Modern Medicines

Many of the medical/biological treatments for mental illness in the first half of the twentieth century were frantic attempts to deal with very serious problems—attempts made by clinicians who had few effective therapies avail able. The attempt to produce convulsions (which often did seem to make people "better," at least temporarily) was popular for a decade or two. One example was insulin shock therapy, in which convulsions were induced in mentally ill people by insulin injection. Electroconvulsive (electric shock) therapy was also used. Originally it was primarily used with patients who had schizophrenia, a severe form of psychosis. Although it was not very effective with schizophrenia, it was found to be useful with patients who had resistant forms of depressive psychosis. Another treatment sometimes used, beginning in the 1930's, was prefrontal lobotomy. Many professionals today would point out that the use of lobotomy indicates the almost desperate search for an effective treatment for the most aggressive or the most difficult psychotic patients. As originally used, lobotomy was an imprecise slashing of the frontal lobe of the brain.

The real medical breakthrough in the treatment of psychotic patients was associated with the use of certain drugs from a chemical family known as phenothiazines. Originally used in France as tranquilizers for surgery patients, their potent calming effect attracted the interest of psychiatrists and other mental health workers. One drug of this group, chlorpromazine, was found to reduce or eliminate psychotic symptoms in many patients. This and similar medications came to be referred to as antipsychotic drugs. Although their mechanism of action is still not completely understood, they improved the condition of many severely ill patients while causing severe side effects for others. The drugs allowed patients to function outside the hospital and often to lead normal lives. They enabled many patients to benefit from psychotherapy. The approval of the use of chlorpromazine as an antipsychotic drug in the United States in 1955 revolutionized the treatment of many mental patients. Individuals who, prior to 1955, might have spent much of their lives in a hospital could instead control their illness effectively enough to live in the community, work at ajob, attend school, and be a functioning member of a family.

In 1955, the United States had approximately 559,000 patients in state mental hospitals; seventeen years later, in 1972, the population of the state mental hospitals had decreased almost by half, to approximately 276,000. Although all of this cannot be attributed to the advent of the psychoactive drugs, they undoubtedly played a major role. The phenothiazines had finally given medicine a real tool in the battle with psychosis. One might believe that the antipsychotic drugs, combined with a modern version of the moral treatment, would enable society to eliminate mental illness as a major human problem. Unfortunately, good intentions go awry. The "major tranquilizers" can easily become chemical straitjackets; those who prescribe the drugs are sometimes minimally involved with future treatment. In the early 1980's, policy makers saw what appeared to be the economic benefits of reducing the role of the mental hospital, by discharging patients and closing some facilities. However, they did not foresee that large numbers of homeless psychotics would live in the streets as a consequence of "deinstitutionali-

zation." The plight of the homeless continues in the early part of the twenty-first century to be a serious problem throughout the United States.

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