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By Herbert Y. Meltzer, M.D.
For patients with schizophrenia, their families, and mental health professionals committed to treating and investigating this group of disorders, now is both the best and worst of times. On the positive side are the development of a new generation of antipsychotic drugs with greater tolerability and efficacy than the venerable neuroleptic drugs and increasingly powerful tools to improve diagnosis, evaluate the efficacy of treatment, develop new treatments, and investigate the causes of schizophrenia. On the negative side are the control of mental health policy for the treatment of schizophrenia in many of our states and localities by individuals and whose decisions are too often driven by fiscal issues, major decreases in the total amount of funding available for treatment, public reactions with regard to recent violent acts committed by people with schizophrenia, and the decreasing involvement of psychiatrists in the direct treatment of schizophrenia and policymaking.
The current situation facing psychiatry with regard to schizophrenia is well illustrated by a discussion of the issues regarding the new antipsychotic drugs. Beginning with the U.S. approval of clozapine in 1989, followed by the approval of risperidone, olanzapine, and quetiapine, with ziprasidone likely to be approved in 1999, the opportunity to improve core deficits such as cognitive impairment and negative symptoms in patients with schizophrenia, while avoiding the worst side effects of the typical neuroleptics, have become a palpable reality. Psychiatrists in the United States, more so than those of any other country in the world, have embraced these drugs as the best treatments for schizophrenia. However, there is still much to be done with regard to educating some members of the psychiatric community about these agents, which is one of the goals of Rod Muņoz's APA presidency.
Similarly, much effort is still needed to help mental health policymakers, in both government and managed care, appreciate the benefits of these agents and provide reasonable access to them without prior approval. In some states, funding for these agents has been provided at the cost of funding for people and agencies needed to deliver these agents effectively, compromising their potential benefits. Advocacy groups such as the National Alliance on Mental Illness have been immensely helpful to organized psychiatry in correcting such misconceived policies.
Of great importance in the struggle to win support for the newer medications has been the message that the treatment of schizophrenia involves far more than the control of delusions and hallucinations, which the typical neuroleptics can accomplish in about 70 percent of patients. A broad definition of outcome in schizophrenia has been an essential demand in making the case for the importance of ending the use of typical neuroleptic drugs for most patients. That definition focuses on the need to restore patients with this illness to as much social and work function as possible by improving cognition, mood, and negative symptoms while not causing extrapyramidal side effects and tardive dyskinesia. These broader outcome measures highlight improved quality of life for patients, including reduced morbidity and mortality (especially from suicide) and reduced family and caretaker burden, and ultimately benefits society through reduced indirect costs of this illness, which now far outweigh the direct costs. These
indirect costs, which mainly consist of lost income and disability income transfers, are in the range of $40 billion a year compared with about $30 billion a year for the direct costs. Currently, the costs of new medications, which are used by approximately 40 percent of patients with schizophrenia, are about $2.2 billion annually, approximately 3 percent of the total costs of the illness. It is essential that health economic studies using cost-utility analysis and consideration of current and future costs of treating this illness with new versus older medications be conducted. These data will help to make the case to health care policymakers for adequate provision of funds for both medication and clinicians.
Coupling these powerful and tolerable new medications with advances in rehabilitation and enlightened social policy regarding housing, work, and partial disability payments may make it possible for the outcome for schizophrenia patients in the next century to be remarkably improved compared with that in the 20th century. Recently published outcome data from each decade of the 20th century have shown a significant slippage in the current decade, back to the levels prior to the introduction of typical neuroleptic drugs. It is time for APA and its members to utilize our knowledge and resources to reverse this alarming development.
Dr. Meltzer is a professor of psychiatry and pharmacology and director of the psychopharmacology division at Vanderbilt University School of Medicine.