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The new england journal of medicine plex issues in psychopharmacology understandable and clear. Barondes’s technique is essentially that of a storyteller recounting the history of the develop-ment of psychiatric drugs in an elegant and lucid style. He enriches this historical account with real- New York, Oxford University Press, 2003. $26. world clinical examples and brings the reader fromthe dawn of psychopharmacology, through all the important developments in the field, and right up t book is a question mark in the title. Better Than to date with breaking research and the potential im-Prozac is about the long road that neuropsycho- plications for the future.
pharmacology has traveled and about hopes for its Barondes’s perspective is particularly valuable future, particularly with respect to creating better because he shows not only a wisdom derived fromdrugs. Drugs that treat psychiatric conditions are long and varied clinical practice but also an under-inherently fascinating. In the 1950s, when effective standing of fundamental neurobiology. I found my-agents became available for use by psychiatric pa- self reinvigorated by this book and refreshed to tack-tients, many doctors thought that drugs with a sim- le the tough problems it outlines. In particular, it isple pharmacologic action could not solve human clear that the achievements of the field in the past 50problems. Of course, this is true, but what the drugs years have been so valuable, and recent advances incan help are psychiatric illnesses, which now seem neurobiology so great, that new and exciting devel-to be caused by abnormal brain function. Many opments are highly likely to happen in the secondyears of consolidation and refinement of the basic half of psychopharmacology’s first century. Bar-concept and of the drugs that were introduced dur- ondes is to be complimented on an excellent book.
ing the 1950s have followed that golden decade. Allan H. Young, M.D., Ph.D.
Much of the early “out of the box” thinking occurred University of Newcastle in Europe, particularly in France. However, the ac- Newcastle upon Tyne NE1 4LP, United Kingdomtion seems to have moved across the Atlantic, and [email protected] field is now dominated by North America, albeitwith some important contributions from variouscenters around the world.
These are interesting times for the field of neu- ropsychopharmacology. Our understanding of the pathophysiological mechanisms that give rise to psychiatric disorders and of the contributions of ge- By Jonathan Michel Metzl. 275 pp., illustrated. netic, metabolic, and indeed psychosocial factors Durham, N.C., Duke University Press, 2003. $24.95. still remains frustratingly provisional. Added to this is a growing distrust of the pharmaceutical industryand its role in developing and marketing new drugs.
With this background, it is easy for those involved telligent, and provocative challenge to the no- in biologic psychiatry and psychopharmacology to tion that biologic psychiatry has replaced psycho-feel beleaguered. Barondes’s excellent book pro- analysis as the dominant therapeutic model invides an antidote. psychiatry. Tracing treatments for depression, anx- Better Than Prozac is one of the few books I have iety, and other mental illnesses from the 1950s to found that is relevant not only to experts in the field the early 21st century, psychiatrist Jonathan Metzland trainee psychiatrists but also to patients and builds an argument that “the history of Freud is spe-their families. It is accessible to all and accomplish- cifically the history of Prozac” by showing how “psy-es the seemingly impossible task of making com- choanalytic themes and psychoanalytic notions of Downloaded from www.nejm.org on June 02, 2004. This article is being provided free of charge for use in Argentina: NEJM Sponsored.
Copyright 2003 Massachusetts Medical Society. All rights reserved.
The new england journal of medicine gender keep showing up in representations of bio- history, culture, and “gender studies.” Metzl — whological psychiatry.” He does so through closely read- holds a Ph.D. in American studies and directs theing representations of psychotropic medications in Program in Culture, Health, and Medicine at thepopular news and fashion magazines from the mid- University of Michigan, in addition to seeing pa-1950s through the early 1960s (e.g., Newsweek, Time, tients — writes for an audience willing to thinkand Cosmopolitan), in psychopharmaceutical adver- beyond traditional categories and to engage in se-tisements from professional journals from 1964 rious cultural criticism. His arguments cross aca-to 1997 (e.g.,the American Journal of Psychiatry and demic disciplines, and readers who are used toArchives of General Psychiatry), and in selected works traditional medical discourse may struggle at timesof American literature between 1990 and 2002 with Metzl’s theoretical perspectives and language,(dubbed the “Prozac narratives”). These periods which draw heavily from cultural studies. But forcorrespond roughly to the heydays of psychiatry’s those who are looking for fresh perspectives, andthree American “wonder drugs” — Miltown, Vali- who are willing to have their assumptions ques-um, and Prozac.
tioned, this book will be a real education and a plea- The book has six chapters. In the first, Metzl de- sure to read.
velops the intriguing premise that the shift from Delese Wear, Ph.D.
