Rereading the article on new drugs from the 1956 Mental Hospitals (1) might cause a cynic to conclude that Santayana was wrong: even a student of history is often condemned to repeat the past. That cynic might view the history of neuroleptic treatment as similar to the labor of Sisyphus. A more benign conclusion is that the large questions in medical science are rarely answered by a sudden illumination of the intellect but rather through the slow accretion of more knowledge.
This interpretation is at least more comforting, if not necessarily more accurate. However, it must seem to some that this accretion of knowledge is occurring in a geologic time frame. So many of the concerns expressed in the 1956 article remain vibrant today. One is reminded of Eugen Bleuler's treatise (2) on autistic thinking in medical practice, in which he illustrated the continuing power of wishful thinking over logical interpretation. It is clear that human nature has not changed dramatically, and we continue to be influenced in our conclusions by many forces, only one of which is rational thinking.
The oft-cited division of psychiatric practice into institution-based versus community-based practice has the advantage of clarity and simplicity but the disadvantage of being wrong. The state hospital was not the only paradigm for psychiatric care before 1950. To use the state hospital as the exclusive paradigm is actually describing only part of the elephant, although an uncomfortably large part because it was all too often the only treatment facility available to the poor. We should also recognize that before 1950, there were some good state hospitals as well as many poor ones. Furthermore, many excellent private hospitals offered more than support and the benefits of time. The best of these hospitals provided a continuum of care—inpatient and outpatient treatment, family education, and other services.
Finally, it is absurd to criticize hospitals, particularly public ones, for not giving effective treatments that did not exist. Often hospitals were little more than asylums, but asylums can have value. Terms such as "warehousing" and "custodial care" capture qualities present in the worst hospitals but ignore the value of humane support available in the best. Moral treatment did not die completely in the 20th century.
Before reserpine and chlorpromazine, somatic treatments were limited in number but far from totally ineffective in certain conditions. Electroconvulsive therapy was a superb treatment for severe depression and an excellent means of controlling extreme agitation. It should not be forgotten that many patients diagnosed as having schizophrenia benefited from insulin coma and insulin subcoma treatments. Admittedly, these treatments were frequently misused, as has been the case with all medical developments. We can all recall the era when penicillin was dispensed inappropriately to individuals who had no likelihood of benefit.
If we restrict our field of observation to persistent schizophrenia, we must admit the limitations in the value of hydrotherapy, electroconvulsive therapy, insulin coma therapy, and other similar treatments. Similarly, we are forced to admit that while the neuroleptic era has contributed greatly to reducing the size of the hospitalized population, it has failed to achieve full psychosocial adaptation in the vast majority of cases.
In 1956 many patients in public facilities were receiving as their pharmacologic treatment paraldehyde, chloral hydrate, amobarbital sodium, and phenobarbital in varying combinations. The few patients who had comorbid epilepsy might well have received some therapeutic benefit. These drugs did not have antipsychotic properties but rather were used as a means of sedation and chemical restraint. The therapeutic goal frequently was control of agitation and reduction in the potential for violence.
The use of physical restraints was pervasive. An important duty of the house officer was to make morning restraint rounds to see if patients were dehydrated or going into exhaustion states. This procedure was particularly important in the summer because air conditioning was a fantasy and electric fans were considered too dangerous. On the admission services, patients were not allowed to wear their clothing for fear of self-injury. They were not allowed their eyeglasses lest they be used to inflict injury. Patients were not even allowed their false teeth, although this particular observer never quite understood the offensive potential. Soft diets were mandatory because the patients were allowed only spoons. At the end of the meal the spoons were counted. If a spoon was missing, the patients were searched, and if necessary strip searched. Dignity was in short supply.
It is difficult to communicate to younger colleagues the miracle that 150 to 300 mg of chlorpromazine a day appeared to be to the house officers of 1956. It not only sedated the patients but actually made them less psychotic. Some patients began to hallucinate less, and their delusions softened. Finally we were like other doctors in that we had a treatment that actually worked. It was truly an intoxicating time. As late as 1966, Dr. Nathan Kline stated: "We have the cure for schizophrenia, but we face the problem of lack of compliance" (personal communication, 1966). He argued that if the patients took their medications, they would be well.
