Schizophrenia: Some Neglected Topics

It is a pleasure to introduce this series of 4 special articles on schizophrenia. As industry support has shaped postgraduate psychiatric education, the quantity of educational programs has grown dramatically while the breadth of topics has not. Within the field of schizophrenia, subjects related to the prescribing of newer antipsychotic agents are covered extensively, often with particular emphasis on the critical topic of metabolic complications.

Within these areas we teach what we know best; the preponderance of evidence from clinical trials on which most lectures are based comes from adult patients with chronic disorders and tends to focus on the response of psychosis and the prevention of relapse. Other aspects of clinical care receive less attention. The articles in this collection address some of these comparatively neglected subjects including the role of nicotine in schizophrenia.

In the first article, Velligan and Alphs provide us with an update on negative symptoms in schizophrenia. The atypical antipsychotics were introduced with the promise of substantial benefit for negative symptoms, but the reality largely proved disappointing to clinicians and families. While some progress has been made in our understanding and treatment of negative symptoms, they remain a source of significant disability and an important area of unmet therapeutic need.

The authors provide guidance to clinicians on the identification and treatment of potentially reversible causes of secondary negative symptoms, such as depression and the neurological adverse effects of conventional neuroleptics. Educating family members about negative symptoms is also important, because family members are often unaware of this aspect of the illness and so may blame the patient for what they perceive as laziness or a deliberate refusal to engage socially or to accomplish basic tasks of daily living.

The central and often neglected involvement of family members is explored by Hackman and Dixon in their excellent review of family services. Traditional mental health training, based on the individual psychotherapy of higher-functioning individuals, has tended to foster an attitude among some clinicians that family members can be excluded from the treatment plan. This stance is unfortunate and potentially quite counterproductive in the care of individuals with schizophrenia. Family members experience significant feelings of loss and burden, both financial and psychological, but can also experience the satisfaction of fundamentally helping loved ones if given the opportunity.

The authors describe the experience of family members and the diverse benefits of psychoeducation and family involvement. They note the difficulty in disseminating and implementing these programs. Fortunately, alternative educational programs, such as the Family-to-Family Program sponsored by the National Alliance on Mental Illness, can be very effective and are usually quite well received by family members.

Evins reviews the topics of nicotine and smoking cessation in patients with schizophrenia. Much attention has been paid to the metabolic adverse effects of antipsychotic agents. Far less attention has been directed at cigarette smoking, which is the single most important modifiable cardiac risk factor and an almost universal problem among patients with schizophrenia. This relative disinterest may reflect, in part, the conviction among clinicians that it is unrealistic to expect patients with schizophrenia to reduce or stop smoking.

As the author makes clear, success rates have steadily improved with new pharmacological and cognitive-behavioral approaches, and these interventions should be made available to all psychiatrically ill patients who smoke. In addition, intriguing links between nicotine receptor function, schizophrenia neurobiology, and the actions of atypical antipsychotics have emerged over the past decade. The authors provide an excellent description of promising therapeutic approaches based on this emerging understanding of nicotine receptor pharmacology.

In their review of antipsychotic prescribing in adolescents, Cullen and colleagues provide a valuable summary of an important area of research that has lagged behind the characterization of these agents in adult patients. They report that atypical antipsychotics are now frequently prescribed for younger patients. The extent to which we can apply lessons learned about efficacy and adverse effects from studies of adult patients remains unclear.

The evidence the authors cite suggests that younger patients may be more vulnerable to metabolic adverse effects. As the authors point out, weight gain can be very stigmatizing at this age and the longer-term consequences of cardiovascular risk factors beginning at an early age are of great concern. They note that recent evidence indicates that endocrine effects may not be as disruptive to development as previously feared. Results from several randomized trials in this area have been published over the past few years, and the NIMH-sponsored Treatment of Early Onset Schizophrenia Disorders Study is currently under way, but much more remains to be done.

Articles found in this Special Report:

• Negative Symptoms in Schizophrenia

• Issues in Family Services for Persons With Schizophrenia

• Atypical Antipsychotics Treatment of Schizophrenia Spectrum Disorders

• Nicotine Dependence in Schizophrenia