In Reply Fountoulakis summarizes our work1 stating: (1) we reported that antipsychotics reduce brain gray matter volume and (2) we proposed that antipsychotics should be avoided when alternatives are present. He comments that there are no alternatives with solidly proven efficacy and that phrases like that could be misleading. His summary is partially incorrect. First, our primary finding was that olanzapine was associated with a reduction in cortical thickness, not brain volume. Cortical volume is a product of cortical thickness and surface area, more directly correlated with surface area than cortical thickness. Prior studies have focused on brain volume but not ours. Second, we clearly stated: “when psychosis is present, the life-threatening effects of untreated illness outweigh any adverse effects on brain structure in clinical decision-making”1 (including metabolic adverse effects, reduced lifespan, or sudden death). However, we also believe that when evidence-based alternatives are available, antipsychotics could be avoided in nonpsychotic disorders such as autism, anxiety disorders, or insomnia for which these medications are widely prescribed.2 This is even more important in children and elderly individuals, as those populations are especially vulnerable.
Voineskos AN, Dickie EW, Mulsant BH. Brain Volume Changes Under Treatment With Antipsychotics—Reply. JAMA Psychiatry. 2020;77(8):877–878. doi:10.1001/jamapsychiatry.2020.1364
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