Schizophrenia: Comprehensive Treatment and Management

Marvin Herz and Stephen Marder, two eminent, internationally known schizophrenia researchers and experienced clinicians, have written a very practical clinician- and patient-focused handbook about schizophrenia and its treatment. Herz, Professor of Psychiatry at Rochester School of Medicine in New York and a previous chairman of the Department of Psychiatry of the State University of New York at Buffalo, is known for his research in relapse prodromes; he attempts to identify schizophrenia patients at high risk of relapse. Marder, an outstanding psychopharmacological clinical researcher and clinician, is Professor and Vice-Chair, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California, Los Angeles, and Director, U.S. Department of Veterans Affairs (VA) VISN 22 Mental Illness Research Education and Clinical Center. Together they bring 60 years of clinical and research experience dedicated to the study and care of schizophrenia. Both are well-funded researchers (e.g., the National Institute of Mental Health and the VA). They review the latest treatment literature, give case vignettes, and share what they have learned and found effective, while providing background information on the latest hypotheses of the disorder (briefly) and how the clinician may be able to influence positively the lives of patients. Their caring and clinical expertise comes through loud and clear. By writing the book themselves rather than collecting a number of collaborators, they have come up with a coherent and comprehensive approach to the treatment of schizophrenia. It is a testimony of the breadth of their experience and how the field has brightened for our patients and their families in recent years.

After discussing the new generation of antipsychotics, Marder and Herz present the psychotherapeutic approaches that have been well studied. Schizophrenia is a multidimensional disorder, so the treatment approach has to be multidimensional, even though the pharmacological approach is the keystone. They are optimistic about what can be done now, more than 100 years after the formulation of the disorder. They point out that the average patient is no longer looking forward to a sentence of progressive deterioration in functioning, loss of contact with reality, alienation, and dependency. Patients today experience the successes and failures of the new approaches, and the new generation of antipsychotics has altered the outlook. At the same time, therapists have to individualize treatment to optimize treatment outcomes because of the variable individual characteristics that patients bring to the disorder. In that light the authors also review the use of polypharmacy.

Schizophrenia: Comprehensive Treatment and Management alerts clinicians that the type of interventions may vary with the natural course of the illness. Adherence to treatment regimens and supportive management, the individual’s changing clinical status and goals over time, and the level of manageable stress at different time points are important themes throughout the book.

In addition to discussions of the neurobiology and genetics, epidemiology, diagnosis, course, and outcome of schizophrenia and schizoaffective disorders, the authors provide DSM-IV diagnostic criteria, rating scales, and treatment regimens. For example, they provide modules for training social and independent living skills in one appendix and the Consumer and Family Guide to Schizophrenia Treatment of the National Alliance for the Mentally Ill in another. Each chapter is followed by a list of up-to-date, relevant references.

Consistent with having their fingers on the pulse of new developments, the authors discuss one of the hottest topics in present-day treatment of schizophrenia: early intervention. Evidence is accumulating that we may be able to delay onset or even prevent the disorder from developing in full by treating prodromal symptoms in high-risk patients who have not progressed to meeting full diagnostic criteria but who may benefit from early psychopharmacological intervention. Conceivably, treating symptomatic young adolescents effectively may help them to grow out of their “window of vulnerability” and thus delay or prevent the onset of the disorder. This is consistent with the view that schizophrenia is a neurodevelopmental disorder with high-risk periods of greater stress vulnerability and subsequent progression of illness. It is also consistent with the view that degenerative changes may occur in some patients and antipsychotics may stimulate nerve growth factors. Although the concept of preventive treatment is still controversial in some quarters, I agree with the authors that this is an important development that could have major therapeutic consequences and that enough data are available for clinicians to ponder the early intervention strategy.

Clearly, two masters are at work here. It was a pleasure to read their expert reviews of the literature intermingled with their own experience. This book with its treatment guidelines will remain a standard for years to come. New drugs are not likely to alter the field dramatically within the next few years, but we can look forward to an update when that happens.