g . ;?

The Treatment of Acute Schizophrenia Without Drugs:

An Investigation of Some Current Assumptions

BY WILLIAM T. CARPENTER, JR., M.D., THOMAS H. MCGLASHAN, M.D.,

AND JOHN S. STRAUSS, M.D.

proaches to schizophrenia have been used for years ·f

The authors examine the course of49 acute and have provided a rich source of information on phe- :~
schizophrenic patients in a program at the National nomenology and treatment effects. However, in the ab- ;i,
Institutes a/Health (NIH) emphasizing psychosocial sence of rigorous research methodology this informa- ;~
treatment and sharply limiting the use ofmedication tion base is often dismissed as anecdotal, and the influ- ;jJ:.;
and contrast it with that oI73 similar patients ence of psychoanalysis and related psychological;
receiving "usual" treatment in a separate study.
Follow-up of the NIH group at one year and the other
approaches on the treatment of schizophrenic patients l:
has waned. There are formidable intricacies involved;:
group at two years demonstrated a small hut in developing appropriate measures of change specifi-.;~
significantly superior outcome for the NIH cohort. In cally relevant to the aims of psychotherapy, and until '~
addition, the 22 NIH patients receiving medication recently little attention has been paid to such assess- :
and the 27 dmg)i'ee patients had similar outcomes at ment problems (4-8). Thus. for example. it is possible)
one year. The authors discuss theleasibility qj'
to demonstrate that drugs are more effective than psy- J
treating aClite schizophrenic patients with minimal lise
chotherapy in reducing a paranoid patient's bellig- j
(~f'l1ledicati(}ll.
erency. but there is no way to assess the effectiveness~:1
of either mode of treatment on this palient's capacity~
for i n t i m a c y . i
FOR MANY understandable and good reasons, psycho- Pharmacological treatment of schizophrenia is ex-};
pharmacology is now preeminent in the treatment of traordinarily important in psychiatry. We bel ieve, how-!
schizophrenic patients. Drug administration reduces ever, that the treatment of schizophrenia has become ~
psychotic symptoms, dulls the pain of anguished so extensively drug oriented that a significant impedi-
patients, renders hospitalized patients dischargeable, ment has a,:isen to the exploration of alternati ve thera-
and maintains patients in the community. It provides a peutic approaches. The situation has reversed from;l~
rational and effective mode by which the physician can the 1950s, when a commitment to psychological treat-'~
induce desired changes in his patient well within the ment philosophies posed a serious resistance to phar- t
context of the medical model. macological innovations. Klein (9) has noted that the A
Psychiatry's receptivity to the use of psycho- automatic and immediate administration of neurolep-'
pharmacology in the treatment of schizophrenic tics to disturbed patients often precedes and precludes
patients has been enhanced by studies documenting even a diagnostic evaluation. This widespread and pre-
the effectiveness of drugs while failing to find any im- mature foreclosure on the optimal treatment of schizo-
pressive evidence for the effectiveness of psychologi- phrenia is reflected by the fact that millions of people
cal therapies (1-3). However, these important studies take neuroleptics as the only important component of
have shortcomings and are regarded by some as an un- their treatment. "
satisfactory test of psychotherapeutic efficacy.
On the other hand, we have little systematic informa-
tion about psychotherapy (4). Psychotherapeutic ap- LIMITATIONS IN KNOWLEDGE OF
SCHIZOPHRENIA
Revised version of a paper presented at the 128th annual meeting of
the American Psychiatric Association, Anaheim, Calif., May 5-9, This narrowing of our clinical approach is especially~
1975. alarming considering how little we know about schizoq
At the time this work was done Dr. Carpenter was Acting Chief, Psy-" phrenia. These limitations include the following:
chiatric Assessment Section and Dr. McGlashan was Chief, Clinical I. We know virtually nothing about the etiology 0
Research Unit, Psychiatric Assessment Section, Adult Psychiatry schizophrenia. Despite evidence for a genetic contrib
Branch, National Institute of Mental Health, Bethesda, Md. Dr. Car-
penter is now Director, Schizophrenia Research, New York State tion in some forms of schizophrenia, we know nothi
Psychiatric Institute, 722 West 168th St., New York, N.Y. 10032. about the nature of this component, how it may con
Dr. McGlashan is Staff Psychiatrist, Chestnut Lodge, Rockville,
Md. Dr. Strauss is Director, Clinical Psychiatry Research, Universi- tribute to vulnerability, or to what extent it account
ty of Rochester School of Medicine, Rochester, N.Y. for the variance in manifest schizophrenia. At present

