The Treatment of Severely Depressed Schizophrenic Patients* MY RE
S I M , M.D.f
Ottawa,
Canada
The diagnosis and treatment of severe masked depression in schizophrenia is discussed, and the difficulties in management are stressed, with particular reference to drug therapy, E.C.T., and psychotherapy. T h e t i t l e o f this p a p e r a c k n o w l e d g e s w h a t m a n y p s y c h i a t r i s t s still d e n y : t h a t a s c h i z o p h r e n i c p a t i e n t c a n be severely d e p r e s s e d . Cur i o u s l y , t h e r e is less c o n t r o v e r s y o v e r t h e p o s s i b i l i t y t h a t a d e p r e s s e d p a t i e n t m a y show s c h i z o p h r e n i c f e a t u r e s . T h i s m a k e s o n e w o n d e r w h e t h e r t h e r e w o u l d have b e e n less resistance t o t h e t e r m "schizo-affect i v e " i f i t h a d b e e n i n t r o d u c e d i n a n o t h e r f o r m , s u c h as " a f f e c t o s c h i z o p h r e n i c . " N o w i t is p r o b a b l y t o o late f o r s u c h a n a l t e r a t i o n . T h a t s c h i z o p h r e n i c p a t i e n t s c a n be v e r y d e p r e s s e d is e v i d e n t f r o m the statistics o n s u i c i d e . E v e n as f a r back as 1849, i n his C r o o n i a n L e c t u r e s t o t h e R o y a l C o l l e g e o f Physicians o f L o n d o n , J o h n C o n o l l y e m p h a s i z e d t h a t d e m e n t i a p r a e c o x was f r e q u e n t l y u s h e r e d i n b y a severe depression. M o r e recent w o r k o n masked depression, largely stimul a t e d by Lesse, has r e f e r r e d t o , a m o n g o t h e r s , d e p r e s s e d p a t i e n t s w h o exhibit schizophrenic features. W h a t K r a e p e l i n i a n a d h e r e n t s have vehemently d e n i e d is n o w g r u d g i n g l y accepted as "atypical" s c h i z o p h r e n i a , w h i l e those w i t h a g r e a t e r e x p o s u r e t o t h e m o r e r e c e n t a n d m o r e acute m a n i f e s t a t i o n s o f m e n t a l illness f u l l y e x p e c t t o find severe d e p r e s s i o n as a c o m m o n c o m p o n e n t o f s c h i z o p h r e n i a . W h i l e s c h i z o p h r e n i c p a t i e n t s d i f f e r i n s o m e respects f r o m n o n p s y c h o t i c m e m b e r s o f society, t h e y also have m u c h i n c o m m o n . T h e y c a n be a n x i o u s a n d a f r a i d , o v e r s e n s i t i v e a n d obsessional, a n d , o f c o u r s e , depressed. T h e y m a y o r m a y n o t have h y p e r t r o p h i e d s u p e r e g o s , a n d t h e y w i l l t h i n k a n d behave a c c o r d i n g l y , so t h a t i n a n e g o - d i s i n t e g r a t i v e phase t h e i r s u p e r e g o q u o t a w i l l c o l o r t h e i r r e a c t i o n s . T h e i r sensitivities may b e c o m e excessive, so t h a t t h e y m a y show p a r a n o i d f e a t u r e s a n d t h e i r obsessional defenses m a y p r o v e i n a d e q u a t e t o t h e d e m a n d s p l a c e d o n t h e m . T h e s e c o u l d c o l o r t h e c l i n i c a l p i c t u r e t o s u c h a n e x t e n t as t o 1
* P r e s e n t e d at the T h i r t e e n t h N a t i o n a l Scientific M e e t i n g o f t h e A s s o c i a t i o n f o r t h e A d v a n c e m e n t o f P s y c h o t h e r a p y . T o r o n t o , C a n a d a , A p r i l 3 0 - M a y 1, 1 9 7 7 . f P r o f e s s o r o f P s y c h i a t r y , F a c u l t y o f M e d i c i n e , U n i v e r s i t y o f O t t a w a . Mailing address: Royal Ottawa Hospital, 1145 C a r l i n g A v e . , O t t a w a , O n t a r i o K 1 Z 7 K 4 , C a n a d a .
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obscure t h e s c h i z o p h r e n i c process. S i m i l a r o b s c u r i n g m a y r e s u l t f r o m p h o b i c a n x i e t y f e a t u r e s ; i t is t h e r e f o r e e q u a l l y a p p r o p r i a t e t o speak o f " m a s k e d s c h i z o p h r e n i a . " T h e lesson h e r e is t h a t i t is n o t e n o u g h t o i d e n t i f y t h e s c h i z o p h r e n i c aspect. I f o t h e r e l e m e n t s e x i s t , t h e y m u s t be recognized a n d , o f course, treated. T h e r e is n o aspect o f m e n t a l illness m o r e i m p o r t a n t t h a n t h a t o f d e p r e s s i o n — f i r s t , because i t is v e r y c o m m o n ; a n d s e c o n d , because i t c a n r e s u l t i n severe m o r b i d i t y , e n c o m p a s s i n g d e a t h by s u i c i d e as w e l l as a n o t n e g l i g i b l e n u m b e r o f h o m i c i d e s . J u s t as severe d e p r e s s i o n m a y be m a s k e d i n a n o n s c h i z o p h r e n i c p a t i e n t , i t m a y also be m a s k e d i n a p a t i e n t w i t h s c h i z o p h r e n i a . T h e r e f o r e , a conscious e f f o r t s h o u l d be m a d e t o detect its presence. B u t t h i s is o n l y a s t a r t . T r e a t m e n t o f d e p r e s s i o n , w h e r e v e r i t m a y be f o u n d , w i l l v a r y a c c o r d i n g t o t h e t y p e a n d severity o f t h e d e p r e s s i o n . T h u s , a d e f i n i t i o n o f its n a t u r e a n d a q u a n t i t a t i v e e s t i m a t i o n are also necessary. T h e severely d e p r e s s e d s c h i z o p h r e n i c p a t i e n t is psychotically d e p r e s s e d a n d s h o u l d t h e r e f o r e be c l e a r l y d i f f e r e n t i a t e d f r o m t h e n e u rotic depressive. H o w does o n e g a u g e t h e s e v e r i t y o f a d e p r e s s i o n ? Suicidal intent, m o r b i d p r e o c c u p a t i o n s , a n d s u c h b i o l o g i c f e a t u r e s as e a r l y w a k i n g , loss o f w e i g h t , a n d d i u r n a l v a r i a t i o n s are a l l p o i n t e r s . Y e t we s o m e t i m e s d e ceive ourselves w i t h t h e l a n g u a g e we use i n d e s c r i b i n g depressive s y m p t o m a t o l o g y . W e speak o f delusions o f g r a n d e u r b u t offeelings o f guilt a n d unworthiness w h e n defining the two extremes o f the manicdepressive psychosis. I t is as i f those w h o w a l k h u m b l y w i t h t h e i r M a k e r c a n n o t be c o n s i d e r e d as d e l u d e d , b u t he w h o boasts h i m s e l f o f t h e m o r r o w is d e f i n i t e l y so. W e s h o u l d r e c o g n i z e t h a t a d i s t o r t i o n o f t h i n k i n g is a d e l u s i o n w h a t e v e r its n a t u r e . T h i s raises a n o t h e r d i f f i c u l t y . P a r t l y because o f t h e above a t t i t u d e , d e l u s i o n has b e e n m o r e closely i d e n t i f i e d w i t h s c h i z o p h r e n i a t h a n w i t h depression. A