Haloperidol: A New Profile?
441
Session III Management and Rehabilitation of the Chronic Institutionalized Patient Chairmani Professor F A Jenner
Rehabilitation of the Chronic Patient: Experience in the USA by Dr James S Howard III (Conlsulltanit Psychiatrist anld Facility Service Chiiefj Departmen7t of Men1tal Health, Freslno, Califorliia, USA) Chronic psychosis is a specific and a highly specialized area of interest which requires a fresh approach and attitude on the part of the therapist for a successful outcome. Usually, years of unsuccessful treatment have come before, with progressive discouragement, disappointment and resignation. It should be said that to ignore the patient's history and to repeat the same mistakes and unsuccessful therapies of the past is to court almost certain failure. Likewise our goals and therapeutic expectations must now be raised for these individuals in the light of recent experience. I would like to share with you a few of my own experiences with several groups of these severely ill people, especially those aspects which may relate to the use of haloperidol.
Dr James S Howard III Lately Clinical Dir-ector, Eastern State Hospital; Consuiltant Psychiatr-ist and
Facility Ser-vice Clhief, Depar tment of Mental Health, Fr-esno, Califor nia, USA
First Stiudy
Patienits anid methods: In the first group (Howard & Schmidt 1973) there were 95 unselected male and female chronic patients. Their average age was 57 years with a mean chronicity of 17 years spent for the most part in custodial care. Seventy per cent carried a diagnosis of schizophrenia and all were assigned to this area due to their severe mental impairment. There were no additional funds, facilities or staff for this programme, only those who would be available on any such ward: a physician, a nurse and a few aides scattered over a 24-hour period. Only nine of these people' had improved sufficiently for release in the preceding eleven years, and yet from this very same group in a five-month period we had 53 of them out of the hospital, on their own or with their families, and in no case were they in a nonpsychiatric custodial care setting. Our criteria for success and eligibility for release were: (1) Alertness, good orientation and awareness of surroundings. (2) Good concentra-
tion, attention span and ability for abstract thinking. (3) Appropriateness and good personal hygiene. (4) Demonstrated responsibility and ability to work outside the area in constructive rehabilitative activities for at least 20 hours per week. To bring about these results no one programme or philosophical concept was followed rigidly. Retrospectively, at the end of five months, it was the opinion of the staff that it was the combination of all treatment modalities (i.e. milieu, occupational therapy, group therapy and chemotherapy) each tailored to the specific needs of the individual, that brought about the good result. As to chemotherapy our approach was essentially the same. If the person could be maintained on the medications he was receiving as a chronic ward patient, and these adjusted upwards or downwards to bring about the fine points of the mental status, it was retained; otherwise it was replaced.
42 Proc. roy. Soc. Med. Volhme 69 1976 Suipplemenit I At the end of the five-month programme all medications were reviewed and it was found that most patients who had improved sufficiently for release were on haloperidol. When using this neuroleptic our starting dose was seen to have been generally 10-15 mg per day. This was then increased at weekly intervals by about 50% until: (I) the patient was responding well by our criteria; (2) the patient was beginning to show side-effects; or (3) a generally set limit of 75 mg per day was reached. If the patient was still psychotic on 75 mg haloperidol per day, a sedating phenothiazine was then added and titrated upwards. Using this method, at the end of five months only 14 of the original 95 were found to be in need of further inpatient psychiatric hospitalization.
Resiilts: The patients' improvement appeared to occur in three stages. First would be a period of little or no improvement until a certain level of medication was reached. At that time the patient was noted to become more alert, aware of surroundings and amenable to the efforts of the therapeutic community. The improvement would then continue with increasing medication until a plateau of improvement was reached, after which increasing the medication further tended to cause the patient to become more sedated, with an increasing incidence of side-effects. When the therapeutic plateau was reached, the patient was then maintained on this schedule, due to the frequent deterioration seen in chronic patients as medications are decreased or discontinued.
