Over the past two decades few disorders have been subject to such big changes in management as schizophrenia. Yet these have gone unnoticed by the general medical and popular press—possibly because these changes have not arisen from breakthroughs in research on genetics, receptors, anatomy, or neuropharmacology.

The new generation of antipsychotic drugs has not fulfilled its promise of substantially increased effectiveness or even of much better tolerability.1 In this week's BMJ Tiihonen and colleagues show that, in practice, some older drugs such as perphenazine are as efficacious as the newer ones.2 This follows the findings of the National Institute of Mental Health clinical antipsychotic trials of intervention effectiveness (CATIE) study that 74% of patients with established symptoms of schizophrenia discontinued their medication within 18 months and there was no overall difference in effect between perphenazine and the newer atypical drugs.1 3 When patients can accept and tolerate clozapine, …