Letters to the Editor
Re: From Chlorpromazine to Clozapine—
Antipsychotic Adverse Effects and the Clinician’s Dilemma
Dear Editor:
Dr Abidi and Dr Bhaskara have accurately described new concerns arising from the use of atypical antipsychotics (1). The pharmacotherapy of schizophrenia remains an ongoing challenge for researchers and clinicians. The atypicals cause fewer extrapyramidal side effects (EPSEs) and tardive dyskinesia (TD), but there is growing concern regarding their significant long-term adverse metabolic and cardiac effects. These risks may be comparable to the EPSEs and TD associated with typical antypsychotics. Since atypical antipsychotics are all equally effective, the choice of drug for any given patient is still determined by their relative adverse-effect profile. Thus early identification of patients at high risk for obesity, diabetes, and cardiac disease is essential and requires increased monitoring and management (1).
Freedman (2) has recently described the current knowledge about the psycho- pharmacologic treatment of schizophrenia, a chronic and debilitating psychotic mental disorder wherein the similar therapeutic response among the new drugs emphasizes that choice be determined by the side effects profile.
The suffering of schizophrenia patients, as well as the disorder’s economic and social costs, is always underestimated. Schizophrenia has a considerable impact on patients, their families, and the health care system (3). Most patients experience repeated episodes with worsening outcomes: 9% suffer lasting impairment, and 43% endure increasingly severe symptoms with no periods of complete remission (4). Schizophrenia patients face impoverished lifestyles, finding it difficult to secure paid employment and to hold on to their jobs when they get them. The development and more widespread use of atypical antipsychotics may lead to a short-term increase in the the proportion of the total cost of schizophrenia attributable to medications. Conversely, their use may lead to reduced hospitalization and allow patients to work and lead a normal social life, apart from the still-unknown cost of dealing with metabolic and cardiac side effects. Early diagnosis and precise treatment with the safest possible antipsychotics are key elements for lowering the social and economic burden of schizophrenia, but clinicians should be aware of the new side effects associated with long-term use of atypical antypsychotics.
References
1. Abidi S, Bhaskara SM. From chlorpromazine to clozapine—antipsychotic adverse effects and the clinician’s dilemma. Can J Psychiatry 2003;48:749–55.
2. Freedman R. Schizophrenia. N Engl J Med 2003;349:1738–49.
3. Knapp M, Simon J, Percudani M, Almond S. Economics of schizophrenia: a review. In: Maj M, Sartorius N, editors. Schizophrenia. 2nd ed. Chichester (UK), John Wiley & Sons, 2002. p 413–60.
4. Watt DC, Katz K, Shepherd M. The natural history of schizophrenia: a five-year prospective follow-up of a representative sample of schizophrenics by means of a standardized clinical and social assessment. Psychol Med 1983;13:663–70.
Antonio E Nardi, MD
Rio de Janeiro, Brazil
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