Of the 53 patients successfully released from the programme, 70% were schizophrenic or about the same percentage of schizophrenics as in the total initial population. On the average they were 48 years of age with a chronicity of 17 years. This may be compared to the schizophrenics left behind whose age averaged 59 years with a mean chronicity of 36 years. As the patients were receiving a variety of antipsychotic agents these were expressed as approximate thioridazine equivalents (ATE). For this the following figures were used: 100 mg chlorpromazine = 2 mg haloperidol = 5 mg thiothixene =5 mg trifluoperazine = 100 mg thioridazine = 50 mg mesoridazine
Expressed in this way, the released schizophrenics were receiving an average of 2146 mg ATE per day at time of release, or about four times as much medication as they were formerly given on the chronic ward. This figure, however, does not reflect a predominant use of the sedating phenothiazines (especially in this older age group)
but rather of the less sedating, more effective antipsychotic agents such as haloperidol. Of the patients released on haloperidol, a few were found to have required as much as 100 mg per day to effect a successful remission. The average was around 35-40 mg per day, used at times in combination with a sedating phenothiazine. The patients released from the nonschizophrenic group tended to be on the average 48 years of age, with a mean chronicity of 5 years; this compares, in their counterparts left behind, with an average age 60 years and an average chronicity of 13 years. The released nonschizophrenics were found to have required 890 mg ATE to effect their release or about twice as much as they were receiving as chronic ward patients; again, most had their successful outcome with haloperidol. In the end, almost all patients on the ward had been given at least a therapeutic trial of medication. On the other hand, as chronic ward patients, a full third of these people were receiving no neuroleptics whatsoever. Upon release, the patients were followed by community mental health agencies and our return rate for this group was about 5 % per year with a 2.5 year follow up. This may be compared to the usual return rate for this group of 80 %
After this programme a similar effort on behalf of 250 slightly older and more chronic patients during a one-year period resulted in 150 being successfully released from the hospital. Included in this group were a number of patients acknowledged to be among the most severely psychotic, treatment-resistant patients in a hospital population of 2000. Seventeen of these were treated with haloperidol alone in doses up to 200 mg per day under double blind conditions, and 8 achieved successful remission and release from the hospital. Of those released, the average dose of haloperidol per day at their time of discharge was 104 mg, with several requiring 150 mg or more; at least one other with a chronic psychosis of 20 years' duration required 320 mg haloperidol a day for a successful outcome (Howard 1974). Second Stuidy Patienits and methods: Another programme for 36 severely psychotic chronic patients was given an eight-week evaluation as part of their regular ongoing treatment. These patients were on the average 48 years of age, with a mean chronicity of 14 years. Seventy-eight per cent carried a diagnosis of schizophrenia and participation in rehabilitative programmes was quite low. In this
Haloperidol: A New Profile? case activities and therapies for the patients remained the same as before the programme was started; it consisted of milieu therapy and behavioural modification by the staff, and a medication clinic by a visiting psychiatrist.
The medication clinic was held twice a week. During the clinic interview, the patient's record was reviewed, a mental status and progress report was taken for each patient, and medication prescribed on this basis.
Results: Three members of the staff then rated each patient as to global level of functioning before the programme and at the eight-week interval. For this a scale of 0-10 was used, 0 being the lowest possible level of functioning and 10 being the highest. The progress of the individual during the eight weeks was then expressed as the difference between the two scores. The mean score for the entire group at the beginning of the programme was 2.2 and at the end was 4.6, an improvement of I1 0 %. The patients were rated at the end of eight weeks as to degree of improvement, whether (I) little or none; (2) moderate or good; or (3) excellent. These ratings were correlated with the numerical values representing the degree of progress. From this correlation it could be seen that those who improved less than two points were generally rated as showing little or no change. Those who improved between two and four points were seen as moderately improved, and those with four or more points of progress were seen as making excellent improvement. In this way 6 (17 %) patients were shown to have achieved excellent improvement in eight weeks; 16 (44%) had achieved moderate improvement; and 14 (39 %) had achieved little or no improvement.
