As nice's brief was to consider atypical anti-psychotics it could not be expected that it would consider other approaches to treatment which might prove to be curative rather than palliative.

Nowhere is it even suggested by NICE that the mode of therapeutic action of neuroleptic drugs is known although it states that "anti-psychotic drugs are believed to work by changing the activity of chemicals that transmit messages to the brain". The main chemical they work on is called dopamine. In fact the "dopamine hypothesis" is still a hypothesis and the anti-psychotic drugs have extensive effects on both body and brain chemistry.

Despite the fact that anti-psychotic drugs are partially effective in reducing psychotic symptoms, the cause of the psychiatric symptoms is unknown. Many bodily diseases can cause psychiatric symptoms indistinguishable from schizophrenia and it would seem reasonable to seek out such physical diseases which may be the cause of the psychosis before initiating the long-term use of anti-psychotics. The raised mortality from heart, gut and endocrine disease and infections should surely alert doctors to the need for thorough physical examinations before drug treatment starts. It would seem very unwise to concentrate on giving powerful palliative drugs to patients with schizophrenia without any knowledge of how they work. It is a blunderbuss approach. Often, if their use is discontinued, the psychotic symptoms may rebound quite ferociously, especially with clozapine, making it quite difficult to again stabilise the patient. If the clozapine cause a fall in the white blood cells to a dangerous level, the drug has quickly to be discontinued and severe psychotic state can emerge. Is a doctor likely to discuss this with a patient? I doubt it.

Very often it is, faux de mieux, necessary to prescribe an anti-psychotic drug. The side-effects of typical drugs are listed as movement disorders, blurred vision, dry mouth, weight gain, fits. Weight gain and fits may be more common and more severe with atypicals but this is not mentioned by NICE. The weight gain, often huge, can cause diabetes and heart disease. The NICE press release says that atypical antipsychotics "can have fewer side-effects". I do not think the evidence supports this. NICE also stresses that antipsychotic medicine "should be initiated as part of a comprehensive package of care that addresses clinical and emotional needs".

I was pleased to read that clozapine should only be used after a six to eight week trial of at least two antipsychotics, one of which should be atypical. Clozapine is, I think, a potentially dangerous drug whose use is associated with adverse events in many systems of the body. Its initial effects, however, appear to be more normalising than the other antipsychotics but it must not be forgotten that it was withdrawn earlier because its use has caused a number of deaths. Now monitoring has been introduced it has again become acceptable for use. I was glad to see that sertindole has been omitted by NICE in its list of acceptable drugs. It had to be withdrawn by the makers as its use was associated with a number of deaths. It was still considered by NICE nevertheless and is available under prescribed conditions.

NICE underplays the paranoia, violence and anger so common in schizophrenia making it seem a much more innocuous disease than it actually is.

As it is expected that the increased use of atypical drugs will lead to a decreased need for hospital beds one must wonder to what extent the patients will actually be monitored by the clinician and the key worker so that "both therapeutic properties and tolerability of the drug (are known) on an ongoing basis". Surely this will be a difficult task when the patient is in the community?

NICE says that: "Given that the evidence reviewed suggests that the atypical antipsychotics are at least as efficacious as the typical agents the committee considered that cost-minimisation analysis was an adequate form of evaluation of cost-effectiveness for the atypical antispychotic drugs versus the typicals." Happily though NICE do not claim the atypicals are better than the typicals, despite their greatly increased costs of £1,220 per year compared to £70 per person a year for the typicals.

There is, of course, no mention of nutrition as an additional potential therapy for schizophrenia. Drugs are all.