14 Am J Psychiatry 134:1, January 1977

 CARPENTER, MCGLASHAN, AND STRAUSS

no factor can be said to be a necessary and sufficient ciates (16) also found discordance between 4 outcome
cause of schizophrenia, or even necessary but in- measures, i.e., mental status, social and role function-
sufficient. ing, rehospitalization, and satisfaction with treatment.
2. Difficult diagnostic issues and patient hetero- Studies assessing the relationship between treatment
geneity limit the interpretation of data from any study and outcome are severely limited unless they are
of schizophrenic patients. based on multiple outcome dimensions.
3. The assessment techniques that measure course The paucity of long-range follow-up studies also re-
and outcome in schizophrenia have serious short- stricts our understanding of the effects of pharmacolog-
comings, especially as applied in studies comparing ical treatment. Most reports focus on changes in the
treatment effects. patient during hospital stay or brief follow-up periods,
Recognition of the paucity of etiological knowledge and few studies go beyond 2 years. Engelhardt (17)
about schizophrenia is important since psychiatrists of- has called attention to the diminishing differences
ten assume that a rea~onedunderstanding of its cause (from clinical assessment) between drug- and placebo-
does exist, lacking only in detail. In fact, no other dis- treated patients as their course is followed over a long-
order in the history of psychiatry has had a richer pan- er period of time. This does not lessen the importance
oply of global claims to its cause and cure. Recognition of the short-term effects of drugs, but it does suggest
of our ignorance is important because, as common that we know very little about their comparative long-
sense suggests and Soskis (10) has demonstrated, term advantages.
etiological assumptions influence a physician's choice
of treatment modality.
The second point-the problem of diagnostic short- ISSUES CONCERNING DRUG TREATMENT
comings-is widely acknowledged but rarely ad-
dressed in study designs evaluating treatment modali- It is often assumed that noxious side effects of neuro-
ties. Thus a group of patients who are called schizo- leptic treatment of schizophrenia are limited to un-
phrenic but who lack descriptive (let alone etiological) pleasant autonomic alterations, extrapyramidal ef-
homogeneity are often studied for treatment response, fects, rare allergies, and infrequent tardive dyski- I
and the study results are generalized as though schizo- nesias. Recent evidence (18-20) has more carefully
phrenia were a single illness (II). documented the relationship between drug treatment
The third point-inadequacies in the assessment of and the inducement or reinforcement of defect or nega-
course and outcome-is the least well recognized but tive symptoms (e.g., anhedonia, social isolation, post-
perhaps the mo~t crucial. There are many dimensions psychotic depression, and amotivational syndromes).
to a patient's fate, and the effect of treatment on a Nevertheless, relatively scant attention has been paid
patient's course cannot be adequately determined un- to this problem or to possible later effects of long-term
less this complexity is taken into account. The capac- drug use on affect modulation, communication, per-
ity to relate socially is not the same as the capacity to ception, or other central nervous system functions. In
hold a job, and neither of these factors can be predict- addition, little notice has been given to the so-called
ed by assessing the patient's symptom picture or the secondary side effects, such as the impact on a child's
necessity for hospitalization. However, all too fre- development should his mother be on long-term heavy
quently the effect of treatment on outcome is deter- medication. This results in a situation not entirely dis-
mined by measuring unitary dimensions such as the similar to that of past enthusiasm for lobotomies, when
length of hospital stay. attention focused on the positive attributes of the pro-
Docherty (12) reviewed the literature on mainte- cedure to such a degree that the short- and long-term
nance drug therapy in schizophrenia and found that on- hazards were overlooked.
ly 4 of 31 studies measured the effectiveness of drug Two recent review articles have suggested that the
therapy on dimensions other than symptom relapse or unequivocal acceptance of neuroleptic therapy in
rehospitalization. While these measures/arcr vitally im- schizophrenia is being reexamined. Tn a review of
portant, they fall drastically short of a comprehensive maintenance drug therapy Davis (2l) pointed out that
assessment of the patient's functioning,.fhis point was there is a subgroup of schizophrenic patients who
documented using 2-year follow-J.lp')~ssessmentsof 85 should not be treated with neuroleptics. Criteria for
schizophrenic patients we evaluated as part of the In- identifying this subgroup are not yet established. Fur-
t~mational Pilot Study of Schizophrenia (IPSS) (13). thermore, Davis believes that most patients on chronic
There were only modest associations between 4 out- maintenance therapy deserve a trial of withdrawal
:;ome variables, i.e., time in hospital, social function, from drugs; this has the potential of enhancing the clin-
work function, and symptoms (14). Furthermore, the ical course as well as reducing the risk of neurological
issociation between any I of these measures at 2-year complications. Davis is joined in this argument by Gar-
"allow-up and the other measures at 5-year follow-up dos and Cole (22), who have stated that "every chron-
Nas minimal, and in some cases negligible (I5). For ex- ic schizophrenic outpatient maintained on antipsychot-
lmple, assessing hospital status during a 2-year follow- ic medication should have the benefit of an adequate
Ip gives minimal information abollt social or work trial without drugs" (p. 35). Based on their review,
'unction at 5-year follow-up. Schwartz and asso- these authors predicted that as many as 50% of all med-

