Antipsychotic Safety and Efficacy Concerns

Treatment for schizophrenia has evolved considerably since antipsychotic agents were introduced in the 1950s, with atypical antipsychotics supplanting the use of first-generation antipsychotics over the past decade. Despite the widespread belief that the atypical antipsychotics are superior to the conventional antipsychotics, clinicians lack compelling evidence about whether these new drugs really are safer or more effective than the older alternatives, or whether some atypical antipsychotics may be more effective than others. Both the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1) sought to determine if atypical antipsychotics were truly safer and more effective than typical antipsychotics, but the evidence provided did not support the superiority of the atypical antipsychotics as expected. However, differences between atypical antipsychotics and typical agents may accrue over time, and the 2 trials may not have had a sufficient duration to determine this benefit. Long-term studies greater than 1 year may provide data to support the belief that atypical antipsychotics are more effective treatments for long-term safety and prevention of relapse in schizophrenia than older agents. While atypicals do have lower incidences of extrapyramidal symptoms and movement disorders than conventional antipsychotics, concerns about these adverse effects have been replaced by concerns about metabolic side effects. Given the widespread use of atypical antipsychotics, the psychiatric community has come to recognize that monitoring of metabolic side effects is the new standard of care for treating severely mentally ill patients.