New generation vs. first generation antipsychotics debate: pragmatic clinical trials and practice-based evidence.

There has been significant confusion about the relative advantage of new generation antipsychotics over first generation antipsychotics as well as of clinical trials performed to evaluate their efficacy vs. those designed to evaluate their effectiveness. Pragmatic or effectiveness clinical trials like CATIE and CUtLASS sponsored by governments have challenged the current worldview of the greater advantages of new generation over first generation antipsychotics and suggested more clinical applicability of older antipsychotics. Public policy regarding the role and place of modern antipsychotics in schizophrenia treatment is usually guided by the imperfect state of clinical trials and by economic constraints. The right question is not whether new generation antipsychotics are better than first generation antipsychotics in terms of effectiveness, tolerability and safety. How to reach personalized , evidence based and value oriented decision making in the complex treatment of schizophrenia and other psychotic disorders, that is the question now. Personalized medicine in psychiatry is not possible without the availability of enough number of different modern antipsychotics.