Atypical Anti-Psychotics and Humpty Dumpty: Where Is the Science, Where Is the Evidence?
This commentary covers the history and concepts behind the imprecisely defined term “atypical antipsychotics”. It discusses the general evidence for the claimed, but poorly evidenced, superior effectiveness of these drugs over previously existing drugs and criticises the evidence for meso-limbic selectivity and the supposed role of post-synaptic serotonin receptors. The hundreds of billions of dollars these drugs cost is outlined as background to assessing which of them might constitute an advance. This commentary is not in itself a critical analysis of efficacy data. It only aims to note the various recent meta-analyses and comments from mainstream opinion. Also, it does not discuss in detail the individual drugs, or their mechanism of action, or analyse their receptor profile: that will be covered in a future commentary.
Anyone familiar with my writing will know that one cannot necessarily set great store by drug trials. Trials purporting to show the equivalent effectiveness of new drugs compared to older drugs are often not worth the paper they are written on (as shown by the extensive caveats expressed in the papers mentioned below). Similarly, genuinely different or superior drugs may only be so in a subset of patients and may not show that difference in an unselected group. Such difference may only be evident to clinicians who treat patients over prolonged periods of time with a variety of drugs. However, claims of such difference/superiority derived from practical experience always have to be regarded with caution. Therefore, the more recent meta-analysis discussed below should not necessarily be taken to indicate that none of these drugs have useful advantages (as opposed to trivial and inconsequential ones). However, these analyses do reflect the fact that the majority of those expert in the analysis of this kind of work are in close agreement about the fact that any general advantages are minimal.