Leaping Tall Buildings—The Science-to-Service Gap in Schizophrenia Treatment

This special section of the Bulletin reflects how far we have come in developing better treatments for persons with schizophrenia and underscores how far we have yet to go to make consistent and sustained differences in the everyday lives of persons with this disorder. The scientific progress impresses, yet the practical challenges of implementation loom large. The section includes 3 excellent articles and a commentary documenting several essential points. (1) At a most basic level, substantial unmet need for care prevails, and about 40%–50% of persons with schizophrenia do not receive any treatment in a given year.1,2 (2) Among those who do receive treatment, the vast majority receive substandard care as judged by evidence-based guidelines and remain significantly symptomatic and disabled in spite of prospects for improvement with better care.1,3 (3) Substantial numbers of patients, especially the most disadvantaged and young, vote with their feet when offered treatment.2 (4) In order to effectively disseminate evidence-based practices, we have many lessons to learn from efforts in other areas of medicine and the social sciences. We need to dramatically change our thinking about how change occurs.3 (5) To effect needed change, many clinical management and policy approaches must be applied by multiple key stakeholders.2–4 Without delving into the specifics of the recent advances in the basic and clinical sciences, the development and enumeration of “evidence-based treatments,” or the various controversies related to their proliferation, it is useful to take stock of the state of treatment technology for persons with schizophrenia. “Technology” in this context subsumes broadly all treatments and interventions, including the psychosocial technologies, psychotherapies, and rehabilitation interventions. At the very least, we now have a much broader range of choice in antipsychotic agents and a number of well-defined and evidence-based psychosocial interventions that they can improve outcomes. This is the good news. Less encouraging is the probability that even if all these technologies were brought to bear in some ideal treatment system, patients would be better, but many would not be well. Many gaps remain before we can offer full recovery, cures, or, best of all, prevention. This situation brings to mind an excellent essay by Pardes et al5 that considered the effects of medical research on health care and the economy. They relate the maturity of the treatment technologies for a given disorder to both the duration of the disorder and treatment costs. Treatment costs increase substantially as the technology advances from palliative care to “halfway” status. The duration of illness also increases with this technology transition as survivorship improves. It is only when technology advances to the “high” level, producing prevention or cures, that costs plummet and length of illness decreases (but not at the cost of shorter lives). The case of polio illustrates this series of transitions. When only watchful waiting and palliative care were possible, costs were relatively low, but life could be short. As the halfway technology of the “iron lung” became available, costs rose and so did survivorship (and length of residual illness). Only when the high technology of preventative vaccination became available did costs and duration of the illness change dramatically for the better. Using this model, we can see that the technology for treating schizophrenia has, fortunately, moved from the palliative phase to that of halfway technologies. This is truly the time for heavy lifting in the evolution of schizophrenia treatment, when palliation can no longer be accepted as a standard of care but when prevention and cure cannot yet be reached. Drake et al,3 Sederer,4 and Kreyenbuhl et al2 amply describe the heavy lifting required to move science into practice. Such lifting is essential to realize the fruits of the many years of basic, clinical, and health services research that have brought us to this point. The lifting requires dramatic changes in how we approach change and the involvement of multiple actors, including local, state, and federal government as well as practitioners, consumers, and families. All the articles underscore the essential role of consumers and families through patient-centered care and shared decision making in shouldering the effort to achieve better outcomes. Clearly, we can no longer tolerate palliative care for persons with schizophrenia. We especially cannot tolerate the fact that so many persons with this disorder receive minimal or no care at all. Whether this situation arises from inadequate social policies, an antiquated and demoralized workforce, clinical parochialism in resisting adoption of evidence-based practices, or to the disengagement of patients and their families, it is simply time to move forward with what we know works and to look forward to even better treatments and outcomes as science continues to advance our knowledge. On the one hand, the science-to-service endeavor is about making practice more scientific. This means not only importing new scientific findings and treatments into practice but also engaging in the ongoing evaluation of this implementation, creating feedback loops that continue to inform whether what we do achieves the desired and expected results. If not, we must adapt accordingly. The science provides a most important lesson that with the application of treatments already available, outcomes can be better. Scientific progress raises expectations about the outcomes of everyday treatment and services. Conversely, we also hear about the corollary pathway of “service to science.” How can science be more practice oriented, more practical? I do not believe that science generally misses this point, and we see in this special section many examples of the practical application of science in real-world settings. However, it is useful to keep in mind the long-standing tradition of “learning at the bedside,” taking challenges identified at the bedside to the laboratory to find better solutions. In this paradigm, today's bedside is the entire community in which a patient lives. We are concerned not just about symptom reduction but about recovery, improving functional status, fuller employment, better living situations, and support to families, to mention but a few challenges. When our science has potential answers for these challenges, we must use them. When science does not have answers or has not yet addressed important practical challenges, scientists need to listen to practitioners, patients, and families. Our science at times may be too “investigator initiated” and not sufficiently “practice initiated.” In sum, our scientific progress lends much hope. The work needed to realize this hope in everyday practice can seem daunting, but the imperative to improve services compels action. Fortunately, we are now in the thick of making a difference!