Traditional Versus Atypical Antipsychotics and by MikeJenny

VIEWS: 150 PAGES: 13


               Traditional Versus Atypical Antipsychotics and

                   Their Effect on Treating Schizophrenia

                              Caitlin Hayden

                       University of New Hampshire
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                        2

                      Traditional Versus Atypical Antipsychotics and

                          Their Effect on Treating Schizophrenia


       In the past, traditional antipsychotic medications have been the standard in

psychopharmacology for treating schizophrenia. Schizophrenia cannot be cured however,

antipsychotic drugs can control the underlying psychotic symptoms associated with the

disorder. One group of antipsychotic medications is the conventional, or traditional, drugs

that are dopamine antagonists (D2 receptor agonists) (Varcarolis, Carson, & Shoemaker,

2006, pg. 404). The second group of antipsychotic medications is atypical drugs that are

serotonin-dopamine antagonists (5-HT2A receptor antagonists). Traditional

antipsychotics aim to control the positive symptoms of schizophrenia; the hallucinations,

delusions, disordered thinking, and paranoia. However, they are becoming obsolete in the

treatment of schizophrenia because of the troubling side effects. The blocking of the D2

receptor causes EPS and anticholinergic effects. (Varcarolis et al., 2006, p.407). For the

record, this group of antipsychotic medications is much less expensive than atypical

agents and come in depot form. In addition to relieving the positive symptoms of

schizophrenia, atypical antipsychotics can also control the negative symptoms of

schizophrenia (blunted affect, deficits in social interaction, and lack of motivation) in

addition to the positive symptoms. This group of antipsychotics emerged 20 years ago

starting with clozapine, also known as Clolzaril. Atypical antipsychotics are said to have

fewer side effects and be better tolerated. Chosen as the first line antipsychotics, they

encourage medication compliance and lessen rate of relapse, improve symptoms of

depression and anxiety, and decrease suicidal behavior (Varcarolis et al., 2006, pg. 405).
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                       3

. Side effects are minimal but serious including: weight gain, metabolic abnormalities

(glucose dysregulation, hypercholesterolemia) that can increase the likelihood of cardiac

conditions and diabetes.

       In spending an entire semester in a mental health clinical rotation, it is evident

that numerous medications are used to treat schizophrenia. A medication regimen is

specific to each individual patient and side effects are handled differently with each

patient. Like all medications, physicians can favor certain ones or have had seen better

results in certain ones when used by some of their patients. In my clinical practicum I

have noticed this clinical issue. Information in textbooks make atypical antipsychotic

medications appear to be the best option to treat schizophrenia but in my clinical

practicum I have seen both groups of antipsychotic medications used and deemed


       Traditional antipsychotics are stereotyped to have undesired side effects that steer

patients away from them but the atypical group also have their respective side effects. I

have worked with patients who have been prescribed atypical antipsychotics and others

patients who have been prescribed traditional antipsychotics. I have actually seen more

patients concerned with weight gain from the atypical agents than the EPSs from the

traditional agents. During my clinical rotation I have seen certain psychiatrists push a

certain group of medications on patients and I have always wondered if there was

evidence to back up that one group of medications is more effective than other. I would

expect that studies would show that atypical medications make for more medication

compliance due to lessened EPSs. However, I would expect the research to mention that

these atypical medications do cause weight gain, something that is undesired for all
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                          4

patients. I would also expect mention of the fact that traditional medications are less

expensive and more available in varying dosages.

                                    Clinical Bottom Line

       Evidence based research provides a basis of reasoning behind a current practice. It

means that the practice has been initiated, attempted, and then either seen to success or

failure. It is important to know if a current practice in place is supported by the best

possible evidence based research because it gives us a stronger backing and support base

for care. It is especially important when informing patients about treating schizophrenia

and the medications that have been shown and tested to be effective. If current practices

are not supported by the best possible evidence based research patients receiving the

treatment may be more apt to question the use or reasoning behind the care. Yes, there

are practices that do work and are not backed by evidence based research however they

are not as widely accepted by patients. In the case of these antipsychotic medications

where all patients have different reactions and results with different medications the

reasoning behind giving certain medications takes more of a personalized approach.

