Schizophrenia is one of the most common psychiatric disorders in adults worldwide – one in 100 people globally are affected over a lifetime. Our understanding of the causes of the condition has increased but antipsychotic drugs are still the firstline treatment for symptoms such as hallucinations, delusions, and cognitive impairment.

The study reported in The Lancet is the largest analysis of its kind. It included 402 studies of 32 different antipsychotics with data for 53,463 participants. The method of analysis used enabled comparisons between drugs that may not have been directly compared in clinical trials.

The study’s findings show that antipsychotics are effective in treating acute psychotic episodes and their use is associated with a lower mortality rate compared with no treatment. However, while these drugs provide effective treatment, they can also cause serious side-effects.  Striking a balance between these side-effects and the drugs’ benefits is a key consideration in prescribing these medications.

Both newer and older antipsychotics were included in the analysis and the difference in their efficacy was found to be relatively small. In contrast the paper highlights a more marked difference in side effects between first and second generation drugs, with newer drugs being associated with more serious side-effects.

Many current prescribing guidelines recommend newer antipsychotics to treat psychosis but information provided by this analysis will help to inform future prescribing decisions. Many older antipsychotics, which are still widely available, may provide an equally effective and more tolerable first line treatment for some patients. These drugs are also often less costly, an important consideration in lower income countries.

Professor Andrea Cipriani, co-author of the study added “We have summarised the best evidence, but now the real challenge is to personalise treatment to each individual. We are already working on this (not only in schizophrenia, but also in depression) and the big challenge is to use the best data in combination with real world outcomes, incorporating preferences and values of patients and clinicians.”