43
These patients had improved from an initial 2.4 up to 4.5 (88%). Nine other chronic patients receiving neuroleptics other than haloperidol in doses averaging 958 mg ATE had improved from an initial 3.8 up to 5.0 (46O% improvement). Notably, all 6 achieving an improvement of 4 or more points during the eight-week period were
receiving haloperidol. Improvement of psychosis was assessed by the physician using a mental status check list which rated improvement in the mental status of psychotics on a scale 0-9. The three items included were: (1) Orientation to time, place, and person (0-3). (2) Ability to perform mathematical calculations consistent with level of education achieved (0-3). (3) Ability for abstract thinking such as interpreting proverbs (0-3). Expressed in this way the mental status of those receiving haloperidol, either alone or in combination with another neuroleptic over the eight-week period, improved from an initial average of 4.3 up to 6.6 (an improvement of 400%). More specifically, those receiving haloperidol plus some other neuroleptic improved from an initial average of 3.8 up to 7.7 (an improvement of 76%). Those receiving haloperidol alone improved from their initial 4.7 up to 6.3 (an improvement of 34 %). Those receiving neuroleptics other than haloperidol had progressed from their initial 4.6 up to 5.3 (an improvement of 13 %).
Disciussiont Experiences such as these with the chronic population over the last five years tend to demonstrate the impact we are now having, particularly with such medications as haloperidol.
Side-effects in the chronic population were rarely encountered and usually mild. It was felt As the patients were receiving a variety of that these were minimized by beginning at a medications, again before and during the pro- lower dosage range and carefully monitoring the gramme, these were converted into approximate patient during the upward titration. Antithioridazine equivalents (ATE). From this it was cholinergic and extrapyramidal effects were the determined that the patients were receiving an most common and were evaluated in terms of the average of about 129 mg ATE per day before the total response of the individual. It was felt that programme and about 2556 mg ATE per day at reducing the dosage, adding anticholinergics and the end of eight weeks. changing to other neuroleptics, especially different generic types, were beneficial procedures. At the eight-week evaluation, II patients were found to be on haloperidol alone in doses Finally, there were those who did not respond averaging 61 mg per day (3000 ATE) and had successfully to any of the various neuroleptics improved in mean level of functioning from an even when given in adequate doses. For these initial 1-9 up to 5.2 (improvement of 174o%). metabolic, endocrine and neurological testing Sixteen patients were receiving haloperidol in was done and the following conditions were doses averaging 59 mg per- day (3000 ATE) in commonly found: (1) hypothyroidism; (2) hypocombination with another neuroleptic in doses glycemia; (3) folate deficiency; (4) Parkinson's averaging 320 mg ATE or 3320 mg ATE total. disease and (5) malnutrition. As these diseases
44 Pr-oc. rEoy. Soc. Med. Voliime 69 1976 Siupplemenlt I
were found and the patients placed on appropriate medical regimes the response to the neuroleptics became much more successful. In conclusion, the plight of the chronic patient has largely been overlooked as psychiatry has moved into the modern era. Until recently his world, a low and gloomy place, has had little to offer except hopelessness, resignation and despair. To bring about a change in this situation it has been necessary to pay less attention to the words of Kraeplin regarding his condition and more attention to the signs and symptoms of the patient. REFERENCES Howard J S ( 1974) Diseases o' the Nervous Systum 35, 458 Howard J S & Schmidt K T (1973) Psyc/hosolatixcs 14, 355
DISCUSSION
Dr Howard in reply to a question from the Chairman said that he had originally come to use haloperidol on a purely empirical basis. In the early 1970s he became interested in the possibility of using non-phenothiazine agents in chronic patients. He found some striking successes in long-term psychotics treated with haloperidol in doses as low as 15 mg per day and further studies were a gradual development from these findings.
As to the work of Kraeplin, he felt that one of the biggest burdens that the psychiatrist carried was the concept that mental illness was something progressive, degenerative and inevitable from which, if the patient ever recovered, he did not originally suffer. Even today, a diagnosis of chronic schizophrenia carried a considerable social stigma. None the less, it was precisely with this type of patient that Dr Howard had had most success.
Dr Howard agreed. His point had been somewhat rhetorical because he had frequently seen patients who had been misdiagnosed. Some patients with nonschizophrenic diagnoses in chronic wards had improved with neuroleptics which would have been much more appropriate for schizophrenia. One had constantly to ask whether the patients had schizophrenia rather than something else. Much more attention should be paid to the signs and symptoms of the patient than to their diagnostic labels. None the less, Dr Storey's point was well taken.