Research might be able to say that certain medications work better than others do because

it was tested on a population of patients with schizophrenia but the results may not

necessarily be applied to all schizophrenia patients. Even still, the research can surely be

used as a reference tool and something to base the current practice on.

                                 Case and Clinical Question
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                          5

       My PICO question is: In treating Schizophrenia, what are the effects of atypical

antipsychotic medications on symptoms and cognitive function compared with traditional

antipsychotics as it relates to medication compliance and undesired side effects? I chose

this as a question to research because while doing my mental health rotation I have come

across a lot of medication discussion and was curious as to if there is evidence available

to prove that one group of antipsychotic medications is better than the other. This

question is interesting to me because medication is a serious part of treating mental

illnesses. What the medications do and how they affect the patient are very important

factors that are questioned by the patient and discussed with them. Antipsychotic

medications in particular, that affect the brain and nervous system, for a patient with

altered brain function can be difficult to advise patients to comply with.

                                     Search and Studies

       I utilized the University of New Hampshire’s Dimond Library to access my

research articles. Under the “Health/Medicine/Sports” category I searched the following

electronic databases: CINAHL, MEDLINE, PsycINFO, and PubMed. I began by using

keywords including “schizophrenia medications”, “antipsychotics”, “atypical

antipsychotics”, and “traditional antipsychotics”. For each search I found numerous

articles with the key words in the title but upon further examination only a handful of

accessible articles were relevant to my PICO question. I came across many informational

articles regarding atypical and traditional antipsychotic medications; I chose to disregard

them for the analysis portion due to the fact that they did not involve or discuss any

clinical trials that could provide statistical results proving or disproving a hypothesis of
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                        6

one group of antipsychotic medications being more effective than the other. One of the

articles that I decided not to use was, “Healthy Promotion in Persons with Schizophrenia:

Atypical Medications”. It went into great detail about the effects of atypical medications

and specific medications and their actions. It touched based on traditional antipsychotics

but was stated in a bias way which is not conducive to my PICO question and the clinical

issue. I came across some difficulty in finding articles pertinent to my topic because

many of the articles were focused solely on atypical antipsychotics or solely on

traditional antipsychotics without mention of the other group of medications. Without

studies which compare the effects of both groups of antipsychotics there is no research to

provide evidence that one group is more superior. I also contribute the difficulty of my

search process to the lack of research surrounding this comparison. However, I did

manage to find the following articles which related directly to my PICO question,

“Double-blind comparison of first- and second-generation antipsychotics in early-onset

schizophrenia and schizo-affective disorder: findings from the treatment of early-onset

schizophrenia spectrum disorders (TEOSS) study”, “Effectiveness of Antipsychotic

Drugs in Patients with Chronic Schizophrenia”, and “Antipsychotic Effects on Cognition

in Schizophrenia: A Meta-Analysis of Randomised Controlled Trials”.


       The first pertinent article that I found was, “Double-blind comparison of first- and

second-generation antipsychotics in early-onset schizophrenia and schizo-affective

disorder: findings from the treatment of early-onset schizophrenia spectrum disorders

(TEOSS) study”. It was a multi-site, double blind study done in the spring of 2006 by a
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                         7

number of doctors, nurse practioners, and nurses. The objective of the study was clearly

stated at the beginning of the article: to compare the safety and efficacy of olazapine and

risperidone (atypical) and molindone (traditional). 116 patients, between the ages of 8

and 19 years old, diagnosed with early onset schizophrenia (EOS) or schizoaffective

disorder were involved. The participants were randomly assigned olazapine, risperidone,

or molindone daily for eight weeks. On the Levels of Evidence Pyramid, a random

control trial is second from the top, making this research study a strong piece of evidence

(University of Illinois, 2009).

