Psychiatric Primary Care

Linda Denise Oakley, Claudette Potter
Mosby-Year Book, Inc, 11830 Westline Industrial Dr, St Louis, MO 63146 USA
1997/448 pp

Strengths

Assessment and DSM-IV diagnosis

Weakness

Specific pharmacologie treatment

Audience

Family physicians and allied mental health professionals

The authors of this ambitious book state, “We have developed a book for primary care practitioners that presents everything from basic mental concepts and terms to clinical examples of psychiatric primary care.”

The book is divided into five parts that deal with basic concepts of assessment and diagnosis; common mental disorders; psychosocial problems; special populations and problems, such as children; and practice notes covering mental health laws, threatening patients, and clinical vignettes.

Illnesses are conceptualized in the biopsychosocial model, and diagnoses are based on DSM-IV definitions. This book is very strong in assessing mental disorders, presenting epidemiologic data, risk factors, psychiatric terminology, and DSM-IV criteria. It is also strong in addressing the psychosocial context in which mental illnesses occur.

This book is too general in the area of management. For example, in treating depression, information on using specific medications and dosages is not provided. As well, while cognitive-behavioural therapy is mentioned, advice on how to use it in specific disorders is not given. This wide-angle perspective on management, especially pharmacologie treatment, probably arises from the nursing background and praètice of the authors.

It is important to note, given the book’s emphasis on DSM-IV diagnoses, that the DSM itself is continually evolving and that its diagnoses are based strictly on empirical clinical presentation. We would be wise to acknowledge the ambiguities of human nature and not thoughtlessly use formulae to reduce the complexities and richness of human expression into 5-digit codes.

This book excels in teaching attitude and background knowledge of psychiatric primary care. However, specific knowledge and skills are still required for proficient practice. The book describes certain important aspects of continuing education in psychiatric primary care for Canadian physicians.

Psychological Problems in General Practice
A.C. Markus; C. Murray Parkes; P. Tomson; M.Johnston
Oxford University Press, 70 Wynford Dr, Don Mills, ON M3C IJ9
1989/406 pp

The authors believe that psychiatry in general practice is a different specialty from psychiatry in hospitals. The authors suggest that a problem-oriented model is more appropriate to family practice. The authors also believe that psychoanalysis is a frame of reference that has outlived its usefulness and have introduced their textbooks with chapters on ethology, psychology, and social science, as well as an introduction to the excellent British literature on the epidemiology of psychiatric illness in general practice.

The bulk of the book focuses on practical management by the primary care team, the family life cycle and its turning points, mind and body relationships, and traditional psychiatric disorders.

This book is well written, comprehensive, and for the most part, the authors have met their objective of providing information about the problems in family practice. I do have several reservations about the book, which perhaps reflect my bias of being a psychiatrist trained in North America and not a British family physician.

There is too much background information in the relatively lengthy book and not enough focus on the common clinical presentations of anxiety, depression, and substance abuse. The reference material is largely from the literature in England, and while I found that fascinating, I wondered whether some of the references and contents were relevant to North American practice.

Finally, the sections on counseling and individual psychotherapy, family and couple therapy, group therapy, etc, are well written, but they seem to expect more of a family physician than training and experience would suggest is reasonable. This book (no. 15 in the Oxford General Practice series) is a good example of newer models and practices for psychological problems in general practice and provides an introduction to literature not available in North American books. There are, however, shorter and more practical paperbacks available in the marketplace.

Atypical Antipsychotics

Most initial published data on atypical antipsychotic drugs in the elderly are clinical trials in nondemented patients with schizophrenia or Parkinson’s disease. In the last two to three years, controlled trials evaluating risperidone (Risperdal) and olanzapine (Zyprexa) in patients with dementia have been published. There is now evidence that these two atypical antipsychotic drugs offer efficacy in this patient population with fewer adverse effect concerns than the typical antipsychotic drugs.

