The skeptical UK view of second-generation antipsychotics

Professor Tim Kendall, director of the National Collaborating Centre for Mental Health in the United Kingdom, gave a plenary lecture on “The Rise and Fall of the Atypical Antipsychotics” at the 7th Annual Pacific Psychopharmacology Conference on 20 September 2013, in Coquitlam, BC. According to Dr. Kendall, the National Institute for Health and Care Excellence (NICE), for which the National Collaborating Centre provides expertise in its psychiatric guideline development, concluded in a 2002 appraisal that the atypical antipsychotics might have greater efficacy and fewer adverse effects than typical antipsychotics. In 2009, NICE issued an updated guideline for schizophrenia treatment based on new evidence and multiple pairwise meta-analyses and found that the atypical or second-generation antipsychotics do not constitute a special class. In his view, the distinction is merely a marketing tool.

In selecting a medication, Dr. Kendall said we should ask our patients, “Would you rather be fat or stiff?” because the decision often comes down to whether patients can better tolerate extrapyramidal or metabolic adverse effects. An exception is clozapine, which falls into the “fat” category but remains the choice for treatment resistance; otherwise NICE does not recommend any specific antipsychotic over another.

A simultaneous economic analysis of antipsychotic treatment also produced provocative findings. Although the price of antipsychotic medications can vary widely, the model found no significant difference in cost effectiveness among the seven antipsychotics included in the analysis (amisulpride, aripiprazole, haloperidol, olanzapine, paliperidone, risperidone, zotepine). The driver of cost is relapse and hospitalization; drug-acquisition cost plays a minor role in the overall expense of a patient’s care. The lesson is that whatever medication a given patient is willing to take and can tolerate may improve adherence, reduce relapse, and save the immense price of inpatient treatment.