If someone you loved had cancer or heart disease, you'd want him or her to be treated with the best drugs available, no matter what the cost. The same holds true for schizophrenia - which affects one in 100 Irish people. Yet in the Republic, confidential industry figures for drug sales suggest that 80 per cent of people with schizophrenia are being treated with old-fashioned anti-psychotics up to 40 years old, despite the fact that new generation drugs have fewer side-effects and keep people out of hospital.
The side-effects caused by the older, "typical" drugs - such as chloropormazine and haloperidol - mimic Parkinson's disease and include stiffness, shaking, akasthesia (inner restlessness), rigidity (causing a mask-like face) and strange staccato effects in the voice. Needless to say, with these symptoms, anybody would appear "mad".
"It doesn't take a genius to see that if someone is shaking and speaking in a staccato voice and going around with twitching arms and a stiff face because their medication is affecting them, they are not going to be perceived as `normal'," says one Dublin psychiatrist with a special interest in schizophrenia. He preferred not to be named to protect the identity of his patient, Paul, interviewed on this page.
This psychiatrist asserts that drug side-effects make it harder for people with schizophrenia to assimilate into the community and may also fool doctors into believing that the person is relapsing, so that the person stays longer in hospital and, once out, may soon return inside for long periods.
The "schizophrenias", as they were originally named by German psychiatrist Eugene Bleuler around the year 1900, are actually two or three separate illnesses whose distinctions are only beginning to be understood. Some schizophrenics are passive and immobilised like the characters in the Robin Williams film, Awakenings; others shout and hear voices and behave in a "mad" fashion.
For many years, schizophrenia has been seen from a neurochemical perspective with the focus on a brain receptor, dopamine. The old drugs work on a single dopamine receptor and often have to be used in huge doses to be effective. The new drugs act on multiple receptor systems, including dopamine, serotonin (linked to depression) and cortisol (a stress hormone). Perhaps due to their broad action, they can be used in much lower doses, avoiding side-effects.
The new "atypical" drugs - such as clozapine, olzapine, resperidone and quetiapine - give a better quality of life, largely because they make the person with schizophrenia function normally. The person can be part of the community, can socialise comfortably and may even be able to get employment outside a sheltered situation, enabling them to come off social welfare.
So why are the old drugs still being used for the majority of schizophrenics? The old drugs cost one-10th the price of the new ones - 38p per day compared to £3.90 per day. And - as Schizophrenia Ireland puts it - "everything is run by accountants these days". Budgetary restraints influence doctors, says the psychiatrist. "No one has told us not to prescribe them, but most clinicians are conscious of costs."
In the long-term, however, the new drugs could be more cost-effective. While their direct cost is higher, their indirect cost is the same because they keep people out of hospital and allow them to assimilate better into society.
According to Orla O'Neill, director of Schizophrenia Ireland, in the past there have been cases of schizophrenics on new drugs having their prescriptions revised by their GPs to older, cheaper versions, because under the GMS scheme, GPs got 50/50 cash-back for writing a cheaper script.
However, since November 1999, when special provisions were made for anti-psychotics in the drug budgeting mechanism of the GMS, GPs are no longer under financial pressure. But, according to Dr Cormac MacNamara of the Irish Medical Organisation's GP Committee, many doctors resent heavy marketing by drug companies of the new schizophrenia medicines - marketing which he likens to "being browbeaten". And, he says, Irish doctors are often simply slow to try out a new medication and abandon one they have been used to prescribing.
There is also the question of the quality of prescribing within psychiatric hospitals, not just for schizophrenics, but for all people with mental health problems. In his 1998 report, the Inspector of Mental Hospitals stated that "drug prescribing in some locations is often arbitrary and made without regard to appropriate clinical diagnosis. The number of patients, particularly long-stay patients, who are on numerous drugs simultaneously, often at high dosages, was striking. In some instances, the prescriptions had not been reviewed for some considerable time."
Add to this damning assessment the belief of mental health lobbyists that the Mental Health Bill 1995, which is only now about to be considered by Government, is minimalist and reactive because it is designed essentially to help the Government save face in Europe where it is likely to be embarrassed by the "Croke" case in the Court of Human Rights, which is being brought by a man who was involuntarily detained in a psychiatric hospital.
According to Orla O'Neill, the Bill addresses the issue of involuntary detention in psychiatric hospital and lacks the comprehensive vision which is actually required.
While Schizophrenia Ireland does not have a view on the drugs used to treat schizophrenia, it believes that patients should have a legal right to frequent review of their medication. Martin Rogan of the Mental Health Association of Ireland describes one young woman who was hospitalised for six years with a psychotic episode so severe that her family had nearly given up hope. Prescribed the new "atypical" drugs for schizophrenia, she made a full recovery and is now living normally in the community. Currently, she is in mourning for the lost six years of her youth, but at least she has a future.