Are older antipsychotic drugs obsolete?

BMJ 2006; 332 doi: http://dx.doi.org/10.1136/bmj.332.7554.1346 (Published 8 June 2006)
Cite this as: BMJ 2006;332:1346

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  1. Rohan Ganguli, professor of psychiatry, pathology, and health and community systems (gangulir@upmc.edu),
  2. Martin Strassnig, resident in psychiatry
  1. Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
  2. Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA

    No

    Antipsychotic drugs have been essential in treating schizophrenia since chlorpromazine was introduced in the mid 1950s. By 1980 over 20 other antipsychotic medications were available, and all of them are now sold as generics. Ever since clozapine was shown in the late 1980s to be more effective for treatment resistant patients with schizophrenia than the older antipsychotic agents,1 numerous new antipsychotic drugs have been synthesised and released, with claims of greater efficacy and better tolerability than the older generic agents. Are these claims true, and how should clinicians go about choosing the appropriate drug for their patients with schizophrenia?

    Several authoritative and widely adopted treatment guidelines for the use of antipsychotics, such as the TIMA algorithm (Texas Implementation of Medication Algorithms), recommend only the newer antipsychotic drugs as first and second line treatments, reinforcing the perception that the older drugs are therapeutically inferior. These new antipsychotics are often referred to as “atypical” or “novel” agents, suggesting that their mechanism of antipsychotic action is different from that of the older drugs. Yet both old and new medications appear to exert antipsychotic effects via blockade of dopamine D2 receptors in the brain.2

    With regard to efficacy, an early meta-analysis …

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