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Schizophrenia Into Later Life: Treatment, Research, and Policy

By Carl I. Cohen, M.D. Washington, D.C., American Psychiatric Publishing, 2003, 344 pp., $36.00 (paper).
Neshanic Station, N.J.

In spite of the hopeful reports of better clinical stabilization and treatment outcomes with the second-generation antipsychotics, schizophrenia has remained the chronic disabling disorder it was in the days of Emil Kraepelin and Kurt Schneider. Caring for and studying chronic schizophrenia have recently gained some respectability with the new emphasis on the possibility of treating cognitive impairment as the core of the disorder, in the hope that we finally will be able to improve the patient’s functional outcome. The new generation of therapeutic studies based on a better understanding of the pathophysiology of schizophrenia has raised the hope of finally making a difference in patients’ lives, beyond treating positive and secondary negative symptoms. In the meantime, our older patients are becoming less visible. They are hidden away in nursing homes, jails, and the street. In spite of the present-day therapeutic opportunities, many patients are not optimally treated and suffer from health problems that are not adequately recognized and treated.

Our elderly patients with schizophrenia face the same conundrum as the younger ones. Psychiatrists and general practitioners often fall short in providing optimal treatment. As long as we do not make inroads against societal bias and make the disorder more "sexy" by developing better therapeutic agents, we will only be tweaking the edges of the disorder to improve the lot of patients with chronic schizophrenia. The specific impairments of schizophrenia require specialized attention that is not available to our aging patients most of the time. Our social service and mental health support systems are complicated, are frequently inadequate, and seem to require a cognitive performance far beyond what most of our patients are capable of.

Dr. Cohen has brought together an impressive group of experts and clinicians, who deal with all the aspects of schizophrenia in later life. In addition to providing practical information for the service provider, the book also reviews relevant literature about outcome and covers subjects such as schizophrenia in old age, comparisons with the younger population, medical problems of aging, epidemiology, aging, medications and their side effects, gender differences, and many other topics. The wide variety of relevant topics is both a strength and a weakness. It is not clear to me who the intended audience is. This comprehensive approach makes the book very useful and at the same time less accessible. As is unavoidable with this kind of book, it is superficial in some aspects and goes into considerable depths in others. It is a primer in certain ways but also loses some of its focus because different clinicians and researchers have different information needs. The book could have benefited from a chapter dealing with practical suggestions for the overextended mental health workers who have this population under their care, as well as from a table listing specific needs cross-referenced with the specific chapters. I would like to see a next edition extended into a handbook about this important topic. It should be required reading for any psychiatrist or mental health worker dealing with older patients who have chronic schizophrenia. Medical students and family members of patients may find useful information to get an idea about the complexity of the disorder.
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