Choice of Antipsychotic

Many clinical practice guidelines (e.g. 14,41) state that the treatment of choice for most patients is now the novel (''atypical'') antipsychotics, such as olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole and amisulpride. This is supported by a recent meta-analysis by Davis et al. [57], challenging earlier views which questioned these guidelines [59]. The benefits of atypical antipsychotics are particularly marked in first-episode patients. Although there is little evidence that novel antipsychotics are more efficacious than the conventional antipsychotics in the treatment of positive symptoms, they may have greater efficacy for negative and neurocognitive symptoms. It is now clear that novel antipsychotics are much better tolerated and produce fewer motor side effects, including, and crucially, tardive dyskinesia. However, the atypicals do have some disturbing side effects of their own, notably weight gain and metabolic/endocrine complications, and hence need to be carefully monitored, particularly in the medium to long term. Nevertheless, because patients are generally more likely to feel better and therefore to take these medications than the older drugs, their real-world effectiveness may prove to be much greater than suggested by efficacy studies. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study in the USA [60] is expected to throw light on this issue. Conventional antipsychotics in low doses may still have a role to play in a small proportion of patients; however, the indications are shrinking progressively.

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