Am J Psychiatry 134:1, January/977 15

 m

TREATMENT OF ACUTE SCHIZOPHRENIA WITHOUT DRUGS

i
L
I .
icated chronic schizophrenic outpatients would do as (NIH) Clinical Center designed to investigate the rela-
I' ' well clinically without medication. tionship between diagnostic and psychobiological vari-
The ascendancy of drug treatment in schizophrenia ables. We selected patients with flagrant psychotic
i
I:!;
has been accompanied by an emphasis on short-term breaks but with reasonably adequate social and work
crisis management, rapid discharge from the hospital, function prior to the onset of their psychotic episodes.
and community-oriented services. These trends spring While this was generally not their first psychotic epi-
from a recognition of the negative effects of chronic sode, most of the patients could be considered acute or
institutionalization and from frustration with lengthy subacute schizophrenics. Informed consent was ob-
psychotherapeutic procedures. These trends may have tained from all patients after the nature of the treat-
gone to extremes; the wisdom of early discharge and ment/research program was fully explained.
I return to the community, for example, is beginning to
be questioned (23, 24).
At admission the patients were removed from all
medication for 3 weeks. Toward the end of this 3-week
Together, these factors have led to the following 5 period a battery of psychobiological, clinical assess- .~

prevalent and understandable, but erroneous, assump- ment, and psychophysiological research procedures
I tions:
l. The schizophrenic patient must be treated with
was undertaken. The patients had a maximum hospital-
ization of 4V2 months; the average stay was slightly
drugs and failure to do so is unethical. less than 4 months (117 days). If the patients were
2. Such patients must be maintained on drugs after placed on drugs after initial testing, they repeated the
symptomatic recovery. 3-week drug-free period to permit research retesting
3. Relapse must be prevented since the psychotic prior to discharge. After discharge testing the patients
state is, in itself. pathogenic and actively nurtures a were hospitalized as necessary for 2 weeks to permit
deteriorating course. reinstitution of medication and reintegration into the
4. No major treatment emphasis besides drugs is es- community. Initial follow-up evaluations were con-
sential for schizophrenics. ducted 1 year after admission.
5. There are relatively few hazards in using medica-
tion. Therapeutic Environment
Although we regard these 5 assumptions as unwar- The therapeutic philosophy was that self-under-"
ranted, we do not subscribe to opposite conclusions. standing and social adaptation are fundamental to the .~
Answers to these problems must be derived from care- process of recovering from psychotic episodes. i
ful scientific study. Our argument is that current treat- Patients were seen in psychoanalytically oriented psy- ';
ment attitudes far outdistance their informational chotherapy 2-3 times a week. All patients participated J
base. The polemics often introduced into discussions in group psychotherapy once a week and most patientsf
of treatment do not reflect scientific fact. However, is- also had family therapy once weekly. Self-understand.i:;
sues at the interface of pharmacotherapy and psycho- ing was emphasized in these sessions; psychotic mani-~'
therapy were intelligently discussed in a recent report festations were regarded as reflections of intrapsychic':;
by the Group for the Advancement of Psychiatry (25). conflict and repetitions of past experience. The treat<t
It seems apparent that our profession should encour- ing psychiatrists ranged in experience from third-year:~
age the continued evaluation of reasoned and innova- residency to second-year postresidency. Senior psy~~<o
tive treatment approaches for schizophrenia. choanalysts experienced in the treatment of schizo-~:
phrenic patients provided weekly supervision. 1 "
Social adaptation was the principal focus in the gen~
THE STUDY eral therapeutic milieu with the nursing staff, occupa-;{
tional therapist, recreational therapist, and others. The}
In this paper we describe a hospital program for staff helped patients both control and understand their!'
acute schizophrenic patients that emphasizes psycho- behavior. Special emphasis was placed on clarifying"
social treatment and sharply limits the use of medica- behavioral communications, helping the patient assesi
tion. The course of patients so treated is examined and his effect on others, and exploring alternative expres~
contrasted with that of similar patients treated in other sions of impulses and ideas. This aspect of the thera:'
hospital facilities: This is not a comparative outcome peutic work was carried out in the informal conta~t;
study using controlled therapeutic protocols. Rather, that the nursing staff had with patients as part of ordi~
we use available data to address one central question: nary ward life. It was also pursued on a group basis fot,
does withholding medication in the context of psycho- 45 minutes a day at rounds where all staff and patient
social treatment bias against a favorable outcome in met to discuss issues relevant to patient care and war'
acute schizophrenia? .
'The young psychiatrists treating the patients were not advocates'.i1f:
any particular psychotherapeutic approach but were interested_~
METHOD learning about the therapeutic potential of the doctor-patient rela·
tionship. Most of the supervisors had worked at Chestnut Lodge..
some point in their professional lives and had been intluenced Il
Our program was established on an II-bed clinical the work of such people as Sullivan (26) and Fromm-Reich
research unit in the National Institutes of Health mann (27).