Even in the public sector, monies rapidly became available to purchase these drugs. However, the drugs quickly seemed to lose some of their efficacy. The dose of 150 to 300 mg of chlorpromazine rapidly escalated to 1,000 mg or more a day. Texas was giving 4 to 5 grams a day. Very little hypertension could be found in Texas hospitals. In public institutions, the great error of the preneuroleptic era was that sedation was often considered an excellent outcome. In the neuroleptic era, the measure of an excellent outcome became the control of positive symptoms, in particular agitation.
Clinicians failed to realize that if patients were to live in the real world outside a hospital, they would have to have a level of psychosocial adaptation that would permit them to remain outside. Behaviors that were ignored in a hospital would not be ignored outside. Bizarreness was not necessarily a problem in a public facility but would be a major problem outside one. Overcoming cognitive deficits and negative symptoms was of more importance than controlling positive symptoms for successful psychosocial integration.
Two great psychiatric revolutions occurred in the 20th century. The first was the psychoanalytic, and the second was the psychopharmacologic. The first led to a sharply increased awareness of the importance of intrapsychic life. It also gave the lie to the position of Jaspers (3) that the communications of psychotic patients were incomprehensible. In the hands of some of its more extreme advocates, psychoanalysis saw all mental aberration as the result of intrapsychic conflict. This model had no room for the nervous system.
The second revolution was the psychopharmacologic. Like all revolutions, it tried to eradicate what went before it rather than to integrate and build on the past. This attitude created a lost opportunity to bring together the mentalist approach of the psychoanalyst with the biologic approach of the psychopharmacologist. It comes as no surprise that the old revolutionaries raised their drawbridges and fired on the enemy. There were no heroes. To this day, it is a sad fact that if one reviews the fellowship or membership list of psychoanalytic organizations and looks for individuals who also are fellows or members of biological organizations, the resulting number will be paltry. As we enter a new millennium, we have still not reconciled this quasireligious division. The administration of pharmacologic agents should not become an alternative, let alone a barrier, to the development of a strong doctor-patient relationship.
The neuroleptic era contributed to the creation of strange bedfellows. On the left, we had individuals who believed that chronic schizophrenia was iatrogenic and others who believed that it represented an appropriate response to an inappropriate world. They were joined from the right by individuals who believed that discharging patients to the community would save money. Excessively rapid discharge led to the problem aptly described as the "revolving door" (4).
The term "community" deserves some comment. It is a term that has benefited from lack of definition. It conveys an aura of the pastoral—people living and working together toward mutually shared goals. It even may suggest a commune. Unfortunately, in reality it often meant a single-room-occupancy hotel in a downtown area that was a dangerous slum. It is difficult not to speculate that as the land value of the state hospital increased, the best way to hide the discharged patients was to send them to the slum areas of the inner city. The so-called community frequently had few or no resources available—let alone the interest—to meet the needs of the patients.
Many of these patients had in no way been prepared to deal with the realities of life outside an institutional setting; they were simply discharged. The left and the right were satisfied, and only the patients were injured. This is not to deny that some successes were achieved. Even a casual review of Mental Hospitals during this period reveals an increasing recognition that chronic patients could be managed outside a hospital. Interestingly, the name of the journal reflected that understanding, as it was changed to Hospital and Community Psychiatry in 1966.
The articles published in the late 1950s reflected an increasing sophistication about what was needed clinically to manage chronic patients outside a hospital—day hospitals, halfway houses, and so forth. This new sophistication also led to a dramatic increase in recognition of the importance of psychosocial rehabilitation. Antipsychotic drugs did not make it automatically possible for the discharged person to function in society. The goal of psychosocial integration into society emerged to replace the therapeutic nihilism that had existed before the introduction of these drugs.
