Recovery From Schizophrenia: Psychiatry And Political Economy

ANTIPSYCHOTIC DRUGS: USE, ABUSE AND NON-USE 241A potential advantage of the minor tranquilizers over the standard antipsychoticdrugs is that, by blocking dopamine release rather than dopamine receptors, thebenzodiazepines should not lead to dopamine supersensitivity, tardive dyskinesiaor prolonged withdrawal psychosis. Another advantage is that the minortranquilizers are much more pleasant to take than the antipsychotic drugs and aregenerally free from serious side effects. A disadvantage is that tolerance appears todevelop to the antipsychotic action of the drugs, rendering them suitable, in mostcases, only for short-term use.Many people with schizophrenia can benefit from a low-dose approach totreatment and some good-prognosis patients may be suitable for drug-freetreatment or gradual withdrawal from medication early in the course of theillness. How can we tell which people do not need to be treated withantipsychotic medication long term?PROGNOSTIC INDICATORSEfforts to pinpoint indicators of good prognosis have revealed that people whosepsychotic illness is more sudden in onset and is a response to a clear life stress,those whose psychosis developed late in life and those who have functioned wellbefore their illness developed (including having good social relationships andgetting married) are more likely to improve and recover. 72 The degree ofaccuracy in using these criteria to predict outcome is not high, however; at bestwe can correctly sort three out of four patients into good-or poor-outcomegroups, but we would be wrong the other quarter of the time. 73One point emerges clearly from the research—the symptoms and clinicalfeatures of the psychotic episode are of little value in predicting outcome. 74Indeed, the diagnosis of schizophrenia itself does not predict an outcome that isnecessarily much worse than the prognosis in other psychoses. 75 The best indicatorof future functioning, according to two pieces of research, is the patient’sfunctioning before he or she fell ill. The measure of previous competence in anyone area, furthermore, is the best predictor of functioning in that same area.Thus, a good work record predicts good vocational functioning, good socialrelations in the past point to good future social functioning and multiple priorhospital admissions indicate the likely extent of future hospital use. 76In practice it is reasonable to assume that a patient who is (a) early in the courseof a schizophrenia-like illness, (b) has previously achieved a reasonable level offunctioning, and (c) whose onset of illness was sudden, deserves a trial of treatmentwithout antipsychotic drugs or gradual withdrawal from antipsychotic medicationafter a few weeks. Some of these patients will eventually improve and do well.Some good-prognosis patients, however, might be diagnosed as experiencingan episode of manic-depressive illness (bipolar disorder). This affective psychosischaracteristically begins later in life than schizophrenia and allows patients theopportunity to develop a higher level of social and vocational functioning. It isoften difficult to distinguish between episodes of affective illness and