Professor K Heinrich (Duisseldorf) congratulated Dr Howard upon his achievements. Similar procedures in Professor Heinrich's hospital had reduced the number of beds in seven years by 650.
However, it was relatively easy to dismiss the patient. It was very difficult to keep them out of hospital and to give them a good social adaptation. He wondered if Dr Howard had looked after the patients after their dismissal from hospital. The return rate was 50% but he wondered about the others who did not return. Dr Howard made it quite clear that his programme was not specifically designed to give everybody haloperidol. He was interested in meeting the individual demands of the patient. If this meant putting the patient in his own car, taking him home, discussing with the family the patient's need to stay on medication and making himself available around the clock, he was prepared to do so. After six weeks of follow up, patients were turned over to the community mental health agencies, but a problem there was to make them understand the need to keep the patient on medication. Dr P N Zissis (Atheis) asked if it wa_s preferable for chronic hospitalized patients to be treated with haloperidol or with a long-acting neuro-
leptic. Dr P Storey (Londoni) said that patients had to be adequately diagnosed before they could be selected. Close attention to the doctrines of Kraeplin would prevent, for example, chronic Parkinson's disease from being misdiagnosed as catatonic schizophrenia. Kraeplin's original work had deficiencies but that did not mean his overall concepts were deficient. If we were going to give powerful drugs then the patients must be selected accurately by listening to them and watching what they did, precisely the methods that Kraeplin
himself adopted.
Dr Howard said the answer depended upon the specific needs of the individual. If a long-acting neuroleptic produced a person who was alert
and who could cope with the world, then that was what he should be kept on. If not, then the medication should be changed. At times, one antipsychotic agent would work for a while, and then it had to be changed. It was impossible to take any rigid dogmatic approach. What was required was a dynamic attitude.
Haloperidol: A New Profilek? Dr D M Lowe (Lincoln) asked what were the causes of relapse in the 5 % per year. Dr Howard said that one of the main causes (which was generally recognized) was that the patient who looked normal and went to the clinic was told by the doctor that he no longer required the medicine. As a result, he relapsed. Dr Howard believed that psychiatry was still at the 'germ theory' level of mental illness. If the patient was mentally ill he needed a medicine; if he came out of his psychosis he no longer needed it. However, the situation was far more complex than that.
Professor W Keup (Berlin) commented on Dr Howard's 'total push' approach. It would be interesting to know what part of his results had been due to haloperidol and how much had been due to other therapeutic approaches and even other drugs. Dr Howard agreed. They had been particularly interested in this question after their initial success. They therefore carried out a double blind study comparing haloperidol with thiothixene and with placebo in the 50 worst patients in the hospital. Some 26% of these resistant and refractory patients improved sufficiently to leave the hospital on the placebo. With medication, this figure was doubled. A negative attitude was certainly to be avoided since it could cancel out the real therapeutic effects.
45
Dr E Shoenberg (London) said that Dr Howard had substituted enthusiasm, care and love for despair and apathy. She wondered how much of his success had been due not to the drug but to this change in the regime. Dr Howard said he would never minimize this milieu effect nor the importance of a positive attitude, since for 26% of the very worst patients it had been successful. Dr G Silverman (Southall) wondered how a double blind trial could be carried out against placebo in view of the obvious parkinsonian side-effects of
haloperidol. Dr Howard said that it was kept double blind by having the medication totally removed from the therapeutic situation. All capsules were identical and dispensed from the pharmacy. In reply to the Chairman's question of whether the sideeffects did not distinguish patients who had the drug from those who had the placebo, Dr Howard said that one of their most flagrant cases of oculogyric crisis had occurred on the placebo.
Professor F A Jenner (Chairman) congratulated Dr Howard for what was obviously the most important thing in medicine, therapeutic optimism and concern; and on his results, even though there was a need to consider in greater detail what they meant at a scientific level. What he had done was extremely important. He had helped a lot of people.
