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Fifty years ago, schizophrenia and related psychotic disorders
were essentially untreatable. There was little that a clinician
could do for a person with psychosis. Up to that time, generations
of young people had been diagnosed with dementia praecox, and many
spent the rest of their lives in institutions.
As we enter the 21st century, the situation has changed dramatically.
A range of effective, albeit imperfect, treatments are now available.
Nearly all persons with these disorders are able to live in the
community, and yet many clinicians, as well as the general public,
continue to believe that psychotic disorders have a uniformly poor
outcome. As well, recent studies demonstrate that few patients receive
what would be termed “optimal treatment” (1).
While treatment improvements remain an important goal, a more immediate
problem is how patients can actually receive the comprehensive programs
of care that we now know to be effective. Helping to bridge the
gap between what we know and what we do is the motivation behind
this excellent new book.
The editors are well known and well respected in the field of schizophrenia.
Both have published widely. Lieberman, currently at the University
of North Carolina, was among the first to study clinical response
in a first-episode population. Murray, at the Institute of Psychiatry
in London, has been instrumental in contributing to the understanding
of schizophrenia as a neurodevelopmental disorder.
In the title of the preface, Lieberman and Murray state their goal
for this new book: “Bridging the Gap Between Optimal Treatment
for Schizophrenia and the Treatment Most Patients Receive.”
They note that patients with schizophrenia are often viewed as a
low priority in the health care system. They note also that “far
too often the prevailing dynamic is to leave well enough alone rather
than trying to find the best treatments and continually seek further
improvement in the patients’ conditions.” With this book,
which brings together contributors from both side of the Atlantic
to present a wide range of topics, the editors hope to bridge that
gap—to bring actual care closer to the potential optimal care.
There is little doubt that anyone who shares this goal will benefit
from the material made available here. This attractively produced
and quite readable book contains several unique and thoroughly first-rate
chapters. Further, its chapters are short and well written, with
large print and many useful tables and references.
A broad target audience will find the book useful, from patients
and families who wish more in-depth information to researchers looking
for an overview of clinical management. Nonetheless, as we read
the book, we had a particular audience in mind: young clinicians
who may be thinking about taking on psychotic disorders—arguably
the most serious of all psychiatric conditions—as a focus for
their own clinical and research efforts. These clinicians may not
have had the time or training to keep up with the rapidly expanding
field of schizophrenia research or observe how these new findings
translate into comprehensive clinical care.
Approaching the book from the point of view of such a clinician
we note that, although each chapter contains excellent information,
the integration and synthesis of this information into a comprehensive
approach to care is not directly addressed. If we were to suggest
a single improvement to this otherwise outstanding book, it would
be for the editors to have themselves written a chapter bringing
together the information in a coherent view of optimal care.
To address this concern in part, we suggest that readers approach
the chapters in an order different from that in which they are presented.
We suggest first reading chapter 23, “First Person Accounts.”
Introducing 5 personal accounts, John Hsiao notes that “clinical
research is carried out on groups of patients and clinical guidelines
are for the aggregate of patients. But in fact, there is no such
‘average’ person with schizophrenia. Each individual and
each family has a unique history, personality and circumstance.”
We argue that comprehensive care begins by recognizing this individuality
and recognizing, as well, our own tendency as clinicians and professionals
to lump patients together under categories. (On a very positive
note, nowhere in the book are people with schizophrenia referred
to as “schizophrenics,” a term that clearly indicates
both a lack of understanding of the individuality of persons with
schizophrenia and a confusion of the person with the illness.)
While it is laudable that the editors have included personal accounts,
it is unfortunate that the accounts are buried at the back of the
book—as so often happens with the actual experience of persons
with psychosis. As well, these personal accounts have all been previously
published in the Schizophrenia Bulletin; the most recent is from
1995. It would have been helpful to have more up-to-date first-person
stories, reflecting the recent changes in attitude and treatment
modalities.
From the point of view of a comprehensive clinical approach, we
suggest that the reader turn next to Chapter 7, “Clinical Interactions
with Patients and Families,” by Diane Perkins, Jennifer Nieri
and Janet Kazmer. This is a marvellous chapter, filled with the
kind of practical information and attitudes that clinicians need.
The authors use a timeline framework to discuss issues arising prior
to illness onset, during the apparent prodrome, at first episode,
and in chronic illness. The importance of providing straightforward
information to patients and their families is demonstrated at each
stage. This chapter represents a refreshing acknowledgement of the
importance of comprehensive care of the family as well as the patient,
together with an appreciation of the way in which both patient and
family experience psychosis. It also includes a brief outline of
the range of treatment modalities required at each stage. The stigma
associated with a diagnosis of schizophrenia is noted. This chapter
is perhaps the best in terms of helping a clinician interested in
organizing comprehensive care for persons with schizophrenia.
The next chapter for clinicians to read might be “The Outcome
of Psychotic Illness,” written by Jane Kelly, Robin Murray
and Jim van Os. It begins with the questions that families ask:
“What will happen to our child? Will our child be able to lead
a normal life? Will our child get sick again? Will our child end
up in an institution?” The information in the chapter provides
a basis for clinicians to formulate answers to these important and
difficult questions. From the start, the chapter emphasizes the
heterogeneity in outcomes and the heterogeneity in symptom presentation.