Risperidone (Risperdal). In 1999, Katz et al. published the first large multicenter, double-blind, placebo-controlled study of risperidone in treating psychosis and behavioral disturbances in an elderly demented population. Among the 625 patients, 73% had a diagnosis of Alzheimer’s disease; average age was 83 years; and their mean baseline Mini-Mental State Examination (MMSE) score was 6.6+6.3, indicative of the most severe stages of dementia. In this 12-week trial, patients received either placebo or risperidone 0.5 mg, 1 mg or 2 mg daily. At endpoint, significantly greater reductions in Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) total scores, as well as the psychosis and aggressiveness subscale scores were seen in patients receiving daily doses of 1 mg (p=0.005) and 2 mg (p=0.001) of risperidone compared to those receiving placebo. The 0.5 mg daily dose of risperidone was superior to placebo at week 12 in reducing BEHAVE-AD aggression scores (p=0.02). Improvement based upon total BEHAVE-AD scores for risperidone 1 mg or 2 mg was 56% in patients under 85 years old and 72% in older patients, while placebo response rate was 51% and 54%, respectively. While risperidone was clearly efficacious, the high placebo response rate indicates what Schneider (1999) described as “the waxing and waning and evanescence of disruptive behavior” in this patient population. The most common adverse effects from risperidone were motor symptoms, dose-related sedation and mild peripheral edema. Extrapyramidal symptoms did not differ significantly between placebo and risperidone 0.5 mg or 1 mg. Risperidone 2 mg daily produced significantly more parkinsonism and hypokinesia than placebo.

A 13-week study compared risperidone and haloperidol (flexible doses of 0.5 mg to 4 mg; 1 mg mean daily doses for both drugs) to placebo in 344 patients with dementia. At week 12, a reduction of 30% in the BEHAVE-AD total score was observed in 72%, 69% and 61% of patients receiving risperidone, haloperidol and placebo, respectively, and in 54%, 63% and 47% of patients by intention-to-treat analysis (no statistically significant difference). At endpoint, risperidone-treated patients did have significantly greater reductions in the aggressiveness scores compared to placebo. The most common adverse effects for both haloperidol and risperidone were sedation and falls, with haloperidol causing significantly more extrapyramidal effects.

Olanzapine (Zyprexa). In 2000, Street et al. published a large double-blind, randomized, placebo-controlled trial evaluating olanzapine in patients with Alzheimer’s disease. In this six-week trial, 206 patients were given placebo or a fixed olanzapine daily dose of either 5 mg, 10 mg or 15 mg. Mean baseline MMSE scores were 6.7+6.4, indicating severe dementia. Significantly greater improvements in agitation/aggression and delusions/hallucinations were observed in patients treated with olanza-pine 5 mg or 10 mg compared to placebo and olanzapine 15 mg. The most improvement was seen in patients treated with 5 mg. The total MMSE score did not change significantly over the course of the clinical trial, although there was a modest improvement in the 5 mg dose group and a modest decline in the 10 mg and 15 mg dose groups. Somnolence was the most common dose-related adverse effect, occurring in 25% to 36% of olanzapine-treated patients compared to 6% with placebo. Gait disturbance occurred in patients receiving 5 mg or 15 mg (20% and 17%, respectively), compared to 2% with placebo. There was no significant cognitive impairment, increase in extrapyramidal effects or central anticholinergic effects at any olanzapine dose compared to placebo. Vital signs and laboratory and electrocardiogram measures were unchanged in each dose group compared to placebo.

Discussion

The modest efficacy of conventional antipsychotic drugs in patients with dementia, coupled with their high potential for extrapyramidal effects, tardive dyskinesia, anticholinergic effects and worsening cognition has meant that many patients’ behavioral symptoms and psychosis have been inadequately treated. The atypical antipsychotic drugs, notably risperidone and olanzapine, now have evidence supporting their efficacy and lower potential for adverse effects. Daily doses of no more than 1 mg to 2 mg of risperidone or 5 mg to 10 mg olanzapine can provide significant therapeutic benefit without the risk of significant adverse effects compared to conventional antipsychotic drugs.