441
Session III Management and Rehabilitation of the Chronic Institutionalized Patient Chairmani Professor F A Jenner
Rehabilitation of the Chronic Patient: Experience in the USA by Dr James S Howard III (Conlsulltanit Psychiatrist anld Facility Service Chiiefj Departmen7t of Men1tal Health, Freslno, Califorliia, USA) Chronic psychosis is a specific and a highly specialized area of interest which requires a fresh approach and attitude on the part of the therapist for a successful outcome. Usually, years of unsuccessful treatment have come before, with progressive discouragement, disappointment and resignation. It should be said that to ignore the patient's history and to repeat the same mistakes and unsuccessful therapies of the past is to court almost certain failure. Likewise our goals and therapeutic expectations must now be raised for these individuals in the light of recent experience. I would like to share with you a few of my own experiences with several groups of these severely ill people, especially those aspects which may relate to the use of haloperidol.
Dr James S Howard III Lately Clinical Dir-ector, Eastern State Hospital; Consuiltant Psychiatr-ist and
Facility Ser-vice Clhief, Depar tment of Mental Health, Fr-esno, Califor nia, USA
First Stiudy
Patienits anid methods: In the first group (Howard & Schmidt 1973) there were 95 unselected male and female chronic patients. Their average age was 57 years with a mean chronicity of 17 years spent for the most part in custodial care. Seventy per cent carried a diagnosis of schizophrenia and all were assigned to this area due to their severe mental impairment. There were no additional funds, facilities or staff for this programme, only those who would be available on any such ward: a physician, a nurse and a few aides scattered over a 24-hour period. Only nine of these people' had improved sufficiently for release in the preceding eleven years, and yet from this very same group in a five-month period we had 53 of them out of the hospital, on their own or with their families, and in no case were they in a nonpsychiatric custodial care setting. Our criteria for success and eligibility for release were: (1) Alertness, good orientation and awareness of surroundings. (2) Good concentra-
tion, attention span and ability for abstract thinking. (3) Appropriateness and good personal hygiene. (4) Demonstrated responsibility and ability to work outside the area in constructive rehabilitative activities for at least 20 hours per week. To bring about these results no one programme or philosophical concept was followed rigidly. Retrospectively, at the end of five months, it was the opinion of the staff that it was the combination of all treatment modalities (i.e. milieu, occupational therapy, group therapy and chemotherapy) each tailored to the specific needs of the individual, that brought about the good result. As to chemotherapy our approach was essentially the same. If the person could be maintained on the medications he was receiving as a chronic ward patient, and these adjusted upwards or downwards to bring about the fine points of the mental status, it was retained; otherwise it was replaced.
42 Proc. roy. Soc. Med. Volhme 69 1976 Suipplemenit I At the end of the five-month programme all medications were reviewed and it was found that most patients who had improved sufficiently for release were on haloperidol. When using this neuroleptic our starting dose was seen to have been generally 10-15 mg per day. This was then increased at weekly intervals by about 50% until: (I) the patient was responding well by our criteria; (2) the patient was beginning to show side-effects; or (3) a generally set limit of 75 mg per day was reached. If the patient was still psychotic on 75 mg haloperidol per day, a sedating phenothiazine was then added and titrated upwards. Using this method, at the end of five months only 14 of the original 95 were found to be in need of further inpatient psychiatric hospitalization.
Resiilts: The patients' improvement appeared to occur in three stages. First would be a period of little or no improvement until a certain level of medication was reached. At that time the patient was noted to become more alert, aware of surroundings and amenable to the efforts of the therapeutic community. The improvement would then continue with increasing medication until a plateau of improvement was reached, after which increasing the medication further tended to cause the patient to become more sedated, with an increasing incidence of side-effects. When the therapeutic plateau was reached, the patient was then maintained on this schedule, due to the frequent deterioration seen in chronic patients as medications are decreased or discontinued.
