3.4 Pharmaceuticals for mental health: a brief history
The ‘revolution’ in drug therapy is widely credited with causing the mass closure of psychiatric hospitals in the 1950s and 1960s, meaning that patients who had previously been considered too much of a danger to themselves or others could be safely housed ‘in the community’ as long as they took the medication. However, the trend for a reduction in numbers was already evident at the time the drugs in question began to be available, and academics such as Joan Busfield and Andrew Scull argue strongly that the correlation between the two is much less clear than previously suggested (Busfield, 1986; Scull, 1984).
Whether or not it enabled closure of the large institutions, there is no question that medication has revolutionised the way people experiencing mental health problems are treated. Drug treatments had obvious advantages over their immediate precursors, physical restraint and lobotomy. Although the effects of the early antipsychotics can be compared to the effects of lobotomy (Breggin, 1993), it was thought that they would have a short-term impact which would cease when the drug was no longer being administered. Combined with the impact of a series of scandals about conditions in long stay hospitals (Scull, 1984), drugs which enabled people to leave institutions appeared highly attractive.
Activity 9: Pros and cons
Consider the advantages of antipsychotic medication in terms of the interests of service users/survivors, professionals and the state, and make brief notes.
Antipsychotic drugs had advantages for all concerned:
For service users/survivors, they reduced the likelihood of institutionalisation and of permanent brain damage through psychosurgery, and opened the possibility of a better life.
For professionals, they moved public perception away from ‘gaoler’ towards ‘doctor’, reinforcing psychiatrists' power to understand and treat ‘madness’ because they could prescribe drug treatment.
For the state, they offered the possibility of cheap management of ‘deviant’ individuals, and a less obviously restrictive set of practices than large institutions, which might (and did) draw criticism from civil liberties campaigners.
However, there were disadvantages. From a service user's/survivor's perspective, the less damaging effects of the drugs had to be weighed against a long list of debilitating side effects. Since the first appearance of antipsychotic drugs in 1952, their side effects have become better understood. Originally termed ‘neuroleptic’ (because they attached themselves to neurons in the brain), the early antipsychotics were considered to have mainly sedative effects. (Another name for drugs in this class is ‘major tranquillisers’; examples are chlorpromazine, thioridazine and haloperidol.) Many of the symptoms later termed ‘side effects’, such as drowsiness and apathy, were originally described as the intended functions of the drugs (Breggin, 1993). Breggin, a fierce critic of the influence of the pharmaceutical industry, argues that only later did the pharmaceutical companies begin to claim that the drugs had a therapeutic effect on psychosis.
Throughout the 1950s and 1960s, the doses of antipsychotics prescribed began to increase, perhaps as a result of aggressive marketing by drug company representatives, who argued that the ability of the drugs to combat symptoms increased with the amount taken (Rogers and Pilgrim, 2003). While there is no evidence that the therapeutic value of the drugs does increase with dose, the same cannot be said of their side effects.
Following the thalidomide crisis in the UK in the late 1950s and early 1960s, when over 6,000 children were born with severe disabilities because of a drug administered to their mothers during pregnancy, a system of routine reporting of any adverse effects of prescribed drugs was introduced, voluntary for health professionals but obligatory for pharmaceutical companies (MHRA, 2003).
This involved doctors completing a yellow slip describing the prescription and reported side effects and submitting it to the Committee on Safety of Medicines. Since the introduction of antipsychotic drugs, critics of the medication had suspected that their adverse effects were being under-reported. It was suggested that virtually everyone for whom these drugs were prescribed experienced some unpleasant effects. In response, Mind launched its own Yellow Card scheme in 1995, encouraging service users themselves to report unwanted side effects directly to the charity. Although run as a campaign and not a scientific study, the results went a long way towards supporting the claims of under-reporting (Cobb, 2001).
In the 1990s the drug companies themselves produced scientific evidence of the unpleasant effects of antipsychotic drugs, but only when a set of new, more expensive alternatives, the ‘atypical’ antipsychotics such as clozapine and risperidone, was available. The effects of the older antipsychotics include a range of movement disorders such as tardive dyskinesia (TD) (Brown and Funk, 1986).