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 available. 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 a job, 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 “deinstitutionalization.” The plight of the homeless continues in the early part of the twentyfirst
century to be a serious problem throughout the United States.