Nevertheless, the failure to provide adequate resources far outweighed the successful programmatic developments that made discharge successful for some patients, and there is little in which we can take pride. Even community mental health centers, which were established during the Kennedy and Johnson administrations, frequently refused to accept chronic patients. Some 40 years later, we can point to a greater range of services, but the highly integrated, comprehensive programs that are required are still too few in number.
Evidence for the failure to provide necessary services abounds. Few patients had families ready, able, and willing to take them in and help provide shelter and upkeep. Many patients rapidly moved to the streets, which often were safer than the available housing. Homelessness is not a form of community. The spectacle of cardboard "housing" on the streets of our large cities during an era of unparalleled wealth is obscene. It is difficult to understand how some critics of institutional care can see this helpless and pathetic state as freedom.
A significant percentage of discharged patients have moved from the hospital to the forensic system. People are being imprisoned for the crime of being mentally ill in public. Who is mad—those who are discharged or those who discharge people from a hospital with the knowledge that a goodly number will be imprisoned for acting in public as they did at the time of discharge? It would appear that our commitment laws are in need of extension.
In the 1956 article on new drugs (1), the authors speak of the need to train a new kind of psychiatrist—a more medical psychiatrist. We certainly met that goal, but with the loss of a complete psychiatrist who is competent in both psychosocial and pharmacologic treatment. We all know good therapists and good pharmacologists, but how many psychiatrists are qualified to do both skillfully? This educational failure is not restricted to psychiatrists. We have failed to train nurses and other professional personnel adequately. A visit to a state facility today will reveal how much still needs to be done. Psychiatry is at the interface of brain and behavior, and therefore its practitioners must be trained in both.
Some of the reassurances in the 1956 article are misplaced. It states that that the new kind of psychiatrist will not be afraid if Parkinsonism occurs but will be able to evaluate and manage its occurrence. However, we should be aware that the nervous system is trying to give the psychiatrist an important message. Too often the message is ignored until the patient develops a dyskinesia or dystonia.
The problem with side effects is with us to this day. The use of clozapine has been restricted by the need to do blood counts. The problem with conducting regular blood counts is both fiscal and temporal. It requires a laboratory budget and staff time. Budgetary constraints are real and cannot be ignored. The cost of health care in the United States is staggering, a fact that must be recognized. Yet, the moral measure of a society is its concern for the powerless and not its concern for the bottom line.
Many of the questions raised in this article are still unanswered. Which patient is most likely to respond to which drug? What are the benefits of the newer antipsychotics versus the older ones? How do the cost-benefit ratios of the new compounds compare with those of the older compounds? How do we deal with the problem that inpatients "cheek" medication and outpatients are not compliant? How long should we treat a first break? How long should we treat a second or third? What factors go into patient improvement other than medication? What do we know about the interaction of medication with psychosocial interventions? How do we best integrate psychosocial rehabilitation with pharmacologic management?
These and so many other questions raised in this article are still with us. However, we should not lose sight of the tremendous gains that have been made since 1956. The vast majority of depressive disorders are treated outside of a hospital. Others are treated with short-term hospitalization. Manic-depression is managed in an effective manner that simply did not exist in 1956. Parenthetically, the improved treatments have forced us to recognize the existence of manic-depressive disease, which was essentially undiagnosed in 1956. Even the group of the schizophrenias is much better managed today than 45 years ago, with many patients having a far better quality of life than was available in 1956.
Schizophrenia, because of its chronic nature, represents an excellent opportunity for an integrated approach to understanding and management. A properly trained psychiatrist will be able to prescribe psychosocial interventions, such as social skills training, as well as prescribe medication. This does not mean that the individual psychiatrist should be able to do everything from social skills training to vocational rehabilitation to psychoeducation to family support. It does mean, however, that the psychiatrist must know what is needed and where it can be found and must be able to play a role in directing a team of professionals who can serve these patients. Not only will the patients benefit from such an approach but so will our discipline.
Dr. Cancro is chairman of the department of psychiatry at New York University School of Medicine, 550 First Avenue, New York, New York 10016 (e-mail, email@example.com).