Book Review
Schizophrenia
Evidence and Experience in Psychiatry. Volume 2: Schizophrenia. Mario Maj, Norman Sartorius, editors. Toronto: John Wiley and Sons; 1999. 492 p. US$95.00.
Reviewer rating*: Good
Review by Mary V Seeman, MD
Toronto, Ontario
Reading this second book in a series by the World Psychiatric Association (WPA) is a humbling experience. It is humbling because not one of its 100 contributors from around the world is Canadian, and I had always thought of Canada as a world leader in the field of schizophrenia studies. It’s true that there is a single contribution by Peter Liddle, writing from his former Vanouver address as Schizophrenia Chair at the University of British Columbia; however, Peter Liddle has now left Canada—another humiliation to our national pride. Judging by the names, 15 contributors are women. It’s hard to know what the correct representation of female authors should be in a book such as this, but a closer-to-equal sex distribution might have represented international interests better.
The book consists of 6 long reviews: 2 are from the US, and 4 are European, with the UK being the main player. Each review is followed by approximately 15 commentaries that seem to come from every corner of the globe except Canada. The book’s intended aim is to provide an international perspective on diagnosis, pharmacotherapy, psychotherapy, stigma, spectrum disorders, and costs, as they pertain to schizophrenia. These topics were probably selected because opinions and practices with respect to them could well differ among countries, and disagreements may have stirred up some interest. Unfortunately the reviews, some excellent and some suffering from language problems and hasty preparation, do not elicit much debate. Invariably, each commentator praises the review and adds some innocuous remarks of little interest to the reader. Therefore, the book’s purpose is not really fulfilled. It would have been more readable if it had comprised only the reviews.
The chapters on diagnosis, pharmacotherapy, psychotherapy, and spectrum disorders—some very thorough and well written—sum up knowledge to date but do not contribute new knowledge. The pharmacotherapy chapter and its commentaries were written sometime prior to 1999 and are already dated, as pharmacotherapy book chapters are wont to be. This rapidly changing field is today preoccupied with the health risks of atypical antipsychotics, yet the chapter and its commentaries do not address this important issue and are insufficiently critical of the newer drugs’ supposed advantages.
The best chapters take a novel approach. They are the chapters by Cancro and Meyerson on prevention of disability and stigma related to schizophrenia and the chapter by Knapp, Almond, and Percudani on costs of schizophrenia. Cancro and Meyerson first cover the history of schizophrenia treatment and conclude that “it is very difficult not to draw the conclusion that these patients mobilize considerable ambivalence in the healer.” The authors do not include modern treatments in this gentle remonstrance, but it is hard not to think that future generations will categorize current treatments in the same way. They then distinguish among impairment, disability, and handicap and discuss the 3 levels of prevention. They cover different rehabilitative approaches from a global point of view and offer a good discussion of stigma and of ways to counteract it. One commentator, Richard Wagner, mentions the WPA-sponsored global antistigma campaign and its first pilot, launched in Calgary, Alberta, in 1997. Warner adds meaningfully to the discussion by providing several examples of antistigma techniques that work.
The chapter by Knapp and others from the London School of Economics and the Institute of Psychiatry is the most comprehensive review of schizophrenia costs that I have ever seen. After defining key terms, it looks at overall schizophrenia costs, especially cost-of-illness evaluations. The authors then examine the specific costs of relapse, inpatient services, residential care, mortality, lost employment, family impact, and public safety. The chapter also addresses different methodologies (for example, cost-offset, cost-minimization, cost-effectiveness, cost-consequences, cost-benefit, and cost-utility analyses). It takes a closer look at pharmacotherapy, psychosocial therapy, and care arrangements with respect to the ratio of outcome over cost. Given finite resources, it examines the evidence for what treatments can be deployed most effectively and most equitably. The authors conclude that across all societies relapse is a particularly costly event and that mortality, given that it occurs in younger adults, has major economic consequences. So too has loss of employment. Other important costs are inpatient services, specialized community accomodation, and family caregiver support. The authors also observe that community treatment can be shown to be cost effective. Family interventions reduce overall cost, and short counselling intervention improves compliance with medication and improves clinical outcome without adding to the cost of standard care. With respect to drugs, they note that clozapine has been shown to be more cost-effective than typical drugs. At the time of writing, comparable evidence for the other atypicals was not available, and evidence for the superiority of any single case management model was lacking. The authors conclude that cost-effectiveness gains seen in empirical research may not necessarily be cost-effective in practice and that this needs constant reevaluation. They also point to the difficulties in measuring indirect costs, such as those incurred by family caregivers.
Overall, this is a good resource book, but it is too expensive for personal libraries.
It is free of production errors but not free of linguistic awkwardness. The format of commentaries on a review is used successfully by some journals. However, it does not work here because the reviews themselves do not take any specific stand. As a result, the commentators have little with which to disagree. In general, they are overly bland and repetitious. I think the WPA should consider a different format for the next book in the series. Perhaps Canadian content would help.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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