scope:

Preface

Schizophrenia remains one of the most common psychiatric disorders, affecting approximately 1% of the world's population. It occurs with a similar frequency in all races and cultures, and while men and women are equally likely to be affected by schizophrenia, its age of onset is earlier and its severity is greater in men. If left untreated, schizophrenia is almost always a lifelong, disabling disease.

Despite the seriousness of this disease, over the past decade we have witnessed major advances in our understanding of schizophrenia and our ability to mitigate its disabling effects. Systematic diagnosis based on well-defined symptom categories has become a worldwide standard. An increased number of symptom categories are now recognized as being central to schizophrenia, including psychotic symptoms, symptoms of thought disorganization, negative symptoms, and mood instability. In addition, subtle deficits in fundamental elements of cognition, such as attention and memory, have been identified in patients with schizophrenia. These deficits, which may predate the onset of more obvious clinical symptoms, appear to be the major block to patients' attempts to return to school or work.

The recognition of new symptom categories and cognitive deficits in schizophrenia patients offers important new avenues for treatment.

The efficacy of antipsychotic drugs developed in the 1950s was largely limited to psychotic symptoms and symptoms of thought disorganization. A new generation of drugs for schizophrenia, called atypical antipsychotics, has recently been shown to have at least equivalent efficacy for psychotic symptoms and thought disorganization as well as increased efficacy for negative symptoms, mood instability, and cognitive deficits. Improved treatment of negative symptoms and cognitive deficits in schizophrenia patients offers the promise that more patients with this disease will return to school or work and resume their lives as satisfied and productive members of society. Improved treatment of mood instability offers the possibility of reducing the rate of suicide in patients with schizophrenia, which is second only to that in patients with major forms of depression. Finally, second-generation antipsychotic drugs have fewer neurological side effects, such as pseudoparkinsonism, which should improve compliance with treatment.

This book is intended as a guide for clinicians who care for patients with schizophrenia and other major psychotic disorders. While recent research has improved our understanding of schizophrenia, it has also provided us with many new tools and increased the complexity of decision-making for clinicians. Psychiatric residents in training as well as more experienced psychiatrists should find this book of value because of its emphasis on recent diagnostic and therapeutic advances. In addition, clinicians from mental health disciplines should find this book useful because of its emphasis on the integration of drug treatment with other modalities of assessment, treatment, and case management. The information in this book is based on evidence from systematic clinical research studies, although findings from these research studies are presented in such a way as to be easily understood by clinicians without extensive backgrounds in research methodology.

The book is divided into three major sections: Assessment and Diagnosis, Treatment, and Special Management Issues. In the Assessment and Diagnosis section, some chapters reflect a more cross-sectional analysis of symptom clusters, while others emphasize a longitudinal or life-cycle perspective. The integration of cross-sectional and longitudinal information is needed to develop a thorough understanding of schizophrenia as a multimodal, lifelong disease. In the Treatment section, chapters are offered on both drug treatments and rehabilitative approaches. The chapters in the Special Management Issues section discuss forensic issues, primary prevention, family education, and service delivery. This last section reflects the realization that the treatment of patients with schizophrenia must be carried out within a community context, and that there are multiple stakeholders in the outcome of treatment and resources management.

Clinicians working with schizophrenia patients today are fortunate in having new and improved tools available for diagnosis, treatment, and case management. The diagnosis and treatment of patients with schizophrenia have become more strongly based on an understanding of the neurobiology of this disease and the realization that patients with schizophrenia have human needs that go far beyond the straightforward goals of "biological" treatments. There are still too many patients who do not benefit from the best treatments available for schizophrenia. The ultimate purpose of this book is to educate clinicians about these treatments so that more patients can share in their benefits.