Introduction

Are All Atypical AntipsychoticsEqual for the Treatment of Cognition

and Affect in Schizophrenia?By Joseph Zohar, MD

One of the major developments in psychiatry in thelast decade is the development and widespread use ofthe new antipsychotics. The field has moved from thetypical dopamine D2-blocking neuroleptics into the newera of antipsychotics with the addition of the serotonin5-HT2A properties to the classical D2 antagonism. These"atypical" antipsychotic drugs (APDs) provide us withnew tools with which to treat our patients. However,do we really know how to make the most of these newmedications? Are we equipped with the knowledge to dothe best matching between the different APDs and thepatients that we will see in an hour's time?

One potential way to get the maximum therapeuticeffect of a specific medication is to improve the match-ing between the compound and the patient that we areseeing, ie, to try and get the best medication for thepatient. For example, the medication one would choosefor a patient with cognitive decline and a tendency tobe overweight, would likely be different from an anti-psychotic one would select for a patient with the samediagnosis, but who is slim and has paranoid delusions. Itis also intuitively clear to us that we should treat first-epi-sode patients differently from those with a 20-year historyof social decline. Similarly, a patient with pronouncedaffective component would receive a different treatmentregimen from a patient who is affectively "flat."

Although we have been hearing and reading a lotabout all the different APDs, it would be quite accurateto postulate that a concise updated summary of the differ-ent APDs, examining them around four different criticalaxes, might be welcomed by our readers.

The topics covered in this supplement are: the differ-ential receptor's profile of APDs and their clinical impli-cations, the issue of cognitive impairment in schizophre-nia and APDs, monitoring guidelines to assess metabolicabnormalities that may occur with APDs, and an updateon treatment after first-episode psychosis.

In the first article, Darius K. Shayegan, BS, andStephen M. Stahl, MD, PhD, address many intriguingquestions such as why does one patient respond to oneagent and not to another? How is it that some patientsexperience side effects with one agent, yet others do not?All these questions focus on the fundamental dilemmaof how to select the medication which is best fitting interms of receptor profile on one hand and the patient'sclinical needs on the other. They also emphasize the issueand importance of appropriate dosing.

Next, Herbert Y. Meltzer, MD, focuses on the cogni-tive impairment and negative symptoms in schizophre-nia. In his scholarly review, Dr. Meltzer describes, amongother issues, the developments in mapping the differentroles of 5-HT receptors (eg, 5-HT2A versus 5-HT6 and5-HTj) in cognition and the potential implications forthe APDs in treating cognitive deficits early on.

The third article deals with the primary hippocraticprinciple of prinvum rum nocere ("first, do no harm") byproviding the reader with practical and useful guidelinesto monitor weight, glucose, and lipid imbalance. In hisarticle, Jonathan M. Meyer, MD, gives us a balancedperspective and practical tools to prevent severe somaticside effects while using APDs.

Finally, Lili C. Kopala, MD, FRCPC, describes therole of APDs in early intervention and long-term main-tenance after first-episode psychosis as a potential way toimprove long-term outcome.

The contributors should be congratulated for theirefforts to bring us a scholarly comprehensive overviewabout different aspects of using APDs. One of the goals ofCNS Spectrums is to bridge the gap between the expertsand the clinician, and I hope that this supplement willindeed succeed in this mission. 1339

Dr. Zohar is professor of psychiatry in the Division of Psychiatry at Chaim Sheba Medical Center in Tel Hashomer, Israel. He is also the inter-national editor of CNS Spectrums.

Volume 9 - Number 10 (Suppl 11) CNS Spectrums - October 2004

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