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Cited by 2,561Schizophrenia research and treatmentMental Health and PsychiatryTreatment of Major Depression

Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis

Leucht, Stefan, Cipriani, Andrea, Spineli, Loukia, Mavridis, Dimitris, Örey, Deniz, Richter, Franziska, Samara, Myrto, Barbui, Corrado +7 more·2013·The Lancet
DOI 10.1016/s0140-6736(13)60733-3
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Abstract

Background The question of which antipsychotic drug should be preferred for the treatment of schizophrenia is controversial, and conventional pairwise meta-analyses cannot provide a hierarchy based on the randomised evidence. We aimed to integrate the available evidence to create hierarchies of the comparative efficacy, risk of all-cause discontinuation, and major side-effects of antipsychotic drugs.Methods We did a Bayesian-framework, multiple-treatments meta-analysis (which uses both direct and indirect comparisons) of randomised controlled trials to compare 15 antipsychotic drugs and placebo in the acute treatment of schizophrenia. We searched the Cochrane Schizophrenia Group's specialised register, Medline, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for reports published up to Sept 1, 2012. Search results were supplemented by reports from the US Food and Drug Administration website and by data requested from pharmaceutical companies. Blinded, randomised controlled trials of patients with schizophrenia or related disorders were eligible. We excluded trials done in patients with predominant negative symptoms, concomitant medical illness, or treatment resistance, and those done in stable patients. Data for seven outcomes were independently extracted by two reviewers. The primary outcome was efficacy, as measured by mean overall change in symptoms. We also examined all-cause discontinuation, weight gain, extrapyramidal side-effects, prolactin increase, QTc prolongation, and sedation.Findings We identified 212 suitable trials, with data for 43 049 participants. All drugs were significantly more effective than placebo. The standardised mean differences with 95% credible intervals were: clozapine 0·88, 0·73-1·03; amisulpride 0·66, 0·53-0·78; olanzapine 0·59, 0·53-0·65; risperidone 0·56, 0·50-0·63; paliperidone 0·50, 0·39-0·60; zotepine 0·49, 0·31-0·66; haloperidol 0·45, 0·39-0·51; quetiapine 0·44, 0·35-0·52; aripiprazole 0·43, 0·34-0·52; sertindole 0·39, 0·26-0·52; ziprasidone 0·39, 0·30-0·49; chlorpromazine 0·38, 0·23-0·54; asenapine 0·38, 0·25-0·51; lurasidone 0·33, 0·21-0·45; and iloperidone 0·33, 0·22-0·43. Odds ratios compared with placebo for all-cause discontinuation ranged from 0·43 for the best drug (amisulpride) to 0·80 for the worst drug (haloperidol); for extrapyramidal side-effects 0·30 (clozapine) to 4·76 (haloperidol); and for sedation 1·42 (amisulpride) to 8·82 (clozapine). Standardised mean differences compared with placebo for weight gain varied from -0·09 for the best drug (haloperidol) to -0·74 for the worst drug (olanzapine), for prolactin increase 0·22 (aripiprazole) to -1·30 (paliperidone), and for QTc prolongation 0·10 (lurasidone) to -0·90 (sertindole). Efficacy outcomes did not change substantially after removal of placebo or haloperidol groups, or when dose, percentage of withdrawals, extent of blinding, pharmaceutical industry sponsorship, study duration, chronicity, and year of publication were accounted for in meta-regressions and sensitivity analyses.Interpretation Antipsychotics differed substantially in side-effects, and small but robust differences were seen in efficacy. Our findings challenge the straightforward classification of antipsychotics into first-generation and second-generation groupings. Rather, hierarchies in the different domains should help clinicians to adapt the choice of antipsychotic drug to the needs of individual patients. These findings should be considered by mental health policy makers and in the revision of clinical practice guidelines.Funding None.

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  • Clozapine is the most effective antipsychotic drug, followed by a mid-efficacy group of amisulpride, olanzapine, risperidone and paliperidone, then the remaining novel and old antipsychotics such as haloperidol and chlorpromazine.

    “Some antipsychotics are more effective for psychosis than others – clozapine has been recognised as the most effective antipsychotic drug, followed by a mid-efficacy group of amisulpride, olanzapine, risperidone and paliperidone, then the remaining novel and old antipsychotics such as haloperidol and chlorpromazine.1”

    From Stopping and switching antipsychotic drugs (2019) · cites this paper as [1]

  • Aripiprazole is associated with fewer adverse effects such as sedation, weight gain, cholesterol and prolactin increase.

    “Unlike other antipsychotics, aripiprazole is associated with fewer adverse effects such as sedation, weight gain, cholesterol and prolactin increase [31].”

    From Clinical Advances in Treatment Strategies for Obsessive-compulsive Disorder in Adults (2023) · cites this paper as [31]

  • Gym-based resistance exercise may offer a clinical pathway to care for young people with early psychosis or veterans with post-traumatic stress disorder.

    “For example, the provision of gym-based resistance exercise may offer a clinical pathway to care for young people with early psychosis, 244 or veterans with posttraumatic stress disorder 245 .”

    From The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness (2019) · cites this paper as [244]

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Authors
Leucht, S., Cipriani, A., Spineli, L., Mavridis, D., Örey, D., Richter, F., Samara, M., Barbui, C., Engel, R. R., Geddes, J. R., Kissling, W., Stapf, M. P., Lässig, B., Salanti, G., & Davis, J. M.
Affiliations
  • TUM Klinikum (DE)
  • University of Verona (IT)
  • University of Ioannina (GR)
  • Ludwig-Maximilians-Universität München (DE)
  • Warneford Hospital (GB)
  • University of Illinois Chicago (US)
Corresponding author
Leucht, Stefan
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2013-09
Volume
382
Issue
9896
Pages
951-962
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(13)60733-3
OpenAlex
W2009832071
Cited by
2,561
References
61
Citations by year
2026: 134 · 2025: 135 · 2024: 161 · 2023: 146 · 2022: 182 · 2021: 215 · 2020: 223 · 2019: 221 · 2018: 217 · 2017: 228 · 2016: 255 · 2015: 243 · 2014: 160 · 2013: 36 · 2012: 3
FWCI
164.63
Type
journal article
Language
en
Open access
closed
Locations
  • The Lancet (publishedVersion)
  • PubMed (publishedVersion)
  • mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
Funders
  • National Institute for Health and Care Research (NF-SI-0611-10150)
  • H. Lundbeck A/S
  • Medical Research Council
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
  • Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
  • Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
Keywords
schizophrenia, antipsychotic drugs, drug efficacy comparison, tolerability, Bayesian framework, weight gain, extrapyramidal symptoms, QTc prolongation, sedation, clozapine, amisulpride, olanzapine, risperidone, paliperidone, zotepine
MeSH terms
Adult, Humans, Schizophrenia, Antipsychotic Agents, Randomized Controlled Trials as Topic, Treatment Outcome

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