research reviews
Should We Abandon Atypical Antipsychotics?
Two recent studies appear to confirm the conclusion that there is no difference between first and second generation antipsychotic medications, at least in terms of efficacy. While this may prove to be true, media coverage has overlooked some essential facts.
This claim seems to imply that patients with Schizophrenia should be switched to older agents, or at the very least, should begin treatment with these agents.
The first study, conducted by the NIMH (National Institute of Mental Health), referred to as CATIE (Clinical Antipsychotic Trials of Interventional Effectiveness) involved 1460 patients with Schizophrenia from 57 sites over a period of 18 months.
The second study conducted by Dr. Peter B. Jones from the University of Cambridge and his associates was published in the Archives of General Psychiatry for October.
In the CATIE study, patients received perphenazine or one of the following second generation antipsychotic medications: olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), or ziprasidone (Geodon). Both studies suggest that either class of drugs is effective in reducing the positive symptoms of schizophrenia.
Contrary to what is suggested by the media, there are clear reasons for continued consideration of second generation as “first line” medications. Jeffrey A. Lieberman, M.D. described the findings of the CATIE study at the American Psychiatric Association’s 58th Institute on Psychiatric Services: Lecture 11. Presented October 6, 2006. (Medscape Medical New.). Dr. Lieberman indicated that these two classes of drugs differ primarily in their “adverse-effect profile”. This is precisely why they were so attractive to psychiatrists and patients in the first place.
The major flaw of the CATIE study was the choice of perphenazine as representative of first generation antipsychotic medications. Nothing could be further from the truth. Experienced psychiatrists, those who practiced before atypical antipsychotics appeared on the market, will recognize perphenazine (Trilafon) as a unique first generation antipsychotic.
While perphenazine is a medium potency agent, it is remarkably free from both EPSE (extrapyramidal side effects) and anticholinergic side effects in most patients. With respect to side effects, it is quite different from both the low potency first generation drugs like chlorpromazine, thioridazine and mesoridazine and the high potency medications such as haloperidol and fluphenazine.
Additionally, for reasons that are not clear, clozapine was distinguished from other newer medications. Clozapine was the first atypical, or second generation, antipsychotic medication and has clearly been shown to be superior to other medications in refractory patients. Patients in the CATIE study who received Clozapine did better than those in the other treatment groups. Therefore, as a whole, the class of atypical antipsychotics shows both some superiority in terms of efficacy and more favorable side effect profiles.
While these studies raise interesting questions, it is doubtful that seasoned psychiatrists and veteran patients will be gathering in crowds to replace second generation antipsychotic medications with the likes of chlorpromazine (Thorazine) or haloperidol (Haldol).
These studies undoubtedly will provide ammunition for proponents of reducing health care costs by limiting the choices doctors and patients currently have with respect to the medication they prescribe or receive.
(Sources: The author's knowledge base, unless otherwise noted.)
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