Relapse prevention in schizophrenia: a systematic review and meta-analysis of second-generation antipsychotics versus first-generation antipsychotics

Few controlled trials compared second-generation antipsychotics (SGAs) with first-generation antipsychotics (FGAs) regarding relapse prevention in schizophrenia. We conducted a systematic review/meta-analysis of randomized trials, lasting >= 6 months comparing SGAs with FGAs in schizophrenia. Primary outcome was study-defined relapse; secondary outcomes included relapse at 3, 6 and 12 months; treatment failure; hospitalization; and dropout owing to any cause, non-adherence and intolerability. Pooled relative risk (RR) (+/-95% confidence intervals (CIs)) was calculated using random-effects model, with numbers-needed-to-treat (NNT) calculations where appropriate. Across 23 studies (n = 4504, mean duration = 61.9+/-22.4 weeks), none of the individual SGAs outperformed FGAs (mainly haloperidol) regarding study-defined relapse, except for isolated, single trial-based superiority, and except for risperidone's superiority at 3 and 6 months when requiring >= 3 trials. Grouped together, however, SGAs prevented relapse more than FGAs (29.0 versus 37.5%, RR = 0.80, CI: 0.70-0.91, P = 0.0007, I-2 = 37%; NNT= 17, CI: 10-50, P = 0.003). SGAs were also superior regarding relapse at 3, 6 and 12 months (P = 0.04, P < 0.0001, P = 0.0001), treatment failure (P = 0.003) and hospitalization (P = 0.004). SGAs showed trend-level superiority for dropout owing to intolerability (P = 0.05). Superiority of SGAs regarding relapse was modest (NNT = 17), but confirmed in double-blind trials, first- and multi-episode patients, using preferentially or exclusively raw or estimated relapse rates, and for different haloperidol equivalent comparator doses. There was no significant heterogeneity or publication bias. The relevance of the somewhat greater efficacy of SGAs over FGAs on several key outcomes depends on whether SGAs form a meaningful group and whether mid-or low-potency FGAs differ from haloperidol. Regardless, treatment selection needs to be individualized considering patient- and medication-related factors. Molecular Psychiatry (2013) 18, 53-66; doi:10.1038/mp.2011.143; published online 29 November 2011