Advances in Psychiatric Treatment (2008) 14: 17-28. doi: 10.1192/apt.bp.107.003970
© 2008 The Royal College of Psychiatrists
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How CATIE brought us back to Kansas: a critical re-evaluation of the concept of atypical antipsychotics and their place in the treatment of schizophrenia

David Cunningham Owens

David Cunningham Owens is Professor of Clinical Psychiatry at the University of Edinburgh (University Division of Psychiatry, Kennedy Tower, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh EH10 5HF, UK. Email: david.owens{at}ed.ac.uk) and an honorary consultant psychiatrist at the Royal Edinburgh Hospital. Previously he was a consultant psychiatrist and member of the external scientific staff of the Medical Research Council at the Clinical Research Centre, Northwick Park Hospital, Harrow. He has published extensively on the biology of schizophrenia and authored a well-received textbook on the extrapyramidal side-effects of antipsychotic drugs (Owens, 1999). He continues to participate in sector-based, general adult psychiatric practice.

The subdivision of the class of antipsychotic drugs into two discrete groups – ‘conventional’ (or first generation) and ‘atypical’ (or second generation) – has been adopted as standard, with the latter generally accepted as ‘better’ and widely recommended as automatic first-line choices. However, this perception has been thrown into confusion with the results of large pragmatic trials that failed to identify advantages with the new, more expensive drugs, while identifying worrying tolerability issues. This article explores the origins of ‘atypicality’, its construction on the back of a confusing and weak clinical validator (diminished liability to promote parkinsonism) and how even in relation to the archetypical atypical, clozapine, the uncertain boundaries of drug-induced extrapyramidal dysfunction may be contributing to confusion about ‘efficacy’ and ‘tolerability’. It argues that abandoning atypicality would open up clinical practice to all drugs of a single class of ‘antipsychotics’ and allow for individualised risk/benefit appraisal as a basis for truly tailored treatment recommendations.




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