Abstract
Allan White, University of Newcastle, Newcastle, Australia:
The accumulation of data indicates that the secondgeneration or ‘atypical’ antipsychotics are as effective or more effective than the older, first-generation ‘typical’ antipsychotics. The ‘typicals’ have a more severe sideeffect profile and are more likely to cause tardive dyskinesia than the ‘atypicals’ [1].
It is therefore an important decision to prescribethe ‘typicals’ which are less effective and which have a higher side-effect profile without informed consent. The debate is essentially financial. Medical administrators in the public sector have to balance the distribution of a limited tax payer dollar with the overall needs of the budget. Were the ‘atypicals’ the same price as the ‘typicals’, there would be no issue. Unlike the administrator, it is the treater who has to face the patient and the lawyer.
At this stage of development, there are no available depot preparations of ‘atypicals’ and it may be argued that compliance is enhanced using depot injections. While this benefit is probably illusory and temporary, medical practice accepts this standard. However, a patient who usually presents himself on time for an injection month after month will probably be equally compliant to medications, particularly with family support and especially if the oral medications are more acceptable.
When one considers the dual benefits of reducing side-effects and improving cognition in patients with schizophrenia by prescribing ‘atypicals’, it is difficult for any clinician to justify using the ‘typicals’ in most circumstances. If a clinician prefers to prescribe the ‘typicals’ versus the ‘atpyicals’, informed consent is essential [2].
Informed consent has three components: (i) discussion of risks and benefits of treatment; (ii) discussion of risks of no treatment; and (iii) discussion of alternative treatments that are available.
Malpractice is a breach of duty which causes damage. Treatment with ‘typicals’ is not malpractice with full disclosure of risks and alternatives and with written informed consent [2].
At this stage of our clinical experience, precedents have not been established and debate, albeit dwindling debate, remains about the utility of the ‘typicals’ in first line treatment of schizophrenia. Non-compliant patients who require Community Treatment Orders and injections of depot antipsychotic medications are an obvious exception.
The fact remains that a medical practitioner who prescribes a medication with unnecessary medical risks exposes himself or herself to an unnecessary medico-legal risk. Informed consent when ‘typicals’ are prescribed is essential and, even under current legal precedents, the lack of informed consent cannot be justified.
Finally, guidelines must be addressed at an organizational level by the appropriate Professional College to increase the protection to an individual prescribing medical practitioner.