The rule of thumb still applies: one-third of patients do extremely
well, one-third do relatively well, and one-third do poorly. The
difficulty is that we currently do not have the means to accurately
predict at first episode which patients will fall into each of these
outcome categories.
The authors offer an overall model taking into account several
risk factors and their association with outcome. It is interesting
that this chapter uses the term “psychotic illness,” rather
than schizophrenia. In this regard, the outcome model includes a
dimension that differentiates psychosis associated with affective
disorders from psychosis associated with schizophrenia.
The term “psychosis,” rather than “schizophrenia,”
is also central to Patrick McGorry’s chapter, a stunning summary
of his current thinking on prevention. The chapter is passionate
and challenging. For those who have not previously encountered McGorry’s
work in early psychosis, this chapter introduces the idea that psychotic
disorders might in some way be preventable. For example, after developing
a pioneering early-psychosis program for patients with a first episode
of psychosis (the Early Psychosis Prevention and Intervention Centre
[EPPIC]), McGorry and his colleagues in Melbourne took the additional
step of looking back to the early course of psychotic illness to
offer care and to conduct research with health-seeking young people
who appeared to be at ultra-high risk of developing a fully diagnosable
psychotic disorder. Perhaps nowhere else in the field of psychiatry
is the possibility of prevention being so systematically explored.
The fact that some of the chapters use the term “schizophrenia,”
while others talk of “psychotic disorders,” reflects an
important ongoing debate within the field.
This debate over the use of the terms “schizophrenia”
and “psychosis” casts a different light on Richard Wyatt’s
chapter on schizophrenia diagnosis. Wyatt includes an extensive
table illustrating the myriad interactions of psychiatric and medical
conditions, genetic syndromes, environmental toxins, and medication
side effects that can result in psychosis. He carefully and thoughtfully
traces the history of the diagnostic criteria for schizophrenia
that culminates in the current DSM-IV and ICD-10 systems. He concludes
with a table of the currently recognized subtypes.
Of importance to clinicians, but not addressed in Wyatt’s
chapter, is the real-life issue of how a schizophrenia diagnosis
is used, along with its meaning to clinicians, patients, and families.
Despite the heterogeneity in its presentations and outcomes, some
clinicians—and many patients and families—view schizophrenia
as a monolithic illness with a universally poor outcome. Because
of these misconceptions (not to mention the mass media’s use
of the term to describe persons with “multiple personalities”),
many clinicians prefer the term “psychotic disorders.”
This term conveys the idea that we are not dealing with a single
disorder (schizophrenia) but with a family of related disorders
that may vary in their presentations and outcomes.
“What causes psychosis?” is another question frequently
asked by patients and their families. In the chapter entitled “Pathobiology
of Schizophrenia,” John Waddington and Maria Morgan provide
the background information that clinicians need to supply patients
and families with information regarding the disorder’s causes.
Here, the authors present a strong argument for a unified developmental
etiology. They review important evidence, including the excessive
presence of minor physical anomalies in persons with schizophrenia,
and they explore the subtleties and misconceptions associated with
the term “neurodevelopmental.” They introduce the concept
of “lifetime trajectory,” emphasizing that brain development
continues in many stages throughout the lifespan.
Clinicians will also benefit greatly from the chapter, “Substance
Abuse Comorbidity,” by Robert Drake and Kim Mueser. Drake and
Mueser directly address the issue of service organization, noting
that “by the end of the 1980s, clinicians, advocates and researchers
called for the formation of integrated programs that combine mental
health and substance abuse services,” and proceed to describe
the nature of integrated treatment programs. That so few integrated
programs exist again demonstrates the gap between optimal care and
actual care.
This book also contains several chapters that are related less
to the specifics of optimal care and more to the issue of organizing
optimal services. In this regard, Robert Rosenheck and Doug Leslie
provide a readable introduction to economic analyses of schizophrenia
treatment—clearly a key topic in terms of bridging the gap
between optimal and actual care. This chapter clarifies methodological
issues. Of particular interest is the observation that the results
of economic studies of the newer and more expensive antipsychotics
depend upon the patients’ prestudy service use: cost savings
may be found for patients with high service use, particularly if
their care involves inpatient services. Conversely, introducing
the more costly medications may lead to an overall cost increase
for patients with relatively low service use.
In “Systems of Care for Persons with Schizophrenia in Different
Countries,” T Scott Stroup and Joseph Morrissey conclude that
no country has yet developed a comprehensive plan for the care of
persons with schizophrenia. They conclude as well that “services
for persons with schizophrenia are sub-optimal worldwide, expect
for a few model programs.” The authors express concern that
persons with schizophrenia “will not fare well in wage-based
economies that use market forces to allocate health care resources.”
Providing optimal care to patients with psychotic illness will
require 2 approaches. Clinicians need to be competent in the latest
treatment modalities, recognizing that optimal care must be comprehensive
and include a range of modalities to address a spectrum of issues.
At the same time, those who direct the funding and organization
of clinical services need to structure health care delivery to allow
clinicians the resources to provide optimal care.
This volume is an important and unique step forward in advancing
the cause of optimal care for persons with psychosis. As the editors
state in the book’s dedication: “We hope that it may help
to ensure that more people suffering a psychotic experience receive
the good care that they deserve.”
1. Lehman AF, Steinwachs DM. Patterns of usual care
for schizophrenia: initial results from the Schizophrenia Patient
Outcomes Research Team (PORT) client survey. Schizophr Bull 1998;24(1):11–20.
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