too-strict adherence to such a belief will persuade the observer t h a t severely d e p r e s s e d p a t i e n t s are r e a l l y s u f f e r i n g e x c l u s i v e l y f r o m a s c h i z o p h r e n i c o r p a r a n o i d state a n d t h a t t h e presence o f depressive f e a t u r e s m a y be d i s c o u n t e d . T h e d i a g n o s t i c c h a l l e n g e is n o t all t h a t f o r m i d a b l e , h o w e v e r , e v e n i f o n e o n l y b r i n g s a r u d i m e n t a r y k n o w l e d g e o f psychopathology to bear. I f instead o f the t e r m " h y p o c h o n d r i a s i s " o n e u s e d " d e l u s i o n s o f disease," t h e depressive n a t u r e o f the p r o b l e m w o u l d become a p p a r e n t . T h e severely d e p r e s s e d p a t i e n t uses s o m a t i c l a n g u a g e t o i n d i c a t e w h a t he feels he deserves t o have a n d w i l l n o t be g a i n s a i d . N o t f o r h i m are t h e t r i v i a o f t h e h y s t e r i c a l h y p o c h o n d r i a c o r t h e somatic m a n i f e s t a t i o n s o f a n x i e t y o f t h e p h o b i c state. H e goes i n f o r d e a t h - d e a l i n g a n d
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socially o s t r a c i z i n g diseases l i k e c a n c e r , s y p h i l i s , a n d , i n p r e v i o u s years, t u b e r c u l o s i s . H e is r e a l l y s a y i n g t h a t h e deserves t o d i e o r be a p a r i a h a n d t h a t these are his j u s t deserts. W h a t is m o r e , these f e a t u r e s are sinister i n i m p o r t , f o r t h e y are t a n t a m o u n t t o a d e a t h s e n t e n c e , w h i c h the p a t i e n t m a y c a r r y o u t e i t h e r because he is d e s p e r a t e o r because he fears t h e l o n g , d r a w n - o u t a g o n y o f his s e l f - i m p o s e d sentence. I n t h e t r e a t m e n t o f a n uncomplicated depressive illness t h e p h y s i c i a n g e n e r a l l y has some c h o i c e . I f t h e c o n d i t i o n is i d e n t i f i e d e a r l y a n d is m i l d , i t will p e r m i t a variety o f approaches. P s y c h o t h e r a p y m a y suffice, f o r t h e r i s k o f u n r e l i a b l e c o n d u c t m a y be n e g l i g i b l e . W h e n t h e r e is n o sense o f u r g e n c y , t h e p s y c h i a t r i s t m a y e v e n i n d u l g e i n d e p t h analysis w i t h r e l a t i v e i m p u n i t y , because s p o n t a n e o u s r e m i s s i o n is also c o m m o n . E v e n i n i n e x p e r t h a n d s , t h e r e f o r e , cures m a y be p r o c l a i m e d w i t h o u t fear o f c o n t r a d i c t i o n . I n t h e moderate case c o n s e r v a t i v e measures s t a n d a n e x c e l l e n t chance o f success. A n e f f e c t i v e a n t i - d e p r e s s a n t l i k e I m i p r a m i n e , w h e n first i n t r o d u c e d , was able t o r e c l a i m 5 0 p e r c e n t o f those w h o p r e v i o u s l y d i d n o t r e m i t w i t h o u t a c o u r s e o f E . C . T . , a n d i t is n o w r e c k o n e d t h a t n o t less t h a n 75 p e r c e n t o f a l l psychotic d e p r e s s i o n s w i l l r e s p o n d s a t i s f a c t o r i l y . I t is t h e r e f o r e w e l l w o r t h a t r i a l . T h e case o f t h e severely d e p r e s s e d s c h i z o p h r e n i c is d i f f e r e n t . O n e must not make the mistake, potentially fatal to the patient, o f sending a b o y o n a m a n ' s e r r a n d . T h i s m a y at t i m e s r e s u l t i n a n o v e r r e a c t i o n , because t h e d i s c r i m i n a t i o n s o f j u d g m e n t r e q u i r e d t o o p t f o r c o n s e r v a t i v e measures as against a c o u r s e o f E . C . T . c a n be v e r y fine i n d e e d . B u t w i t h s u c h h i g h stakes i t is w i s e r t o be c a u t i o u s a n d n o t t o t a k e risks w i t h t h e p a t i e n t ' s l i f e . S h o u l d t h e p h y s i c i a n w i s h t o p o s t p o n e his d e c i s i o n , he s h o u l d have his p a t i e n t a d m i t t e d t o a h o s p i t a l a n d p l a c e d u n d e r strict observation a n d c o n t r o l , w i t h daily review by the psychiatrist. T h e corr e c t d e c i s i o n c a n o n l y be a c h i e v e d by a c o n t i n u o u s d i a g n o s t i c exercise. M o r e o v e r , s u c h a n a p p r o a c h c a n o n l y l e a d t o i m p r o v e m e n t i n one's e x p e r t i s e . E v e n so, o n e m a y still m a k e m i s t a k e s , b u t t h e t r i u m p h s o f c o n s e r v a t i v e t r e a t m e n t m u s t be w e i g h e d against t h e losses o f p a t i e n t s w h o c o m m i t suicide a n d w o u l d n o t have d o n e so i f a c o u r s e o f E . C . T . had been p r o m p t l y administered. T h e d e g r e e o f r e l i a b i l i t y o f a severely d e p r e s s e d n e u r o t i c p a t i e n t is l a r g e l y l i n k e d t o his capacity f o r c o o p e r a t i o n a n d t o his c o n f i d e n c e i n t h e p s y c h i a t r i s t . W i t h t h e severely d e p r e s s e d s c h i z o p h r e n i c t h i n g s are d i f ferent. Because t h i n k i n g is grossly d i s t o r t e d a n d t h e p a t i e n t is h y p e r s e n s i t i v e , r e l i a b i l i t y c a n n o t be e x p e c t e d . W h a t m a y be t h e u l t i m a t e g u a r a n t e e o f r e l i a b l e c o n d u c t i n a severely d e p r e s s e d p a t i e n t — n a m e l y , his w o r d — c a n n o t be a c c e p t e d as v a l i d w h e n t h e r e is a n
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associated s c h i z o p h r e n i c illness. W i t h s u c h a h i g h level o f b u i l t - i n u n p r e d i c t a b i l i t y , i t w o u l d be a g a m b l e t o d e l a y effective t r e a t m e n t ; f u r t h e r m o r e , i t w o u l d e x p o s e t h e n u r s i n g s t a f f t o a s i t u a t i o n w h i c h m a y w e l l be b e y o n d its c o m p e t e n c e a n d w h i c h m a y w e a k e n its c o n f i d e n c e i n t h e psychiatrist. T h e i n d i c a t i o n s are t h a t , f o r t h e severely d e p r e s s e d s c h i z o p h r e n i c p a t i e n t , a n a d e q u a t e c o u r s e o f E . C . T . o f f e r s t h e best p r o s p e c t f o r speedy remission. B u t w h a t is a n a d e q u a t e c o u r s e o f E . C . T . ? T h e r e is so m u c h m i s i n f o r m a t i o n o n this subject t h a t a l t h o u g h t h e t r e a t m e n t has b e e n used f o r n e a r l y 4 0 years, i t is still g i v e n i n e x p e r t l y . A n a d e q u a t e c o u r s e is n o t a m a n d a t o