16 Am J Psychiatry 134:1, January 1977

 /
CARPENTER, MCGLASHAN, AND STRAUSS

life. This process was no doubt facilitated by the unit's tifying schizophrenic patients (33), the presence of
small size and ample staff. The average staffing pattern Schneider's first-rank symptoms (34), and a profile
included 3 psychiatrists (with both clinical and re- analysis of variance across 27 psychopathological di-
search responsibilities), 1 social worker, 1 half-time ac- mensions (35) comparing NIH and IPSS patients.
tivities worker, and 13 nurses and nursing assistants Prognostic and outcome variables were assessed using
(divided among 3 shifts, 7 days a week). schedules developed by Strauss and Carpenter (36).
Brief mention should be made of our milieu ap- Premorbid, diagnostic, and outcome data were collect-
proach because the question inevitably arises as to ed using semistructured interviews developed for
whether seriously ill, drug-free schizophrenic patients work in the IPSS (13, 36) (i.e., Present State Examina-
can be managed from day-to-day, let alone be treated tion, Psychiatric History, and Social Description
in a therapeutic community. Jones (28) originally em- schedules) .
phasized patient responsibility, democracy, and over- Before reporting the results, we should again empha-
lap of roles within staff and between staff and patients size that neither the NIH program nor the IPSS was
in a therapeutic milieu. The utility of such an ap- designed for treatment evaluation. In these 2 separate
proach with schizophrenic patients has come under projects, similar clinical data were collected without
question because these patients are often fragmented any preconceived plan to compare patients. This
and regressed, with a poorly developed social capacity causes certain methodological problems, and we use
and a strong tendency toward severe withdrawal (29). these data illustratively rather than definitively. One
Taking this into account, we evolved a therapeutic must keep in mind that "usual community care" was
community organized around a clearly defined medical just that, and patients were not on controlled therapeu-
model. Hierarchical staff role definitions were pre- tic protocols. NIH patients, on discharge, entered a va-
served, and the psychiatrist in charge of the unit had riety of treatment settings (or none at all) but rarely re-
final responsibility for the treatment program. All ceived intensive psychotherapy. In fact, treatment dur-
nembers of the community were responsible for shar- ing the follow-up period was similar for the NIH and
ng information and ideas relevant to the clinical opera- IPSS groups. The question we address with these data
ion. Attendance at' ward meetings and therapeutic ses- is whether treating acute and subacute schizophrenic
;ions was required. This organization pr.ovided the patients without drugs results in untoward outcome.
irm external ego boundaries necessary for regressed
latients, yet maximized the immense resources of the
;roup to enhance effective social intercourse, elimi- RESULTS
late isolation, and press patients to quickly resume in-
'ividual responsibility. The use of medication was The study (NIH) patients and comparative (IPSS)
,roscribed only during the research drying-out peri- patients were similar in important respects. Table I
ds; otherwise, the patient's doctor could elect to use provides descriptive information for each sample.
rugs, although emphasis was always on psychosocial There were no statistically significant differences be-
·eatment. Further descriptions of this clinical pro- tween any of the variables. Sign and symptom charac-
-am have been reported elsewhere (30, 31). teristics of all patients were determined within 10 days .
after admission. The profile analysis of variance across
'~e Two Patient Cohorts 27 psychopathological dimensions (e.g., anxiety, audi-
In this report we compare the first 49 diagnosed
'hizophrenic patients admitted to the NIH research
lit with 73 patients seen as part of the IPSS (13). The TABLE 1
'SS patients received the "usual" hospital care in Descriptive Data on the NIH and IPSS Schizophrenic Patients
'ince Georges County, Maryland (metropolitan
'ashington, D.C.), about 1970. 2 Two of us (W.T.C. NIH Group IPSS Group
d J.S.S.) made index diagnoses in both groups fol- Item (N=49) (N=73)
wing the descriptions and categories of DSM-IJ (32).
Ibtype diagnoses in the NIH patients were catatonic, Mean age (years) 23.7±7.8 28.9±8.3
Sex
ranoid, acute schizophrenin-eaction, and schizo-af- Female 29 52
~tive schizophrenia. The 73 IPSS' patients given Male 20 21
~se 4 subtype diagnoses were included in the study. Marital status
so used for diagnosis was a 12-point system for iden- Ever married 15 43
Never married 34 30
Socioeconomic c1ass*
I 5 2
II J2 5
ese patients and the hospital facilities have been described else-
lere (30). Usual treatment involved the ubiquitous lise of neuro- III 15 24
ltic medication, Sllpport from the nursing staff, and contact with IV 12 28
~chiatrists and social workers at least weekly during hospital- V 4 J4
tion. Psychiatrists in these facilities Were more experienced than VI I 0
: NIH clinical associates, but nursing staff-to-patient ratios were
s favorable. • According to Hollingshead and Redlich (37),

