Recovery From Schizophrenia: Psychiatry And Political Economy

ANTIPSYCHOTIC DRUGS: USE, ABUSE AND NON-USE 235British studies of the family environment of people with schizophrenia citedabove.By way of contrast, some forms of outpatient therapy that do aim to reduce thestresses in the patient’s environment have proved successful. Julian Leff and his coworkerswere able to minimize the impact of critical and over-involved relativeson patients with schizophrenia through family therapy and thus to reduce therelapse rate in these patients. 49 New Zealand psychiatrist Ian Falloon in associationwith a team of researchers in California achieved a similar result working with thefamilies of people with schizophrenia in their homes—family-treated patientsshowed fewer psychotic symptoms and fewer relapses. 50 Subsequent research hasreliably shown similar benefits from programs providing family education andsupport in schizophrenia. 51We may conclude that when people with schizophrenia are in an environmentthat is protective but not regressive, stimulating but not stressful, and warm butnot intrusive (whether it be their own family home or a residential treatmentunit) many of these patients will need less antipsychotic drug treatment. On theother hand, people with schizophrenia who are exposed to significant stress(whether it be status loss, intrusive relatives, over-enthusiastic psychotherapy orhunger, cold and poverty)—will have a high relapse rate and will requiresubstantial doses of antipsychotic drugs to achieve adequate functioning levels.Many patients, of course, do not choose to be in a highly protective setting -they prefer independence. Life cannot be made stress-free unless one chooses towithdraw from the excitement of daily living. In practice, for most patients drugfreetreatment is not feasible. In the best community treatment systems there is aplace for the judicious use of antipsychotic medication. A reasonable goal for themajority of people with schizophrenia is to use moderate doses of medication thatlead to a genuine improvement in quality of life without adding to theirhardships.In Western society in recent decades, nevertheless, too few people withschizophrenia have received adequate treatment or have been placed in reasonablysuitable therapeutic settings. A recent US household survey of the adequacy oftreatment for people with serious mental illness revealed that only 40 per cent ofthe seriously mentally ill had received any treatment in the prior year, and in lessthan 40 per cent of these cases was the treatment minimally adequate—meaningthat only 15 per cent of seriously mentally ill people were getting acceptable care.People with psychotic disorders received the most inadequate care. 52 Those ininstitutions may fare quite poorly. A study of the mentally ill in Utah nursinghomes showed that their dosage of medication progressively increased with timebut that their levels of activity decreased. 53 With the advent of antipsychoticdrugs and the advance of radical deinstitutionalization policies, too many havebeen thrust into highly stressful environments. As we saw in Chapter 8, around athird of all Americans with schizophrenia exist in settings that scarcely pretend tobe therapeutic—in jail, on Skid Row, in nursing homes or boarding homes.