r y n u m b e r at a p r e s c r i b e d f r e q u e n c y . I t s h o u l d be a n i n d i v i d u a l l y t a i l o r e d p r o g r a m t h a t takes i n t o a c c o u n t t h e p r e m o r b i d state, t h e i n i t i a l severity o f t h e c o n d i t i o n , a n d t h e r e s p o n s e t o each t r e a t m e n t . T h e r e f o r e , t h e s p a c i n g a n d n u m b e r o f t r e a t m e n t s w i l l v a r y f o r each p a t i e n t . F o r some p a t i e n t s i t m a y be necessary t o give t h e first t h r e e t r e a t m e n t s o n successive days, w h i l e f o r t h e m a j o r i t y t h r e e t r e a t m e n t s d u r i n g t h e first w e e k w i l l be a d e q u a t e . T h e t o t a l n u m b e r o f t r e a t m e n t s has b e e n so subjected t o m y t h o l o g y a n d t h e m a g i c o f n u m b e r s t h a t i t m a k e s the Fliess-Freud correspondence read like a n engineer's handbook. Clear g u i d a n c e i n t h e l i t e r a t u r e is h a r d t o c o m e b y . A s t u d y by H o d g s o n a n d S i m o n 3 6 4 p a t i e n t s w i t h u p t o f o u r years f o l l o w - u p s h o w e d t h a t w i t h less t h a n e i g h t t r e a t m e n t s relapse was m o r e c o m m o n , b u t t h e f r e q u e n c y was n o less i m p o r t a n t t h a n t h e t o t a l n u m b e r o f t r e a t ments. 2
W i t h schizo-affective psychoses o f a m o r e c h r o n i c n a t u r e , i t m a y be necessary t o c o n t i n u e a l i t t l e l o n g e r — s p a c i n g t r e a t m e n t s a f t e r t h e f i f t h one to weekly intervals, a n d after the e i g h t h to fourteen-day i n t e r v a l s — to a total o f ten o r even twelve treatments. Occasionally a patient's i l l ness is r e f r a c t o r y t o E . C . T . , a n d w i t h n o r e a l r e s p o n s e a f t e r t h e t h i r d o r f o u r t h t r e a t m e n t m a n y psychiatrists w e a k e n i n t h e i r resolve a n d d o u b t w h e t h e r t h e y s h o u l d c o n t i n u e . I t is possible t h a t e v e n a f t e r t h e s e v e n t h t r e a t m e n t t h e r e w i l l be n o detectable r e s p o n s e , at w h i c h p o i n t t h e p r e s s u r e by r e s i d e n t s a n d nurses t o d i s c o n t i n u e can be v e r y s t r o n g indeed. T h e r e is o n l y o n e a n s w e r . T h e g r o u n d m u s t be c a r e f u l l y r e e x a m i n e d , a n d i f t h e i n d i c a t i o n s f o r s t a r t i n g t h e c o u r s e i n t h e first place r e m a i n v a l i d , o n e m u s t c o n t i n u e . A n d to the surprise o f the d o u b t e r s a n d t o t h e r e l i e f o f t h e p s y c h i a t r i s t , a r e m i s s i o n w i l l be s e c u r e d . T h e r e is n o r o o m h e r e f o r t e a m decisions, because i t is h i g h l y u n l i k e l y t h a t a n y m e m b e r o f t h e t e a m w i l l have m o r e r e l i a b l e e x p e r i e n c e t h a n t h e psychiatrist. H e m u s t listen a n d pay a t t e n t i o n to factual evidence, b u t t h e r e s p o n s i b l e d e c i s i o n c a n n o t be l e f t t o t h e a n o n y m i t y o f a t e a m a p -
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p r o a c h . As f o r i n v o l v i n g o t h e r p a t i e n t s i n t h e d e c i s i o n - m a k i n g , t h e less said t h e b e t t e r . A n o t h e r w o r d o f c a u t i o n . Schizo-affective psychoses, especially i f a c u t e , can be s y m p t o m a t i c o f u n d e r l y i n g o r g a n i c f a c t o r s , c e r e b r a l a n d systemic. T h u s , o n e m u s t d o a t h o r o u g h p h y s i c a l s c r e e n i n g , n o t o v e r l o o k i n g exotic c o n d i t i o n s l i k e a n islet-cell t u m o r o f t h e pancreas a n d p o r p h y r i a a n d , o f c o u r s e , t o x i c states i n d u c e d by h a l l u c i n o g e n i c d r u g s and amphetamines. L i f e can be v e r y h a r d f o r t h e c l i n i c i a n , b u t m e d i c i n e w o u l d be v e r y d u l l i f i t w e r e n o t . So m u c h f o r t h e depressive aspect. W h a t o f t h e s c h i z o p h r e n i c side? I n acute schizo-affective r e a c t i o n s , such as p o s t o p e r a t i v e states a n d p u e r p e r a l psychoses, t h e s c h i z o p h r e n i c e l e m e n t is so closely l i n k e d t o t h e d e p r e s s i o n t h a t t r e a t m e n t o f t h e d e p r e s s i o n f r e q u e n t l y results i n a c o m plete r e m i s s i o n o f t h e s c h i z o p h r e n i c f e a t u r e s . T h i s is n o t s u r p r i s i n g f o r t h r e e reasons: t h e s c h i z o p h r e n i c e l e m e n t is u s u a l l y o f r e c e n t o r i g i n ; t h e r e is e v i d e n c e o f a n e f f e c t i v e p r e m o r b i d p e r s o n a l i t y , a n d t h e d e l u s i o n a l a n d e v e n h a l l u c i n a t o r y c o n t e n t is h e a v i l y l a d e n w i t h depressive symptomatology. Should remission n o t occur, however, effective measures t o c o n t r o l t h e s c h i z o p h r e n i c f e a t u r e s s h o u l d be t a k e n , sim u l t a n e o u s l y w i t h t h e c o u r s e o f E . C . T . i f necessary. E a c h p s y c h i a t r i s t has his f a v o r i t e t r a n q u i l i z e r , a n d t h e r e is m u c h t o be said f o r a c q u i r i n g e x p e r t i s e w i t h o n e d r u g as o p p o s e d t o h a v i n g o n l y a n o d d i n g acquaintance with many. For the r a p i d c o n t r o l o f schizophrenic features, H a l o p e r i d o l (Haldol) 5 m g m . t . i . d . generally suffices, b u t i n t h e acute phase i t must—not should—be given p a r e n t e r a l l y . O n e is f r e q u e n t l y c a l l e d i n t o c o n s u l t a t i o n o v e r a p a t i e n t w h o s e psychotic f e a t u r e s r e m a i n u n c o n t r o l l e d d e s p i t e massive doses o f t r a n q u i l i z e r s . T h e r e is a n o b v i o u s e x p l a n a t i o n , w h i c h is e i t h e r o v e r l o o k e d o r d e n i e d : t h e p a t i e n t has n o t b e e n s w a l l o w i n g o r r e t a i n i n g t h e tablets. Since i t has b e e n established a g a i n a n d a g a i n t h a t r e f r a c t o r y o r r e l a p s i n g s c h i z o p h r e n i c s d o n o t absorb t h e i r m e d i c a t i o n , t h e t i m e has s u r e l y c o m e t o accept this as a r u l e unless p r o v e n o t h e r w i s e a n d t o give the d r u g i n a f o r m t h a t ensures t h a t t h e p a t i e n t has r e c e i v e d i t . T h e r e is another danger. I f t h e p s y c h i a t r i s t c o n c l u d e s t h a t massive doses are i n e f f e c t i v e , he m a y be p e r s u a d e d t o t r y s o m e t h i n g e v e n m o r e p o w e r f u l . B u t s h o u l d this be g i v e n p a r e n t e r a l l y , t h e p a t i e n t m a y a c t u a l l y be r e c e i v i n g his first—and t h e r e f o r e m u c h t o o s t r o n g — d o s e . O n c e t h e acute phase is u n d e r c o n t r o l , t h e p s y c h i a t r i s t s h o u l d d e c i d e w h e t h e r t h e s c h i z o p h r e n i c process w i l l r e q u i r e l o n g - t e r m t r e a t m e n t . T h i s decision should d e p e n d o n the p r e m o r b i d personality, the h o m e b a c k g r o u n d , a n d a l l t h e o t h e r factors n o r m a l l y t a k e n i n t o a c c o u n t i n t h e treatment o f the schizophrenic patient. I f schizophrenic features
