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The Distinction Between Antipsychotic Drug Classes Becomes More Blurred
Results from the British study, CUtLASS
In industry-sponsored phase III randomized clinical trials (RCTs), atypical (or second-generation) antipsychotics have consistently been more effective than neuroleptics (or first-generation antipsychotics), especially for negative symptoms. Atypicals have also been better tolerated, less likely to cause extrapyramidal symptoms, and more acceptable to patients. In the British government–sponsored Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1), researchers randomized 227 patients with chronic schizophrenia to receive a neuroleptic or an atypical antipsychotic for 1 year. Patients’ psychiatrists chose medications and doses and, if a switch was necessary, were expected to prescribe a medication from the same class.
There were no significant between-group differences on the primary outcome measure, a well-validated, blindly rated quality-of-life scale that assessed social, psychological, and occupational functioning. Even more startling, the groups showed no significant differences in extrapyramidal effects, compliance, attitudes toward medication, positive and negative syndrome scores (including a negative-symptom subscale), depression, or global functioning. Associated mean costs of care were statistically equivalent between the groups.
Comment: In most RCTs examining efficacy of atypicals, the comparison drug is haloperidol, often provided in high doses that are not adjusted by blood levels and without any necessary antiparkinsonian treatments. In contrast to industry-sponsored RCTs, practical clinical trials (see also the CATIE study) enroll subjects resembling typical clinical patients with chronic illnesses and complex comorbidities. When more clinician choice is permitted and patient samples are more diverse, retention rates drop and the superiority of the atypicals becomes less clear. Atypicals remain preferable for many patients, but current research does not tell us which agents are best for which patients or whether tardive dyskinesia will become more common once atypicals are taken for longer periods.
— Steven Dubovsky, MD
Published in Journal Watch Psychiatry November 6, 2006
Citation(s):
Jones PB et al. Randomized controlled trial of the effect on Quality of Life of second- vs first-generation antipsychotic drugs in schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1). Arch Gen Psychiatry 2006 Oct; 63:1079-87.
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