Am J Psychiatry 134:1, January 1977 17

-'\ / /
 CARPENTER, MCGLASHAN, AND STRAUSS

e. This process was no doubt facilitated by the unit's tifying schizophrenic patients (33), the presence of
. all size and ample staff. The average staffing pattern Schneider's first-rank symptoms (34), and a profile
eluded 3 psychiatrists (with both clinical and re- analysis of variance across 27 psychopathological di-
arch responsibilities), 1 social worker, 1 half-time ac- mensions (35) comparing NIH and IPSS patients.
vities worker, and 13 nurses and nursing assistants Prognostic and outcome variables were assessed using
ivided among 3 shifts, 7 days a week). schedules developed by Strauss and Carpenter (36) .
. Brief mention should be made of our milieu ap- Premorbid, diagnostic, and outcome data were collect-
proach because the question inevitably arises as to ed using semistructured interviews developed for
whether seriously ill, drug-free schizophrenic patients work in the Ipss (13, 36) (i.e., Present State Examina-
can be managed from day-to-day, let alone be treated tion, Psychiatric History, and Social Description
in a therapeutic community. Jones (28) originally em- schedules).
phasized patient responsibility, democracy, and over- Before reporting the results, we should again empha-
lap of roles within staff and between staff and patients size that neither the NIH program nor the IPSS was
in a therapeutic milieu. The utility of such an ap- designed for treatment evaluation. In these 2 separate
proach with schizophrenic patients has come under projects, similar clinical data were collected without
question because these patients are often fragmented any preconceived plan to compare patients. This
-and regressed, with a poorly developed social capacity causes certain methodological problems, and we use
and a strong tendency toward severe withdrawal (29). these data illustratively rather than definitively. One
'. Taking this into account, we evolved a therapeutic must keep in mind that "usual community care" was
community organizec! around a clearly defined medical just that, and patients were not on controlled therapeu-
model. Hierarchical staff role definitions were pre- tic protocols. NTH patients, on discharge, entered a va-
served, and the psychiatrist in charge of the unit had riety of treatment settings (or none at all) but rarely re-
_final responsibility for the treatment program. All ceived intensive psychotherapy. Tn fact, treatment dur-
:members of the community were responsible for shar- ing the follow-up period was similar for the NIH and
ing information and ideas relevant to the clinical opera- IPSS groups. The question we address with these data
tion. Attendance at'ward meetings and therapeutic ses- is whether treating acute and subacute schizophrenic
'sions was required. This organization pr.ovided the patients without drugs results in untoward outcome.
firm external ego boundaries necessary for regressed
patients, yet maximized the immense resources of the
group to enhance effective social intercourse, elimi- RESULTS
nate isolation, and press patients to quickly resume in-
'dividual responsibility. The use of medication was The study (NIH) patients and comparative (lPSS)
proscribed only during the research drying-out peri- patients were similar in important respects. Table I
'ods; otherwise, the patient's doctor could elect to use provides descriptive information for each sample.
drugs, although emphasis was always on psychosocial There were no statistically significant differences be-
treatment. Further descriptions of this clinical pro- .tween any of the variables. Sign and symptom charac-
gram have been reported elsewhere (30,31). teristics of all patients were determined within 10 days
after admission. The profile analysis of variance across
27 psychopathological dimensions (e.g., anxiety, audi-
.~ In this report we compare the first 49 diagnosed
ischizophrenic patients admitted to the NIH research
unit with 73 patients seen as part of the IPSS (13). The TABLE 1
IPSS patients received the "usual" hospital care in Descriptive Data on the NIH and IPSS Schizophrenic Patients
Prince Georges County, Maryland (metropolitan
'Washington, D.C.), about 1970. 2 Two of us (W.T.C. NIH Group IPSS Group
and J.S.S.) made index diagnoses in both groups fol- Item (N=49) (N=73)
. lowing the descriptions and categories of DSM-II (32).
'Subtype diagnoses in the NIH patients were catatonic, Mean age (years) 23.7±7.8 28.9::':8.3
Sex
paranoid, acute schizophrenic reaction, and schizo-af- Female 29 52
fective schizophrenia. The 73 IPSS patients given Male 20 21
these 4 subtype diagnoses were included in the study. Marital status
I~ISO used for diagnosis was a 12-point system for iden- Ever married 15 43
Never married 34 30
Socioeconomic c1ass*
~(- I 5 2
~"These patients and the hospital facilities have been described else-
II 12 5
If.;n;' where (30). Usual treatment involved the ubiquitous use of neuro-
Jeptic medication, support from the nursing staff, and contact with
III
IV
15
12
24
28
~i psychiatrists and social workers at least weekly during hospital- V 4 14
( Ization. Psychiatrists in these facilities were more experienced than VI 1 0
:.:- the NIH clinical associates, but nursing staff-to-patient ratios were
:::; less favorable. • According (0 Hollingshead and Redlich (37).