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persist i n spite o f E . C . T . , t r a n q u i l i z e r s i n d e p o t dosage s h o u l d be g i v e n . M o d e c a t e is at p r e s e n t t h e m o s t p o p u l a r i n N o r t h A m e r i c a . A n i n i t i a l test dose o f 12.5 m g m . is r e c o m m e n d e d . I f a f t e r 10 days t h e r e are n o u n t o w a r d side effects, a dose o f 25 m g m . can be g i v e n a n d r e p e a t e d at three-to-four weekly intervals. One word of caution. In s c h i z o p h r e n i c s w i t h a h i s t o r y o f d e p r e s s i o n t h e r e is a r i s k t h a t M o d e c a t e may lead to a recurrence a n d even to suicide; the t e r m "postpsychotic d e p r e s s i o n " has b e e n a p p l i e d i n these instances. F o r t u n a t e l y , t h e r e is a n o t h e r d e p o t - d o s e t r a n q u i l i z e r , F l u p e n t h i x o l ( D e p i x o l ) , available i n E u r o p e f o r t h e past five years. M a n y psychiatrists i n t h e U n i t e d K i n g d o m , a n d n o d o u b t e l s e w h e r e , are s w i t c h i n g t o i t f r o m M o d e c a t e . I n a d d i t i o n t o its t r a n q u i l i z i n g a c t i o n , w h i c h is n o less t h a n t h a t o f M o d e c a t e , i t has a n a n t i - d e p r e s s a n t a c t i o n , a n d t h u s does n o t cause t h e p o s t p s y c h o t i c d e p r e s s i o n s y n d r o m e . F l u p e n t h i x o l is also u s e f u l i n p r e v e n t i n g o r c l e a r i n g t h e a m o t i v a t i o n a l phase so f r e q u e n t l y f o u n d i n s c h i z o p h r e n i c s w h o have lost t h e i r f l o r i d p s y c h o t i c f e a t u r e s . T h e i n i t i a l dose o f 20 m g m . is f o l l o w e d b y a dose o f 4 0 m g m . s h o u l d t h e r e be n o u n d e s i r a b l e side effects. T h e s e a r e s i m i l a r t o those f o u n d i n M o d e c a t e , t h a t is, d y s t o n i c m o v e m e n t s a n d a k a t h i s i a . W h a t a b o u t p s y c h o t h e r a p y ? T h i s is a l m o s t a r h e t o r i c a l q u e s t i o n . I t is d o u b t f u l w h e t h e r a n y c o m m i t t e e o f e x p e r i e n c e d p s y c h i a t r i s t s w o u l d select t h e severely d e p r e s s e d s c h i z o p h r e n i c p a t i e n t f o r p s y c h o t h e r a p y , because a l l c r i t e r i a f o r g o o d selection are absent. A f t e r t h e d e p r e s s i o n has c l e a r e d , t h e r e m a y be a case f o r s u p p o r t i v e p s y c h o t h e r a p y , a l t h o u g h i f f u r t h e r h e l p is n e e d e d i t is m o r e l i k e l y t o c o m e f r o m a w e l l - p l a n n e d program of rehabilitation. Because these p a t i e n t s h a v e a l r e a d y d e m o n s t r a t e d t h e i r capacity t o react c a t a s t r o p h i c a l l y , d e p t h analysis is c o n t r a i n d i c a t e d . T h o u shalt n o t m a k e t h y p a t i e n t w o r s e . A t t h e same time one should not underestimate the degree o f psychopathologic e x p e r t i s e a n d t h e delicate a n d s o p h i s t i c a t e d h a n d l i n g these p a t i e n t s r e q u i r e i f t h e n u a n c e s o f changes i n d e f e n s e m e c h a n i s m o r ego s t r u c t u r e are t o be r e a d i l y r e c o g n i z e d a n d q u i c k l y d e a l t w i t h . T h e s u p e r v i s i o n o f these p a t i e n t s s h o u l d n o t be l e f t t o t h e u n s k i l l e d , f o r i t is a c o n t i n u o u s d i a g n o s t i c a n d t h e r a p e u t i c exercise, w h i c h goes f a r b e y o n d d r u g p r e s c r i b i n g a n d E . C . T . a n d w h i c h calls f o r a l l t h e r e s o u r c e s o f t h e experienced a n d w e l l - t r a i n e d psychiatrist. W h a t w i l l be t h e results o f t r e a t i n g a severely d e p r e s s e d s c h i z o p h r e n i c p a t i e n t ? T h i s w i l l , o f c o u r s e , d e p e n d l a r g e l y o n t h e psyc h i a t r i s t . I f t h e i n i t i a l assessment a n d t r e a t m e n t is e x p e r t l y h a n d l e d , w i t h due consideration given to the complexities o f the p r o b l e m , the results s h o u l d be e x c e l l e n t a n d o n e s h o u l d n o t be satisfied w i t h less. I f g o o d results are n o t o b t a i n e d , t h e answer is t o t r y h a r d e r .
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SUMMARY T h e p r o b l e m o f m a s k e d d e p r e s s i o n is n o w w e l l r e c o g n i z e d a n d some o f t h e m a s k i n g m a y be w i t h s c h i z o p h r e n i c f e a t u r e s . T h e c o r o l l a r y t o t h i s is t h a t t h e r e are some f o r m s o f m a s k e d s c h i z o p h r e n i a w i t h depressive f e a t u r e s , some o f w h i c h m a y be severe. T h e f o r m u l a t i o n o f these p r o b l e m s calls f o r d i a g n o s t i c s k i l l i n assessing t h e ego a n d s u p e r ego s t r u c t u r e a n d t h e d e f e n s e m e c h a n i s m s b r o u g h t i n t o p l a y . T r e a t m e n t o f severe d e p r e s s i o n i n s c h i z o p h r e n i a calls f o r a sensible a p p r o a c h t o t h e use o f p h e n o t h i a z i n e s , u s i n g t h e d e p o t - d o s e t y p e r a t h e r t h a n a n o r a l p r e p a r a t i o n . A c o u r s e o f E . C . T . s h o u l d n o t f o l l o w a set r o u t i n e r e g a r d i n g n u m b e r a n d f r e q u e n c y b u t s h o u l d be i n d i v i d u a l l y t a i l o r e d t o each p a t i e n t . P s y c h o t h e r a p y has a l i m i t e d r o l e , b u t a t h o r o u g h g r o u n d i n g i n p s y c h o p a t h o l o g i c processes a n d s k i l l i n t h e i r r e c o g n i t i o n is essential. REFERENCES 1. L e s s e , S . 2.
