Nickels Blog

Blog by Dr. Sam

Dear Friends,

BLOG #2, August 2016

Anti-psychotic medication – first or second generation?

This question is very important for users and family caregivers around the world. We want ourselves or our loved ones to have the best medicine to help in the recovery process and to be able to work.

We often think that if there are new drugs, they have to be better, and this is what the ads from pharmaceutical companies tell us. But it is true? It is an important question because the cost is very high for many new drugs.

Researchers in global mental health have begun to investigate these questions. Some studies show no difference between the impact of first and second generation mental health medications. But there are differences.(1) For example, first generation meds are cheap and often have very unpleasant side effects. The second generation meds can cause weight gain and secondary problems of other diseases such as diabetes, lipid increases, and heart or cardiovascular problems.(2)

In a recently published study from Germany (Effects of anti- psychotics of the first generation versus second generation in the quality of life of people with schizophrenia. A randomized, double-blind study, by Grunder et al, 2016)(3) the authors say studies in the last 10 years have not strongly shown the superiority of the second generation antipsychotics (SGA) over the first generation of antipsychotic (FGA). In this study, 136 adult patients received FGA (haloperidol [3-6 mg] or flupentixol [6-12 mg]) or SGA (aripiprazole [10-20 mg], olanzapine [10-20 mg], or quetiapine [400-800 mg]) randomly selected.(4) Subjects were followed for 6 months and measured quality of life (SF-36 and CGI-I), weight (BMI), and number of hospitalizations.

The results showed adverse events (hospitalization or capacity reduction function) were higher for patients given SGA (57%) vs. FGA (48%). Self-report quality of life was better for patients given SGA vs. FGA measured by SF-36, but there was not a difference (benefit) between the two groups as measured by CGI-I. There was weight gain for patients given SGA. The authors concluded that 1) the quality of life is better for patients given SGA, but 2) one has to balance this benefit with metabolic problems (side effects) of some SGA.

What does the World Health Organization (WHO) say? “New” atypical “antipsychotics given to patients have an effect equal to, but are more tolerable than, conventional neuroleptic drugs”(5) The WHO manual “mhGAP”(6) is a mental health treatment manual for use by medical and other staff in primary care clinics where there are no psychiatrists in low-resource countries. The manual states: If you do not respond well to more than one typical antipsychotic (FGA, such as haloperidol, chlorpromazine, and fluphenazine) for a while and with sufficient doses: 1) review the diagnosis, 2) ensure that it is not a result of using alcohol or other drugs, 3) ensure-the patient is taking the medication, 4) consider increasing dose or change medication 5) think of atypical antipsychotic (SGA) if the cost and availability is not a constraint, and 6) use clozapine for those who do not respond to any other antipsychotic drug.

What can conclude from the perspective of users and family carers? It is clear that the situation is complex. The options depend on access to all medicines, and this depends on costs. But one can not say that the SGA are better than FGA. It is best that each patient and family work closely with your doctor, provide your doctor information about the side effects and how they change over time, and clearly discuss the problems of other diseases that affect the patient. Because each person responds differently to medications, this process can take time, sometimes years, to find the best medicine. And over the years, sometimes the effect of medications on a person change as well, becoming less effective, or growing in side effects. One has to have patience with the process, with drugs, and with the patient.

We must always remember that the drug is never enough. Patients need support, education, understanding of their families, and programs for the recovery of self-esteem, friends, and work. Above all, love always works.

Dr. Sam

Notes and References

Dr. Sam is Samuel Nickels. It is not a psychiatrist or psychologist. He is a researcher of mental health, a social worker, and a family caregiver with a brother who has schizophrenia. You can respond to blogs directly to the web site, or contact Dr. Sam (SamuelNickels @

1 Royal College of Psychiatrists’ Public Education Editorial Board. (2014). Antipsychotics. Royal College of Psychiatrists. Available free online.

2 Meltzer HY, Davidson M, Glassman AH, Vieweg WV. (2002). Assessing Risks versus clinical cardiovascular benefits of atypical antipsychotic drug treatment [cardiovaculares diagnose clinical risks versus benefits of treatment for atypical antipsychotic drugs]. Journal of Clinical Psychiatry, 63, Suppl 9 25-29.

