In Reply: We thank Drs. Remington and Shammi for their thoughtful comments and for giving us the opportunity to clarify the inspiration for—and the intent of—our recommendations. We agree wholeheartedly with them and with the authors whose work they cite that the second-generation antipsychotics, other than clozapine, offer only modest improvements, at best, over their predecessors. Rather, the expectation of a more favorable outcome for many patients with schizophrenia derives from the observations of Harding and Brooks (1) and from Strauss and Carpenter (2), among others, who studied the longitudinal course of patients treated with first-generation antipsychotics beginning nearly half a century ago.
Indeed, the expectation of a pharmacologic magic bullet to cure schizophrenia may contribute to the reluctance of our professional peers to actively pursue the outcomes that were reported possible in these earlier studies. Such reluctance has been well highlighted in findings of the small number of treatment programs that meet the Schizophrenia Patient Outcomes Research Team standards, which were widely accepted in theory but only rarely in practice (3).
Such outcomes are enhanced by applying the best overall treatment methods currently available (4). These approaches require considerably more than pharmacologic interventions and thus will require both program restructuring and more effective use of resources. Motivation to improve will grow as differences emerge between outcomes of treatment programs that are competing for ever-scarcer funds. Programs will ultimately be evaluated by payers on the basis of successful outcomes. Dramatic differences in outcomes are already emerging in the general health arena (5), and in our field they cannot be far behind.