Dr. Sussman is editor of Primary Psychiatry and professor of psychiatry at the New York University School of Medicine in New York City.
Dr. Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
An understanding of the etiology of schizophrenia has eluded theoreticians and investigators for centuries. The question of whether it is possible to recover from the disorder has also proven to be frustrating to those seeking an understanding of the true course of the illness. Three of the feature articles in this issue of Primary Psychiatry provide overviews of some of the most important recent findings about these issues.
Mark G. A. Opler, PhD, and colleagues present some of the more significant findings on schizophrenia. They note how there are multiple pathways to schizophrenia that may be reflected in neurobiologic differences, the heterogeneous clinical presentation of the disease, and in differential responses to treatment. Several findings about factors that increase risk have been confirmed. These include genes, particularly the evidence for genetic associations and the function of suspected susceptibility genes; advanced paternal age and potential mechanisms by which it exerts its influence on pathology; and selected environmental exposures, such as chemicals and poor nutrition. This article also reviews likely gene-gene and gene-environment interactions.
Cannabis, or marijuana, is the most widely used illegal drug in the United States, with nearly 45% of teenagers in the US having smoked cannabis before graduation from high school. Smoking cannabis is also common among young adults. It is viewed by many as a relatively benign recreational drug, but compelling evidence has implicated cannabis as a possible cause of schizophrenia. Despite the social acceptance of cannabis use, in part because there is a pervasive belief that cannabis use is benign, cannabis use can lead to psychosis. Lauren L. Bodkin, PsyD, and colleagues describe what may make some teenagers vulnerable to psychosis in the context of cannabis use, considers motivations for their use, and makes recommendations for treatment approaches to be used by clinicians, as based on the existing literature. They describe a particularly vulnerable subset of youths who possess a genetic variation that manifests in particular behaviors and experiences, including schizotypy. Apart from the psychiatric dimension of chronic cannabis use, the authors note, it has been estimated that smoking five joints/day may be equivalent to smoking one pack of cigarettes/day in terms of exposure to cancer-causing chemicals. In addition to outlining the varied risks associated with cannabis use, the article contains useful guidelines for intervention when clinicians encounter patients at elevated risk.
Paul H. Lysaker, PhD, and Kelly D. Buck, APRN, BC, summarize the results of data from multiple sources and observe that many psychiatric and general practitioners remain unaware that most people with schizophrenia will achieve significant periods of recovery during their lives. The authors note that while these data are grounds for optimism, the idea of recovery has been received with resistance and as an evolving concept it has yet to be defined in an agreed upon matter. Progressive deterioration was long considered a hallmark of schizophrenia, but evidence suggests that this is more the exception than the rule. Examples of recovery as a process include the resolution of problems associated with the illness, the development of an optimistic outlook on life, and the development of a sense of worth and intrinsic value. The article clarifies the concept of recovery and its implications for practice, and offers a review of definitions, operational criteria, and studies of the incidence and correlates of recovery from schizophrenia. They conclude with a review of clinical practices that might be employed to promote recovery. Even though gains are often followed by losses and relapse, the authors argue that these may become opportunities for insight and personal growth.
Mark Zimmerman, MD, and colleagues note that to determine the impact of treatment in clinical practice it is necessary to evaluate outcome. At the moment, assessments of outcome are typically based on unstructured interactions that yield unquantified judgments of progress. Even among psychiatrists, use of standardized scales to monitor outcome is rare. The authors explain why available self-report questionnaires are a cost-effective option to monitor outcome. They state that standardized scales should be routinely used to measure outcome when treating depression and that this should be the standard of care. They conclude with a challenge to readers who are not convinced by their arguments and who do not adopt a measurement-based approach toward treating depression. PP