       The entire article is very easy to comprehend and follow as it is divided into

method, results, discussion, and conclusion. Each division is elaborated upon and

provides detailed information regarding the study setting and design, participants,

interventions, outcomes, and statistical analyses. The major limitation of the study was

identified as the small sample size which inhibited the ability to identify predictors of

response or adverse effects and only allowed for the identification of large differences. I

identified this as a weakness of the evidence. A small sample signs means that the results

cannot be generalized to a larger population. However, in the conclusion,

recommendations for further study and analysis on this topic are stated. Overall, I would

consider this research article to be a good base for evidence practice, although it should

be used to accompany other research articles. It was well written, and had a well designed

and well organized study that was completed thoroughly. From the study results the

authors were able to state that, “risperidone and olanzapine did not demonstrate superior

efficacy over molindone for treating early-onset schizophrenia and schizoaffective

disorder” and, “the results question the nearly exclusive use of second-generation
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                           8

antipsychotics to treat early-onset schizophrenia and schizoaffective disorder”(Sikich et

al., 2008).

        Another article that I located was “Effectiveness of Antipsychotic Drugs in

Patients with Chronic Schizophrenia”. It was a CATIE (Clinical Antipsychotic Trials of

Intervention Effectiveness) study. Initiated by the National Institute of Mental Health,

this study was aimed at comparing perphenazine, a first generation (traditional)

antipsychotic, to newer (atypical) drugs. In the abstract, a purpose was not clearly

identified, although it stated that, “the relative effectiveness of second-generation

(atypical) antipsychotic drugs as compared with that of older agents has been

incompletely addressed, though newer agents are currently used far more commonly”

(Lieberman et al.,2005). In this double-blind, randomized control trial, 1483 patients

were assigned to receive olanzapine, perphenazine, quetiapine, or risperidone and then

followed for up to 18 months or until treatment was discontinued.

        One strength of this research article that relates to reliability is the fact that it was

stated that the study was approved by the institutional review board at and informed

consent was obtained from the patients or legal/guardians. A hypothesis of significant

differences in the overall effectiveness of olanzapine, perphenazine, quetiapine,

risperidone, and ziprasidone in treating schizophrenia reflecting variations in efficacy and

tolerability, was tested using patient characteristics and symptoms. These factors were

measured using the PANSS (Positive and Negative Syndrome Scale) and the Clinical

Global Impressions (CGI) Scale. The study design, participants, interventions, objectives

and outcomes, and statistical analysis were all included and discussed thoroughly in the

research article. Charts and tables were included to show the results. The article had a
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                       9

very professional tone that was organized and well written. The authors recognized that

dosage may have been a factor in effecting the results. Although the dose range was

approved by the FDA, all participants of the study reacted differently. Results showed

that 74 percent of the patients discontinued their assigned medications prior to the

eighteenth month due to intolerable side effects. Olanzapine (an atypical antipsychotic)

had the lowest discontinuation rate and it was concluded that, “patients with chronic

schizophrenia in this study discontinued their antipsychotic study medications at a high

rate, indicating substantial limitations in the effectiveness of the drugs” (Lieberman et


       The final article that I found was a meta-analysis of 18 randomized control trials

testing the effects of antipsychotic medications, both atypical and traditional.

“Antipsychotic effects on cognition in schizophrenia: A meta-analysis of randomised

controlled trials” was completed in November of 2008 by using the Medline database to

find studies that had the same aim: seeing if the use of atypical agents provided better

results than traditional agents in treating patients with schizophrenia. The Medline search

was “a) limited to randomised controlled trials which examined adult patients, aged

between 16 and 65, diagnosed with schizophrenia, or a schizoaffective or

schizophreniform disorder; b) used at least one standardised neuropsychological test that

appears in the Lezak manual, and c) present the necessary data to estimate an effect size

(i.e., means and standard deviations on neuropsychological measures, or t, F, or p

values)” (Guilera, Pino, Gómez-Benito & Rojo, 2009). The antipsychotic medications

used in the studies included olanzapine, risperidone, haldolperidol, clozapine, and

TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                      10

       A meta-analysis is a specific type of systematic review and at the top of the

Levels of Evidence Pyramid (University of Illinois, 2009). Because it compares and

summarizes numerous studies it is considered the strongest level of evidence. As with

most meta-analyses, the summary of all research studies comes with limitations. For this

particular meta-analysis the limitations were recognized as study design, pharmacological

method used, and neuropsychological tests administered. The 18 studies examined

consisted of both double blinded and non blinded designs which may indicate that the

results of the non blinded studies are biased. Also, there was no consistency regarding

dosage of the medications used. The variability of the neuropsychological tests affects the

results as they relate to efficacy. The authors of the meta-analysis categorized cognitive

function into 11 domains and listed all of the tests that are associated with each. This

allowed the 18 studies to be divided and assessed based on the cognitive domain they

tested. The authors then translated the cognitive testing to measurements on the global

cognitive index. In reviewing the 18 independent studies, atypical agents showed slight

improvements in the global cognitive index (Guilera et al., 2009). However, due to the

limitations mentioned, conclusions regarding atypical agents improving neurological

status more so than traditional agents can not be made. The authors recommended that

more research be done around atypical agents versus traditional agents. Overall, this

research article was well written, well organized and very thorough; the authors made

sure to include every little detail about the strengths and weaknesses of the meta-analysis.

                                Comments and Conclusion
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                         11

       After analyzing the research articles that I found relating to my PICO question (In

treating Schizophrenia, what are is the effect of atypical antipsychotic medications on

symptoms and cognitive function compared with traditional antipsychotics as it relates to

medication compliance and undesired side effects?) I was able to sense a common theme.

The results of the meta-analysis and the two other studies can not provide statistical

significance stating that atypical antipsychotics are more effective in treating

schizophrenia than traditional antipsychotics. From this information I am without any

best evidence supporting or refuting my PICO question.

       Based on what I have learned from my research and search process, the research

in this area of nursing is incomplete. All of the studies stated that further research must be

completed to appropriately address the topic. I agree that more research needs to be done.

Using evidence based practice is becoming more and more popular and desired in all

nursing and healthcare fields and mental health is no exception. In order for current

practices to be considered the best practices they must be backed by evidence. Future

research studies must be tightly controlled and well designed to ensure that there is

consistency in the methods and results. Of course, larger samples sizes will enable the

results of the studies to be generalized to a population of schizophrenia patients.

        I have gained an ample amount of information regarding atypical and traditional

antipsychotic medications in regards to their actions, side effects, patient reactions, and

medication compliance. And in the event that I endure the mental health route I will

continue to follow research regarding this topic. With this knowledge nurses (myself

included) can better aid and educate their patients about such medications. On a more
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                              12

general note this research has made me more aware of current practices backed by

evidence based research and sparked my curiosity regarding other nursing topics.
TRADITIONAL VS ATYPICAL ANTPSYCHOTICS                                                          13


Beebe, L. (2003). Health promotion in persons with schizophrenia: atypical medications.

        Journal of the American Psychiatric Nurses Association, 9(4), 115-122. Retrieved

        from CINAHL Plus with Full Text database.

Guilera, G., Pino, O., Gómez-Benito, J., & Rojo, J. (2009). Antipsychotic effects on

        cognition in schizophrenia: A meta-analysis of randomised controlled trials. The

        European Journal of Psychiatry, 23(2), 77-89. Retrieved from PsycINFO


Lieberman JA, Stroup TS, McEvoy JP, et al. (2005) Effectiveness of Antipsychotic

        Drugs in Patients with Chronic Schizophrenia. New England Journal of Medicine;

        353 (12): 1209-1223.

Sikich, L., Frazier, J., McClellan, J., Findling, R., Vitiello, B., Ritz, L., et al. (2008).

        Double-blind comparison of first- and second-generation antipsychotics in early-

        onset schizophrenia and schizo-affective disorder: findings from the treatment of

        early-onset schizophrenia spectrum disorders (TEOSS) study. American Journal

        of Psychiatry, 165(11), 1420-1431. Retrieved from CINAHL Plus with Full Text

University of Illinois-Chicago (2009). Evidence-based practice in the health sciences:

        Evidence-based nursing tutorial. Retrieved from

Varcarolis, E.M, Carson, V.B., & Shoemaker, N.C. (2006). Foundations of psychiatric

        mental health nursing: a clinical approach. St. Louis, Missouri: Elsevier.

To top