Optimizing Individual Outcomes in Schizophrenia: Challenges and Opportunities
Despite significant advances in our understanding of the nature of the disease and development of more effective treatments, schizophrenia remains one of the most challenging medical conditions of our time.
February 2007, Vol. XXIV, No. 2
Despite significant advances in our understanding of the nature of the disease and development of more effective treatments, schizophrenia remains one of the most challenging medical conditions of our time. In every decade of life, individuals with schizophrenia are twice as likely to die as those who do not have schizophrenia and, on average, those who have schizophrenia die 15 to 20 years sooner than the general population.
The significant social impairment and high prevalence (0.6% of the population) of the illness make it a leading cause of medical disability worldwide. Available treatments are not always effective and are associated with a range of adverse effects that can add a substantial treatment burden to the disease.
Antipsychotic medications substantially reduce the positive symptoms associated with the illness but are minimally effective in ameliorating the negative and cognitive symptoms that principally impede the ability of those affected to lead productive and personally meaningful lives. Despite the many challenges, however, the individualized provision of a comprehensive array of treatment/rehabilitative/social support services can effectively promote recovery of persons with schizophrenia.1 As we strive to elucidate the etiology and pathophysiology of schizophrenia and endeavor to develop more effective treatments, our efforts should be continually guided by the central objective of reducing the impact of schizophrenia on the lives of those affected by it.
These articles address some of the most significant challenges in schizophrenia. Since the greatest degree of functional decline occurs early in the course of the illness (with much of it preceding the initial overt expression of positive symptoms), early recognition and effective individualized treatment is of great importance. Saran and colleagues review our current understanding of biologic markers in schizophrenia and summarize the future potential for preventing or limiting the debilitation currently associated with the illness.
Suicide is a frequent tragic consequence of schizophrenia, with close to 50% of patients attempting suicide at least once during their life and about 10% completing suicide. Harkavy-Friedman presents a succinct summary of the problem and an approach to assessing and treating it.
The doubling of age-standardized mortality in schizophrenia is significantly accounted for by the increase of ischemic heart disease; this in turn is substantially explained by the greater occurrence of metabolic risk factors (diabetes, dyslipidemia, obesity, etc) among persons with schizophrenia. Meyer lucidly outlines current knowledge of the metabolic syndrome in schizophrenia and summarizes its clinical significance, prevalence, differential risk with different antipsychotic treatments, and optimal approaches for effective monitoring and treatment.
Although the onset of schizophrenia is generally in late adolescence or early adulthood, it can begin in childhood; childhood-onset schizophrenia, while extremely rare, is a particularly malignant form of the illness. Khurana and colleagues provide a pithy update of our current understanding of childhood-onset schizophrenia, highlighting diagnostic and therapeutic challenges.
Persons with schizophrenia frequently first come to clinical attention during an acute exacerbation of the illness. Jibson updates state-of-the-art pharmacologic treatment of acute schizophrenia, noting that the foundation for successful recovery is frequently laid by the quality of treatment decisions and planning in this acute phase.
In contrast to pharmacotherapy, the role of psychotherapeutic interventions in the treatment of schizophrenia is poorly recognized. Kuipers describes the evolving role of cognitive-behavioral therapy and family intervention in the treatment of schizophrenia and provides some practical recommendations about their application in clinical practice today.
Collectively, these articles underscore some of the major challenges and opportunities in our efforts to improve outcomes for individuals with schizophrenia. While existing treatments may not be completely satisfactory, they can substantially reduce disease burden and make a meaningful difference in the lives of patients. Even as we strive to develop more effective treatments for the future, we can improve our use of existing treatments to optimize individual outcomes and reduce the considerable morbidity and mortality associated with schizophrenia.
Dr Tandon is adjunct professor of psychiatry at the University of Florida in Gainesville and chief of psychiatry in the office of mental health at the State of Florida Department of Children and Families in Tallahassee. This article is not part of the purview of Dr Tandon's current employment by the State of Florida, which bears no responsibility for its contents. The author has disclosed that he has no current significant relationships with or financial interests in any commercial organizations pertaining to this activity.
Reference1. Tandon R, Targum SD, Nasrallah HA, Ross R. Strategies for maximizing clinical effectiveness in the treatment of schizophrenia. J Psychiatr Pract. 2006;12:348-363
