Despite schizophrenia's longstanding affliction of humankind,¹ effective treatments for this debilitating disorder only became available in the middle of the 20th century.² Numerous, now landmark, studies^3-5 demonstrated incontrovertibly that chlorpromazine, the prototypic antipsychotic, was more effective than nonpharmacologic treatment (eg, placebo, psychotherapy) in alleviating the acute symptoms of schizophrenia and preventing their recurrence. Although many effective antipsychotics have been introduced in the wake of chlorpromazine, the pace of real progress through drug development and innovation has been arduous and slow.

Any doubts about this unfortunate reality should be eliminated by the results described in Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1),^6,7 which are virtually identical to those described previously from Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE).^8,9 These studies found few differences in effectiveness between first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) in nonrefractory patients—a conclusion that runs counter to the impressions of many clinicians and previous studies suggesting marked superiority of the SGAs and that belies the huge advantage in market share enjoyed by the SGAs in the United States and other parts of the world. However, the results of these studies are generally consistent with numerous meta-analyses^10-22 carried out during the past decade in an effort to discern a clearer picture of the comparative effectiveness of antipsychotic drugs than could be derived from any previous individual trial. (The 1 exception to these meta-analyses is that of Davis et al²³.) This convergence of evidence should dispel the illusion of the vast superiority of the SGAs and should have wide-ranging effects on practice patterns and policies.