Comprehensive Care of Schizophrenia:A Textbook of Clinical Management, 2nd ed

edited by Jeffrey A. Lieberman, MD, and Robin M. Murray, MD, DSc. Oxford University Press, New York, NY, 2012, 448 pages, $79.99 (paper).

This textbook has 19 chapters by 40 expert authors, addressing (1) course and outcome, (2) pathobiology, (3) juvenile psychosis, (4) early psychosis, (5) pharmacologic treatment, (6) chronicity and treatment resistance, (7) cognitive-behavioral treatment, (8) rehabilitation, (9) community treatment, (10) treatment nonadherence, (11) suicide, (12) violence, (13) substance abuse, (14) medical comorbidity, (15) interactions with patients and their families, (16) male-female differences, (17) genetics, (18) economics, and (19) personal reflections by 5 persons diagnosed with schizophrenia. Chapters average 22 ± 11 pages in length (72% as text, 28% as references); the longest is on pharmacotherapy (61 pages). A majority (68.4%) of chapters have coauthors from different countries: United States (55.0%), England (22.5%), Australia (10.0%), other European countries (7.5%), Canada (2.5%), and Japan (2.5%), although most of the material represents a largely British Commonwealth–American perspective.

As with most multiauthored texts, there is some variation in approaches among chapters, but only minor overlap of material. References more recent than 2010 are rare, indicating that most content pertains to experience and research up to the mid-2000s. Very appropriately, the book addresses several clinically and scientifically difficult topics, including treatment resistance and options for treatment when clozapine is unsatisfactory; pregnancy; violence; medical comorbidity; substance abuse (including tobacco but not caffeine); international and regional variance in financing of clinical care, especially for treatment involving more than antipsychotic drugs; and cultural factors affecting clinical presentations and treatment. A notable impression is that largely failed efforts at “deinstitutionalization” of chronically, severely mentally ill persons since the 1960s to adequate alternative treatments are actually continuing in attempts to refine psychological, social, supportive, and rehabilitative interventions for such persons. Many approaches to treatment and rehabilitation appear to be improving slowly, although reliable access to comprehensive and flexible clinical care continues to vary enormously geographically, owing to cultural, political, and economic factors.1

The book makes a concerted effort to strike an optimistic, or at least balanced, view of schizophrenia and its treatment. The opening chapter rightly emphasizes the tendency to consider schizophrenia as largely chronic, if not progressive, and associated routinely with major disability. This concept arose from unproved 19th century hypotheses concerning “neurodegeneration” and has been perpetuated in a century of studies of clinical samples of opportunity, often in hospitals or other institutions, rather than samples of persons with psychotic symptoms in the general population. Kraepelin also viewed psychotic disorders as chronic or progressive, debilitating, “nonaffective” conditions (dementia praecox), versus more episodic disorders with prominent disturbances of mood and arousal and a more favorable prognosis (manic-depressive insanity). This basic but debated concept continues to dominate leading international diagnostic systems, which also require a degree of chronicity (months) for diagnosis of schizophrenia and schizoaffective disorders.2,3

Despite laudable attempts to maintain an optimistic perspective, the frequently chronic, disabling nature of many cases and the marked limitations of available medical and psychosocial treatments for schizophrenia are realities.4 Indeed, this book acknowledges a number of limitations and controversies, such as about early clinical interventions prior to diagnosable manifestations of psychosis, lack of progress beyond antipsychotic medicines of limited efficacy, and a paucity of research to support nonpharmacologic treatments, despite their apparent clinical utility and face-plausibility.

Indeed, a general observation is that the conceptualization and diagnosis of schizophrenia have made limited progress over the past century, despite great effort that is largely ignored in this edition. The prominent variability in symptomatic features, course, and outcome among individual patients, and the strong dependence of diagnosis on broad versus strict criteria,5 leave unanswered whether schizophrenia is a single, heterogeneous disorder or a group of phenomenologically similar idiopathic conditions. In either case, heterogeneity surely contributes importantly to inconsistent findings in biological as well as clinical studies. Broader issues not addressed are the categorization, psychopathological details, and treatment of the varied disorders marked by psychotic features, which differ widely in symptomatic expression, course, and outcome. Indeed, most relatively brief, acute psychotic conditions fail to remain stable diagnostically over several years of follow-up.6,7 An additional challenge follows the late observation by Kraepelin that many, perhaps most, psychotic disorders encountered in psychiatric institutions do not fit neatly into his 2 major groups.8 An indication of this challenge is continued uncertainty about how to conceptualize, diagnose, and treat so-called schizoaffective disorders with both prominent psychotic and affective features,9 as well as the delusional disorders.10

Overall, the second edition of Comprehensive Care of Schizophrenia is a carefully prepared, authoritative, compact, readable, and very useful overview. It does not provide detailed and quantitative reviews of specific topics, and it is not a clinical manual with highly specific prescriptive information about methods of assessment and treatment of schizophrenia patients. Nevertheless, it delivers basic information about most clinically relevant aspects of understanding and providing adequate clinical care for persons diagnosed with schizophrenia.

References

1. Masters GA, Baldessarini RJ, Öngür D, et al. Factors associated with length of psychiatric hospitalization. Compr Psychiatry. 2014;55(3):681–687. PubMed doi:10.1016/j.comppsych.2013.11.004

2. World Health Organization. Mental and behavioural disorders. International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10). Geneva, Switzerland: World Health Organization; 1994.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Press; 2013.

4. Baldessarini RJ. Chemotherapy in Psychiatry. 3rd ed. New York, NY: Springer Press; 2013. doi:10.1007/978-1-4614-3710-9

5. Hegarty JD, Baldessarini RJ, Tohen M, et al. One hundred years of schizophrenia: a meta-analysis of the outcome literature. Am J Psychiatry. 1994;151(10):1409–1416. PubMed

6. Salvatore P, Baldessarini RJ, Tohen M, et al. McLean-Harvard International First-Episode Project: two-year stability of DSM-IV diagnoses in 500 first-episode psychotic disorder patients. J Clin Psychiatry. 2009;70(4):458–466. PubMed doi:10.4088/JCP.08m04227

7. Salvatore P, Baldessarini RJ, Tohen M, et al. McLean-Harvard International First-Episode Project: two-year stability of ICD-10 diagnoses in 500 first-episode psychotic disorder patients. J Clin Psychiatry. 2011;72(2):183–193. PubMed doi:10.4088/JCP.09m05311yel

8. Trede K, Salvatore P, Baethge C, et al. Manic-depressive illness: evolution in Kraepelin’s Textbook, 1883–1926. Harv Rev Psychiatry. 2005;13(3):155–178. PubMed doi:10.1080/10673220500174833

9. Pagel T, Baldessarini RJ, Franklin J, et al. Characteristics of patients diagnosed with schizoaffective disorder compared with schizophrenia and bipolar disorder. Bipolar Disord. 2013;15(3):229–239. PubMed doi:10.1111/bdi.12057

10. Fear CF. Recent developments in the management of delusional disorders. Adv Psychiatr Treat. 2013;19(3):212–220. doi:10.1192/apt.bp.111.010082

Ross J. Baldessarini, MD

rbaldessarini@mclean.harvard.edu

Author affiliation: Harvard Medical School, Boston, Massachusetts.

Potential conflicts of interest: None reported.

Funding/support: Supported in part by a grant from the Bruce J. Anderson Foundation and by the McLean Private Donors Research Fund.