Am J Psychiatry 134:1, January 1977 17

----.
 TREATMENT OF ACUTE SCHIZOPHRENIA WITHOUT DRUGS

,;. tory hallucinations, restricted affect) revealed clinical continued for the 3-week research test period. The oth-
y.'.' similarity in both pattern and severity of symptoms. er 4 drug-treated patients are omitted here since their
., :
This method and the psychopathological dimensions phenothiazines were discontinued earlier for clinical'
have been previously described (35, 38). The NIH and rather than research reasons. Only I of the 18 patients.
IPSS cohorts were also similar (i.e., not significantly withdrawn from phenothiazines showed any evidence.
different statistically) in their respective mean prognos- of clinical deterioration during this 3-week drug-free.
i." tic scores (38.3±6.5 and 37.9±5.2). The prognostic period. In fact, many patients improved during the'
scale consisted of IS items measuring factors found by drying-out period (e.g., they showed more sponta-
previous workers to have prognostic significance (36). neity, fuller affect, less psychomotor retardation, and
Evaluation of outcome was based on assessment of more social and work initiative). The nursing staff
work function, social function, time spent in a hospital made daily global ratings of psychiatric illness on an 8-
during the year,3 and symptoms during the month pre- point scale (O=no pathology and 7=severe psychosis).
, i
ceding follow-up evaluation. Mean outcome scores Ratings were significantly lower after medication was
demonstrated a small but significant superiority for the discontinued for these 18 patients; mean ratings for the
:;: i NIH patients (l2.7±3.2 versus 1I.I±4.0 for the IPSS last week on drugs and the third week off drugs were
.' i
,
Ii
, patients, p<.05, nonpaired t test). 3.2 and 2.5, respectively (p<.05, paired t test). The
;, ; I
. , Since some of the NIH patients received a therapeu- treating physicians had tentatively planned to discharge.
tic trial with phenothiazines, further comparisons with- these 18 patients on phenothiazines, but resumed medi-
i in this cohort can be made. NIH patients treated with cation in only 7 of them.
medication (N =22) were compared with those who
I, were drug-free throughout their hospital stay (N =27).
Mean prognostic scores were essentially the same for DISCUSSION

