I have to admit, I was started to see a Consumer Reports article on the
“Best Buy” drugs for the treatment of schizophrenia and bipolar
disorder. So now
treating mental illness is like buying a toaster oven?
Seriously, at first
it seemed kind of inappropriate. After all you cannot assess
pharmaceuticals the same way you assess ordinary consumer products, can
First, let me say that I like the magazine. I don’t
subscribe to it, but I do look at it from time to time, and I do
consult it for certain things. For instance, in 1995, when I
went to buy a microwave oven, I first went to the bookstore in the mall
and looked at one of their compilations. I had my son read
it, actually, who was seven at the time. He asked me some
questions, such as “Which is more important to you, operating speed,
ease of use, or number of features?” We went through the
process of selecting a model, and put the book back on the shelf.
Then we went to Sears. A salesman came up to us and asked if
he could help. My kid blurted out “We’re looking for a
Kenmore microwave oven, model number 4522672,” or something like that.
I don’t actually recall the model number, although it was
quite a few digits.
After the salesman picked up his jaw, he said, “uh, OK, follow me.”
They did not have that exact model any more, so we got the most similar
It worked great; still does. Problem solved.
But can you do the same thing with drugs for schizophrenia?
Imagine going to the doctor and having your son blurt out,
“He needs to be on Zyprexa.”
It could happen, of course. No one is safe from these
Our Recommendations — A Summary
Antipsychotic drugs help many people with schizophrenia live more
meaningful, stable lives with fewer – and sometimes no
– periods of hospitalization. But they are a highly
problematic class of medicines. A sizeable percentage of
people with schizophrenia get little or no benefit when they take an
antipsychotic while others get only a partial reduction in
symptoms. Side effects pose a major barrier to continuous
use. In studies, for example, three of every four people
stopped taking an antipsychotic or switched to a different one within
Newer and quite expensive antipsychotics marketed heavily to doctors
over the past 15 years have largely eclipsed an older generation of
drugs developed in the 1950s and 1960s. Research for years
appeared to indicate that the newer drugs were better, largely because
they had fewer side effects. But recent large-scale studies
now indicate that, overall, the older drugs work just as well, at far
Taking effectiveness, safety, side effects, patient variability, dosing
convenience, and cost into account, we have chosen the following as
Consumer Reports Best Buy Drugs:
* Generic perphenazine – as
initial treatment for people newly diagnosed with schizophrenia and for
people with schizophrenia who have failed on a newer drug and whose
doctor thinks perphenazine is worth a try. Patients taking
perphenazine should be monitored closely for muscle tremors and spasms.
* Olanzapine (Zyprexa) – for
certain people with schizophrenia who take perphenazine first and get
no or minimal benefit and/or experience intolerable side
effects. Zyprexa is not a good option, however, for people
who are overweight, have blood sugar abnormalities, diabetes, or heart
* Risperidone (Risperdal) –
for people with schizophrenia who take perphenazine first and get
minimal benefit and/or experience intolerable side effects.
* Generic clozapine – for
people with moderate to severe schizophrenia who have not responded at
all to two or more other antipsychotics and have had little
reduction in symptoms.
The choice of generic perphenazine – if a patient responds
well to it – saves about $200 to $500 a month ($2,400 to
$6,000 a year) compared to Zyprexa and Risperdal, depending on the dose
We make no choice of a Best Buy antipsychotic for people with bipolar
disorder. There is not enough evidence to do so.
This information and our report were last updated in November 2006.
Report (400k PDF)
Note, however, that I endorse the full report, but find the synopsis a
bit misleading. I also worry a bit that people might look at
certain summary statements, and mistake them for conclusions, without
carefully reading the whole thing and drawing their own conclusions,
which is the only way to make good use of such a report.
Also, there are some statements that worry me a bit:
or more antipsychotic medicines at the same time. This increases the
risks of side effects, and the benefits are unproven.
It is true that use of multiple antipsychotics does increase risk, and
cost, and there is no clear evidence of benefit…in a population of
people. That does not mean that no individual will benefit,
just that in a population, it is hard to show a systematic benefit.
Although you generally want to stick with treatment
strategies that are backed by a stack of evidence, sometimes
circumstances are such that it makes sense to try things that do not
have a solid evidence base. That is a complex issue, though,
and I do not fault them strongly for not explaining that fully.
poses, clozapine is prescribed only for people with schizophrenia who
have not benefited from any other antipsychotic drug.
Clozapine is used for persons with bipolar disorder, too, and
schizoaffective disorder. It is clearly the most efficacious
drug we have. It is also the most dangerous, and pretty much
everyone gets adverse effects of some sort. But, if you ask a
bunch of psychiatrists which drug they would want to take if they
developed schizophrenia, some of them would want to start with
By the way, I’ve never started someone on clozapine without first
trying at least two atypicals, and one typical. Just because
I think I would want to start with clozapine does not mean that I
recommend that others do so. I am probably a lot more willing
to face the risks than most people would be.
To get to the main point: even though it may seem odd to think of a
“best buy” drug for schizophrenia, there is some sense to their
approach. They clearly did a lot of work on this, and it is
worth reading. It is important to read the whole thing,
though, before making any important decisions, and to keep in mind —
very seriously — their disclaimer that the report does not constitute
medical advice. (Additional disclaimer: this blog — any blog, for that
matter — does not constitute medical advice.) Rather, it is
one source of information to be considered among others.