Clinical Manual for Treatment of Schizophrenia

In hierarchies of evidence-based medicine, expert opinion is portrayed as the least rigorous form of evidence, as the academic equivalent of bread in old food pyramids, i.e., reasonably nutritious, but not as potent as the randomized controlled trials and meta-analyses that are the equivalent of leafy green vegetables. Yet expert opinion is also portrayed, like bread in the food pyramid, as the foundation of evidence-based medicine, and thus the question becomes: On what sort of bread and what sort of expert opinion will you dine?

The editors of this volume have produced a concise, contemporary, well-referenced text that is an effective introduction and update for clinicians who care for people with schizophrenia. The book is neither a collection of algorithms nor a textbook, but a focused collection of 12 chapters. Although the authors come from several countries, academic centers, and disciplines, they are united in their efforts to provide concise, clinically oriented summaries that synthesize research on the etiology, diagnosis, and treatment of people with schizophrenia.

Like any such synthesis, all readers will have a list of things they did not find in the book. I would have liked the authors to have 1) used clinical statistics, such as number needed to treat, when evaluating interventions, 2) integrated a cost-benefit analysis of the interventions, 3) included a separate chapter on the physical comorbidities that cause so much morbidity and mortality in people with schizophrenia, 4) more thoroughly addressed the adverse sexual effects of antipsychotics, 5) reviewed the use of omega-3 fatty acids and other interventions for prodromal psychosis, 6) thought through recent studies on the association between sudden cardiac death and antipsychotics, and 7) further explored the effects of DSM-5 on the diagnosis of schizophrenia.

However, if the purpose of a book like this is to ground our treatment of people with schizophrenia in evidence-based practices, then it is a clear success. Each of the 12 chapters is readable, well-referenced, and provides both historical perspective and contemporary detail. Each chapter can profitably be read together or independently, but the book is best used as the starting point for particular learning. Pick a chapter, read it through, and then explore the references. For example, the introductory chapter is ideal for a more generalized audience, such as medical students. The chapter on psychopharmacology would make an ideal introduction for psychiatry residents. For practitioners interested in adding therapeutic techniques to their work, the chapter on psychological interventions ably introduces the major methods. The chapters on basic science and cognition are more technical and most helpful for people interested in posing research questions.

Indeed, this book raises as many questions as it answers. Why, after all our advances, does schizophrenia remain such a puzzle? Upon finishing the book, I am reminded again that most of our evidence about this most alienating of disorders is based on robust association. The contours of schizophrenia are increasingly well-known, but its interior geography remains essentially uncharted.

Given this fundamental gap in our knowledge, the book might have benefited from the perspective of people with schizophrenia, perhaps in the final chapter on remission and recovery. While the authors of this chapter provide an articulate, concise, and contemporary account of remission and recovery as defined by psychiatric researchers, I found myself wondering how a person with schizophrenia would define these terms. I recognize that this was not the goal of the manual, but I acutely felt the absence of these experiences in the final chapter. After all, what are we left with but to endure along with the people who have schizophrenia, a chronic, often disabling illness for which we have no cure?

While this manual addresses this question and the perspective of people with schizophrenia only obliquely, it does provide clinicians with a series of informed questions with which to engage the vast medical literature. In this era, when medical evidence surrounds us—in newspaper summaries, in smartphone apps, and in throwaway journals that clog our mailboxes—more than ever, we need expert opinion that selects, summarizes, and interprets the relevant data in a transparent fashion. In this sense, it is an ideal foundation upon which to build our knowledge of treating schizophrenia. I recommend the book to anyone who works with people with schizophrenia and wants an accurate and able account of the literature.