I the drug-free and drug groups (38.6±7.3 and 38.1 ±5.3,

respectively). A profile analysis of variance across 27
dimensions revealed no difference in overall pattern of
psychopathology. Mean outcome scores at I year
The first part of this paper focused on the paucity of,
knowledge regarding etiology, course, and treatment;"
of schizophrenia-information gaps that should, but'
were similar for the drug-free and medicated groups do not, preclude the polarization and polemics preva~~
(12.8±2.8 and 12.4±3.8, respectively). lent in our field. '*
Detailed longitudinal data collected on most of the In presenting our experience with a psychosociaF
NIH patients permit additional points of contrast. Av- treatment approach, we have demonstrated that failing;
erage hospital stay was insignificantly longer for those to use neuroleptics during an acute psychotic episode;
patients treated with phenothiazines (126 days com- does not necessarily result in a disadvantageou(
pared to 108 days for drug-free patients). Drug-free course and outcome, and it may have some advan~
patients were insignificantly less likely to be rehospita- tages. We have used our data to argue against state~
lized (35% compared to 45%) or to be treated with ments to the effect that failure to use medication iiI
drugs (44% compared to 67%) during the follow-up pe- acute schizophrenic patients is, ipso facto, unethical;;
riod. Patients receiving medication were significantly at worst or poor clinical judgment at best. Our finding;
more likely to have a postpsychotic depression (de- is similar to Goldstein's report, (40) of treatment advan$
fined in reference 20) (p<.05) and were rated as more tages in a subgroup of acute schizophrenic patients?
depressed near discharge (p< .025, nonpaired t test), al- when medication was withheld during the first 27 days
though they haG not been more depressed at admis- of hospitalization and to Bockoven and Solomon's re'
sion (39). port (41) of comparable 5-year outcome in patienf,s
A final observation involves 18 NIH patients who treated before and after the availability of major tra~
were being treated with drugs when their discharge qu ilizers. i;,
was scheduled. These patients had been receiving 200- Considering these reports, our experience, and t~
600 mg of chlorpromazine daily for an average of 46 recent reviews by Davis (21) and Gardos a~.
days (range =20-65 days) when all medication was dis- Cole (22), an interesting possible effect of drugs on ill
course of schizophrenia emerges. Davis (21) note.
that patients receiving higher dosages of neurolepti
"The IPSS follow-up was conducted 2 years after admission accord- are far more likely to relapse on placebo substitutiQ
ing to the plans and goals of the IPSS. The NIH project was a sepa-
rate study. and initial follow-up I year after admission was de- than patients receiving no medication (or low dosages
signed to collect biological as well as clinical data. Since this result- prior to placebo. Gardos and Cole (22) noted a tre,n
ed in a postdischarge period of only 8-9 months, outcome scores from 3 studies suggesting that patients who relap
were extrapolated to 12 months for the time in hospital measure.
Assessment of social and work function was based on the 8- to 9- while receiving drugs appear to have a higher rehg
month period, and symptom evaluation was based on the month pri- pitalization rate than patients who relapse while rec~!"
or to follow-up assessment. This discrepancy is unfortunate, but it ing placebo. This finding implies that relapse dutl
appears to,bias outcome against the NIH patients, because 13 NIH
patients were seen for a second follow-up evaluation 24-30 months drug administration is greater in severity than relap
after admission and had significantly better outcome scores than when no drugs are given. :~
they had I year after admission (p< .05, paired t test). Two-year fol-
low-up of all the NIH patients was precluded by the authors mov- The most plausible explanation, and the one'a"
ing to other institutions. vanced by the authors of both reviews, is that t~9