Of the 53 patients successfully released from the programme, 70% were schizophrenic or about the same percentage of schizophrenics as in the total initial population. On the average they were 48 years of age with a chronicity of 17 years. This may be compared to the schizophrenics left behind whose age averaged 59 years with a mean chronicity of 36 years. As the patients were receiving a variety of antipsychotic agents these were expressed as approximate thioridazine equivalents (ATE). For this the following figures were used: 100 mg chlorpromazine = 2 mg haloperidol = 5 mg thiothixene =5 mg trifluoperazine = 100 mg thioridazine = 50 mg mesoridazine
Expressed in this way, the released schizophrenics were receiving an average of 2146 mg ATE per day at time of release, or about four times as much medication as they were formerly given on the chronic ward. This figure, however, does not reflect a predominant use of the sedating phenothiazines (especially in this older age group)
but rather of the less sedating, more effective antipsychotic agents such as haloperidol. Of the patients released on haloperidol, a few were found to have required as much as 100 mg per day to effect a successful remission. The average was around 35-40 mg per day, used at times in combination with a sedating phenothiazine. The patients released from the nonschizophrenic group tended to be on the average 48 years of age, with a mean chronicity of 5 years; this compares, in their counterparts left behind, with an average age 60 years and an average chronicity of 13 years. The released nonschizophrenics were found to have required 890 mg ATE to effect their release or about twice as much as they were receiving as chronic ward patients; again, most had their successful outcome with haloperidol. In the end, almost all patients on the ward had been given at least a therapeutic trial of medication. On the other hand, as chronic ward patients, a full third of these people were receiving no neuroleptics whatsoever. Upon release, the patients were followed by community mental health agencies and our return rate for this group was about 5 % per year with a 2.5 year follow up. This may be compared to the usual return rate for this group of 80 %
After this programme a similar effort on behalf of 250 slightly older and more chronic patients during a one-year period resulted in 150 being successfully released from the hospital. Included in this group were a number of patients acknowledged to be among the most severely psychotic, treatment-resistant patients in a hospital population of 2000. Seventeen of these were treated with haloperidol alone in doses up to 200 mg per day under double blind conditions, and 8 achieved successful remission and release from the hospital. Of those released, the average dose of haloperidol per day at their time of discharge was 104 mg, with several requiring 150 mg or more; at least one other with a chronic psychosis of 20 years' duration required 320 mg haloperidol a day for a successful outcome (Howard 1974). Second Stuidy Patienits and methods: Another programme for 36 severely psychotic chronic patients was given an eight-week evaluation as part of their regular ongoing treatment. These patients were on the average 48 years of age, with a mean chronicity of 14 years. Seventy-eight per cent carried a diagnosis of schizophrenia and participation in rehabilitative programmes was quite low. In this
Haloperidol: A New Profile? case activities and therapies for the patients remained the same as before the programme was started; it consisted of milieu therapy and behavioural modification by the staff, and a medication clinic by a visiting psychiatrist.
The medication clinic was held twice a week. During the clinic interview, the patient's record was reviewed, a mental status and progress report was taken for each patient, and medication prescribed on this basis.
Results: Three members of the staff then rated each patient as to global level of functioning before the programme and at the eight-week interval. For this a scale of 0-10 was used, 0 being the lowest possible level of functioning and 10 being the highest. The progress of the individual during the eight weeks was then expressed as the difference between the two scores. The mean score for the entire group at the beginning of the programme was 2.2 and at the end was 4.6, an improvement of I1 0 %. The patients were rated at the end of eight weeks as to degree of improvement, whether (I) little or none; (2) moderate or good; or (3) excellent. These ratings were correlated with the numerical values representing the degree of progress. From this correlation it could be seen that those who improved less than two points were generally rated as showing little or no change. Those who improved between two and four points were seen as moderately improved, and those with four or more points of progress were seen as making excellent improvement. In this way 6 (17 %) patients were shown to have achieved excellent improvement in eight weeks; 16 (44%) had achieved moderate improvement; and 14 (39 %) had achieved little or no improvement.
