Managing Schizophrenia

This slim paperback contains eight chapters that essentially are updated articles previously published in peer-reviewed journals of Adis International. The editor, who is the commercial manager for the publisher, indicates in a brief foreword that the book "adopts a disease management approach to schizophrenia … to provide information and ideas on how best to manage this chronic disabling illness."

In this book, the individual parts may actually be better than the whole. Particularly appealing is the book's international perspective. Three of the eight sets of authors are American, two Austrian, and one each Canadian, Danish, and British. However, there is little, if any, continuity between the chapters, and they contain a fair amount of redundancy and an occasional inconsistency.

The individual articles are of high quality overall. Mortensen's overview of the epidemiology of schizophrenia is well written. Particularly informative is his discussion of the difficulty of conducting incidence studies and therefore the possibility of variation in disease risk among different populations. He provides an excellent review of risk factors for schizophrenia.

Lehman's chapter relating the findings of the Schizophrenia PORT study to a disease management approach is another well-done review. Fleishhacker and Hummer, from Austria, present what I found to be the most useful chapter in the volume, a discussion of pharmacotherapy of schizophrenia. These authors discuss a number of important issues: the continued uncertainty about the "atypicality" of the novel antipsychotic drugs; the unexplained discrepancy in clozapine dosing practices between the United States and Europe; and the reluctance to recommend lifetime pharmacological relapse prevention for schizophrenia, whereas no such reluctance occurs in other fields of medicine.

Fleishhacker and Hummer, citing the literature, essentially dismiss the intermittent or targeted pharmacotherapy approach for general practice. In the next chapter, Maryland researchers Buchanan and Carpenter review the same studies and give targeted treatment a more positive spin, although not a convincing one in my opinion.

Taylor, from England, addresses the switch from conventional to atypical antipsychotics. His general recommendation that conventional antipsychotics be stopped before clozapine therapy is begun seems overly cautious, especially considering the increasing use of combined treatment with conventional and novel agents, a topic not covered in this volume.

The final chapters of the book cover the effect of extrapyramidal syndromes on compliance with medication regimens, assessing quality of life for patients with schizophrenia, and pharmacoeconomics. Although the review of extrapyramidal syndromes is well done, today there is probably greater need for a review of the emerging adverse metabolic effects of the novel agents. The chapter on pharmacoeconomics suggests that the novel agents—and not just clozapine—should still be reserved as second-tier agents, a position that conflicts with current consensus guidelines.

Overall, this is a worthwhile collection of papers that will be of interest to students and clinicians who are interested in schizophrenia, particularly from a multinational perspective. But it is neither a coherent volume nor timely enough to be put on one's must-read list.

Dr. Munetz is chief clinical officer for the Summit County (Ohio) Alcohol, Drug Addiction, and Mental Health Services Board and professor of psychiatry at the Northeastern Ohio Universities College of Medicine in Rootstown.