The subdivision of the class of antipsychotic drugs into two discrete groups
– ‘conventional’ (or first generation) and ‘atypical’ (or second generation)
– has been adopted as standard, with the latter generally accepted as
‘better’ and widely recommended as automatic first-line choices. However,
this perception has been thrown into confusion with the results of large
pragmatic trials that failed to identify advantages with the new, more
expensive drugs, while identifying worrying tolerability issues. This
article explores the origins of ‘atypicality’, its construction on the back
of a confusing and weak clinical validator (diminished liability to promote
parkinsonism) and how even in relation to the archetypical atypical,
clozapine, the uncertain boundaries of drug-induced extrapyramidal
dysfunction may be contributing to confusion about ‘efficacy’ and
‘tolerability’. It argues that abandoning atypicality would open up clinical
practice to all drugs of a single class of ‘antipsychotics’ and allow for
individualised risk/benefit appraisal as a basis for truly tailored
treatment recommendations.