Opportunities and challenges presented by the new generation antipsychotics

The widespread availability of the new generation of atypical antipsychotics offers the clinician valuable new opportunities to prescribe effective and well-tolerated drug treatments for schizophrenia. As a group, the atypical antipsychotics are distinguished from the conventional agents by their lower propensity to induce extrapyramidal symptoms (EPS). In addition, some of these agents seem to be less likely to cause hyperprolactinaemia; this may contribute to a lower incidence of sexual and hormonal side-effects than with standard treatment regimens. EPS and sexual difficulties cause considerable distress to patients; there are grounds for predicting that better tolerability will lead to better compliance with treatment and thereby better long-term outcome. There is accumulating evidence that the atypical antipsychotics are more efficacious than the standard treatments; this may reflect greater tolerability and enhanced compliance with treatment, in addition to intrinsic efficacy. But, at the same time, the new treatments pose fresh challenges to the clinician. These agents differ from one another and the traditional antipsychotics in their pharmacology, side-effects and dosing requirements; clinicians are thus required to develop new treatment strategies, if these drugs are to be deployed to best effect. In particular, it is important that the new treatments are given rationally. Polypharmacy should be avoided, as this is unlikely to be more effective, and may lead to the tolerability benefits of the new agents being lost. Although clozapine is, rightly, reserved for treatment-resistant patients, on grounds of haematological safety, the practice of reserving other atypical antipsychotics for specific groups of patients, such as those with severe illness or established EPS, is misguided and results in the advantages of the atypical agents being denied to many patients who might otherwise have benefited greatly. These newer agents are best used within the setting of a strong therapeutic alliance between clinician and patient, in which an ongoing dialogue regarding symptoms, side-effects and treatment expectations is an important element. Used rationally, they offer new opportunities for clinicians and renewed hope to many patients.