Atypicals vs. typicals

The aim of a recent study of acute response to antipsychotic treatment in first episode non-affective psychosis was to help “clinicians to identify those patients with a decrease likelihood of responding to routine pharmacological approaches is meant as a first step to optimize therapeutic effort to benefit individuals in this vulnerable group.” The researchers found that “patients with an early age of onset of schizophrenia, a poor premorbid adolescent functioning, and with a lower severity of psychopathology at intake seem to have a decrease likelihood of responding to antipsychotic treatment.”

With respect to type of medication as a predictor of response, the researchers hypothesized that “likelihood of response would be different among the groups of antipsychotic treatment.” Similar to the CATIE study, the researchers did not find a significant difference between typical (haldol) and atypical (risperidone or olanzapine) antipsychotic treatment and clinical improvement, at least in the early weeks of treatment.

The evidence is mounting that the knee-jerk assumption that atypicals should be the first line medication for treatment of psychoses is diminishing. Thanks to the Pharma funded medication algorithms, the switch has largely been made to atypicals in the public mental health system.

But, it has been very costly. For example, the Medicaid expenditures for antipsychotics increased 160% between 1995 and 1998 when the total number of prescriptions only increased 20%. That is because the proportion of atypical prescriptions grew from 17.5% in 1995 to 51% 3 years later in 1998. The cost grew as well, from $487 million in 1995 to $1.3 billion in 1998. Imagine how much more of the pie the pharmaceutical companies are getting now, 8 years and many marketing dollars later. Also imagine if that money were available for services, such as medication education and close monitoring for efficacy and side-effects. Decisions about medication should be based on efficacy and side-effects, not classification alone. And Clozapine shouldn’t be abandoned just because it is off-patent and isn’t being marketed by the Big Pharma reps. If money were freed up for better medication management services, clinicians would be in a better position to evaluate efficacy and side-effects and make more informed prescribing decisions.