|Older Drug May Be More Cost-Effective for Some
Patients with Schizophrenia
A new study analyzing the economic implications of the Clinical
Antipsychotic Trials of Intervention Effectiveness (CATIE) concludes
that the older (first generation) antipsychotic medication perphenazine
was less expensive and no less effective than the newer (second
generation) medications used in the trial during initial treatment,
suggesting that older antipsychotics still have a role in treating
schizophrenia. The study, published in the American Journal
of Psychiatry on December 1, 2006, was funded by the National
Institutes of Health’s National Institute of Mental Health (NIMH).
The $42.6 million CATIE trial aimed to help doctors and the 2.4
million Americans who suffer from chronic schizophrenia tailor
treatments to individual needs. It is the first study to directly
compare several second generation antipsychotic medications and
a representative first generation antipsychotic medication.
“The results from CATIE should encourage doctors to reconsider
the use of perphenazine as another choice for patients with schizophrenia,” said
NIMH Director Thomas R. Insel, M.D.
More than 90 percent of antipsychotic prescriptions are written
for second generation medications, despite the fact they are more
expensive than the first generation agents used to treat schizophrenia.
The majority of clinicians have traditionally believed that the
newer antipsychotics are more effective and better tolerated than
older agents, and many experts argued that these advantages justified
the difference in cost.
Robert Rosenheck, M.D., of Yale University, and colleagues analyzed
costs and quality-of-life factors associated with each of the five
medications used in Phase 1 of the CATIE trial — olanzapine,
quietapine, risperidone, ziprasidone, and perphenazine. They found
that total monthly health costs, a figure that includes both average
medication costs and inpatient and outpatient costs, were up to
30 percent lower for those taking the perphenazine than for those
taking the second generation medications. In addition, the researchers
found no statistically significant difference in overall effectiveness
between perphenazine and the second generation antipsychotics,
with regard to symptom relief and side effect burden.
The findings echo what was implied in the results of the first
phase of CATIE, http://www.nimh.nih.gov/press/catie_release.cfm,
expanding the treatment options for patients with schizophrenia.
It casts doubt on the notion that the second generation antipsychotics
are better than the first generation antipsychotics, and suggests
that perphenazine and other first generation antipsychotics may
be just as beneficial for some patients.
Still, several conditions of CATIE limit any firm conclusions
about perphenazine’s perceived advantages. Not all patients respond
the same to different medications. In addition, the study lasted
18 months — long enough to determine how patients respond
to and initially tolerate the drugs, but not long enough
to consider some serious long-term side effects, such as development
of the movement disorder tardive dyskinesia (TD), diabetes, cardiovascular
problems, or other medical conditions that can develop even years
after a patient with chronic schizophrenia starts taking an antipsychotic
medication. Despite these caveats, the study results suggest new
ways of thinking about medication treatments for schizophrenia.
“These results encourage doctors to revisit the older medication
as an alternative, especially if a treatment change is warranted,” said
Dr. Rosenheck. “By showing that perphenazine and possibly other
older antipsychotics may be on equal footing with the second generation
antipsychotics, CATIE has opened the door to more choice in treatment
The National Institute of Mental Health (NIMH) mission is
to reduce the burden of mental and behavioral disorders through
research on mind, brain, and behavior. More information is available
at the NIMH website, http://www.nimh.nih.gov.
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Human Services. It is the primary federal agency for conducting
and supporting basic, clinical and translational medical research,
and it investigates the causes, treatments, and cures for both
common and rare diseases. For more information about NIH and
its programs, visit www.nih.gov.