I judge from reading comments written in response to my previous blog posts that some people regret the use of drugs in the treatment of psychiatric disorders.  They feel it may interfere with making friends with patients. They suggest that other treatments, diet and exercise, for instance, might work better and avoid the potential dangers of drug side-effects. I, myself, have decried the use of anti-depressants in situations where they are not likely to work. Also, I think the minor tranquilizers are given out too frequently and have hidden disadvantages. In addition to concerns about these particular drugs, I am aware that all psychoactive medications can be prescribed improperly, just as every other kind of medicine can be prescribed by physicians improperly, at the wrong times and in the wrong amounts. But the use of psychoactive medications has had an extraordinary effect on the treatment of the mentally ill, such an extraordinary effect, I am not sure I can describe it adequately.

I first walked on a psychiatric ward at Bellevue Hospital in 1955. I was a first year medical student. I was on some errand or other. At attendant unlocked the heavy doors, one after the other, that shielded the patients from the outside world, or vice versa. It was a female ward.  As I stepped onto the ward I was attacked by three or four women, at least one of whom was grabbing my genitals and smiling weirdly at me. All were unkempt and screaming. They wore gowns, which were slipping off them. They were barefoot. While I stood there, two male attendants silently pulled the women off me and dragged and shoved them into rooms that I noticed had no doorknobs, seclusion rooms. The women immediately set to pounding on the other side of the doors.

This was the picture of care at that time at a distinguished hospital. A movie made around that time described someone hospitalized on a psychiatric facility; it was called, “The Snake Pit.”

In the early 1950s, before the advent of Thorazine, an anti-psychotic, and Tofranil, an anti-depressant, there was no treatment for mental illnesses other than electric shock therapy and insulin shock therapy. I don’t count the person who was travelling around the country sticking an ice-pick in patients’ brains in order to ameliorate their symptoms. (It was not an instrument that looked like an ice pick; it was an ice pick.) This treatment did not work. Electric shock therapy did work against depression and is still prescribed today, but at that time was done without anesthesia or muscle relaxants with the result that patients convulsed and often fractured bones as a side-effect of treatment. Insulin shock treatment, which also produced a convulsion, was still being used in the treatment of schizophrenia in Europe when I was stationed there in the early 1960s. It did not work.

At that time every other hospital bed in the country was occupied by a psychiatric patient! In other words, there were as many patients hospitalized for psychiatric illnesses as there were for all other illnesses combined! Great state hospitals housed these patients by the thousands, some of whom remained there for many years, their lives devastated by their illnesses.

When I walked onto that Bellevue ward, these new drugs had begun to appear, but were not being given universally, since they reflected a seismic shift in the way patients were treated. When I was an interne in 1960, violent patients were still being treated ineffectually with huge doses of Amytal, a barbiturate, which served to put patients in a comatose-like state, only to have them wake up violent a few hours later. Thorazine was still not used as generally as it would be only a few years later because it was thought to cause liver toxicity, which it did not.

Psychiatric diagnoses were different than those made now. Schizophrenia was noted to come in four different forms, including hebephrenia, where patients were so deteriorated they smeared feces on the walls. Having begun to practice psychiatry when Thorazine came into common use, I have never seen a hebephrenic. The last catatonic patient I saw came to my attention in the emergency room in 1961. He was writhing silently but continuously while three policemen sat on his chest and abdomen. I was afraid they were going to kill him. It took increasing doses of Thorazine, administered against the patient’s wishes, before he chose to stop fighting. He spoke calmly and went to the ward to which I admitted him without further complaint.

Straight-jackets were in wide-spread use, and occasionally, wet packs, which were used to tie up aggressive patients so that they could not move. There was one horrendous incident, which I will not describe here, where an attendant left five such patients alone tied down to stretchers. One patient got loose and attacked the others with his teeth.

All this changed when anti-psychotic medicines came in. There were four or five anti-depressants that appeared one after the other. Other so-called major tranquilizers appeared, Haldol, and then Stelazine, Mellaril, and ultimately, dozens more. Lithium was prescribed for manic-depressive illnesses. And the world changed.  Not all at once. When I worked at a municipal hospital in the mid-1960s patients were still sitting around in ward meetings wearing straight-jackets. At that point no such thing was necessary; and when a policy was instituted that every time a doctor ordered a straightjacket in the hospital, he had to explain it to me, they were never used again.

Over the years, the state hospitals closed, and the treatment of acutely psychotic patients became what it is today. All because of these drugs.(c) Fredric Neuman 2012 Follow Dr. Neuman's blog at fredricneumanmd.com/blog

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