In a comment to Study Questions Advantages of Newer Antipsychotics for Early Schizophrenia,1 Peter Buckley notes
Although readers, particularly policy makers, will inevitably be drawn to the “Should I choose an FGA [First Generation Antipsychotic] or SGA [Second Generation Antipsychotic]” content of this study, it seems to me that the most striking finding is (yet again) how frequently patients stop their medications. The 72 percent overall “All Cause” Discontinuation rate bears an uncanny resemblance to the 74 percent in CATIE and to the similar rate in the one-year CAFE first-episode study. Thus, medication non-adherence is a major treatment issue right from the onset of treatment. Set in that light, the differences observed in the study between agents are relatively modest. The data do not endorse the preferential “lead off” with any particular agent. Indeed, much like the discussion that followed the publication of the CATIE study, these data make the case for wide availability and choice of antipsychotic medications, rather than confining to a selective FGA first or X drug before trying Y among the SGAs.
Commentary
For those viewers who may be unfamiliar with the pharmacologic content of this text or the writing style used in the medical literature, I offer – with apologies to Dr. Buckley – this unauthorized translation of his comment into the vernacular:
As Dr. Buckley points out, nuanced distinctions between classes of antipsychotics tend to wash out in the tsunami of of a 70% discontinuance rate.
At the risk of oversimplifying his argument, I submit that the rate-limiting step in the improvement of treatment with antipsychotics (and many other areas of treatment as well) is the understanding and management of patient compliance rather than the discovery of the next generation of pharmaceutical agents.
- While Dr. Buckley’s comment can stand on its own for our purposes, I’ve excerpted a portion of Study Questions Advantages of Newer Antipsychotics for Early Schizophrenia to provide context. The full article, which summarizes the original study, is available at the link, as is Dr. Buckley’s full comment.
An open-label study comparing first- and second-generation antipsychotic drugs in first-episode psychosis finds that patients continued to take the newer drugs for significantly longer, even though psychopathological symptoms, as measured by a standard rating scale, indicated no differences between drugs. The report, published in the March 29 Lancet, notes that extrapyramidal symptoms were more common with the first-generation drug haloperidol, but also raises the question of whether physician bias against the older drug may be at play.