FOR RELEASE
AM'S FRIDAY, FEB. 17

THE FIRST YEAR'S EXPERIENCE WITH LARGE-SCALE USE OF
CHLORPROMAZINE AND RESERPINE IN THE MENTAL HYGIENE
INSTITUTIONS OF NEW YORK STATE: A PRELIMINARY REPORT

 

TESTIMONY BEFORE
HOUSE APPROPRIATIONS SUBCOMMITTEE ON LABOR-H.E.W. HEARINGS
ON FISCAL 1957 BUDGET (REP. JOHN FOGARTY, CHAIRMAN)
10:00 A.M., THURSDAY, FEBRUARY 16, 1956
by
DR. HENRY BRILL - Albany, New York
Assistant Commissioner of Mental Hygiene, New York State.
Mr. Chairman and members of the Committee:

The new drugs, chlorpromazine and reserpine, first were generally avail-
able for clinical use in this country in the spring of 1954. Since then they have
become the most extensively applied form of medical treatment for mental disorder
in the New York State hospitals, have reduced the need for restraint and seclusion
of disturbed patients by more than half and have created a general clinical opinion
that they help patients return to the community as the shock therapies do.

Studies now in progress will soon provide some department-wide statistics
on the immediate results of drug therapy as to release and relapse but much work
remains to be done in this direction and it will of course take several years before
we can be sure of the long-term figures.

These medications have found their place as an addition to other forms of
treatment and not as a replacement, and since their advent the number of patients

reached has been very largely increased. On March 31, 1954, just before the drugs
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began to be tried, we had 4, 530 patients under all forms of physical therapy for
mental illness and cases were completing treatment at the rate of some 15, 000 per
year. By December 31, 1955 this rate had risen to over 40,000 per year and there
were 18,543 patients currently under treatment, of which 16,243 were receiving
chlorpromazine or reserpine.

No previous method of psychiatric therapy has ever had such rapid and
general acceptance in our hospitals. The nearest approach was by electric shock
therapy now in use since 1940 but the largest monthly number of patients to com-
plete a course of electric shock was 1,182 in June 1954, as compared with 2,670
for the new drugs in December 1955.

The large-scale application of the drugs was preceded by a long series of
pilot studies which by December 1954 had been extended to include over 1, 800
patients treated by several dozen experienced psychiatrists scattered among the
state's 20 mental hospitals and some of the state schools. Ata joint meeting
where these physicians pooled their information, there was substantial agreement
that chlorpromazine and reserpine represented a significant addition to the psy-
chiatric therapies and should be made available for routine use in the state hospitals
and schools. This recommendation was made with the full realization that it had
been far easier to recognize that these medications were active and useful than it
would be to measure the degree of this activity accurately and to compare it with
other methods, Much basic information on the natural history of mental disorders
was and still is lacking and many of the established methods have not themselves
been completely evaluated but there was enough information available to justify

proceeding promptly. The new drugs were found in our experience to be quite safe,
although in a certain percentage of cases complications developed. This form of
therapy was accepted easily by patients and was capable of reaching a much larger
number of patients than had ever been possible before.

A special allocation of funds was secured and with the full cooperation of
the state's legislative, budgetary and purchasing authorities, general use of chlor-
promazine and reserpine was begun throughout the institutions of the Department of
Mental Hygiene in January 1955. The first year of the program has been marked
by rapid growth, the field of application has widened, and the drugs are being used
in all of the department's hospitals and schools.

The trend has been consistent in a wide variety of locations with the excep-
tion that some groups show a preference for one and some for the other of the two
drugs. Recently there has been an increasing tendency to use them together for
certain purposes. During the fiscal year ending March 31, 1956 the cost of drugs
will be-$750, 000 and there is every indication that it will be higher next year.

Because of the large number of patients which it has been able to reach,
the drug program may well be able to show a measurable impact on the over-all
operations of the department and a broad statistical study is now under way to in-
vestigate the question. This involves the machine processing of many thousands
of reparts and analysis of data on cases treated, returns to the community, re-
lapses, permanent discharges and the role played by a number of important modi-

fying factors, such as age, sex, type of illness, duration of illness and others. *

* Acknowledgment is made to the Albert and Mary Lasker Foundation for assist-
ance in this research.
Information is being accumulated rapidly and within a few months we should
have some preliminary data on the immediate results of drug therapy in terms of
department-wide figures. At present, the most that can be done is to search for
statistical clues and straws in the wind; so far these appear to be favorable. Over-all
figures for returns to the community have risen by 19 per cent since April 1, 1955
and in November 1955, 1,425 patients were able to leave the hospital, as compared
with 1,177 in November 1954. There has also been a distinct but limited decrease
in the total number of patients re-entering hospitals, but the task still remains to
find out whether this recent improvement is coincidental or if it was brought about
by drug therapy. On the negative side, it must not be forgotten that the hospitals
have also continued to advance other programs which may very well influence these
figures. Preliminary indications are that at least a part of the over-all improve-
ment is concentrated among some of the kinds of patients who have been receiving
drug therapy intensively as, for example, the disturbed long-term cases, while
rates have changed little thus far in categories of patients who are not normally
treated with these drugs.