43
These patients had improved from an initial 2.4 up to 4.5 (88%). Nine other chronic patients receiving neuroleptics other than haloperidol in doses averaging 958 mg ATE had improved from an initial 3.8 up to 5.0 (46O% improvement). Notably, all 6 achieving an improvement of 4 or more points during the eight-week period were
receiving haloperidol. Improvement of psychosis was assessed by the physician using a mental status check list which rated improvement in the mental status of psychotics on a scale 0-9. The three items included were: (1) Orientation to time, place, and person (0-3). (2) Ability to perform mathematical calculations consistent with level of education achieved (0-3). (3) Ability for abstract thinking such as interpreting proverbs (0-3). Expressed in this way the mental status of those receiving haloperidol, either alone or in combination with another neuroleptic over the eight-week period, improved from an initial average of 4.3 up to 6.6 (an improvement of 400%). More specifically, those receiving haloperidol plus some other neuroleptic improved from an initial average of 3.8 up to 7.7 (an improvement of 76%). Those receiving haloperidol alone improved from their initial 4.7 up to 6.3 (an improvement of 34 %). Those receiving neuroleptics other than haloperidol had progressed from their initial 4.6 up to 5.3 (an improvement of 13 %).
Disciussiont Experiences such as these with the chronic population over the last five years tend to demonstrate the impact we are now having, particularly with such medications as haloperidol.
Side-effects in the chronic population were rarely encountered and usually mild. It was felt As the patients were receiving a variety of that these were minimized by beginning at a medications, again before and during the pro- lower dosage range and carefully monitoring the gramme, these were converted into approximate patient during the upward titration. Antithioridazine equivalents (ATE). From this it was cholinergic and extrapyramidal effects were the determined that the patients were receiving an most common and were evaluated in terms of the average of about 129 mg ATE per day before the total response of the individual. It was felt that programme and about 2556 mg ATE per day at reducing the dosage, adding anticholinergics and the end of eight weeks. changing to other neuroleptics, especially different generic types, were beneficial procedures. At the eight-week evaluation, II patients were found to be on haloperidol alone in doses Finally, there were those who did not respond averaging 61 mg per day (3000 ATE) and had successfully to any of the various neuroleptics improved in mean level of functioning from an even when given in adequate doses. For these initial 1-9 up to 5.2 (improvement of 174o%). metabolic, endocrine and neurological testing Sixteen patients were receiving haloperidol in was done and the following conditions were doses averaging 59 mg per- day (3000 ATE) in commonly found: (1) hypothyroidism; (2) hypocombination with another neuroleptic in doses glycemia; (3) folate deficiency; (4) Parkinson's averaging 320 mg ATE or 3320 mg ATE total. disease and (5) malnutrition. As these diseases
44 Pr-oc. rEoy. Soc. Med. Voliime 69 1976 Siupplemenlt I
were found and the patients placed on appropriate medical regimes the response to the neuroleptics became much more successful. In conclusion, the plight of the chronic patient has largely been overlooked as psychiatry has moved into the modern era. Until recently his world, a low and gloomy place, has had little to offer except hopelessness, resignation and despair. To bring about a change in this situation it has been necessary to pay less attention to the words of Kraeplin regarding his condition and more attention to the signs and symptoms of the patient. REFERENCES Howard J S ( 1974) Diseases o' the Nervous Systum 35, 458 Howard J S & Schmidt K T (1973) Psyc/hosolatixcs 14, 355
DISCUSSION
Dr Howard in reply to a question from the Chairman said that he had originally come to use haloperidol on a purely empirical basis. In the early 1970s he became interested in the possibility of using non-phenothiazine agents in chronic patients. He found some striking successes in long-term psychotics treated with haloperidol in doses as low as 15 mg per day and further studies were a gradual development from these findings.
As to the work of Kraeplin, he felt that one of the biggest burdens that the psychiatrist carried was the concept that mental illness was something progressive, degenerative and inevitable from which, if the patient ever recovered, he did not originally suffer. Even today, a diagnosis of chronic schizophrenia carried a considerable social stigma. None the less, it was precisely with this type of patient that Dr Howard had had most success.
Dr Howard agreed. His point had been somewhat rhetorical because he had frequently seen patients who had been misdiagnosed. Some patients with nonschizophrenic diagnoses in chronic wards had improved with neuroleptics which would have been much more appropriate for schizophrenia. One had constantly to ask whether the patients had schizophrenia rather than something else. Much more attention should be paid to the signs and symptoms of the patient than to their diagnostic labels. None the less, Dr Storey's point was well taken.
