Editor - The impressive meta-regression analysis by Geddes et al in
the 2nd December 2000 BMJ has left us feeling a little disappointed in its
"side-stepping" of current issues. The authors believe that "cost is not a
crucial issue at present" as the majority of outcome scores for the
atypical antipsychotics are the same as those for the typical
antipsychotics. However, the predominant message of the article is that
typicals should be prescribed first-line rather than atypicals. We
strongly disagree with the notion that "cost is not a crucial issue at
present" as it is apparently the only differentiator between the new and
old antipsychotics. If cost was not a "crucial issue" why would Geddes and
his co-workers recommend which type of antipsychotic should be prescribed
first?
As trainee psychiatrists, perhaps we suffer from too much of what Kapur
describes in his editorial as "clinical hope" but we do see a key first-
line role for atypicals. We appreciate our flexibility of being able to
work collaboratively with patients and are able to discuss factors such as
weight gain, akathisia, parkinsonism, sexual dysfunction and risk of
tardive dyskinesia. In offering a choice of medication to our patients
they effectively have a choice over their potential side-effects.
Prescribing only typicals would reduce this choice.
The authors state that no single antipsychotic is to be favoured over
another and we would like to have all treatment options available in our
first line armoury.
We encourage Geddes and his colleagues to recognise that cost is a crucial
issue and to realise that in effect they are presenting a cost-
minimisation analysis.
Richard Duggins Senior House Officer in Psychiatry
David Rhinds Senior House Officer in Psychiatry
William Hall Senior House Officer in Psychiatry
Division of Psychiatry, University of Nottingham,
Duncan MacMillan House, Nottingham NG3 6AA
Rapid Response:
Atypical Antipsychotics-choice and cost
Editor - The impressive meta-regression analysis by Geddes et al in
the 2nd December 2000 BMJ has left us feeling a little disappointed in its
"side-stepping" of current issues. The authors believe that "cost is not a
crucial issue at present" as the majority of outcome scores for the
atypical antipsychotics are the same as those for the typical
antipsychotics. However, the predominant message of the article is that
typicals should be prescribed first-line rather than atypicals. We
strongly disagree with the notion that "cost is not a crucial issue at
present" as it is apparently the only differentiator between the new and
old antipsychotics. If cost was not a "crucial issue" why would Geddes and
his co-workers recommend which type of antipsychotic should be prescribed
first?
As trainee psychiatrists, perhaps we suffer from too much of what Kapur
describes in his editorial as "clinical hope" but we do see a key first-
line role for atypicals. We appreciate our flexibility of being able to
work collaboratively with patients and are able to discuss factors such as
weight gain, akathisia, parkinsonism, sexual dysfunction and risk of
tardive dyskinesia. In offering a choice of medication to our patients
they effectively have a choice over their potential side-effects.
Prescribing only typicals would reduce this choice.
The authors state that no single antipsychotic is to be favoured over
another and we would like to have all treatment options available in our
first line armoury.
We encourage Geddes and his colleagues to recognise that cost is a crucial
issue and to realise that in effect they are presenting a cost-
minimisation analysis.
Richard Duggins
Senior House Officer in Psychiatry
David Rhinds
Senior House Officer in Psychiatry
William Hall
Senior House Officer in Psychiatry
Division of Psychiatry, University of Nottingham,
Duncan MacMillan House, Nottingham NG3 6AA
Competing interests: No competing interests