Multivariant Masks of Depression.
Hodgson, O. E . F . and Sim, M. Hospital Clinic.
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The diagnosis and treatment of severe masked depression in schizophrenia is discussed, and the difficulties in management are stressed, with particular reference to drug therapy, E.C.T., and psychotherapy. T h e t i t l e o f this p a p e r a c k n o w l e d g e s w h a t m a n y p s y c h i a t r i s t s still d e n y : t h a t a s c h i z o p h r e n i c p a t i e n t c a n be severely d e p r e s s e d . Cur i o u s l y , t h e r e is less c o n t r o v e r s y o v e r t h e p o s s i b i l i t y t h a t a d e p r e s s e d p a t i e n t m a y show s c h i z o p h r e n i c f e a t u r e s . T h i s m a k e s o n e w o n d e r w h e t h e r t h e r e w o u l d have b e e n less resistance t o t h e t e r m "schizo-affect i v e " i f i t h a d b e e n i n t r o d u c e d i n a n o t h e r f o r m , s u c h as " a f f e c t o s c h i z o p h r e n i c . " N o w i t is p r o b a b l y t o o late f o r s u c h a n a l t e r a t i o n . T h a t s c h i z o p h r e n i c p a t i e n t s c a n be v e r y d e p r e s s e d is e v i d e n t f r o m the statistics o n s u i c i d e . E v e n as f a r back as 1849, i n his C r o o n i a n L e c t u r e s t o t h e R o y a l C o l l e g e o f Physicians o f L o n d o n , J o h n C o n o l l y e m p h a s i z e d t h a t d e m e n t i a p r a e c o x was f r e q u e n t l y u s h e r e d i n b y a severe depression. M o r e recent w o r k o n masked depression, largely stimul a t e d by Lesse, has r e f e r r e d t o , a m o n g o t h e r s , d e p r e s s e d p a t i e n t s w h o exhibit schizophrenic features. W h a t K r a e p e l i n i a n a d h e r e n t s have vehemently d e n i e d is n o w g r u d g i n g l y accepted as "atypical" s c h i z o p h r e n i a , w h i l e those w i t h a g r e a t e r e x p o s u r e t o t h e m o r e r e c e n t a n d m o r e acute m a n i f e s t a t i o n s o f m e n t a l illness f u l l y e x p e c t t o find severe d e p r e s s i o n as a c o m m o n c o m p o n e n t o f s c h i z o p h r e n i a . W h i l e s c h i z o p h r e n i c p a t i e n t s d i f f e r i n s o m e respects f r o m n o n p s y c h o t i c m e m b e r s o f society, t h e y also have m u c h i n c o m m o n . T h e y c a n be a n x i o u s a n d a f r a i d , o v e r s e n s i t i v e a n d obsessional, a n d , o f c o u r s e , depressed. T h e y m a y o r m a y n o t have h y p e r t r o p h i e d s u p e r e g o s , a n d t h e y w i l l t h i n k a n d behave a c c o r d i n g l y , so t h a t i n a n e g o - d i s i n t e g r a t i v e phase t h e i r s u p e r e g o q u o t a w i l l c o l o r t h e i r r e a c t i o n s . T h e i r sensitivities may b e c o m e excessive, so t h a t t h e y m a y show p a r a n o i d f e a t u r e s a n d t h e i r obsessional defenses m a y p r o v e i n a d e q u a t e t o t h e d e m a n d s p l a c e d o n t h e m . T h e s e c o u l d c o l o r t h e c l i n i c a l p i c t u r e t o s u c h a n e x t e n t as t o 1
* P r e s e n t e d at the T h i r t e e n t h N a t i o n a l Scientific M e e t i n g o f t h e A s s o c i a t i o n f o r t h e A d v a n c e m e n t o f P s y c h o t h e r a p y . T o r o n t o , C a n a d a , A p r i l 3 0 - M a y 1, 1 9 7 7 . f P r o f e s s o r o f P s y c h i a t r y , F a c u l t y o f M e d i c i n e , U n i v e r s i t y o f O t t a w a . Mailing address: Royal Ottawa Hospital, 1145 C a r l i n g A v e . , O t t a w a , O n t a r i o K 1 Z 7 K 4 , C a n a d a .
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obscure t h e s c h i z o p h r e n i c process. S i m i l a r o b s c u r i n g m a y r e s u l t f r o m p h o b i c a n x i e t y f e a t u r e s ; i t is t h e r e f o r e e q u a l l y a p p r o p r i a t e t o speak o f " m a s k e d s c h i z o p h r e n i a . " T h e lesson h e r e is t h a t i t is n o t e n o u g h t o i d e n t i f y t h e s c h i z o p h r e n i c aspect. I f o t h e r e l e m e n t s e x i s t , t h e y m u s t be recognized a n d , o f course, treated. T h e r e is n o aspect o f m e n t a l illness m o r e i m p o r t a n t t h a n t h a t o f d e p r e s s i o n — f i r s t , because i t is v e r y c o m m o n ; a n d s e c o n d , because i t c a n r e s u l t i n severe m o r b i d i t y , e n c o m p a s s i n g d e a t h by s u i c i d e as w e l l as a n o t n e g l i g i b l e n u m b e r o f h o m i c i d e s . J u s t as severe d e p r e s s i o n m a y be m a s k e d i n a n o n s c h i z o p h r e n i c p a t i e n t , i t m a y also be m a s k e d i n a p a t i e n t w i t h s c h i z o p h r e n i a . T h e r e f o r e , a conscious e f f o r t s h o u l d be m a d e t o detect its presence. B u t t h i s is o n l y a s t a r t . T r e a t m e n t o f d e p r e s s i o n , w h e r e v e r i t m a y be f o u n d , w i l l v a r y a c c o r d i n g t o t h e t y p e a n d severity o f t h e d e p r e s s i o n . T h u s , a d e f i n i t i o n o f its n a t u r e a n d a q u a n t i t a t i v e e s t i m a t i o n are also necessary. T h e severely d e p r e s s e d s c h i z o p h r e n i c p a t i e n t is psychotically d e p r e s s e d a n d s h o u l d t h e r e f o r e be c l e a r l y d i f f e r e n t i a t e d f r o m t h e n e u rotic depressive. H o w does o n e g a u g e t h e s e v e r i t y o f a d e p r e s s i o n ? Suicidal intent, m o r b i d p r e o c c u p a t i o n s , a n d s u c h b i o l o g i c f e a t u r e s as e a r l y w a k i n g , loss o f w e i g h t , a n d d i u r n a l v a r i a t i o n s are a l l p o i n t e r s . Y e t we s o m e t i m e s d e ceive ourselves w i t h t h e l a n g u a g e we use i n d e s c r i b i n g depressive s y m p t o m a t o l o g y . W e speak o f delusions o f g r a n d e u r b u t offeelings o f guilt a n d unworthiness w h e n defining the two extremes o f the manicdepressive psychosis. I t is as i f those w h o w a l k h u m b l y w i t h t h e i r M a k e r c a n n o t be c o n s i d e r e d as d e l u d e d , b u t he w h o boasts h i m s e l f o f t h e m o r r o w is d e f i n i t e l y so. W e s h o u l d r e c o g n i z e t h a t a d i s t o r t i o n o f t h i n k i n g is a d e l u s i o n w h a t e v e r its n a t u r e . T h i s raises a n o t h e r d i f f i c u l t y . P a r t l y because o f t h e above a t t i t u d e , d e l u s i o n has b e e n m o r e closely i d e n t i f i e d w i t h s c h i z o p h r e n i a t h a n