Progress in the understanding and treatment of schizophrenia continues at a rapid pace. This field has advanced substantially in knowledge, conceptual focus, and treatment options even in the few years since the last issue of the Psychiatric Clinics of North America devoted to schizophrenia (in 1998). The current issue, aptly entitled “Schizophrenia: contemporary clinical perspectives,” reflects this progress. Distinguished academic clinicians and neuroscientists provide comprehensive overviews of the present state of knowledge on the course, complications, neurobiology, treatment, and so cietal impact of schizophrenia.
Drs. Adler and Strakowski evaluate the current nosological status and boundaries of the definition of schizophrenia. Cognition has re-emerged as a core aspect of this condition; Dr. Sharma highlights the range of cognitive impairments. He also points out how innovative treatments may result in subtle improvements in cognition. The genetic contribution to schizophrenia is substantial, as Drs. McDonald and Murphy emphasize. They describe how the search for a distinct gene or genes has become more complex and has incorporated the latest advances in neurogenetics. The treatment implications of genetics research, including the evolving field of pharmacogenetics, is also briefly covered. As this article also illustrates, the current focus on neurodevelopmental arrest in schizophrenia is similarly reflected in research on the expression of neurodevelopmental genes and growth factors in persons with schizophrenia. As Drs. Clarke and O'Callaghan describe, neurodevelopmental schizophrenia shows a trajectory of childhood milestone delay, scholastic underachievement, and early emergence of prodromal features of psychosis. Espousing a classical, epidemiologically based approach to primary prevention, they point out that it is now reasonable to consider strategies at various stages (eg, enhanced obstetrical care, identification of high risk cohorts, early intervention) that may (speculatively) intervene and treat schizophrenia earlier in its course. Although the pathobiological substrates underlying schizophrenia ultimately remain undetermined, the field of schizophrenia research is replete with abnormal chemical findings that may be of fundamental significance. Because of the role of lipids in membrane synthesis, this specific abnormality may provide a unifying hypothesis to explain the underlying cognitive deficits, timing of onset (during synaptic pruning of brain cell membranes), and variable clinical course of schizophrenia. The article by Drs. Mahadik and Evans gives a critical overview of the latest findings on membrane dysfunction and its relevance to our current understanding of the nature of schizophrenia, its clinical correlates, and the functional impact of phospholipid dysregulation upon treatment with antipsychotic medications.
Dr. Tune points out that the illness course of schizophrenia into middle and late life has been inadequately studied. This is surprising given the large percentage of elderly patients with this diagnosis residing in nursing homes or state facilities. Dr. Tune highlights the characteristics of late-onset schizophrenia and makes the case that these observations may, speculatively, reflect differences in the neurobiology of schizophrenia when it emerges later in life. There is also a growing appreciation of the need to detect and treat significant comorbidities that frequently complicate the illness course of schizophrenia. Dr. Green and colleagues illustrate the deleterious impact of comorbidities, both physical and psychiatric, upon the course of schizophrenia. They highlight that depression occurs in over half of patients and is the main risk factor for suicide in schizophrenia. They describe new information on this aspect of care. Additionally, they cover the topic of comorbid substance abuse, a common co-occurrence that is also associated with relapsing illness and poor outcome. They outline the emerging evidence for efficacious treatments that can reduce craving and abuse behaviors, particularly when combined in an overall program approach to care.
Perhaps the most obvious advances have occurred in the treatment of persons with schizophrenia. In a very short time, the pharmacotherapy of schizophrenia has grown in options, diversified in approaches, and ultimately provided heightened optimism for superior clinical outcomes among persons who suffer with this illness. Dr. Emsley's article critically evaluates the relative role of each new antipsychotic during key timepoints (first episode, acute relapse, maintenance, end-stage/refractory) in the care of persons with schizophrenia. It must be acknowledged that although the advances in pharmacotherapy can allow for more effective treatment without motor side effects, these drugs also have their own adverse effect profiles. Dr. Wirshing and colleagues review the emerging adverse effect profile of atypical antipsychotics. They highlight that these adverse effects will pose significant challenges—and opportunities—for the comprehensive care of persons with schizophrenia.
Nonpharmacological treatments are another key element of the comprehensive care of persons with schizophrenia. Drs. Lauriello and Bustillo illustrate the potential synergy between pharmacotherapy and psychosocial therapies. In a complementary article, Dr. Joubert describes how the rapid pace of drug development and the broader range of psychotherapeutic options has placed real demands on our field to remain current, to pursue “best practices,” and to make informed choices about resource allocation and service delivery using available evidence. This article describes current efforts to incorporate evidence-based medicine principles into the management of schizophrenia. It is paradoxical to some extent that these broad developments in treatment (offering the potential for significant functional improvement for persons with schizophrenia) occur in the context of prevailing misunderstanding, stigma, and public misconceptions about schizophrenia. Drs. Buckley and colleagues describe how violence and its association with active and untreated or inadequately treated schizophrenia is the major contributor to the stigmatization of serious mental illness. The final article, written by Dr. Thompson (whose sister suffers from schizophrenia), provides insights into the complexity of stigma and its effects on siblings. It also describes a successful national approach to enhancing awareness of and services for schizophrenia.
This issue on schizophrenia synthesizes a wide array of newly acquired information about the epidemiology, neurobiology, and treatment of this distressing condition. The efforts of the authors to provide a scholarly account of the current “state of play” of schizophrenia research and treatment are much appreciated.
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