Recovery From Schizophrenia: Psychiatry And Political Economy

Chapter 4DeinstitutionalizationWhat accounts for the finding arrived at in the previous chapter, that theproportion of patients with schizophrenia found to be in hospital at follow-updeclined dramatically before the advent of the antipsychotic drugs? A widely heldbelief about modern mental health care is that these drugs, introduced in themid-1950s, brought a new dawn to psychiatry, making possible effectivetreatment and community care for psychotic patients. Chlorpromazine, the firstof the antipsychotic drugs, initiated a “therapeutic revolution” in the hospital andcommunity treatment of schizophrenia, argued psychiatrist John Davis in theComprehensive Textbook of Psychiatry. He continued:Those changes have resulted in a massive reduction in the number ofhospitalized schizophrenic patients, a finding all the more remarkable since,up to the introduction of the new drugs, there had been a steady increase inthe number of hospitalized mental patients. The shift in the fate of mentalpatients is the most convincing proof of the efficacy of those agents. 1Dr Davis illustrated the point with a graph showing the rise and fall in thenumber of residents of US state and county mental hospitals during this century.His graph is essentially similar to the broken line in Figure 4.1, with the additionof the letters CPZ and an arrow pointing to the peak of the graph in themid-1950s indicating the time chlorpromazine began to be widely used. Theobservation that the antipsychotic drugs made deinstitutionalization possible hasbecome a truism of modern psychiatric practice. But how accurate is it?A moment’s reflection discloses that the figures relevant to this issue are not theabsolute numbers of mental hospital residents, but the numbers as a proportion of thegeneral population. A graph of the rate of mental hospitalization—the continuousline in Figure 4.1—reveals a different picture. Whereas the absolute number ofmental hospital residents peaked in 1955, the rate of hospital use peaked in 1945and never climbed as high again.Although there has been a marked decline in the population of mental hospitalssince the introduction of the antipsychotic drugs, it is clear that something elsewas happening in the first postwar decade to alter patterns of psychiatric hospitaluse.