The Corpus Callosum

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 you?  

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 one.  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 diseases.

I was skeptical when I read the synopsis, but I must say, the actual report is fairly good.  

Treating Schizophrenia and Bipolar Disorder

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 18 months.

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 lower cost.

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 disease.

    * 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 required.

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.

Full 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:


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.


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 clozapine.

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.