Studies have shown that about 70 percent of schizophrenics clearly
improve on these drugs, with 20 percent improving minimally at best, and
5 percent getting worse. But over the course of a lifetime, improvements
are more limited; while one-fourth do recover fully from their first
psychotic episode and never experience a relapse, and another fourth
recover well enough to live and work independently, the remaining half
need help in taking care of themselves the rest of their lives,
especially when their illness flares up, as often happens with this
notoriously cyclical disease.
But medications don't work when schizophrenics don't take them. And
experts estimate that half to three-fourths of schizophrenics stop taking
their medications within one year of walking out the hospital door. Most
are unable to understand that they need the drug to get better most, in
fact, can never see past their delusions to realize they're sick in the
first place.
Many drugs also have a harrowing array of side effects. A
schizophrenic who takes antipsychotics for years might find that his
hands shake, his tongue pokes and curls out of his mouth, his emotions
feel numb and flat. Or he might feel unbearably agitated. New hope has
come with the recent introduction of the drug Clozaril, which can produce
seemingly miraculous recoveries in about one-third of people for whom no
other medication worked. And in mid-1993, the FDA approved yet another
antipsychotic, risperidone, which appears to be as effective as Clozaril
with fewer side effects.
THE SEARCH FOR MODEL TREATMENT
Balancing the civil rights of the severely mentally ill against
society's right to safety.
Many experts have come to the conclusion that the aggressive use of
so-called outpatient commitment laws may be the best answer. Already in
place in a handful of states but used regularly in only a few progressive
counties, outpatient commitment permits schizophrenics only about three
visits to the psychiatric emergency room before they are put on long-term
court-ordered medication as a condition of leaving the hospital or
avoiding a jail term. The counties soon find that keeping a close eye on
each patient, making sure they're followed up and taking their
medication--and not standing around naked in the middle of an airport, as
was a man I recently saw--is a lot less expensive than waiting for them
to get so sick they must return to the hospital.
Some psychiatrists argue, however, that outpatient commitment laws
are beside the point. What's really needed are good community programs
that put care-givers in close, regular contact with schizophrenic
patients. Such programs which amount to the community mental health
centers envisioned by President Kennedy, are seen as the missing
foundation of what should be the country's response to the crisis of
homeless, violent schizophrenics.
Two fundamental models have been developed:The clubhouse model was
first pioneered by Fountain House in New York City. About 400 severely
men tally ill people each day come to socialize with fellow patients,
develop work skills, and get ongoing help in finding housing, finding a
job, managing money--and taking medications.
Says Jim Schmitt, Fountain House director, "The biggest thing is
not just housing. They have to have a life--something to do during the
day--or life becomes oppressive."
The second model, based on the Program of Assertive Living
Treatment (PACT) in Dane County, Wisconsin, has the doctors and social
workers go to the schizophrenics, by making weekly, sometimes even
twice-daily, house calls.
The federal Substance Abuse Mental Health Services Administration
has put $20 million toward creating a model program in one city. In New
York, meanwhile, the governor and legislature agreed late in 1993 that
five of the state's all-but-empty psychiatric hospitals will be closed
with the $210 million in savings dedicated to community treatment
programs--an estimated 20 to 25 percent increase in the state's spending
on such programs.
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