w i t h depression. A too-strict adherence to such a belief will persuade the observer t h a t severely d e p r e s s e d p a t i e n t s are r e a l l y s u f f e r i n g e x c l u s i v e l y f r o m a s c h i z o p h r e n i c o r p a r a n o i d state a n d t h a t t h e presence o f depressive f e a t u r e s m a y be d i s c o u n t e d . T h e d i a g n o s t i c c h a l l e n g e is n o t all t h a t f o r m i d a b l e , h o w e v e r , e v e n i f o n e o n l y b r i n g s a r u d i m e n t a r y k n o w l e d g e o f psychopathology to bear. I f instead o f the t e r m " h y p o c h o n d r i a s i s " o n e u s e d " d e l u s i o n s o f disease," t h e depressive n a t u r e o f the p r o b l e m w o u l d become a p p a r e n t . T h e severely d e p r e s s e d p a t i e n t uses s o m a t i c l a n g u a g e t o i n d i c a t e w h a t he feels he deserves t o have a n d w i l l n o t be g a i n s a i d . N o t f o r h i m are t h e t r i v i a o f t h e h y s t e r i c a l h y p o c h o n d r i a c o r t h e somatic m a n i f e s t a t i o n s o f a n x i e t y o f t h e p h o b i c state. H e goes i n f o r d e a t h - d e a l i n g a n d
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socially o s t r a c i z i n g diseases l i k e c a n c e r , s y p h i l i s , a n d , i n p r e v i o u s years, t u b e r c u l o s i s . H e is r e a l l y s a y i n g t h a t h e deserves t o d i e o r be a p a r i a h a n d t h a t these are his j u s t deserts. W h a t is m o r e , these f e a t u r e s are sinister i n i m p o r t , f o r t h e y are t a n t a m o u n t t o a d e a t h s e n t e n c e , w h i c h the p a t i e n t m a y c a r r y o u t e i t h e r because he is d e s p e r a t e o r because he fears t h e l o n g , d r a w n - o u t a g o n y o f his s e l f - i m p o s e d sentence. I n t h e t r e a t m e n t o f a n uncomplicated depressive illness t h e p h y s i c i a n g e n e r a l l y has some c h o i c e . I f t h e c o n d i t i o n is i d e n t i f i e d e a r l y a n d is m i l d , i t will p e r m i t a variety o f approaches. P s y c h o t h e r a p y m a y suffice, f o r t h e r i s k o f u n r e l i a b l e c o n d u c t m a y be n e g l i g i b l e . W h e n t h e r e is n o sense o f u r g e n c y , t h e p s y c h i a t r i s t m a y e v e n i n d u l g e i n d e p t h analysis w i t h r e l a t i v e i m p u n i t y , because s p o n t a n e o u s r e m i s s i o n is also c o m m o n . E v e n i n i n e x p e r t h a n d s , t h e r e f o r e , cures m a y be p r o c l a i m e d w i t h o u t fear o f c o n t r a d i c t i o n . I n t h e moderate case c o n s e r v a t i v e measures s t a n d a n e x c e l l e n t chance o f success. A n e f f e c t i v e a n t i - d e p r e s s a n t l i k e I m i p r a m i n e , w h e n first i n t r o d u c e d , was able t o r e c l a i m 5 0 p e r c e n t o f those w h o p r e v i o u s l y d i d n o t r e m i t w i t h o u t a c o u r s e o f E . C . T . , a n d i t is n o w r e c k o n e d t h a t n o t less t h a n 75 p e r c e n t o f a l l psychotic d e p r e s s i o n s w i l l r e s p o n d s a t i s f a c t o r i l y . I t is t h e r e f o r e w e l l w o r t h a t r i a l . T h e case o f t h e severely d e p r e s s e d s c h i z o p h r e n i c is d i f f e r e n t . O n e must not make the mistake, potentially fatal to the patient, o f sending a b o y o n a m a n ' s e r r a n d . T h i s m a y at t i m e s r e s u l t i n a n o v e r r e a c t i o n , because t h e d i s c r i m i n a t i o n s o f j u d g m e n t r e q u i r e d t o o p t f o r c o n s e r v a t i v e measures as against a c o u r s e o f E . C . T . c a n be v e r y fine i n d e e d . B u t w i t h s u c h h i g h stakes i t is w i s e r t o be c a u t i o u s a n d n o t t o t a k e risks w i t h t h e p a t i e n t ' s l i f e . S h o u l d t h e p h y s i c i a n w i s h t o p o s t p o n e his d e c i s i o n , he s h o u l d have his p a t i e n t a d m i t t e d t o a h o s p i t a l a n d p l a c e d u n d e r strict observation a n d c o n t r o l , w i t h daily review by the psychiatrist. T h e corr e c t d e c i s i o n c a n o n l y be a c h i e v e d by a c o n t i n u o u s d i a g n o s t i c exercise. M o r e o v e r , s u c h a n a p p r o a c h c a n o n l y l e a d t o i m p r o v e m e n t i n one's e x p e r t i s e . E v e n so, o n e m a y still m a k e m i s t a k e s , b u t t h e t r i u m p h s o f c o n s e r v a t i v e t r e a t m e n t m u s t be w e i g h e d against t h e losses o f p a t i e n t s w h o c o m m i t suicide a n d w o u l d n o t have d o n e so i f a c o u r s e o f E . C . T . had been p r o m p t l y administered. T h e d e g r e e o f r e l i a b i l i t y o f a severely d e p r e s s e d n e u r o t i c p a t i e n t is l a r g e l y l i n k e d t o his capacity f o r c o o p e r a t i o n a n d t o his c o n f i d e n c e i n t h e p s y c h i a t r i s t . W i t h t h e severely d e p r e s s e d s c h i z o p h r e n i c t h i n g s are d i f ferent. Because t h i n k i n g is grossly d i s t o r t e d a n d t h e p a t i e n t is h y p e r s e n s i t i v e , r e l i a b i l i t y c a n n o t be e x p e c t e d . W h a t m a y be t h e u l t i m a t e g u a r a n t e e o f r e l i a b l e c o n d u c t i n a severely d e p r e s s e d p a t i e n t — n a m e l y , his w o r d — c a n n o t be a c c e p t e d as v a l i d w h e n t h e r e is a n
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associated s c h i z o p h r e n i c illness. W i t h s u c h a h i g h level o f b u i l t - i n u n p r e d i c t a b i l i t y , i t w o u l d be a g a m b l e t o d e l a y effective t r e a t m e n t ; f u r t h e r m o r e , i t w o u l d e x p o s e t h e n u r s i n g s t a f f t o a s i t u a t i o n w h i c h m a y w e l l be b e y o n d its c o m p e t e n c e a n d w h i c h m a y w e a k e n its c o n f i d e n c e i n t h e psychiatrist. T h e i n d i c a t i o n s are t h a t , f o r t h e severely d e p r e s s e d s c h i z o p h r e n i c p a t i e n t , a n a d e q u a t e c o u r s e o f E . C . T . o f f e r s t h e best p r o s p e c t f o r speedy remission. B u t w h a t is a n a d e q u a t e c o u r s e o f E . C . T . ? T h e r e is so m u c h m i s i n f o r m a t i o n o n this subject t h a t a l t h o u g h t h e t r e a t m e n t has b e e n used f o r n e a r l y 4 0 years, i t is still g i v e n i n e x p e r t l y . A n a d e q u a t e c o u r s e is n o t a m a n d a t o r y n