Switching in the era of atypical antipsychotics. An updated review

The introduction of the newer atypical antipsychotic medications in the 1990s was the first major change in the psychopharmacologic treatment of schizophrenia in many years. Many patients previously treated with conventional antipsychotics showed marked improvement when switched to one of the newer agents. Yet the principles involved in switching patients to these agents initially posed a challenge for clinicians, with many patients becoming unstable and relapsing during switches. Now, a decade later, switching techniques are better understood, but, with atypical antipsychotics now the standard of care, new challenges have emerged. Surveys confirm a steady decrease in use of older antipsychotics and an increase in use of first-line atypical agents since 1994. Before the newer atypical agents, elective antipsychotic changes in "stable" outpatients were uncommon, but with more choices available, rates of switching, mostly from one atypical agent to another, are now 30%-50% a year in many outpatient clinics, a trend that is likely to continue with the expanding range of target symptoms and growing expectations for better outcomes. Whereas relapse prevention was once considered the primary goal, the focus has moved beyond stability towards recovery. This article focuses on recent developments in switching and highlights differences in the switching profiles of the most recently introduced antipsychotics, ziprasidone and aripiprazole, and compares their switching characteristics with those of the other first-line atypical antipsychotics.