Recovery From Schizophrenia: Psychiatry And Political Economy

Chapter 10Antipsychotic drugs: use, abuse and nonuseHundreds of double-blind studies of the efficacy of the various antipsychotic (orneuroleptic) drugs have now been conducted. The large majority of these studiessuggest that these drugs are significantly more effective than inactive placebos inimproving the condition of people with acute and chronic schizophrenia. 1 Timeafter time, in many thousands of treatment settings, clinical experience has shownthat the different antipsychotic drugs can bring dramatic relief from psychoticsymptoms in most people with schizophrenia. Long-term use of thesemedications appears to help forestall relapse. Twice as many patients withschizophrenia will relapse if placebos are substituted for their active medicationthan if they continue to take an antipsychotic drug. 2 Yet the overall outcome inschizophrenia, as shown by the analysis of dozens of follow-up studies inChapter 3, has not improved since the introduction of the antipsychotic drugs in1954. How can this be?There are two probable answers:• Although the antipsychotic drugs usually have a positive short-term effect onthe symptoms of schizophrenia they may have had in some cases—particularlyin good-prognosis cases—a negative effect on the long-term course of the illness.• The emphasis on treatment of acute symptoms with medication has often ledto a neglect of patients’ community treatment and rehabilitation needs and totheir exposure to high levels of symptom-provoking stress.We should examine these two issues in detail, but, in doing so, we need torecognize that in the past decade and a half there have been major changes in thedrug treatment of schizophrenia. Clozapine, a new type of antipsychoticmedication with a novel mechanism of action, was introduced in the US in 1989,and has proven effective in cases of schizophrenia that were unresponsive to thestandard drugs. 3 Like the standard antipsychotic drugs clozapine probably exertsits effect by blocking the effect of the neurotransmitter dopamine in a part of thebrain known as the mesolimbic system.Clozapine, however, blocks the effect of dopamine for much briefer periods oftime than the standard antipsychotic drugs 4 and also has a blocking action on the