Patients with dementia display a broad range of cognitive impairments and behavioral and psychotic symptoms. Common behavioral symptoms include verbal and physical aggression, hyperactivity, disinhibition, and pacing and wandering; common psychotic symptoms include paranoia, delusions and hallucinations. These behavioral and psychotic symptoms are the leading cause for the use of more restrictive supervised environments, including institutionalization.

Effective pharmacologic and nonpharmacologic treatment of these symptoms is desirable and, in addition, might delay nursing home placement. Pharmacologic and nonpharmacologic interventions are indicated based upon consideration of the safety of both the patient and those around them. Conventional antipsychotic drugs have limited value for psychotic and behavioral symptoms, but recently the results of several large controlled trials of atypical antipsychotic drugs have become available.

Conventional Antipsychotics

The use of conventional antipsychotic drugs in patients with dementia has a long history of concerns regarding limited efficacy as well as adverse effects that often exceed any therapeutic benefits. In the 1980s, these concerns led to the nursing home provisions of the 1987 Omnibus Budget Reconciliation Act (OBRA 1987) mandating reductions of antipsychotic drugs in an effort to limit their use. OBRA 1987 identified specific indications for antipsychotic drugs that included psychotic symptoms and specific aggressive behaviors, and it also identified symptoms of impaired memory, uncooperative attitude, poor self-care and wandering as inappropriate indications for antipsychotic drug therapy. It was recognized that while low doses of conventional antipsychotic drugs (e.g., haloperidol [Haldol] 1 mg/day to 3 mg/day) could be effective for severe aggressive behaviors and psychotic symptoms, higher doses could in fact worsen cognition. Furthermore, extrapyramidal effects could limit improvements in quality of life achieved through improvement in behavioral symptoms.

In 1990, Schneider et al. published a meta-analysis of controlled clinical trials of conventional antipsychotic drugs published from 1954 to 1989. While the authors concluded that these drugs were effective, only 18% of patients received beneficial effects beyond those from placebo. A later meta-analysis evaluated published studies from 1962 to 1995 comparing conventional antipsychotic drugs to placebo in treating behavioral disorders of dementia. Their conclusion was similar in that no significant difference was found in efficacy between individual antipsychotic drugs, with a modest therapeutic benefit of 26% for antipsychotic drugs beyond that from placebo.

Thioridazine (Mellaril) and haloperidol have been the most commonly used drugs in this patient population. Thioridazine poses particular concerns regarding orthostasis, anticholinergic effects and sedation, while haloperidol carries a high risk of movement disorders and the need to use an anticholinergic drug to treat them. Daily doses of haloperidol above 2 mg or of thioridazine above 75 mg tend to be less effective and are associated with greater adverse effects.

Observations obtained from carefully studied individual cases and from mass experiments would indicate that the tranquilizing drugs act by suppressing the patient’s symptomatology. They suppress certain clinical manifestations in the patient in the same way as an anti-epileptic drug suppresses epileptic discharges. From a clinical point of view this is a real accomplishment. However, we have at present no indication that any of these compounds will touch upon the substructure of the psychotic individual, or that they influence qualitatively the matrix on which the psychosis develops. These compounds quantitatively influence the patient’s symptoms by reducing their intensity to a varying degree thereby enabling the patient to function. In many instances this reduction in the intensity of symptoms will need psychotherapeutic supplementation in order to solve some of the patient’s conflicts.

The integration of the drug therapies with other forms of psychiatric treatment will be the most important contribution of psychiatric research and therapy in our day. As usual, if some new therapeutic agent is introduced, we observe negation on the one hand and exaggeration on the other. We believe that pharmacotherapy is definite progress in psychiatric treatment and will benefit a number of patients. On the other hand, none of the known chemotherapeutic agents have been so effective that we can say whole psychiatric disorder entities will be wiped out, or as it has been stated, that hospitals will be closing and patients will not be admitted. These chemotherapeutic agents may somewhat reduce the admission rate to hospitals, but this has not been noticeable as yet. We have noted, however, that the discharge rate is higher in the mental hospitals. This may be due to the fact that the period of treatment of the patient can be shortened. There are some indications that patients who have been treated in a hospital and are now maintained on tranquilizing drugs outside of the hospital, do not relapse as often as patients who received other forms of treatment. We need more information on this very important point. If, after a comparatively short period of hospitalization, we could treat many of these patients, even if only on a symptomatic level and on an outpatient status, with the compounds we are using today for the treatment of psychoses such as schizophrenia, it would be a considerable achievement. We would like to call your attention to the fact that without any great fanfare and without even considering it spectacular, 80 per cent of epileptic patients are today controlled with the different chemical compounds now available, outside the hospital. This has been accomplished even though the etiology of epilepsy is unknown and the action of the chemical compounds on the epileptic disorder results in only symptomatic relief but does not affect the etiology.

