The Rise and Fall of Atypical Antipsychotics: The belief in pharmaceutical marketing messages

 

via BJPsych:

Editorial

The rise and fall of the atypical antipsychotics

TIM KENDALL

Declaration of interests:
T.K. receives about £1.4 million per year from the National Institute for Health and Clinical Excellence (NICE) to develop clinical practice guidelines for the National Health Service in England and Wales. He also receives funding/grants from other bodies including the Academy of Medical Royal Colleges, the Department of Health and NICE International to undertake systematic reviews or guideline development. T.K. is a co-opted member of the Council of the Royal College of Psychiatrists and contributed to the development of the College Report CR148 on psychiatrists’ relationship with the pharmaceutical industry

the final two paragraphs:

In the recently updated NICE schizophrenia guideline we also found that there were no consistent differences between atypicals and typicals, SGAs and FGAs; there were no important differences between any of the antipsychotics in terms of clinical or cost effectiveness (except for clozapine in treatment-resistant schizophrenia); the side-effects varied from drug to drug and were not determined by class; and all the antipsychotics were associated with potentially serious dose-related and other side-effects. 4 Although some of the newer drugs are associated with lower rates of EPS/tardive dyskinesia, they are also linked to different and equally severe side-effects such as diabetes, and some other newer drugs may have similar rates of EPS to the older drugs. From Girgis et al in this issue, it now seems unlikely that there are any longerterm benefits for using atypicals or SGAs in the first episode.

In creating successive new classes of antipsychotics over the years, the industry has helped develop a broader range of different drugs with different side-effect profiles and potencies, and possibly an increased chance of finding a drug to suit each of our patients. 4 But the price of doing this has been considerable – in 2003 the cost of antipsychotics in the USA equalled the cost of paying all their psychiatrists. The story of the atypicals and the SGAs is not the story of clinical discovery and progress; it is the story of fabricated classes, money and marketing. The study published today is a small but important piece of the jigsaw completing a picture that undermines any clinical or scientific confidence in these classes. With the industry reputation damaged by evidence of selective publishing and its deleterious effects, 15,16 and the recent claims that trials of at least one of the new atypicals have been knowingly ‘buried’, 2 it will take a great deal for psychiatrists to be persuaded that the next new discovery of a drug or a class will be anything more than a cynical tactic to generate profit. In the meantime, perhaps we can drop the atypical, second-generation, brand new and very expensive labels: they are all just plain antipsychotics. here

As interesting as the above article is, I found what the editor of the British Journal of Psychiatry, Peter Tyrer said about the SGAs interesting, and the response to Tim Kendall's editorial from The Last Psychiatrist, illuminating.

From the Editor's desk

1. Peter Tyrer

Spotlight on antipsychotics

The act of prescribing an antipsychotic drug in psychiatry is like sex; it is almost universal in practice yet indiscriminate use can lead to multiple pathologies. Where it differs from sex is that the act is almost completely devoid of pleasure for most parties involved. Patients tend to hate these drugs because of their panoply of adverse effects – not for nothing was chlorpromazine named Largactil – and practitioners, unless they are avid psychopharma- cologists, feel their prescription is a necessary evil that is likely to change the relationship with their patients from a cooperative to a coercive one, particularly in a hospital environment.^1,2 We would all feel a lot better if this range of drugs was replaced by one that was at least equally effective and did not have the potential to attack every organ system in the body when it wasn’t looking, or even looked for, in clinical and research practice.³ Six papers in this issue touch on this subject from different angles. After looking at the similarities between the long-term benefits of clozapine and chlorpromazine in schizophrenia (Girgis et al, pp. 281–288), Kendall (pp.266–268) goes for the full frontal assault on the way guidance has been distorted by the pharmaceutical industry, ‘a story of fabricated classes, money and marketing’, with most changes being no more ‘than a cynical tactic to generate profit’. I have to declare my own interest here; I cannot see any justification for separating first- and second-generation antipsychotics and think these terms should be dropped far, far away from rediscovery by gullible psychiatrists.⁴ But Leucht & Davis (pp. 269–271) rightly emphasise the variability of antipsychotic drugs and that prescription should follow a ‘shared decision-making process’ with the patient, provided, some would add, that this is an honest and genuine one.⁵ Frighi et al (pp. 289–295) show that in those with intellectual disability, adverse effects are not usually major. My own explanation of this somewhat surprising finding is that because shared decision-making is much more difficult with this group than with those of normal IQ and that a minority of patients is unduly sensitive to these drugs, much lower doses are prescribed than in others and so there are fewer adverse consequences. Suzuki et al (pp. 275–280) confirm my own impressions from clinical practice that if there is no clinical response to an antipsychotic drug fairly soon after prescription (within 6 weeks) then its further prescription should be questioned, and long-term usage regarded as rare. (emphasis mine) here

via The Last Psychiatrist:
The Rise And Fall Of Atypical Antipsychotics [sic]

His point is that the atypicals aren't really better than the typicals (duh.)  Of course he's right, but in being factually accurate he is being deliberately deceitful.  

To be clear: I am obviously aware of the buried data and the obfuscatory shell games of Big Pharma, but the truth of these medications has been available even without resorting to studies no one would have read anyway.  But in order to hide the fact that no one really paid much attention to the actual data that was in front of them (they took the word of the local thought leader and figured that was that) they pretend that the problem is the buried data. (empasis mine) here

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