It still remains to be determined how permanent the results of treatment
will be and how many patients will relapse after they have left the hospital. In
this field, drugs have an advantage over all the other physical methods of therapy
since it is relatively easy to continue the medication after patients return home or
to resume it should there be a relapse.

In most areas our over-all statistical studies are still quite incomplete
but our data on the effect of drug therapy in the care of disturbed patients is quite

convincing and has been consistent. As the use of chlorpromazine and reserpine
has increased, the need for restraint and seclusion has fallen during the entire year
until it now stands at less than half the lowest figure ever reached before the use of
this type of treatment, although previous efforts in this direction had been sustained
and vigorous.

The full meaning of this fact can be appreciated only after a visit to one of
the hospitals where the effects on the disturbed wards can actually be seen. The
marked diminution of hostile, noisy and destructive behavior has produced a strik-
ing change in the atmosphere and the physical appearance of these wards which now
for the first time have been able to keep such items as bedspreads, tablecloths and
ward decorations in use where they never were tolerated before. Other methods
have of course achieved similar results in the past for periods of time and with
limited groups of patients but the drug therapy effect has been reproduced rapidly
ona broad scale with the facilities already available and has been relatively easy
to maintain.

The personal service previously absorbed in security activities can now
be diverted to constructive therapeutic purposes for the patients and most important
is the fact that an increased number are able to return to their homes even among
long-standing cases, indicating that these drugs are not merely a superior form of
sedative but actually have a direct therapeutic effect.

In speaking of these successes it is difficult not to forget the limitations
of the drugs and even more the limits of our present knowledge. One can easily
build up hopes, some of which are beyond reason and must be disappointed and others
for which no solid basis exists. This would be unfair to everyone and could only tend

to bring discredit or severe criticism against a very valuable type of treatment.
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Most of all it should be stressed that the drugs are only an addition to the previous
methods of treatment and not a replacement. Experience shows that they operate
best as a part of an organized therapeutic regimen and the details of their integra-
tion into such a pattern are still being developed. They have accomplished a great
deal with disturbed patients but have brought about only reduction of restraint and
seclusion, not its abolition. Many of these cases still require other treatments,
including shock therapy or psycho-surgery, as do patients of other categories when
they respond partially or not at all to the drugs.

There should be no misunderstanding about the number of good remissions
in chronic patients who are disturbed. Most of these are at least somewhat more
calm and cooperative but only a relatively small number improve sufficiently to re-
. turn to the community and the figure is outstanding only in comparison with what
could be accomplished previously.

The favorable reaction of disturbed mentally defective patients has given
some parents the false hope that these drugs may influence the retardation itself,
and drug success in the control of mental agitation and excitement among senile and
arteriosclerotic patients has led relatives to ask whether the effects of brain dam-
age and deterioration may not also respond. Unfortunately, both are outside the
province of these drugs.

Some of the questions about the drug treatments can have no answer for
some time, one of first importance being "Will this form of therapy produce a
stable response or will results tend to disappear within a few years or less?''; on
the other hand, will this method added to what we already have slow down the re-
lentless growth which has marked the history of state hospitals since the days of

Dorothea Linde Dix?
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Such a change could result from a reduction of admissions due to treat-
ment of patients at home or from an increase in hospital releases or from a
combination of both. Up to the present there has been no decrease in admis-
sions to the New York State hospitals, although this may develop later. The
outlook with regard to hospital releases has been presented as far as it has
been clarified. These questions and many others must be answered by careful
investigations over a sufficient period of time.

For the present, the use of chlorpromazine and reserpine is well justi-
fied by the results which they have already been shown to produce. This is the
judgment of a very large number of competent observers who have had the op-~
portunity to work with the medications. The full assessment of the value of
these drugs, their place in the psychiatric armamentarium and their influence
on future psychiatric theory and practice can be determined only in the future

when many more investigations than we have today will be available.