Effective Medicines To Treat Schizophrenia- Part IV
Ali Madeeh Hashmi writes about the treatment of schizophrenia, what medicines are effective, the stages at which there is no treatment, and the side effects of these medicines.
Treatment of Schizophrenia
The treatment of schizophrenia, like most mental illnesses, falls along two lines into what we might call ‘medical’ treatment and ‘psychological’ treatment or alternatively, ‘pharmacological (medication) treatment’ and ‘non-medication treatment’. In general, the operative principal in treating emotional illnesses is that milder versions of the illness can usually be handled without medication.
As the illness gets more and more severe, the need for medicines becomes more urgent. One reason for this is that the most severe mental illnesses like schizophrenia often impair a person’s ability to think and communicate and since psychological treatment (psychotherapy, sometimes erroneously referred to as ‘counseling’) relies on a person’s ability to participate actively in the treatment, people with severe illness simply lose the ability to participate in any meaningful way in psychological treatment.
Once the illness has been tamed somewhat by medications, psychotherapy can then help a person pick up the pieces and hopefully move towards a semblance of normalcy. This does not imply that medication treatment for schizophrenia or any mental illness is any kind of panacea.
On the contrary, the confusion and uncertainty that surrounds the diagnosis of mental illness extends into medication treatment as well. Since we do not know what the cause of mental illness is, we can only hazard a guess as to what treatments might work. It’s not coincidental that most medications to treat psychiatric illnesses were originally discovered purely by accident and there remains a vigorous (and mostly healthy) debate about how much they help (or if they help at all).
A few days ago, I got a call from someone that I have seen off and on for many years. *Umar* (not his real name) called to say he was not well. He had asked to see me urgently just before I had to travel out of the country for a few weeks. I knew he was under some stress related to the new business he was trying to run. He filled me in on what was going on. It was the usual teething problems of any new business: cash flow problems, employee issues, slow sales etc. It had been going on for several months and he had found himself becoming increasingly anxious to the point where he now was avoiding going in to work or even talking to any of his employees. A couple of days ago he messaged me to tell me he was becoming increasingly paranoid and had started to feel ‘special’. From his experience with psychotic episodes before (from which he had fortunately recovered completely), he knew he was headed towards another one. He pleaded with me to give him some medication saying, only half-jokingly, ‘please, I don’t want to go mad again’.
We tried some medicines over a few days but it didn’t help and he slid over into frank psychosis, requiring another hospital stay. When his family called me to get him admitted to the hospital, he was agitated and aggressive, talking about being a prophet and not sleeping. At this stage, there is no way to avoid medicines.
Medicines for Psychosis
Most medicines used to treat psychiatric illness have some convenient labels; we have ‘anti-depressants’ and ‘anti-psychotics’, ‘anti-anxiety’ medicines and ‘mood stabilizers’. These labels though, disguise a very basic truth: just as we don’t really know what caused a specific episode of a mental illness in most cases (although there may be some clues), medicines to treat the illness also are rather ‘blunt instruments’ with one medicine often used to treat multiple conditions. Thus medicines we call ‘anti-depressants’ also treat different types of anxiety and other conditions. The ‘anti-psychotic’ medicines can also be used in very low doses for acute anxiety, dementia and other conditions. They are, thus, not really as ‘disease specific’ as their names might suggest.
Underlying this rather confusing method of determining the appropriate treatment is the same dilemma we encountered earlier; no one really knows what the specific ‘cause’ of a mental illness is, nor how it exactly affects the brain and the body. This reflects on the way medication treatments for mental illness were discovered and developed. Many of the earliest treatments for depression and psychosis, some still in use today, came about purely by accident.
The earliest antidepressants for example were fortuitously discovered by some sharp observers working in a TB sanatorium in the 1940s who saw that many TB patients given the anti-TB drug Iproniazid became gregarious and cheerful, a sharp change from their earlier melancholy state. This led to the discovery of the earliest class of antidepressants, some of which are still in use today called ‘Tricyclic antidepressants’.
Around the same time, the French pharmaceutical company Rhone-Poulenc accidentally discovered the calming properties of a compound they were researching as an aide to anesthesia. This became the first antipsychotic, later called ‘Chlorpromazine’ and spawned a whole generation of medicines for psychosis and agitation, the derivatives or which are still with us today. Because of this history and our continuing confusion about the exact cause and mechanism of mental illnesses, medication treatments also remain rather haphazard at best. In some cases, misuse or outright abuse of medicines can become a real problem.
Antipsychotics- The Beginning
In the last 70 odd years, starting with Chlorpromazine, multiple medicines have been developed to treat psychosis and schizophrenia. The earlier ones, like Chlorpromazine and later Haloperidol, discovered by Janssen Pharmaceutica in 1958 were later joined by a host of others which worked in a similar fashion. Haloperidol would go on to become hugely popular for the treatment of schizophrenia and would become the most prescribed antipsychotic in the world. The success of these drugs to calm the agitation and sometimes aggression of psychotic patients was, in part, responsible for the ‘de-institutionalization’ movement in the United States which would fundamentally change the model of treatment for chronic mental illnesses like schizophrenia. Beginning in the 1960s and continuing for the next 2-3 decades, this movement would see thousands of people with severe mental illness, many of whom had spent years or even lifetimes inside large state mental hospitals (or ‘asylums’) being sent out into the community to live with families or in shelter homes, the idea being that this was a more humane and perhaps more effective treatment method than keeping them confined in hospitals.
While Chlorpromazine, Haloperidol and other medicines did help many patients with psychosis obtain some control over their symptoms, it came at a cost. Many people who took these medicines over years developed serious and at times disabling side effects including involuntary movements of muscles which could make even day to day activities difficult, a phenomenon sometimes referred to, rather unkindly, as the ‘zombie shuffle’ (in medical parlance, these abnormal involuntary movements are called ‘tardive dyskinesia’, a reference to the delayed onset of this side effect which can happen sometimes after years).
While problematic, antipsychotic medicines did help many people, at least in the short term and were still a vast improvement over their predecessor treatments which often did no good at all and in some cases were positively harmful to patients. Their biggest shortcoming was their negligible benefit for the stubborn ‘negative symptoms’ of psychosis: apathy, poor motivation, low energy and a general disinterest in life. Patients with psychosis treated with these medicines became calmer and stopped hallucinating but they also became passive and unmotivated to do even simple things like bathing and housework. They lost all desire to do anything in life and worse, seemed to have no distress about it.
A patient comes to mind. Let’s call her Farhat. She was initially referred to me by her sister, one of my students. Farhat’s story was familiar. She was an ordinary young woman who went to school and later graduated college. She was apparently alright until her parents married her off to a man working in Canada. A few months after arriving in Canada, she suffered her first psychotic break. She was paranoid, not sleeping and hallucinated often. After a couple of hospital stays and some medicines she got a little better and the family decided to move back to Pakistan. She eventually had two children. When I saw her, she was better than she used to be but still psychotic.
After medication treatment, this resolved but the husband’s main complaint became that she was ‘just there’. She would do what she was told but never took any initiative. Her husband had to wake the children for school, make them breakfast and help them with their studies while she sat on the couch and stared at the wall. We tried several different medicines but none of them touched her ‘negative symptoms’. She remained oblivious to her family and to her own state. Her psychosis did not return but she did not fully recover either.
–To be continued–
The writer is a psychiatrist practicing in Lahore. He taught and practiced Psychiatry in the United States for 16 years. He tweets @Ali_Madeeh