The use of chemical compounds in psychiatry will be not only a symptomatic tool in controlling more effectively than heretofore some of the psychiatric disorders, but will lead inevitably to intensified research and a better understanding of the biochemical function of the nervous system and also a better understanding of the function of the nervous system in relation to emotional disorders.

This brings up one of the most important issues on which no general agreement has been reached. A certain number of patients receiving the drugs function adequately, lose their symptoms, feel comfortable, and for all practical purposes are able to live a normal life. This may often be within the framework of some limitations, but nevertheless conspicuous mental symptomatology is absent. It has not been established as yet how many patients are able to do that by receiving only the drug and without any psychotherapy. In the state hospital system, we see quite a number of patients who show improvement under these drugs and maintain their improvement after they are discharged even though they receive very little psychotherapy. In a considerable number of patients, psychotherapy is needed in addition to the drug treatment. This is especially true of patients who are improving and are becoming aware of some of their conflicts or adaptational difficulties with the environment and would like to have help in overcoming these difficulties.

A considerable number of patients become more amenable to psychotherapy while under the drug. Because the psychiatrist’s time is not absorbed by giving these patients reassurance, some of the adaptational difficulties and conflicts can be disclosed more rapidly and at times more incisively than otherwise. How psychotherapy should be applied to patients under the influence of the tranquilizing drugs is still under investigation. We are all groping in this field and no definite conclusions can be drawn. We do not know how far psychotherapy can be modified or applied over a much shorter period than has been customary in the past. Do the drugs support or replace certain psycho-therapeutic functions or not? It is also unclear how the psychotherapeutic techniques should be modified with patients under the influence of drugs. It is obvious that a patient who is not anxious, who is relaxed, and who is not constantly preoccupied with what is going on inside of himself is far better able to externalize interest and participate in group or in individual psychotherapy than otherwise. Even in optimum circumstances, psychotherapy with a psychotic individual is a very tedious, hard, and uncertain job. It is possible that with the help of the newer chemical compounds and perhaps even more with those still to be introduced, psychotherapy with these patients will become more effective and more economical of time.

Some psychiatrists have raised fears that many patients under the influence of these drugs will lose their anxiety. This is particularly true of some neurotic patients. In this event they would not have the motivation to undergo psychotherapy. It is possible that in some patients the drugs remove the discomfort and the patient will not seek any other psychiatric help. It is not yet clear if in those patients where the drugs are so successful that they are completely symptom free and functioning well, whether they really need further psychiatric treatment or not. This will have to be decided in each individual case.

Some psychiatrists also maintain that the extensive use of these drugs is deplorable because they deprive the patient of his incentive to undergo psychotherapeutic or analytic work which is the only treatment able to affect the patient’s emotional difficulties on a causal level. We would like to call attention to the fact that in present-day psychiatry there are only a few conditions where we are able to apply a causal treatment. Most of our treatments as used today, somatic or psychotherapeutic, are symptomatic. To be able to claim that psychotherapy does a causal etiological job in a psychotic individual would imply that we know the origin of these disorders. Based on present-day psychiatric knowledge, the etiology of quite a number of neurotic disorders is also obscure. Therefore, to assume that one treatment is symptomatic and another is causal is unwarranted.

