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The rise and fall of the atypical antipsychotics

  • Tim Kendall (a1)


The antipsychotics brought hope and optimism to people with schizophrenia and to those who care for them. There have been successive classes of antipsychotics used by the pharmaceutical industry to persuade doctors and patients that ‘new’ is better. Evidence is growing that the primary purpose of these fabricated classes is for marketing. It is time we stopped using these expensive labels – they are all just antipsychotics.

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The rise and fall of the atypical antipsychotics

  • Tim Kendall (a1)
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Dedicated follower[s] of fashion(1)

[Please note - this letter is in reaction to not only editorial by Kendall but also that of Leucht & Davis]

How many countless millions have been - and continue to be - squandered, how many psychiatrists in low and middle income countries haveerroneously felt that they are giving a second class service to those who cannot afford expensive drugs(2), how many guidelines have appeared ridingsafe bandwagons of their own making(3) before we allow ourselves to look coolly at best evidence? In 1999, before NICE began to spend 1.4m pounds per year on this and related topics(4) the Centre for Reviews and Dissemination in York (UK) published Effectiveness Bulletins including onefocusing on drug treatments for schizophrenia.(5) This bulletin, using best available evidence, states "The newer 'atypical' antipsychotics may be a further refinement, but not a revolution, in the care of those with schizophrenia." This caused reaction that was less to do with judicious use of evidence than impassioned overvalued ideas.(6) It was clear that, again, the profession - as well as consumer groups - had been - to use Prof Peter Jones' gentle chiding description - "beguiled"(7) into failing to consider best evidence in a way that was most advantageous for people with schizophrenia, their carers and funders of care.

Independent and systematically compiled best available evidence on the effects of treatments such as the antipsychotic drugs continues to be maintained.(8) The confidence of the message of 1999 has increased and developed but, largely, not changed. Something is worryingly wrong if we need reminded as late as 2011 that antipsychotic drugs are not all the same.(9) After all, even advertising has, for every successive Janssen antipsychotic since 1958, been assuring us that the new drug is "equally clinically effective [but] with a different side-effect profile".

It is evident that psychiatry has had few leaders in the last decadesthat are prepared to think and then act based on judicious use of best evidence. (10) Far too many of us have been dedicated followers of fashion. This leaves us prey to those who lobby for the latest treatment, be they stylishly packaged drugs with poorly reported lists of adverse effects, seductive therapies often with no consideration of potential harm, or trendy but untested re-configurations of care.


1. Davies R and the Kinks. Dedicated follower of fashion. 1966 [Accessed 2011 Oct 6]. Available from:

2. Adams CE, Tharyan P, Coutinho ESF, Stroup TS. The schizophrenia drug-treatment paradox: pharmacological treatment based on best possible evidence may be hardest to practise in high-income countries. Br J Psychiatry. 2006 Nov;189:391-2.

3. Taylor D, McConnell H, McConnell D, Kerwin R. The South London and Maudsley NHS Trust 2001 Prescribing Guidlines. 6th ed. London: Taylor & Francis; 2000.

4. Kendall T. The rise and fall of the atypical antipsychotics. British Journal of Psychiatry. 199(4):266-8.

5. Drug treatments for schizophrenia [Internet]. [Accessed 2011 Sep 15];Available from:

6. Schizophrenia drug dispute intensifies [Internet]. BBC. 2000 Dec 3 [Accessed 2011 Oct 6];Available from:

7. In Antipsychotics, Newer Isn't Better [Internet]. 2006 Oct 3 [Accessed 2011 Oct 6];Available from:

8. The Cochrane Collaboration, editor. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK: John Wiley & Sons, Ltd;1996 [Accessed 2010 Oct 19]. Available from:

9. Leucht S, Davis J. Are all antipsychotic drugs the same? British Journal of Psychiatry. 2011;199(4):269-71.

10. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996 Jan 13;312(7023):71-2.

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Conflict of interest: None declared

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