u m b e r at a p r e s c r i b e d f r e q u e n c y . I t s h o u l d be a n i n d i v i d u a l l y t a i l o r e d p r o g r a m t h a t takes i n t o a c c o u n t t h e p r e m o r b i d state, t h e i n i t i a l severity o f t h e c o n d i t i o n , a n d t h e r e s p o n s e t o each t r e a t m e n t . T h e r e f o r e , t h e s p a c i n g a n d n u m b e r o f t r e a t m e n t s w i l l v a r y f o r each p a t i e n t . F o r some p a t i e n t s i t m a y be necessary t o give t h e first t h r e e t r e a t m e n t s o n successive days, w h i l e f o r t h e m a j o r i t y t h r e e t r e a t m e n t s d u r i n g t h e first w e e k w i l l be a d e q u a t e . T h e t o t a l n u m b e r o f t r e a t m e n t s has b e e n so subjected t o m y t h o l o g y a n d t h e m a g i c o f n u m b e r s t h a t i t m a k e s the Fliess-Freud correspondence read like a n engineer's handbook. Clear g u i d a n c e i n t h e l i t e r a t u r e is h a r d t o c o m e b y . A s t u d y by H o d g s o n a n d S i m o n 3 6 4 p a t i e n t s w i t h u p t o f o u r years f o l l o w - u p s h o w e d t h a t w i t h less t h a n e i g h t t r e a t m e n t s relapse was m o r e c o m m o n , b u t t h e f r e q u e n c y was n o less i m p o r t a n t t h a n t h e t o t a l n u m b e r o f t r e a t ments. 2
W i t h schizo-affective psychoses o f a m o r e c h r o n i c n a t u r e , i t m a y be necessary t o c o n t i n u e a l i t t l e l o n g e r — s p a c i n g t r e a t m e n t s a f t e r t h e f i f t h one to weekly intervals, a n d after the e i g h t h to fourteen-day i n t e r v a l s — to a total o f ten o r even twelve treatments. Occasionally a patient's i l l ness is r e f r a c t o r y t o E . C . T . , a n d w i t h n o r e a l r e s p o n s e a f t e r t h e t h i r d o r f o u r t h t r e a t m e n t m a n y psychiatrists w e a k e n i n t h e i r resolve a n d d o u b t w h e t h e r t h e y s h o u l d c o n t i n u e . I t is possible t h a t e v e n a f t e r t h e s e v e n t h t r e a t m e n t t h e r e w i l l be n o detectable r e s p o n s e , at w h i c h p o i n t t h e p r e s s u r e by r e s i d e n t s a n d nurses t o d i s c o n t i n u e can be v e r y s t r o n g indeed. T h e r e is o n l y o n e a n s w e r . T h e g r o u n d m u s t be c a r e f u l l y r e e x a m i n e d , a n d i f t h e i n d i c a t i o n s f o r s t a r t i n g t h e c o u r s e i n t h e first place r e m a i n v a l i d , o n e m u s t c o n t i n u e . A n d to the surprise o f the d o u b t e r s a n d t o t h e r e l i e f o f t h e p s y c h i a t r i s t , a r e m i s s i o n w i l l be s e c u r e d . T h e r e is n o r o o m h e r e f o r t e a m decisions, because i t is h i g h l y u n l i k e l y t h a t a n y m e m b e r o f t h e t e a m w i l l have m o r e r e l i a b l e e x p e r i e n c e t h a n t h e psychiatrist. H e m u s t listen a n d pay a t t e n t i o n to factual evidence, b u t t h e r e s p o n s i b l e d e c i s i o n c a n n o t be l e f t t o t h e a n o n y m i t y o f a t e a m a p -
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p r o a c h . As f o r i n v o l v i n g o t h e r p a t i e n t s i n t h e d e c i s i o n - m a k i n g , t h e less said t h e b e t t e r . A n o t h e r w o r d o f c a u t i o n . Schizo-affective psychoses, especially i f a c u t e , can be s y m p t o m a t i c o f u n d e r l y i n g o r g a n i c f a c t o r s , c e r e b r a l a n d systemic. T h u s , o n e m u s t d o a t h o r o u g h p h y s i c a l s c r e e n i n g , n o t o v e r l o o k i n g exotic c o n d i t i o n s l i k e a n islet-cell t u m o r o f t h e pancreas a n d p o r p h y r i a a n d , o f c o u r s e , t o x i c states i n d u c e d by h a l l u c i n o g e n i c d r u g s and amphetamines. L i f e can be v e r y h a r d f o r t h e c l i n i c i a n , b u t m e d i c i n e w o u l d be v e r y d u l l i f i t w e r e n o t . So m u c h f o r t h e depressive aspect. W h a t o f t h e s c h i z o p h r e n i c side? I n acute schizo-affective r e a c t i o n s , such as p o s t o p e r a t i v e states a n d p u e r p e r a l psychoses, t h e s c h i z o p h r e n i c e l e m e n t is so closely l i n k e d t o t h e d e p r e s s i o n t h a t t r e a t m e n t o f t h e d e p r e s s i o n f r e q u e n t l y results i n a c o m plete r e m i s s i o n o f t h e s c h i z o p h r e n i c f e a t u r e s . T h i s is n o t s u r p r i s i n g f o r t h r e e reasons: t h e s c h i z o p h r e n i c e l e m e n t is u s u a l l y o f r e c e n t o r i g i n ; t h e r e is e v i d e n c e o f a n e f f e c t i v e p r e m o r b i d p e r s o n a l i t y , a n d t h e d e l u s i o n a l a n d e v e n h a l l u c i n a t o r y c o n t e n t is h e a v i l y l a d e n w i t h depressive symptomatology. Should remission n o t occur, however, effective measures t o c o n t r o l t h e s c h i z o p h r e n i c f e a t u r e s s h o u l d be t a k e n , sim u l t a n e o u s l y w i t h t h e c o u r s e o f E . C . T . i f necessary. E a c h p s y c h i a t r i s t has his f a v o r i t e t r a n q u i l i z e r , a n d t h e r e is m u c h t o be said f o r a c q u i r i n g e x p e r t i s e w i t h o n e d r u g as o p p o s e d t o h a v i n g o n l y a n o d d i n g acquaintance with many. For the r a p i d c o n t r o l o f schizophrenic features, H a l o p e r i d o l (Haldol) 5 m g m . t . i . d . generally suffices, b u t i n t h e acute phase i t must—not should—be given p a r e n t e r a l l y . O n e is f r e q u e n t l y c a l l e d i n t o c o n s u l t a t i o n o v e r a p a t i e n t w h o s e psychotic f e a t u r e s r e m a i n u n c o n t r o l l e d d e s p i t e massive doses o f t r a n q u i l i z e r s . T h e r e is a n o b v i o u s e x p l a n a t i o n , w h i c h is e i t h e r o v e r l o o k e d o r d e n i e d : t h e p a t i e n t has n o t b e e n s w a l l o w i n g o r r e t a i n i n g t h e tablets. Since i t has b e e n established a g a i n a n d a g a i n t h a t r e f r a c t o r y o r r e l a p s i n g s c h i z o p h r e n i c s d o n o t absorb t h e i r m e d i c a t i o n , t h e t i m e has s u r e l y c o m e t o accept this as a r u l e unless p r o v e n o t h e r w i s e a n d t o give the d r u g i n a f o r m t h a t ensures t h a t t h e p a t i e n t has r e c e i v e d i t . T h e r e is another danger. I f t h e p s y c h i a t r i s t c o n c l u d e s t h a t massive doses are i n e f f e c t i v e , he m a y be p e r s u a d e d t o t r y s o m e t h i n g e v e n m o r e p o w e r f u l . B u t s h o u l d this be g i v e n p a r e n t e r a l l y , t h e p a t i e n t m a y a c t u a l l y be r e c e i v i n g his first—and t h e r e f o r e m u c h t o o s t r o n g — d o s e . O n c e t h e acute phase is u n d e r c o n t r o l , t h e p s y c h i a t r i s t s h o u l d d e c i d e w h e t h e r t h e s c h i z o p h r e n i c process w i l l r e q u i r e l o n g - t e r m t r e a t m e n t . T h i s decision should d e p e n d o n the p r e m o r b i d personality, the h o m e b a c k g r o u n d , a n d a l l t h e o t h e r factors n o r m a l l y t a k e n i n t o a c c o u n t i n t h e treatment o f the schizophrenic patient. I f schizophrenic features
