A new study comparing the benefits of second-generation antipsychotics (SGAs) with their older counterparts in patients with schizophrenia has yielded a surprising result. The study, funded by the UK National Health Service, found that the overall differences between first- and second-generation antipsychotics "did not reach statistical significance."
Appearing in the October 2006 issue of Archives of General Psychiatry, the findings from the project called the Cost Utility of the Latest Antipsychotics in Schizophrenia Study (CUtLASS) surprised the research team that reported them.
"If the investigators themselves had any bias or previous expectations, it was in favor of SGAs; we were surprised to refute that hypothesis," they wrote. "The results of this pragmatic randomized trial refute the hypothesis that the use of SGAs is superior to the use of FGAs [first-generation antipsychotics] in terms of quality of life at 1 year," they wrote, adding, "The confidence intervals for this effect in the opposite direction were wide, including the possibility of a small benefit for SGAs, but much smaller than we had hypothesized."
"What this study and the CATIE [Clinical Antipsychotic Trials of Intervention Effectiveness] study suggest is that FGAs, which are much cheaper than the SGAs, are a reasonable choice," said Anthony F. Lehman, MD, chair of the department of psychiatry at the University of Maryland School of Medicine. "In the recent era, one felt like he was giving inferior care if he prescribed an older drug."
But Lehman noted that treatment for schizophrenia is not a one-size-fits-all proposition. "Taking it from the data to actual practice, what we have to remember is that no one is average. All of these studies tell us about average effects. On average, the agents yield about the same results. That doesn't really predict for an individual patient what's going to happen.
"In clinical practice, you select a drug based on a variety of factors for the needs of the patients: the history of side effects, the prior response to a particular agent, the preference the patient has. You can even add cost into this. You make an informed choice for the patient [of] the best drug to at least start with. What these studies show is that the advantages of one or the other drug may be less than we might have thought they were."
In recent years, second-generation or atypical antipsychotics have attracted a following based in part on concerns that patients receiving the older, or first-generation, drugs "have had a suboptimal outcome, with symptomatic relapses and disabling adverse effects, particularly sedation and extrapyramidal symptoms [EPS]," according to the CUtLASS researchers.