There is data showing that atypicals could be better for the treatment of a psychotic disorder because they prevent neurodegeneration. Putting in the terms "plasticity atypical antipsychotic" into a google, google scholar, or pubmed search will show several articles showing such.
Except for the above, I don't see much of a reason to argue that either a typical or atypical is superior so long as you are monitoring for the side effects such as EPS and NMS, but the above is important. I've seen several patients that truly do need a typical antipsychotic and daily treatment in forensic and long-term facilities where the level of psychosis is often worse than what you see in a usual inpatient unit.
Despite the above I still have plenty of patients where I give typicals. E.g. I've seen several patients respond well to a phenothiazine such as Fluphenazine, but they don't have any or less improvement with an atypical. In that case, after discussing the issue with the patient, I sometimes prescribe the typical with a lose dose of the atypical, but the typical is the mainstay of their treatment. The atypical is only there for the neuroprotective reasons. I've also seen patients needing high doses of a few medications including more than one antipsychotic, and yes, when I got these patients, I put them on one medication at at time, hoping that that's all they would need and I only increased dosages and meds if one was tried and it didn't work. It's unfortunate but like I said, I tend to get some really way way way more psychotic people than I did in residency where most patients were only hospitalized for a few days and if it was tougher than that, we transferred them to the long-term facility.
A problem I'm seeing with several of the atypicals is that drug reps have created a type of taboo mentality with the typicals. Yes, there are benefits with the atypicals, but you have to see the whole for what it is. A doctor that limits their experience to the atypicals and does not try Fluphenazine, for example, may have missed that Fluphenazine actually worked well for a particular patient but none of the atypicals worked as well.
Another thing I've learned since I've come to Ohio is that several of the doctors here showed me data that Loxapine could act as an atypical. (Glazer WM (1999). "Does loxapine have "atypical" properties? Clinical evidence". The Journal of Clinical Psychiatry 60 (Suppl 10): 42–6. PMID 10340686.). It's a cheap medication and I have seen several patients do well on Loxapine. Why give them $700 Zyprexa if $20 Loxapine is doing the trick nicely?
I've also seen some places where the drug reps have leveraged all the doctors into giving everyone an atypical. E.g. the person is depressed but now they're give Abilify 5 mg QAM as the only treatment for depression. (Dammit, it's only an augmentation agent, and dammit, there are plenty of other meds that could've been tried that are far cheaper, with more data, and for most people-less side effects!)
I sometimes marvel at how smart doctors are supposed to be yet so many of them seem so dense to me. It's not IMHO from lack of brains, but from lack of giving a damn.
