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CLINICAL SCENARIO

You are a psychiatrist following a 49-year-old man who has had schizophrenia for more than 20 years. He had an acute psychotic episode in his mid-20s and was admitted to a psychiatric hospital for 3 weeks. He made good recovery and has managed to continue work in a small factory. He has been taking chlorpromazine, 200 mg/d, for many years, still has occasional hallucinations, and has no close friends except for his sister's family, who live a block away. Half a year ago, work stress increased, the patient began to take medication only irregularly, and he experienced a mild exacerbation, becoming fearful, developing insomnia, and hearing voices more frequently. You increased his chlorpromazine dose to 300 mg/d, and the patient became less agitated but is still moderately symptomatic. After taking the increased dose of chlorpromazine, the patient has reported hand tremors that trouble him, and his movements are stiff. He does not mind the stiffness, but his family worries because “he looks odd, aloof, and ill.” He and his family now wonder whether he should try a new antipsychotic drug that had been publicized at schizophrenia support group meetings they have attended.

You are impressed with the recent report of a government-funded large trial comparing 4 newer antipsychotic drugs and 1 old-generation drug (chlorpromazine belongs to this latter class) among 1500 patients with chronic schizophrenia.1 The authors concluded that, although most of the patients in each group discontinued use of their medication, olanzapine proved the most effective in terms of the rates of overall discontinuation and symptom reduction. Patients did not, however, tolerate olanzapine as well, and the drug can produce weight gain and elevations in blood glucose and lipid levels.

After hearing about the treatment options, the patient comments, “Doctor, tell me how much better I will actually feel while taking these medications and also what side effects I might get. I care more about these than being able to stay on one medication longer than the others.” Skimming the article in question, you feel you are incompetent to answer this patient's questions. You promise him and his family that you will get back with more information in understandable terms in a week and advise him to continue taking chlorpromazine until then.

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Types of Instruments and Tests in Medicine

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Why do we offer treatment to patients? There are 3 reasons. We believe that our interventions increase longevity, decrease symptoms, or prevent future morbidity. Decreasing symptoms or feeling better includes avoiding discomfort (eg, pain, nausea, and breathlessness), distress (emotional suffering), and disability (loss of function).2

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At least in part because of the difficulty in measurement, for many years, clinicians were willing to substitute physiologic or laboratory tests for the direct measurement of these end points or tended even to ignore them altogether. During the past 20 years, however, the increasing prevalence of chronic diseases has led clinicians to recognize the importance of direct ...

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