Users' experiences of treatments must be considered

EDITOR—Geddes et al highlight the poor quality of research into antipsychotic drugs.1 People who use these medicines, and their carers, would strongly echo these views.

Yet the authors use these weak data, putting them through the sophisticated statistical technique of meta-regression analysis, to produce a didactic response: “conventional drugs should remain the first treatment.” The analysis combines studies of six different atypical antipsychotics, including one (clozapine) that is seen by most clinicians as quite different, conducted over 21 years in several different countries. No examination of likely confounding effects is reported; insufficient figures were included in the paper to check. The team's draft report in July 1999, however, suggests that the correlation between effect difference and control dose of haloperidol may be an artefact of including the different atypical antipsychotics in a single analysis.

This is bad science, and worse medicine. Geddes et al have identified important hypotheses: that the optimal dose of conventional antipsychotics may be lower than previously believed and that this dose range may give comparable average efficacy and tolerability to those of atypical antipsychotics. These hypotheses are worthy of study but are not shown by the method used.

Each antipsychotic has a different range of benefits and side effects, and these are of different importance to each user. Given the highly disabling effects of side effects on people's lives, users must have informed choice. They should also expect that their doctor is free to prescribe the best. If the person is too ill to discuss options and there are no other factors, current evidence—repeated by Geddes et al—points to atypical antipsychotics as the first choice.

The National Schizophrenia Fellowship, in partnership with Mind and the Manic Depression Fellowship, has published the largest ever survey of users' experiences of treatments. The results confirm the seriousness of …