January, 2006. Too often in the history of psychiatry we have become focused on new theories or findings that create a great deal of excitement, but that become so absorbing that we may, for a time, lose sight of the big picture. We saw this happen in the heyday of psychoanalysis, when neurobiology seemed to vanish, and faulty or inadequate upbringing was identified as the cause of practically all psychopathology-we especially demonized mothers and even laid schizophrenia at their feet. A while later, as phenothiazines, tricyclics, and lithium became more widely used, biology became the culprit, and we spoke of "chemical imbalance" as widely explanatory of many psychiatric conditions. If there is a current trend, it may be neurogenetics as the search intensifies for the patterns of contributing genes that put one at risk to develop complex psychiatric illnesses.
These lines of investigation are all important and have moved the field forward exponentially; they lead to discoveries and breakthroughs that result in new understanding of pathology and new and better treatment. In my view, however, while embracing each of these steps forward, it helps to keep one eye on the past and remember what we've already learned. One way to do this is to zero in on the individual patient, which of course is what we teach our residents to do, and to learn as much as possible about biological risk factors, family history, early development, strengths and talents, accomplishments, and symptoms and disabilities. In this way, for example, a patient with schizophrenia becomes a person with a life, a history, a family, a set of memories, and a potential to overcome or compensate for the illness, however severe and persistent that illness may be.
In this issue of the Journal, a number of different components of treatment for patients with schizophrenia are examined and presented. Nolan and Volavka describe an inpatient observational method to help minimize violent episodes for that minority of patients whose psychotic illnesses include such behavior. Gorman discusses two interesting patients presented by Lindenmayer, who became stabilized in outpatient treatment with the use of long-acting injectable medication. Currier and Medori review and compare the use of oral versus intramuscular antipsychotics in the context of psychiatric emergencies (complementing the Expert Consensus data on the treatment of behavioral emergencies, presented in the November, 2005 Supplement of the Journal). Meyer and colleagues focus on the high prevalence of the metabolic syndrome in a group of Veterans with schizophrenia, and Wirshing and collaborators demonstrate the value of nutrition education to achieve weight loss and mitigate the risk of the metabolic syndrome and other medical risk factors in a similar population of patients. Gaudiano reviews studies of cognitive-behavioral therapy in patients with schizophrenia, demonstrating the added value and improved overall response to treatment that can be achieved by adding this form of psychotherapy to standard medication treatment. And finally, Preskorn makes this very argument in his column, pointing out that the latest developments in antipsychotic medications "have been at best an incremental" improvement and emphasizing the importance of the concomitant use of psychotherapy. Such a biopsychosocial approach for even our most disabled patients is not, of course, a new idea; the great Adolph Meyer, among others, pointed us in this direction many years ago, a reminder of the importance of the pioneering contributions by outstanding scholars in our past, whose work we are wise not to forget.
John Oldham, MD