Edward S. Hume, M.D., J.D. General Adult Psychiatry
A new calculus for treating psychotic patients Updated 1999/10/15
When I was just starting in psychiatry out at Washington University, we were learned that we needed to diagnose "affective" disorders (now called mood disorders) when possible: one could treat mania with a "neuroleptic" (a "typical" antipsychotic medicine) without really helping the patient. Treat a psychotic mood disorder appropriately and you could save a patient from decades of mistreatment with unpleasant chemicals.
As we learn more about such "neuroleptic" side effects such as akinesia, akathisia, dystonia, pseudoparkinsonism and tardive dyskinesia, we find that people with mood disorders are more sensitive to these bad side effects. So, as long as neuroleptics were our only antipsychotics, overdiagnosing mood disorders was a good idea: schizophrenia, after all, would wait. Underdiagnosing it would not harm the patient, we thought.
There are two reasons to change that opinion.
First of all, there is research indicating that early intervention will reduce the severity of schizophrenia. Each psychotic episode leaves a person at least a bit (or a lot) more disabled than before, never returning to "baseline". Starting treatment early and keeping it going, along with sheltering a first-break psychotic patient, can make a significant difference in prognosis. For this reason alone it behooves us clinicians to diagnose schizophrenia accurately the first time and start treatment early.
The other reason not to underdiagnose schizophrenia is the arrival of safe "atypical" antipsychotics. These non-neuroleptic medicines avoid most or all of the bad side effects of the neuroleptic antipsychotics, especially tardive dyskinesia.
Bottom line: it is now very important to diagnose a patient's psychosis accurately.
[A corollary: with the arrival of the
non-neuroleptic antipsychotics, perhaps the courts should look
again at the assumptions underlying various
right-to-refuse-treatment legal decisions. Most of these court
holdings are implicitly based on the various side effects of the
"typical" (neuroleptic) antipsychotics.
In any case, one can (as I do) argue in
treatment-over-objection hearings that a treatment plan entailing
the use of the new "atypical" antipsychotics for the
objecting patient is not likely to harm him or her.]