We feel the following trends in the use of the tranquilizing drugs should be checked. First, patients should not receive a tranquilizing drug without proper physical and mental examination. We know that some of the drugs can lead to physical complications and therefore the physical status of the patient at the beginning of medication is of importance. Complications are known to develop with chlorpromazine and reserpine. We have less knowledge about complications concerning the milder tranquilizing drugs, but we do not believe that we can state at present that no complications can develop and that they are harmless. It is unwise to claim on the one hand that these different compounds ire highly effective and exert specified actions on the nervous system and other parts of the body, and on the other hand try at the same time to convey the idea that they are completely harmless agents, which in their chemical action are similar to a placebo. No chemical compound effective in the realm of psychiatric disorders can be considered completely harmless for the simple reason that these drugs not only produce physical symptoms, but can also produce emotional symptoms. The physical symptoms are those which are usually the most conspicuous. Therefore, we have known for some time what physical side-effects can be produced by chlorpromazine or by the Rauwolfia compounds. It was only later that we became aware of the fact that in some patients these compounds produce undesirable emotional states, instead of relieving them. In a paper dealing with the effect of chlorpromazine on moderate and mild emotional disturbances we have indicated that at times emotional complications may occur. The same is true with the use of the Rauwolfia preparations. Actually far more cases of depression occurring during Rauwolfia medication were reported by reliable investigators than with the other compounds. We do not know enough about the milder tranquilizing compounds like meprobamate which are used in the milder emotional disorders. We also do not know if psychic complications occur with any frequency or not.

Second, we believe that if a tranquilizing drug is prescribed, a proper indication for its use should be present. In other words, it should not become a reflex panacea, meaning that any and every kind of nervous and emotional complaint should be treated by giving one or another of the tranquilizing drugs. It would be deplorable if the emotional complaints of the patient were not assessed and properly evaluated, and if all forms and kinds of emotional disorders regardless of how they occur, in what configuration they manifest themselves, and what causes are behind them, would be treated by the administration of a tranquilizing drug.

Another difficulty which we frequently encounter is that the patient is not kept under close enough medical surveillance as to what mental and physical symptoms he may develop under the influence of these drugs. The first few weeks of treatment with these drugs are a crucial time and frequent observation of the patient is essential. We have seen patients develop depressions who were told to take the medication and to return in two or three weeks, with the assumption that the drug would either help or not help, but that it could not produce undesirable effects. Many physicians are aware of some of the physical complications which can be produced by these drugs, but are far less aware of the mental alterations which can be observed. Fortunately, in the majority of the patients there is an amelioration, but in some there is an aggravation, of the existing symptomatology and sometimes even new symptoms occur.

A patient who is using the drug on a maintenance dosage level does not have to be seen as frequently as a patient still under full treatment. However, even patients who are on a maintenance dose should be seen every few weeks to determine whether or not the drug still controls the symptoms, whether the amount given can be reduced, or even if the drug can be withdrawn. It is also important to decide whether the patient will or will not require psychiatric help in addition to the drug treatment.

We would also like to emphasize that it is much more difficult to establish the maintenance dose of the patient than the primary therapeutic dose. We all use maintenance dosages and for the patient who has been on the drug for a few weeks or a few months the dosage is usually reduced to a level at which we believe he will be able to function properly. To determine the maintenance dose needs a considerable amount of experimentation in some patients. It is not always easy to establish the proper amount. In some patients a definite adaptation and tolerance develops. In such cases the dosages can be raised, but we have encountered patients who even with raised dosages do not respond in the same way they did at the beginning of therapy. In these circumstances a change to another drug is definitely indicated.

There is considerable controversy in the literature as to how long the treatment of a patient should be continued when he is responding well to a drug. Should such a patient be treated for a few months and then cut off or should the patient be given the drug indefinitely? In a certain number of patients it is possible to stop the drug after a few weeks or months and then find that the patient is able to get along without it. We regret to say that in a large number of psychotic patients and also in a considerable number of neurotic patients responding to the drug, it will have to be continued for a long time — if not indefinitely. If the drug is withdrawn the clinical symptoms of the patient recur, sometimes gradually and slowly, and at other times quite suddenly. It has not yet been determined how long a patient should be maintained on a drug and more information than we have today must be obtained on this important point.