3 Grunder, Heinze, Cordes, et al. (2016). Antipsychotic effects of first generation versus second generation antipsychotics on quality of life in People with schizophrenia: A double blind randomized study [Effects of antipsychotics of the first generation versus second generation in the quality of life of people with schizophrenia: a randomized double studio blind]. Lancet Psychiatry.

4 Haloperidol, known as Haldol. Flupentixol, known as Depixol. Aripiprazole, known as Abilify. Olanzapine, known as Zyprexa. Quetiapine, known as Seroquel.

5 Chisholm, Gureje, Saldivia, et al. (2008). Schizophrenia treatment in the Developing World: an interregional and multinational cost-effectiveness analysis. Bulletin of the World Health Organization, 86 (7). 497-576.

6 World Health Organization. (2010). mhGAP intervention guide for mental neurological and substance use disorders in non-specialized health settings: Mental Health Gap Action Programme (mhGAP). Disponsible in Spanish free online (




I’m tickled to finally begin a blog, something I’ve been thinking about for a while. Blogs by Tom Insel, the director of the U.S. National Institute of Mental Health, the Mental Health Innovation Network, and other bloggers have taught and inspired me. The focus of this blog will be reflections on issues of import to users of mental health services (“users”) and their families and caregivers.

I will focus on the international scale and on issues of relevance to the work of our organization in Central America with users and families there. One study (Creating high impact nonprofits, 2007) discussed how strong nonprofits combine SERVICE with ADVOCACY to increase their impact. Advocacy is important because it can help us address root causes, involved the government in partnerships, change laws, and increase funding for programs. It can also empower people with disabilities and their families as strong advocates for themselves.

One of the current big advocacy issues is the need to include mental health treatment in the new Sustainability Development Goals. From 2000 to 2015 these goals were referred to as the Millennium Development Goals (MDGs), an effort by the U.N. to help countries focus on the important issues—for example, reducing infant mortality, eradicating extreme poverty, and achieving universal primary education. These goals have been strong motivators to countries and foundations working globally. For example, El Salvador now provides free primary education for all its children.

However, MDGs do not mention mental health. This was a result of stigma and a lack of understanding about how prevalent mental health problems are and how important it is to a person’s health to treat both her physical and mental health problems. For example, people with heart disorders often suffer depression and people with common mental disorders may miss taking their diabetes medication.

The next round of global goals for development, called the Sustainable Development Goals (SDGs), are in the process of being revised now. This is our opportunity to advocate for inclusion of mental health on the global development agenda.

This will have a tremendous impact on how governments and foundations the world over fund development and health programs over the coming 15 years. Here are a few ways you can advocate.

  1. The U.N. has a fun web-link where you can choose 6 priorities for the new SDGs. Be sure to go to the bottom of the page under “Suggest a Priority” and list MENTAL HEALTH, then go back up to choose 6 other priorities. The site creates a mini-video for you with your priorities listed:
  2. You can write the two U.S. leaders listed below. Just tell them “I want mental health included in the Sustainability Development Goals!” Or you can fill out and email the template at this link: ( )

The Honorable Samantha Power                                                          
U.S. Ambassador to the United Nations
799 United Nations Plaza, New York, NY 10017 (online via form:

Secretary of State, John F. Kerry
U.S. Department of State
2201 C Street NW, Washington, DC 20520 (online via form:

  1. You can show your support on the following global mental health website by listing your name and/or organization as supporting this effort to include mental health in the new SDGs:

 Thanks for making your voice heard!

Sam Nickels
Director, Mental Health International
A project of the Center for Health and Human Development


PS… Here’s the message I sent to Amb. Power at the UN and Sec. Kerry at STATE DEPT:

Please include mental health among the new Sustainability Development Goals. 1 in 4 people in the world suffer from mental illness. Comorbidity is high between physical and mental illnesses – we cannot address one without the other. 3000 suicides occur daily around the world and depression is the leading cause. People with mental illness suffer higher rates of unemployment than any other kind of disability group, so they and their families are among those who suffer the highest rates of poverty. Effective treatments are available and recovery is possible–if they have the needed supports.