Academic journal article Journal of Social Work Education

Research on the Drug Treatment of Schizophrenia: A Critical Appraisal and Implications for Social Work Education

Academic journal article Journal of Social Work Education

Research on the Drug Treatment of Schizophrenia: A Critical Appraisal and Implications for Social Work Education

Article excerpt

SCHIZOPHRENIA IS CONSIDERED the epitome of severe and persistent mental disorder and remains the focus of considerable research activity, mostly about its psychopharmacological treatment. The introduction of neuroleptic (antipsychotic) drugs in the 1950s launched a biological revolution in psychiatry and profoundly altered the treatment of schizophrenic disorders. By the mid-1980s, however, professionals could no longer avoid recognizing the drugs' significant drawbacks. Antipsychotics cause movement disorders (extrapyramidal symptoms, EPS) in acute treatment which often become irreversible in long-term treatment. They cause or worsen negative symptoms, such as apathy and psychomotor retardation. Antipsychotics are ineffective in short-term treatment to suppress psychotic symptoms and in long-term treatment to prevent relapses in at least a substantial minority of patients (Cohen, 1997a). By 1986, the physician credited with introducing them in psychiatry asked, "Are the antipsychotics to be withdrawn?" (Deniker, 1986).

The tide began to shift following the widely heralded reintroduction of clozapine into common use in 1990, when older neuroleptics began to be called "typical," "conventional," or "classical" in their propensity to cause movement disorders. Clozapine was "atypical" in that it did not cause profound catalepsy in rats (the animal model of neuroleptic-induced parkinsonism in humans), and seemed to manifest a broader spectrum of biochemical actions. Since then, other neuroleptics referred to as "atypical" have been marketed in the United States. These include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), sertindole (later withdrawn from the market), and ziprasidone (Geodon). These newer drugs have ushered what one social work author describes as "great optimism and expectation today in the psychopharmacotherapy of schizophrenia" (Bentley, 1998, p. 387). The social work literature on these drugs has echoed in nature the claims made for the newer drugs by psychiatrists. For example, in a textbook on social work intervention in mental health, Sands (2001) states that "`Atypical antipsychotics' ... treat the negative as well as the positive symptoms of schizophrenia and have fewer side effects than their predecessors" (p. 296). In an article on "What Social Workers Need to Know" about psychopharmacological treatment of schizophrenia, Bentley (1998) states, "The newer neuroleptics are called atypical specifically because they are not associated with EPS ..." (p. 389). In a textbook on clinical social work and medications (Austrian, 2000), the chapter by Hird (2000), a physician, concurs: "Now, a number of new `atypical' antipsychotics are more effective in treating the negative' symptoms without introducing the severe side effects of the earlier antipsychotic medications" (p. 284). Although these benefits would, in effect, constitute a veritable revolution in the field of schizophrenia treatment, the articles in which these statements appear do not provide the authors' rationales for arriving at their judgments. The judgments merely seem to echo the supportive descriptions of atypicals in scores of psychiatric journal articles.

Supportive statements notwithstanding, evidence has existed since the arrival of atypicals to illustrate what has been a recurring pattern in psychiatry: as an older treatment falls into disrepute, the benefits of a newer treatment are overstated (Cohen, 1994). There are now scores of reports of EPS such as severe dyskinesias and dystonias (e.g., Ahmed et al., 1999), severe akathisia (e.g., Jauss et al., 1998), neuroleptic malignant syndrome (AI-Waneen, 2000; Karagianis, Phillips, Hogan, & LeDrew, 1999; Stanfield & Privette, 2000), as well as tardive dyskinesia (TD) (e.g., Ananth & Kenan, 1999; Spivak & Smart, 2000) associated with nearly every atypical drug on the market. In a 2000 study by Modestin, Stephan, Erni, and Umari of 200 patients treated for several years with older neuroleptics or with clozapine, the authors conclude: "On the whole, long-term relatively extensive use of clozapine has not markedly reduced the prevalence of extrapyramidal syndromes in our psychiatric inpatient population. …

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