18 Am J Psychiatry 134:1, January 1977

p /

...: .... ~.~~

 CARPENTER, MCGLASHAN, AND STRAUSS

ients receiVIng higher dosages of medication or similar for patients who did and did not receive drugs;
, se patients relapsing while receiving neuroleptics this suggests that variables other than clinical status
e more severely ill. An alternative, albeit unlikely, (perhaps, for example, staff anxiety or treatment atti-
ypothesis should at least be entertained to explain tudes of the patient's psychiatrist) contributed to medi-
ese findings: it is possible that treatment with pheno- cation use. Consonant with this, we found that the
iazine medication actually increases the risk of re- patient's date of admission was a powerful predictor of
"pse. There is no question that, once patients are whether or not drugs were used. The first 10 patients
laced on neuroleptics, they are less vulnerable to re- and 8 of the last II patients admitted to the program
pse if maintained on neuroleptics. But what if these received drugs. We viewed this as a problem in the
tients had never been treated with drugs to begin treatment program transition in that about 6 months
'th? Virtually all of the outpatient maintenance stud- were required to establish the program initially. Simi-
s begin with fully medicated patients (many of whom larly, toward the end of the program the treatment phi-
ave recently been discharged from the hospital) who losophy of the unit could not be fully maintained be-
re then divided into drug and placebo groups. These cause patients and staff anticipated a change in treat-
tudies usually do not include a group of patients who ment orientation. In any case, simply knowing the date
ave been free of drugs from the moment of their of admission and identifying patient's doctors were suf-
'reakdown and hospitalization. In essence, we have ficient to predict who would receive medication.
ittle reliable data on the frequency of relapse during We can only speculate why patients did not relapse
··'e natural course of the schizophrenic process. The when drug therapy was discontinued. It is clear, how-
ockoven and Solomon study (41) relates to this ques- ever, that relapse in chronic schizophrenic patients fol-
on in that one cannot simply say that before neurolep- lowing medication withdrawal should not be gener-
'cs were available relapse rates were higher. alized to an acute schizophrenic population. In addi-
'In any case, in an illness with so many paradoxes, tion, increased symptoms after drug reduction during
, raise the possibility that antipsychotic medication an active psychotic period should not be confused with
y make some schizophrenic patients more vulner- the reappearance of psychotic symptoms (relapse) in a
Ie to future relapse than would be the case in the nat- recovered patient. We suggest that the 17 patients who
I course of their illness. Thus, as with tardive dyski- did not relapse after phenothiazine discontinuation
'sia, we may have a situation where neuroleptics in- were no longer symptomatically psychotic. Medica-
rease the risk for subsequent illness but must be tion may have been therapeutic earlier, but it was no
'aintained to prevent this risk from becoming mani- longer needed. The further improvement in these
est. Insofar as the psychotic break contains potential patients during drug withdrawal may be related to a lift-
for helping the patient alter pathological conflicts with- ing of the negative elfects of phenothiazines, with gen-
"'himself and establish a more adaptive equilibrium eral activation ofalfect, motivation, movement, ability
"ith his environment, our present-day practice of im- to experience pleasure, and social involvement.
ediate and massive pharmacological intervention Duri ng the 3 years of this program we systematically
ay be exacting a price in terms of producing "recov- sought our patients' impressions regarding many as-
"red" patients with greater rigidity of character struc- pects of the program. This was done at discharge and
:\i:~~.re who are less able to cope with subsequent life follow-up. These data suggest that patients found the
resses. NIH therapeutic program significantly different from
:There are methodological shortcomings in our programs they had participated in in other hospitals.
dy, since a comparative investigation of treatment Generally, patients reported experiencing more an-
not the goal of the research programs. Two critical guish with our treatment approach, whereas they felt a
blems are the differences in timing of the follow-up greater sense of frustration and of being "frozen in the
valuations and the failure to control treatment in ei- psychosis" in settings emphasizing drug treatment.
"er patient group. Earlier in this paper we cited evi- Many of the patients found their social experiences in
ence suggesting that the first problem probably the NIH ward both gratifying and informative, and
, sed outcome against the psychosocially treated they reported that their lives had been enhanced as a
tients. Regarding the second problem, we have result of their therapeutic experience. A few patients
. ed this report on observations of "usual" treat- made negative assessments; they felt their psychosis
nt in different settings. Since few patients in either was destructive and their attempts to understand it
hert received intensive psychosocial therapy after were of no value. These reports highlight the impor-
charge, the advantages and/or disadvantages of psy- tance of a continued search for subgroups of schizo-
bsocial treatment may be obscured by similarities in phrenic patients who are responsive to different thera-
low-up treatment. peutic approaches.
Two interesting questions remain from the observa- In conclusion, our clinical observations in a biologi-
:is on the NIH patients. What determined who re- cally oriented clinical research project employing psy-
"ed medication, and why did patients removed chosocial treatment techniques argue for the feasibility
"'''' phenothiazines for research protocols fail to re- of treating acute schizophrenic patients with minimal
? With regard to the first question, our analysis use of medication. The experience can be gratifying
aled that symptom and prognostic statuses were for patients and staff. Patients in such a program have

Am J Psychiatry 134:1, JanualY 1977 19

TREATMENT OF ACUTE SCHIZOPHRENIA WITHOUT DRUGS

not fared poorly compared with patients treated in 19. Rivera-Calimlim L, Nasrallah H, Strauss J. et al: Clinicai,i
sponse and plasma levels: effect of dose. dosage schedules,':,.
more conventional settings. We found it possible to drug interactions on plasma chlorpromazine levels. Am Jfi
use a research strategy for investigating drug-free chiatry 133:646-652. 1976 '~
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therapeutic approach to these-patients within the schizophrenia. Arch Gen Psychiatry 33:231-239. 1976 '.,~
framework of a medical model. 21. Davis JM: Overview: maintenance therapy in psychiatry',"
Schizophrenia. Am J Psychiatry 132: 1237-1245. 1975 S
22. Gardos G, Cole J: Maintenance antipsychotic therapy: is":
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20 Am J Psychiatry /34:/, January /977