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Dominance of second-generation antipsychotics – time for reflection?

Published online by Cambridge University Press:  02 January 2018

Benjamin R. Underwood
Benjamin R. Underwood*
Affiliation:
St Clement's Hospital, Foxhall Road, Ipswich IP3 8LS, email: [email protected]
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Abstract

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Psychiatric Bulletin , Volume 31 , Issue 6 , June 2007 , pp. 233
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Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Copyright © Royal College of Psychiatrists, 2007

Bleakley et al (Psychiatric Bulletin, March 2007, 31, ) 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 (Reference Rosenheck, Perlick and BinghamRosenheck et al, 2003; Reference Lieberman, Stroup and McEvoyLieberman et al, 2005; Reference Jones, Barnes and DaviesJones 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.

Declaration of interest

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

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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.Google Scholar
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