Book Review

Contemporary Issues in the Treatment of Schizophrenia

N Engl J Med 1995; 333:1574December 7, 1995

Article

Contemporary Issues in the Treatment of Schizophrenia
Edited by Christian L. Shriqui and Henry A. Nasrallah. 863 pp. Washington, D.C., American Psychiatric Press, 1995. $95. ISBN: 0-88048-681-3

Schizophrenia is a most interesting and vexing disease. Its prevalence is high (0.85 percent), its economic impact is severe, and the disease processes undermine a myriad of brain functions, causing distinctively human impairments. Patients have altered perception, false beliefs, disturbance of thought, and often remarkably reduced drive, inability to initiate action, and restriction in emotional experience and expression. Illness usually begins early in life and is long-lasting. The cause, cure, and prevention of schizophrenia are not yet understood, but there have been substantial advances in comprehending and treating this illness. Recent developments involving new antipsychotic medications, empirically validated psychosocial treatment, the deinstitutionalization of patients, and increasing homelessness and substance abuse among schizophrenic populations require a reconception of the care and treatment of persons with this disease.

Shriqui and Nasrallah provide a welcome textbook on the new issues in the treatment of schizophrenia. The essential introductory material on biochemistry, neuropathology, and genetics facilitates the understanding of the basis for drug action in schizophrenia. Especially relevant is an update on the dopamine hypothesis (speculative with respect to schizophrenia but parsimonious in explaining the action of antipsychotic drugs), with emphasis on serotonin and glutamate. The review of brain abnormalities revealed post mortem implicates limbic-system structures that are especially relevant to the disordered thought and memory, false perceptions, and false beliefs associated with the positive psychotic symptoms of schizophrenia. Abnormalities found outside the limbic structures are often associated with dorsolateral prefrontal cortical circuitry of putative relevance to the negative symptoms of schizophrenia. These findings may contribute to an understanding of the different treatment characteristics of positive and negative symptoms.

The varied clinical manifestations of schizophrenia require a range of treatments. Diagnosis is reviewed, and seven chapters consider phenomenologic issues relevant to treatment. Attention to the multiple sources of negative symptoms in schizophrenia and the importance of developing treatment for the primary illness process that leads to reduced drive, motivation, and emotion is timely. Clinical trials may confound primary and secondary forms of negative symptoms. Tandon and colleagues make clear the relevance of these issues. Siris provides an informative guide to the recognition of different depressive syndromes and their treatment. Hoff finds that treatment has negligible effects on impairments in attention, information processing, memory, and executive and language function, and she postulates that these impairments may impede cognitive rehabilitation.

The editors have provided 23 chapters on drug treatment, side effects of drugs, and psychosocial treatments. Challenges in drug treatment relate to the new drugs, the complex issue of therapy for negative symptoms, the important problem of poor compliance with medication, and minimal effective dosing. Much useful information is provided in these chapters, but there is some redundancy. A solid review of the use of clozapine in treating refractory schizophrenia is presented. The superior antipsychotic efficacy of this drug is documented, but other new, atypical compounds are presented with a bit more enthusiasm than the experimental data justify. This is particularly true in the chapter dealing with drug treatment for negative symptoms, where little attention is given to distinguishing primary from secondary negative symptoms. The latter are responsive to treatment, but the new drugs are presented as more promising than they actually are for primary negative symptoms.

The reader will find excellent discussions of the management of noncompliance with neuroleptic therapy and the low-dose and targeted medication strategies in maintenance treatment. Since the antipsychotic drugs have had a strong effect on the psychotic component of schizophrenia and have reduced relapse rates, it has been surprisingly difficult to document a substantial effect on long-term outcome. Wyatt presents an interesting discussion of why such benefits may have been obscured and speculates on the mechanisms that could be involved in reducing long-term morbidity.

Side effects of medication complicate treatment, and patients' poor insight into their illness further challenges clinicians. The book provides excellent material related to the extrapyramidal syndrome but gives inadequate attention to side effects that influence the quality of life, such as weight gain, sexual dysfunction, and affective disturbance. The new, atypical medications cause different side effects, but these are not addressed in this section. Most interesting is Jones's review of material that supports the hypothesis that neuroleptic drugs or their withdrawal, or both, can induce psychosis. The data are not yet compelling, but concern about drug-withdrawal psychosis is heightened by reports of rebound psychosis after the discontinuation of clozapine.

The book's discussion of psychosocial treatments is excellent. Psychodynamic therapy has not been established as efficacious in schizophrenia. The psychosocial treatments espoused in this book emanate from an entirely different theoretical background. Psychosocial treatments aimed at reducing stress, teaching coping skills, enhancing social ability, and providing education and family-management techniques have proved to be effective in reducing rates of relapse. The methods of integrating pharmacologic and psychosocial treatments are considered, as are special issues relating to the quality of life, functional outcomes, rehabilitation, and the care of patients who abuse psychoactive substances.

William T. Carpenter, Jr., M.D.
University of Maryland School of Medicine, Baltimore, MD 21228