Antipsychotic drugs help many people with schizophrenia live more meaningful, stable lives with fewer — and sometimes no — periods of hospitalization. But they are a highly problematic class of medicines. A sizeable percentage of people with schizophrenia get little or no benefit when they take an antipsychotic while others get only a partial reduction in symptoms. Side effects pose a major barrier to continuous use. In studies, for example, three of every four people stopped taking an antipsychotic or switched to a different one within 18 months.

Newer and quite expensive antipsychotics marketed heavily to doctors over the past 15 years have largely eclipsed an older generation of drugs developed in the 1950s and 1960s. Research for years appeared to indicate that the newer drugs were better, largely because they had fewer side effects. But recent large-scale studies now indicate that, overall, the older drugs work just as well, at far lower cost.   Taking effectiveness, safety, side effects, patient variability, dosing convenience, and cost into account, we have chosen the following as Consumer Reports Best Buy Drugs:

• Generic perphenazine — as initial treatment for people newly diagnosed with schizophrenia and for people with schizophrenia who have failed on a newer drug and whose doctor thinks perphenazine is worth a try. Patients taking perphenazine should be monitored closely for muscle tremors and spasms.
• Olanzapine (Zyprexa) — for certain people with schizophrenia who take perphenazine first and get no or minimal benefit and/or experience intolerable side effects. Zyprexa is not a good option, however, for people who are overweight, have blood sugar abnormalities, diabetes, or heart disease.
• Risperidone (Risperdal) — for people with schizophrenia who take perphenazine first and get minimal benefit and/or experience intolerable side effects.
• Generic clozapine — for people with moderate to severe schizophrenia who have not responded at all to two or more other antipsychotics and have had little reduction in symptoms.

The choice of generic perphenazine — if a patient responds well to it — saves about $200 to $500 a month ($2,400 to $6,000 a year) compared to Zyprexa and Risperdal, depending on the dose required.

We make no choice of a Best Buy antipsychotic for people with bipolar disorder. There is not enough evidence to do so.