Antipsychotics

Question 1

Comparative efficacy of antipsychotics

Answer 1

most effective antipsychotics for symptom reduction appear to be olanzapine and clozapine (level 2 [mid-level] evidence)

risperidone appears less effective than olanzapine but more effective than haloperidol, chlorpromazine, quetiapine and ziprasidone (level 2 [mid-level] evidence)

amisulpride may have efficacy similar to olanzapine, risperidone, and ziprasidone (level 2 [mid-level] evidence)

aripiprazole may be less effective than olanzapine and as effective as risperidone for treatment of schizophrenia (level 2 [mid-level] evidence)

quetiapine may be less effective than risperidone, olanzapine, or paliperidone, but may produce fewer movement disorders in patients with schizophrenia (level 2 [mid-level] evidence)

perphenazine may have efficacy similar to other antipsychotics with fewer dropouts (level 2 [mid-level] evidence)

zuclopenthixol dihydrochloride orally may be more effective short-term than other typical antipsychotics, but high rate of extrapyramidal symptoms (level 2 [mid-level] evidence); zuclopenthixol decanoate injection may reduce relapses more than other depot antipsychotics (level 2 [mid-level] evidence)

Question 2

Antipsychotic efficacy in refractory schizophrenia

Answer 2

second-generation antipsychotics no more effective for improving outcomes (quality of life, symptoms, adverse effects) compared to first-generation antipsychotics in patients with schizophrenia requiring medication change due to inadequate response or adverse effects (level 1 [likely reliable] evidence)

clozapine appears preferable to haloperidol in patients with refractory schizophrenia
addition of aripiprazole to risperidone or quetiapine not associated with greater symptom improvement (level 2 [mid-level] evidence)

addition of memantine (but not risperidone) to clozapine may improve symptoms in patients with refractory schizophrenia (level 2 [mid-level] evidence)