These risk-attribution measures demonstrate the dilemma clinicians face when trying to match schizophrenia patients with antipsychotics. CATIE was “an N of 1,493” subjects, whereas each patient we see in clinical practice is “an N of 1.” One patient may need a more-robust response; another may need improved tolerability.
We strive for balance, seeking to optimize efficacy—often by raising the dosage—while minimizing adverse effects.
What to tell patients
CATIE phases 1 and 2 provide a compelling rationale for individualized treatment, which should be standard clinical practice for schizophrenia:
- All drugs used in phases 1 and 2 worked.
- All showed noteworthy adverse effects that were different for each drug.
- Different patients responded differently to each drug.
Using our clinical judgment and available information, we must match—as best we can—the individual patient’s characteristics with the antipsychotics’ risk: benefit profiles. CATIE phases 1 and 2 provide independent information on the comparative efficacy and tolerability of each medication.
The CATIE investigators and NIMH have done a great service to our field in providing a rich repository of timely information to inform clinical practice. But the CATIE study was not designed to answer all our questions about treating schizophrenia.8,9 Clinicians and patients need to look elsewhere for guidance on the roles of:
- psychosocial treatments
- recovery and the therapeutic alliance in maximizing outcomes
- long-acting SGA formulations
- aripiprazole (addressed in CATIE phase 3)
- SGAs in first-episode schizophrenia
- FGAs when a patient does not adequately respond to an initial SGA.
Related resources
- Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). www.CATIE.unc.edu.
- Lieberman JA. What the CATIE study means in clinical practice. Psychiatr Serv 2006;57(8):1075.
Drug brand names
- Aripiprazole • Abilify
- Clozapine • Clozaril
- Olanzapine • Zyprexa
- Perphenazine • Trilafon
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Ziprasidone • Geodon
Disclosures
Dr. Buckley receives research/grant support from AstraZeneca Pharmaceuticals, Bristol-Myers Squibb Co., Eli Lilly & Co., Janssen Pharmaceutica, Pfizer, and Solvay Pharmaceuticals, and is a consultant to Abbott Laboratories, Alamo Pharmaceuticals, AstraZeneca Pharmaceuticals, Bristol-Myers Squibb Co., Eli Lilly & Co., Janssen Pharmaceutica, Merck & Co., and Pfizer.
Acknowledgement
The author thanks Del Miller, MD, for comments given on a draft of this paper.