In addition to discussing uses of tranquilizing drugs in a general way, we have also been asked to discuss their abuses. It is obvious that with any new treatment approach, and especially if it develops fairly rapidly, certain abuses also develop. These abuses are even more understandable if we consider that the etiology of many of the disorders is unknown. The use of these compounds therefore cannot be applied as specifically and clearly as in disorders with a known origin. However, this does not mean that in some instances the tranquilizing drugs are not used indiscriminately.

The American Psychiatric Association recently issued a statement concerning the use of these drugs by the public for the relief of everyday tensions. It outlined the contributions made by these drugs to psychiatric practice. At the same time it pointed out that these drugs are used by the public for the relief of common anxiety, emotional upsets, nervousness, and the routine tensions of everyday living. A market research firm has stated that thirty-five million prescriptions for such drugs were filled in 1956 and that three out of ten prescriptions written by physicians in 1955 were for tranquilizers. We do not want to enlarge here on the public health aspects of this observation. You will recognize that in this situation we are not dealing with abuses alone, but we are faced with a tremendous demand to regulate nervous tension and anxiety by medication. An unsuspected large segment of the population is obviously seeking a safe tension-reducing agent. We believe that in addition to the psychiatric and medical measures which must be taken to delineate the indications for these drugs for different emotional disorders, it will be necessary to study in detail the reasons why such a great demand exists in the population for such drugs that have this tension-reducing property and why such a large segment of the population feels they are in need of such support and relief.

The drugs, of course, are used not only in psychotic patients but in many neurotic patients. The tranquilizing drugs are prescribed in large quantities outside of mental hospitals and practically every physician today prescribes these drugs to patients when he assumes that some emotional symptomatology is present. Observations made in this country do not confirm some of the statements made in the European literature that many severely neurotic patients recover after receiving the drug for a few weeks. In some anxious patients the drugs are of great value. In others with similar symptomatology they are not effective. There are neurotic patients who, under the influence of the drugs, and more particularly the Rauwolfia preparations, develop symptoms of depersonalization, depression, and other unwarranted manifestations, which aggravate their condition and interfere with their treatment. The value of these drugs in neurotic patients is far from being adequately assessed. It is undeniable that some neurotic patients function better under the influence of the drugs. In other neurotic patients no improvement is noted. We feel that the drugs are more effective in the gross mental disorders than in the neuroses, but much more investigation will be necessary to arrive at a definite conclusion.

The drugs are quite effective in psychosomatic cases and especially in those cases where a great deal of vegetative nervous system discharge is present. In these patients the drugs contribute a great deal to the better management of the patient.

There is considerable discussion in the current literature about dosages of the tranquilizing drugs. The dosage is a highly individual affair and actually no standards can be quoted. For instance, some patients respond to 50 mg. of chlorpromazine and others need 1500 mg. Some patients respond to 1 mg. of reserpine and others need 18 mg. One of the common errors in the treatment of these patients is the fact that these great dosage ranges are not recognized and the proper dosage has not been worked out and adapted to the patient’s condition. Some have raised the question as to how far we should go in dosage to achieve clinical results. Some use very high dosages. We feel that we should increase the dosage considerably if the patient does not respond. For instance, with chlorpromazine we use dosages up to 1200 mg. but I know of some physicians who use up to 4000 mg. daily. It is not yet definite how far we should go and there is a point of no return in clinical improvement. With reserpine some use up to 18 to 20 mg. daily. Again we do not know how far we should raise the dosage to improve the patient’s condition. We believe that with chlorpromazine the patient should be given up to 1200 mg. and with reserpine up to 18 mg. for a period of time before deciding that the patient will not respond to the drug.