Professor K Heinrich (Duisseldorf) congratulated Dr Howard upon his achievements. Similar procedures in Professor Heinrich's hospital had reduced the number of beds in seven years by 650.
However, it was relatively easy to dismiss the patient. It was very difficult to keep them out of hospital and to give them a good social adaptation. He wondered if Dr Howard had looked after the patients after their dismissal from hospital. The return rate was 50% but he wondered about the others who did not return. Dr Howard made it quite clear that his programme was not specifically designed to give everybody haloperidol. He was interested in meeting the individual demands of the patient. If this meant putting the patient in his own car, taking him home, discussing with the family the patient's need to stay on medication and making himself available around the clock, he was prepared to do so. After six weeks of follow up, patients were turned over to the community mental health agencies, but a problem there was to make them understand the need to keep the patient on medication. Dr P N Zissis (Atheis) asked if it wa_s preferable for chronic hospitalized patients to be treated with haloperidol or with a long-acting neuro-
leptic. Dr P Storey (Londoni) said that patients had to be adequately diagnosed before they could be selected. Close attention to the doctrines of Kraeplin would prevent, for example, chronic Parkinson's disease from being misdiagnosed as catatonic schizophrenia. Kraeplin's original work had deficiencies but that did not mean his overall concepts were deficient. If we were going to give powerful drugs then the patients must be selected accurately by listening to them and watching what they did, precisely the methods that Kraeplin
himself adopted.
Dr Howard said the answer depended upon the specific needs of the individual. If a long-acting neuroleptic produced a person who was alert
and who could cope with the world, then that was what he should be kept on. If not, then the medication should be changed. At times, one antipsychotic agent would work for a while, and then it had to be changed. It was impossible to take any rigid dogmatic approach. What was required was a dynamic attitude.
Haloperidol: A New Profilek? Dr D M Lowe (Lincoln) asked what were the causes of relapse in the 5 % per year. Dr Howard said that one of the main causes (which was generally recognized) was that the patient who looked normal and went to the clinic was told by the doctor that he no longer required the medicine. As a result, he relapsed. Dr Howard believed that psychiatry was still at the 'germ theory' level of mental illness. If the patient was mentally ill he needed a medicine; if he came out of his psychosis he no longer needed it. However, the situation was far more complex than that.
Professor W Keup (Berlin) commented on Dr Howard's 'total push' approach. It would be interesting to know what part of his results had been due to haloperidol and how much had been due to other therapeutic approaches and even other drugs. Dr Howard agreed. They had been particularly interested in this question after their initial success. They therefore carried out a double blind study comparing haloperidol with thiothixene and with placebo in the 50 worst patients in the hospital. Some 26% of these resistant and refractory patients improved sufficiently to leave the hospital on the placebo. With medication, this figure was doubled. A negative attitude was certainly to be avoided since it could cancel out the real therapeutic effects.
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Dr E Shoenberg (London) said that Dr Howard had substituted enthusiasm, care and love for despair and apathy. She wondered how much of his success had been due not to the drug but to this change in the regime. Dr Howard said he would never minimize this milieu effect nor the importance of a positive attitude, since for 26% of the very worst patients it had been successful. Dr G Silverman (Southall) wondered how a double blind trial could be carried out against placebo in view of the obvious parkinsonian side-effects of
haloperidol. Dr Howard said that it was kept double blind by having the medication totally removed from the therapeutic situation. All capsules were identical and dispensed from the pharmacy. In reply to the Chairman's question of whether the sideeffects did not distinguish patients who had the drug from those who had the placebo, Dr Howard said that one of their most flagrant cases of oculogyric crisis had occurred on the placebo.
Professor F A Jenner (Chairman) congratulated Dr Howard for what was obviously the most important thing in medicine, therapeutic optimism and concern; and on his results, even though there was a need to consider in greater detail what they meant at a scientific level. What he had done was extremely important. He had helped a lot of people.
