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Book Forum: Schizophrenia   |    
Comprehensive Care of Schizophrenia: A Textbook of Clinical Management
Am J Psychiatry 2003;160:402-403. doi:10.1176/appi.ajp.160.2.402
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Neshanic Station, N.J.

Edited by Jeffrey A. Lieberman, M.D., and Robin M. Murray, F.R.C.Psych. London, Martin Dunitz (Malden, Mass., Blackwell Science, distributor), 2001, 374 pp., $49.95.

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Drs. Lieberman and Murray are two clinical researchers who have made major contributions to the understanding and treatment of schizophrenia. Dr. Lieberman is Professor and Chair of the Department of Psychiatry at the University of North Carolina, Chapel Hill, and one of the foremost schizophrenia experts in the United States. His major contributions are in the area of methylphenidate challenge tests and brain magnetic resonance imaging studies. Professor Murray occupies the Maudsley Chair of Psychiatry at the Institute of Psychiatry in London. He has been the British champion for the neurodevelopmental model of schizophrenia. Both Dr. Lieberman and Professor Murray have dedicated their careers to schizophrenia.

Schizophrenia remains a devastating illness for patients and baffling to clinicians. However, Drs. Lieberman and Murray pulled together an expert group from their extensive network of colleagues to write a comprehensive and practical resource book for clinicians. Their effort has produced an important overview of how patients with schizophrenia can and should be treated. To reach audiences on both sides of the Atlantic, half of the authors come from each side of the ocean, and so do the authors of the two introductions: Dr. Norman Sartorius of the World Health Organization in Geneva and E. Fuller Torrey of the Stanley Medical Research Institute in Bethesda, Md.

The Decade of the Brain, as the 1990s were called, stimulated research in schizophrenia and brought the focus back to the patient. This book is clearly a consequence of the greater emphasis on schizophrenia research over the last 15 years. We find chapters on diagnosis, both DSM-IV and ICD-10; onset in childhood and adolescence; early detection; outcome; pharmacological, cognitive behavior, and rehabilitative treatment; suicidality and violence; substance abuse and other comorbid disorders; compliance (perhaps the word "adherence" is more politically correct); clinical and medical management; women; ethnic and cultural impact on the disorder and its treatment; economic impact of schizophrenia; and, finally, self-reports from patients and a chapter on new directions in research.

What makes this book different from others? The editors instructed their authors well: avoid contradictory statements or ideological discussions. Several themes run consistently through the book: how existing treatments can be optimized while new developments are included and pushing concepts that may lead to prevention or delay of the onset of the illness, such as early treatment of behavioral prodromes. Everybody seems to agree that antipsychotics are the drugs of choice, but they have limitations in the overall outcome. Psychosocial, cognitive behavior, and rehabilitative interventions are presented as an integrated part of the care delivery. The clinician will find only a brief overview of brain imaging because brain imaging has no consequences (yet) for treatment outcome.

Do policy makers ever read such books? Do policy makers understand the economics of the treatment of schizophrenia and the economic costs of maintaining the status quo? Do they care what deinstitutionalization for budgetary reasons did to the chronically mentally ill without adequate community support?

This book assists clinicians in understanding what their patients need to know, what their expectations are, and how assessments and prescriptions are perceived. The patient self-reports add to the value of the book. The psychopharmacologists will find the discussions of drugs, treatment resistance, clinical and medical management, supportive care, compliance, and new developments of interest. The book has been written not just for psychiatrists. Social workers and other clinicians will find much of interest as well. Medical students will find some chapters overwhelming but may glean the impression that there is a lot more to psychiatry than talking to people with problems.

Antipsychotic and other psychotropic drugs are among the most powerful in medicine. We can do a lot for our patients at the beginning of the 21st century. At the same time, our expectations have been raised since clozapine was recognized. We want improvement in negative symptoms, cognition, social functioning, and quality of life for our patients. We want the high numbers of patients who have a treatment-resistant form of the disorder (more than 40%) and those who still have residual symptoms (more than 30%) to decrease. The authors address how to work toward these goals.

This is a book written for clinicians, researchers, patients, and their advocates. There is either too much detail or there is not enough, but that represents a major strength as well. Such an approach enforces clarity.




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