Considerable difficulty arises in determining the dosages in ambulatory treatment. Some do not wish to give the higher doses because they feel this would create complications. Accordingly, the patient is often kept on a comparatively low dosage and, if he does not respond, the treatment is given up or a trial of other drugs begins, even though the patient would have been well controlled by receiving a higher amount of the first drug. In ambulatory patients it is important to decide how far the dosage of the drug can be raised without interfering with the ambulatory status. If the patient does not respond, temporary hospitalization is advisable in order to use higher doses rather than to discontinue treatment and assume that the patient does not respond to the medication. The second issue, which is also controversial, is how long the use of the drugs should be continued. Some advocate that the drug be discontinued if the patient does not respond within two months. We feel that this is probably too short a time to judge and would prefer to set the termination date after four months. This implies that the patient should have received the drug in adequate amounts. If a patient does not respond to one of the tranquilizing drugs the question arises, should he be switched to another? This can be done and there are patients who respond better to one compound than to another. Observations show, however, that a considerable number of patients who do not respond to one also do not respond to another of the drugs. We believe that a considerable amount of research will have to be done on this aspect of drug therapy and if possible try to learn the physical and psychic indications that determine which drug should be used.

At present we are using drugs in large numbers of patients. This does not necessarily mean that these patients should not have a physical and mental examination and that details of their psychiatric illness are not appraised. Mass use of the drugs should not assume that the patient is physically well, suffering from some form of emotional disorder, and then prescribing one or the other of the tranquilizing drugs to relieve the emotional state. When we discuss some of the abuses which occur in using the drugs we will again emphasize that it is important to establish a psychiatric appraisal of the situation and know for what the drug is to be used.

The tranquilizing drugs are most effective in psychotic patients and especially in early catatonic and paranoid schizophrenic patients. Hebephrenic and simple types of schizophrenia show alteration in behavior, but they do not achieve the same amount of reintegration with the drugs observed in the other two groups. This is not new and agrees with observations learned from shock therapy and lobotomy. Again we make the observation that catatonic and paranoid forms of schizophrenia are more apt to reintegrate than the other forms of schizophrenia which have a far more disorganizing effect on psychic functioning.

In manic depressive patients the tranquilizing drugs are very effective in the manic state. They are not effective in the depressive states except in patients who suffer from agitated or tense depressions. Simple depressions, retarded depressions, and so-called neurotic depressions usually do not respond well to the drugs, and usually respond well only if features of tension or agitation are mixed in the clinical symptomatology. Actually one of the commonest mistakes today is to give a depressed patient these drugs, leave the patient unattended, and assume that the drug will control the patient’s symptomatology. The number of suicidal attempts under tranquilizing drugs is rising. Depressed patients, unless carefully supervised, should not receive tranquilizing drugs in an ambulatory setting. We should be aware of the fact that depressed patients are capable of committing suicide even when they are under the influence of the drug.

The tranquilizing drugs are very effective not alone in cutting tension and excitement, but also in influencing states of confusion or states of delirium. They are valuable adjuncts in trying to clear confusional states in the organic psychoses. For instance, in alcoholic patients who suffer from confusion, in some arteriosclerotic patients, or in patients suffering from head injuries, the drugs are most effective in calming the patient and in shortening these confusional episodes. The drugs have no effect, however, on the symptomatology of organic psychoses which fall in the realm of dementia or deterioration. In other words, patients with an enfeebled intellect respond only insofar as their behavior is better controlled and in that they are not excited or upset. A dementing process is not prevented or influenced by the drugs.

The efficacy of the tranquilizing drugs in certain psychoses is well established. The questions which are not settled are, how permanent is the improvement of these patients, how long should treatment continue, and, statistically, how many patients respond. These questions are still open and some time will elapse before we will have reliable answers to them. There is nearly complete agreement among those who use the tranquilizing drugs in state hospital settings that these drugs control excitement and disturbed behavior far better than previously used treatment. The use of restraint has dropped very markedly with the use of the drugs. Many of the patients under the influence of tranquilizing drugs not only behave better, but are able to engage in activities, are able to follow a therapeutic regime and indulge in active participation. Therefore, the idea expressed by some that these patients are only sedated and because of the sedation do not display any initiative, is not correct for the majority of patients. This is especially true for those patients who are maintained on comparatively small amounts of the drugs which do not interfere with their mental functioning and do not slow down their actions.