Thoughts About Schizophrenia 66 Years After Chlorpromazine.

I n one of its recent state-of-the-art review sections, the Journal of the American Medical Association highlighted state-of-the-art care of patients with Parkinson disease: “treatment is symptomatic focused on improvement in motor.and nonmotor (eg, constipation, cognition, mood, sleep) signs and symptoms. Palliative care is part of Parkinson disease management”. For me, the Journal of the American Medical Association review served as a counterpoint to the humane contemporaneous essays by Shader on psychotherapy, psychopharmacology, and other interventions in the care of patients with schizophrenia. Patients with Parkinson disease receive medications and/or deep brain stimulation for relief of their motor symptoms, as well as an array of services beyond complex prescribing. These include physical therapy and supportive home or nursing home care as needed. The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) defined schizophrenia as “abnormalities in one or more of the following domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms. ” (American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V). Washington, DC: American Psychiatric Association; 2013:87–110). Although the International Classification of Diseases, Eleventh Revision includes each of these same elements, it also explicitly lists cognitive symptoms in the diagnosis, including deficits in speed of processing, attention/concentration, orientation, judgment, abstraction, verbal or visual learning, and working memory. As far back as 2 decades ago, cognitive deficits were viewed as key determinants of functional outcome. Armed with these concerns and with the strong support of the then Director of the National Institute of Mental Health, the Institute initiated a consensus development process to encourage drug development to address cognitive deficits in patients with schizophrenia. The cognitive battery that emerged from the conference included attention/vigilance, working memory, verbal learning and memory, visual learning and memory, reasoning and problem solving, speed of processing, and social cognition. Kraepelin and Bleuler both considered cognitive impairment to be a core part of the syndrome of “dementia praecox” and schizophrenia. With the discovery of the effects of chlorpromazine in patients with schizophrenia, the generic label of first(and, later second) generation drugs proceeded from “major tranquilizers” to “neuroleptics” to “anti-psychotics”—and a “core syndrome” that persists in DSM-V. Has our field's definition of the syndrome, to precisely fit the predominant target of approved medication, enabled policy makers, insurers, and other payers to ignore the most disabling effects of schizophrenia? In addition to acute treatment and symptomatic management, efforts to diminish disability and to enhance function are part of the core of essential services for patients with Parkinson disease, stroke, and other central nervous system conditions with residual impairment. In a Cri de Coeur, Keefe argued for the inclusion of cognitive impairment in DSM-V. Summarizing a significant literature, he noted that, compared with positive and negative symptoms, cognitive deficits were better able to explain poor functional outcomes in areas such as work and independent living, and in psychosocial rehabilitation programs. He observed that “psychiatrists rarely consider cognitive function in their evaluation of patients with schizophrenia. ” Although neuropsychological evaluations would increase the costs of diagnosis of these patients, the assessment of cognitive impairment could inform strategies to reduce, or compensate for, functional deficits. Unlike Alzheimer disease or Parkinson disease, palliative care to reduce disability and/or to enhance well-being is too often not part of the treatment plan for patients with schizophrenia. In one of his recent essays, Dr Shader referred to the pioneering work of Liberman et al, who developed the Social Skills Training Program to foster independent living and relationship building among patients with schizophrenia. Although a subsequent Cochrane Collaborative Report failed to find a statistically significant difference between social skills training and a comparison “discussion” group, it is likely that the time was not right to start a clinical trial of strategies designed to address cognitive remediation in patients with schizophrenia. The failure to find a difference between the different modalities does not negate the value of targeted palliative care for the cognitive deficits in patients with schizophrenia and the value of the intervention in establishing a caring doctor-patient relationship.