Schizophrenia: Concepts and Clinical ManagementBMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7234.586/a (Published 26 February 2000) Cite this as: BMJ 2000;320:586
- Glyn Lewis, professor, division of psychological medicine
Eve C Johnstone, Martin S Humphreys, Fiona H Lang, Stephen M Lawrie, Robert Sandler
Cambridge University Press, £45, pp 271
ISBN 0 521 58084 6
Schizophrenia is an exceptionally disabling condition, accounting for a substantial proportion of the 10% of NHS costs that is spent on mental health. It often starts in young adulthood, affects up to about 0.5% of the population, and in many cases leads to a lifelong disability profound enough to prevent paid employment.
Eve Johnstone has been at the forefront of schizophrenia research for over 20 years, for much of that time in collaboration with Tim Crow in a partnership that became as familiar to psychiatrists as Marks and Spencer is to the high street shopper. However, her summary of the past few decades of research makes a sobering read: “The magnitude and intractability of the problems associated with schizophrenia leave an overwhelming impression. Of course there have been advances … it has been enormously exciting and rewarding, yet at times heartbreakingly sad, because the advances are not really doing anything for the patients.”
Written in conjunction with colleagues from Edinburgh, Eve Johnstone's book is a useful summary of current knowledge. An overarching aetiological theory is not proposed—indeed, the conclusion that “we have been able to implicate the brain in schizophrenia” seems rather obvious. The suggestion that psychosis can be thought of as along three dimensions—positive, negative, and disorganised—with distinct pathological mechanisms is well argued but probably still falls short of being an accepted theory.
Recent therapeutic advances are also briefly described, though more space would be needed to do them justice. This is one aspect where some lightening of mood might be justified. New atypical antipsychotic drugs are being developed that, despite the hype, may have some advantages. There is also evidence that cognitive-behavioural and family therapy are effective treatments. Much lip service has been paid to a “bio-psycho-social” approach to treatment. We are now increasingly able to support this clinical principle with some hard empirical evidence, although large pragmatic trials are still uncommon.
Much schizophrenia research has been conducted on either side of an ideological fault line, with biological psychiatrists investigating cerebral ventricular enlargement while social psychiatrists study family dynamics. There are now encouraging signs that the field is gradually evolving a more rounded, multidisciplinary approach. Psychological processes are studied in conjunction with their localisation in the brain by means of functional imaging techniques. Likewise, new psychological therapies have been developed to enhance adherence with both prescribed medication and attendance at outpatient clinics and day care.
Schizophrenia remains a stigmatised and enigmatic condition. It seems easy to justify the cliché that “further research is needed.”
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