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persist i n spite o f E . C . T . , t r a n q u i l i z e r s i n d e p o t dosage s h o u l d be g i v e n . M o d e c a t e is at p r e s e n t t h e m o s t p o p u l a r i n N o r t h A m e r i c a . A n i n i t i a l test dose o f 12.5 m g m . is r e c o m m e n d e d . I f a f t e r 10 days t h e r e are n o u n t o w a r d side effects, a dose o f 25 m g m . can be g i v e n a n d r e p e a t e d at three-to-four weekly intervals. One word of caution. In s c h i z o p h r e n i c s w i t h a h i s t o r y o f d e p r e s s i o n t h e r e is a r i s k t h a t M o d e c a t e may lead to a recurrence a n d even to suicide; the t e r m "postpsychotic d e p r e s s i o n " has b e e n a p p l i e d i n these instances. F o r t u n a t e l y , t h e r e is a n o t h e r d e p o t - d o s e t r a n q u i l i z e r , F l u p e n t h i x o l ( D e p i x o l ) , available i n E u r o p e f o r t h e past five years. M a n y psychiatrists i n t h e U n i t e d K i n g d o m , a n d n o d o u b t e l s e w h e r e , are s w i t c h i n g t o i t f r o m M o d e c a t e . I n a d d i t i o n t o its t r a n q u i l i z i n g a c t i o n , w h i c h is n o less t h a n t h a t o f M o d e c a t e , i t has a n a n t i - d e p r e s s a n t a c t i o n , a n d t h u s does n o t cause t h e p o s t p s y c h o t i c d e p r e s s i o n s y n d r o m e . F l u p e n t h i x o l is also u s e f u l i n p r e v e n t i n g o r c l e a r i n g t h e a m o t i v a t i o n a l phase so f r e q u e n t l y f o u n d i n s c h i z o p h r e n i c s w h o have lost t h e i r f l o r i d p s y c h o t i c f e a t u r e s . T h e i n i t i a l dose o f 20 m g m . is f o l l o w e d b y a dose o f 4 0 m g m . s h o u l d t h e r e be n o u n d e s i r a b l e side effects. T h e s e a r e s i m i l a r t o those f o u n d i n M o d e c a t e , t h a t is, d y s t o n i c m o v e m e n t s a n d a k a t h i s i a . W h a t a b o u t p s y c h o t h e r a p y ? T h i s is a l m o s t a r h e t o r i c a l q u e s t i o n . I t is d o u b t f u l w h e t h e r a n y c o m m i t t e e o f e x p e r i e n c e d p s y c h i a t r i s t s w o u l d select t h e severely d e p r e s s e d s c h i z o p h r e n i c p a t i e n t f o r p s y c h o t h e r a p y , because a l l c r i t e r i a f o r g o o d selection are absent. A f t e r t h e d e p r e s s i o n has c l e a r e d , t h e r e m a y be a case f o r s u p p o r t i v e p s y c h o t h e r a p y , a l t h o u g h i f f u r t h e r h e l p is n e e d e d i t is m o r e l i k e l y t o c o m e f r o m a w e l l - p l a n n e d program of rehabilitation. Because these p a t i e n t s h a v e a l r e a d y d e m o n s t r a t e d t h e i r capacity t o react c a t a s t r o p h i c a l l y , d e p t h analysis is c o n t r a i n d i c a t e d . T h o u shalt n o t m a k e t h y p a t i e n t w o r s e . A t t h e same time one should not underestimate the degree o f psychopathologic e x p e r t i s e a n d t h e delicate a n d s o p h i s t i c a t e d h a n d l i n g these p a t i e n t s r e q u i r e i f t h e n u a n c e s o f changes i n d e f e n s e m e c h a n i s m o r ego s t r u c t u r e are t o be r e a d i l y r e c o g n i z e d a n d q u i c k l y d e a l t w i t h . T h e s u p e r v i s i o n o f these p a t i e n t s s h o u l d n o t be l e f t t o t h e u n s k i l l e d , f o r i t is a c o n t i n u o u s d i a g n o s t i c a n d t h e r a p e u t i c exercise, w h i c h goes f a r b e y o n d d r u g p r e s c r i b i n g a n d E . C . T . a n d w h i c h calls f o r a l l t h e r e s o u r c e s o f t h e experienced a n d w e l l - t r a i n e d psychiatrist. W h a t w i l l be t h e results o f t r e a t i n g a severely d e p r e s s e d s c h i z o p h r e n i c p a t i e n t ? T h i s w i l l , o f c o u r s e , d e p e n d l a r g e l y o n t h e psyc h i a t r i s t . I f t h e i n i t i a l assessment a n d t r e a t m e n t is e x p e r t l y h a n d l e d , w i t h due consideration given to the complexities o f the p r o b l e m , the results s h o u l d be e x c e l l e n t a n d o n e s h o u l d n o t be satisfied w i t h less. I f g o o d results are n o t o b t a i n e d , t h e answer is t o t r y h a r d e r .
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SUMMARY T h e p r o b l e m o f m a s k e d d e p r e s s i o n is n o w w e l l r e c o g n i z e d a n d some o f t h e m a s k i n g m a y be w i t h s c h i z o p h r e n i c f e a t u r e s . T h e c o r o l l a r y t o t h i s is t h a t t h e r e are some f o r m s o f m a s k e d s c h i z o p h r e n i a w i t h depressive f e a t u r e s , some o f w h i c h m a y be severe. T h e f o r m u l a t i o n o f these p r o b l e m s calls f o r d i a g n o s t i c s k i l l i n assessing t h e ego a n d s u p e r ego s t r u c t u r e a n d t h e d e f e n s e m e c h a n i s m s b r o u g h t i n t o p l a y . T r e a t m e n t o f severe d e p r e s s i o n i n s c h i z o p h r e n i a calls f o r a sensible a p p r o a c h t o t h e use o f p h e n o t h i a z i n e s , u s i n g t h e d e p o t - d o s e t y p e r a t h e r t h a n a n o r a l p r e p a r a t i o n . A c o u r s e o f E . C . T . s h o u l d n o t f o l l o w a set r o u t i n e r e g a r d i n g n u m b e r a n d f r e q u e n c y b u t s h o u l d be i n d i v i d u a l l y t a i l o r e d t o each p a t i e n t . P s y c h o t h e r a p y has a l i m i t e d r o l e , b u t a t h o r o u g h g r o u n d i n g i n p s y c h o p a t h o l o g i c processes a n d s k i l l i n t h e i r r e c o g n i t i o n is essential. REFERENCES 1. L e s s e , S . 2.
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