psychoanalysis to biologic psychiatry was, and is, Northeastern Ohio Universities College of Medicine incomplete, by exposing “those pieces of the prior Rootstown, OH 44278regime that remain imbricated after the shift . . . [email protected][and that] can govern the form and function of theregime that takes its place.” Metzl constructs hisargument with a fascinating compendium of printimages that show how both psychoanalytic and bi- ologic constructs are often similarly engaged in “maintaining traditional gender roles” and how the uses of “psychotropic medications often redeploy Washington, D.C., American Psychiatric Publishing, 2003. $36. all the cultural and social baggage of the psychoan- In case readers need a refresher in the various theoretical orientations psychiatry has embraced health problem that carries substantial person- during the past half-century, Metzl traces the “al- al and social burdens. As the fourth leading causeleged demise” of psychoanalysis from 1955 through of disability among adults, schizophrenia compro-the present. In subsequent chapters, he explores the mises the social and occupational functions of those“marriage of mothers and medications” through who have this disease. The life stories of young peo-the rhetoric of Miltown, America’s “first psycho- ple troubled by unexplained cognitive and social im-pharmacological wonder drug,” showing how, in pairments are poignant, and only somewhat less sothe visual construction of patienthood in advertis- is the public presentation of psychosis when percep-ing, a woman’s sanity was connected to her marital tual abnormalities, disorganization of thought andstatus, and mental illness was “presented as a threat behavior, and ideas of persecution begin to domi-to the nuclear family.” His analysis of Prozac as de- nate the patient’s experience. Many patients alsopicted in popular memoirs such as Elizabeth Wurt- have a pathologic restriction of affect. Stigma fur-zel’s Prozac Nation (New York: Riverhead, 1995) and ther complicates the schizophrenic patient’s adap-in Persimmon Blackbridge’s novel Prozac Highway tation to society. The family members of a person(Vancouver, B.C., Canada: Press Gang, 1997) is par- who has schizophrenia are often the principal care-ticularly illuminating. In his conclusion, Metzl chal- takers, since the health care system fails to addresslenges psychiatry to “expose its own synapses and this illness with adequate knowledge and resources.
dendrites with the same vigor with which it has ex- Persons who have schizophrenia very often becomeposed those of its patients . . . [and to] become homeless, and their abnormal behavior is often ad-more aware of its own, uniquely biased spectator dressed by the justice system. The high rates of sub-positions.” stance abuse and suicide indicate the personal toll Prozac on the Couch is an intriguing and challeng- among those who have schizophrenia.
ing work standing at the intersection of medicine, The challenges in later life are profound for per- Downloaded from www.nejm.org on June 02, 2004. This article is being provided free of charge for use in Argentina: NEJM Sponsored.
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sons with schizophrenia. In Schizophrenia into Later schizophrenia deal with extraordinarily complex is-Life, Carl I. Cohen has put together a succinct over- sues. Deinstitutionalization of the mentally ill placedview of current knowledge on treatment, research, a new burden on their parents, but what happens asand policy with regard to older persons who have the parents age? Nursing homes and alternative, su-schizophrenia. The first thing to note is that there pervised residential facilities are now the primaryis a general lack of research and policy attention to settings for the life care of older persons who havethe effects of schizophrenia in elderly populations. schizophrenia but are poorly prepared to cope withThat noted, it should also be recognized that sever- the special issues of psychosis and coexisting med-al major conceptual issues have been resolved with ical conditions. Persons with schizophrenia as aempirical study. Among these issues is the question group have a high-risk lifestyle that may includeof whether schizophrenia is an early-onset, progres- smoking, substance abuse, and poor diet, as well assive neurodegenerative disease with a severe defect a lack of exercise, companionship, intellectual activ-state as the late-life outcome. The answer is no. The ities, and medical care. The contributors to Schizo-disease progression usually occurs in the early stag- phrenia into Later Life make clear the shortfall in re-es, and there is little evidence of a substantial neuro- search, training, and resources that needs to bedegenerative process. Among a surprising propor- addressed in order to direct attention to these com-tion of patients who have schizophrenia, symptoms plex health care challenges. The critique of Medicareand life functions improve late in life. However, a and Medicaid, managed care, and what are knownsubgroup of patients have a rapid cognitive and as the carved-in and carved-out mental health servic-functional decline late in life, which may be associ- es is informative. Health care planners will pay spe-ated with white-matter neuropathology.
cial attention to the discussion of innovative models Is late-onset schizophrenia the same disease as of long-term care for this population.
early-onset schizophrenia? Yes. At least, there is a Cohen addresses these issues with a distin- substantial similarity in the symptoms, the respons- guished group of contributors, who provide a broades to treatment, and the associated biologic varia- overview of current knowledge and practice with re-bles. The prognosis for persons with late-onset dis- spect to late-life schizophrenia. The book is an easyease is more favorable, perhaps because their coping read and free of jargon, and it will prove informativeskills and the social niche they occupy have been es- to mental health administrators, citizen advocatestablished before the onset of disease. Another sub- for the mentally ill, and mental health clinicians. Ittype of the disease that is marked by deficits in affect, will be important also to many general physiciansdrive, and cognition and that has a poor prognosis who attend the elderly, especially in nursing facili-develops less frequently in patients who have late- ties. In a book this broad, integration across topicsonset schizophrenia.
is difficult, but in the final chapter Cohen draws The chapters that address pharmacologic and from the field of gerontology to provide an integra- biobehavioral treatment and rehabilitation review tive model that may be used to guide future research.
