What are some of the most important contemporary issues in schizophrenia and the ways research can inform exemplary clinical practice?
SPECIAL REPORT: SCHIZOPHRENIA
It is a pleasure and a privilege to introduce to you this collection of brief yet compelling articles that highlight contemporary issues in schizophrenia and the ways research can inform exemplary clinical practice.
The article by Carlos A. Larrauri, MSN; Alessio Travaglia, PhD; and Linda S. Brady, PhD, describes the rollout of an innovative consortium to help provide information and tools to aid in implementing best practices for early intervention in schizophrenia. The context of this work is in the evolution of secondary prevention and now primary prevention for schizophrenia.
The most recent National Institute of Mental Health RAISE initiative demonstrates how best practices in the comprehensive care of individuals who experience their first episode of schizophrenia can result in better outcomes—a pragmatic example of secondary prevention.
The project described here echoes other examples of population-based projects in other countries (eg, Australia, Netherlands, England) that demonstrate how primary prevention (or interventions targeted before psychosis emerges), and then secondary prevention methods of minimizing the detrimental impact of a first psychosis, collectively can improve overall outcomes in schizophrenia. The work of this consortium is both timely and innovative.
Accurate diagnosis is always a challenge, whether it is at the onset of psychosis or later in the course of psychosis when mood symptoms and other comorbidities complicate the clinical situation. The article by Brian Miller, MD, PhD, MPH, reminds us of this diagnostic and nosological challenge. The article leads with an illustrative case report and then tells us how a large Israeli study of schizophrenia found a prominent overrepresentation of schizoaffective disorder in its sample.
This is not surprising and it resonates with clinical practice. It also challenges the more rarified distinctions drawn by the DSM, wherein criteria for schizophrenia and schizoaffective disorder seem to be explicit—and yet they are often found to overlap and obfuscate over the longer duration of a psychotic illness.
The duration of prolonged psychosis is also associated with relative refractoriness to antipsychotic treatments, necessitating a consideration of clozapine therapy. Clozapine remains the gold standard of treatment for refractory schizophrenia. Its use is curtailed by its adverse effect profile, which includes both serious and troublesome adverse effects—either of which can also lead to patients stopping use of this drug even in the face of improvements in symptoms.
The case report by Jonathan E. Hickman, MSN, RN, PMHNP-BC, describes the management of clozapine therapy during the treatment of a blood cancer in a patient who has treatment-refractory schizophrenia.
The background for this report comes from a provocative Finnish study, which found an excess of hematological cancers in patients with schizophrenia who were receiving clozapine treatment. Although the effect was small, it was also observed to occur in a dose-dependent manner. The case report here illustrates the “do no harm” dilemma faced by clinicians, and it is a very interesting account by a skilled clinician who provides excellent advice.
I hope you thoroughly enjoy reading these 3 articles about various contemporary issues in the treatment of schizophrenia. I know I did.
Dr Buckley is chancellor of the University of Tennessee Health Science Center in Memphis.