address an interesting and relevant question regarding which antipsychotics healthcare professionals would choose for themselves. It is reassuring that their choices are broadly in keeping with the medications that they give their patients.

What is striking is the overwhelming preference for second-generation antipsychotics. The authors cite this preference as support for the widespread use of these drugs and state that risperidone and olanzapine have advantages in effectiveness over conventional antipsychotics. The evidence base for this is not as clear as it once appeared. Three recent, large, independent trials have not found superior effectiveness for second-generation antipsychotics (although they did not consider aripiprazole) and have failed to show an advantage in terms of quality of life or patient preference compared with conventional antipsychotics (Rosenheck et al, 2003; Lieberman et al, 2005; Jones et al, 2006).

How then do we explain the enthusiasm for these medicines among healthcare professionals? It is perhaps worth considering that although some of the side-effects of typical antipsychotics are rapid (e.g. extrapyramidal symptoms), the side-effects of the second-generation atypical antipsychotics (e.g. metabolic syndrome) may be delayed, and this may reduce their impact on health professionals. Other possible explanations include clinical optimism for new treatments, greater familiarity with second-generation antipsychotics, delayed dissemination of new evidence and effective marketing of these drugs.

It is no longer the case that the literature overwhelmingly supports the use of atypical over conventional antipsychotics. Perhaps it is time to revisit the evidence and debate current practice.

References

JONES, P., BARNES, T. R., DAVIES, I. et al (2006) Randomized controlled trial of the effect on Quality of Life of second-vs first-generation antipsychotic drugs in schizophrenia. Archives of General Psychiatry, 63, 1079 -1087.[Abstract/Free Full Text]

LIEBERMAN, J. A., STROUP, T. S., MCEVOY, J. P., et al (2005) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine, 353, 1209 -1222.[Abstract/Free Full Text]

ROSENHECK, R., PERLICK, D., BINGHAM, S., et al (2003) Effectiveness and cost of olanzapine and haloperidol in the treatment of schizophrenia. JAMA, 290, 2693 -2702.[Abstract/Free Full Text]


Related articles in PB:

Which antipsychotics would mental health professionals take themselves?
Stephen Bleakley, Olubanke Olofinjana, and David Taylor
PB 2007 31: 94-96. [Abstract] [Full Text]  

Crime rates and local newspaper coverage of schizophrenia
Arun K. Chopra and Gillian A. Doody
PB 2007 31: 206-208. [Abstract] [Full Text]  




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