the few studies that have been conducted of elder- William T. Carpenter, M.D.
ly populations with schizophrenia. These studies Maryland Psychiatric Research Center present a rational adaptation of methods that have Baltimore, MD 21228been validated in the treatment of younger popula-tions with this disease to the special problems as-sociated with aging and schizophrenia. For exam-ple, low doses of new-generation antipsychotic drugs have advantages in the treatment of elderly patients, who are at increased risk for adverse neu-rologic and cognitive effects of the first-generation Edited by Robin M. Murray, Peter B. Jones, Ezra Susser, Jim van Os, and Mary Cannon. 454 pp. Cambridge, antipsychotic drugs. The long-term consequences United Kingdom, Cambridge University Press, 2003. $80. of some new-generation drugs (e.g., hyperlipide- mia, weight gain, and diabetes) are a lesser concernin the treatment of aging patients.
Historically, epidemiologic contributions to re- The chapters on coexisting medical conditions, search on schizophrenia have involved descriptive health services, patterns of care, and changes in the studies of the incidence and prevalence of the dis-caregiving required for older persons who have ease and associated risk factors, as well as longitudi- Downloaded from www.nejm.org on June 02, 2004. This article is being provided free of charge for use in Argentina: NEJM Sponsored.
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The new england journal of medicine nal studies of its course and outcome. The Epidemi- tion between the structure of the brain and the de-ology of Schizophrenia, which is a comprehensive velopment of schizophrenia.
review of the subject, adds to this foundation by The most interesting research on schizophrenia including chapters on temporal variation, urbaniza- today concerns the association among risk factors,tion and migration, prodromal factors, molecular prodromal onset, and prevention. Although the con-genetics, and prevention.
cept of a predisposition to schizophrenia has fasci- The study of molecular genetics and the preven- nated researchers for close to 100 years, the study of tion of schizophrenia are of particular interest to such a predisposition is recent. It is clear from lon-both researchers and clinicians. Even though it is gitudinal studies of persons at high risk, familyacknowledged that genetic mechanisms have a studies of cognitive function, and studies based onprominent role in the cause of schizophrenia, the neuroimaging, neurochemistry, psychophysiology,nature of the genetic transmission remains largely and social functioning that the predisposition tounknown. At one end of a continuum is the possi- schizophrenia involves more than the clinical symp-bility that a mutation in a single gene may cause toms required for a diagnosis of the disorder ac-schizophrenia, and at the other end is the prospect cording to the Diagnostic and Statistical Manual of Men-that many genes may interact with one another — tal Disorders or the International Classification of Diseases.
and with the patient’s environment — to cause this An understanding of the interactions among manyillness. The rapid pace of recent technological ad- dimensions (e.g., the neuroanatomical, neurochem-vances in molecular genetics has greatly increased ical, neuroendocrine, and psychophysiological) willthe feasibility of using linkage analysis and associ- provide an increasingly integrated view of the pre-ation studies to search for potential susceptibility disposition to schizophrenia. As the identificationgenes. The most important implications of a suc- and validation of prodromal features progress,cessful search for a genetic cause of schizophrenia clearer targets for treatment will become available.
is how this knowledge will influence diagnosis and As investigators in the field develop interventionstreatment. Eventually, the discovery of causative to reduce symptoms, the pressure to define a syn-genes will almost certainly lead to more accurate di- drome of predisposition will become more acute.
agnoses and more effective treatment.
Both of these lines of research will aid the devel- Section III presents the most recent findings on opment of interventions to prevent the develop- the genetic epidemiology of schizophrenia. Results ment of psychosis in those with a predispositionof classic family studies, high-risk studies, twin to schizophrenia.
studies, and adoption studies are presented in detail Every chapter in this book adds to the base of by Cardno and Murray in chapter 10. Zammit and knowledge needed to develop the tools necessarycolleagues do an excellent job in an overview of the for the prevention of schizophrenia. The book con-current status of molecular genetics, including link- cludes by mapping the current and future strategiesage studies and association studies. It is widely ac- needed for work toward the goal of preventing thecepted that there is a gene–environment interaction disease. I recommend this book highly. All the in-involved in the causes of schizophrenia. Chapter 12 gredients required for an understanding of the epi-presents an evidence-based description of the role demiology of schizophrenia are between its covers.
of environmental factors in the genetic epidemiolo- The editors have made a remarkable effort to organ-gy of the disease; the models of gene–environment ize the material into a consolidated work.
interaction are of special interest. Van Erp and col- Ming T. Tsuang, M.D., Ph.D.
leagues take the gene–environment interaction tothe next level by introducing into it variables associ- Harvard Medical School ated with neuroimaging. By tying the interaction to [email protected] results of brain mapping, the book presents the Book Reviews Copyright 2003 Massachusetts Medical Society.
reader with an opportunity to understand the rela- Downloaded from www.nejm.org on June 02, 2004. This article is being provided free of charge for use in Argentina: NEJM Sponsored.
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Source: http://gis.chililab.org/sites/default/files/The%20Epidemiology%20Of%20Schizophrenia.pdf