Recovery From Schizophrenia: Psychiatry And Political Economy

THE POLITICAL ECONOMY OF SCHIZOPHRENIA 217after all of the presenting features had resolved. During the four-year period ofthe program, only one resident of the area progressed to display the full featuresof schizophrenia. Falloon suggests that the observed incidence of schizophreniaduring the period of the program was ten times less than in the same area adecade before. It is difficult to conclude, however, that the program reduced theincidence of schizophrenia, since it is very possible that a number of youngpeople vulnerable to schizophrenia migrated out of the area to seek training andeducation in urban areas. Given the small size of the catchment area, a handful ofcases lost to migration would produce a large apparent decrease in incidence.A second pre-illness detection and treatment study was conducted by PatrickMcGorry’s team at the PACE clinic. 110 Thirty-one pre-illness subjects wereassigned to preventive treatment with low doses of an antipsychotic drug,risperidone, and cognitive therapy, and 28 were assigned to supportivepsychotherapy alone. Only 3 of 31 preventive treatment subjects developedpsychosis after six months compared to 10 of the 28 in the control group. Wecould conclude that the onset of psychosis was delayed in about seven of theexperimental group. This is a positive outcome, but we have to set it against somenegative aspects. These are: (a) three patients took risperidone without benefit;(b) 21 patients were told they were at high risk for schizophrenia, when theywere not; and (c) the same 21 took risperidone unnecessarily. How does onedecide, moreover, how long the 28 patients who took risperidone and didn’tdevelop psychosis should continue to take medication? For about three-quarters ofthe group the medication is unnecessary, but one doesn’t know which those are.Should they continue taking medication for six months or six years or longer?To summarize: educating providers of psychiatric and obstetric care and peoplewith schizophrenia and their relatives about the risk of obstetric complicationsincreasing the risk of schizophrenia could bring about a small decrease in theincidence of the illness, safely and at low cost. On the other hand, the positiveaspects of preventive intervention with those considered to be at risk forschizophrenia are limited to the hope for preventing a disabling and costly illness;the negative aspects are substantial and include the likelihood that the accuratedetection rate will be extremely low when targeted at the general population, apaucity of interventions of proven effectiveness in non-symptomatic individuals, aconsiderable risk of harm to those wrongly labeled, and the diversion of scarcehealth service funds from the treatment of established cases of the illness wherethe interventions are known to be effective.We may be grateful that the increase in the incidence of schizophrenia thataccompanied industrialization appears to be on the decline, and it is possible thatwe can hasten this process by improving access to good obstetric care, but effortsto reduce the incidence of schizophrenia by treating those who are at high riskfor developing the disorder are premature.