23 November 2010. Schizophrenia goes into the scanner in the November 11 issue of Nature. A series of thought pieces and news articles cover a large part of the terrain that is the schizophrenia universe, from genomics to stigma. The tone of the series alternates between cautious and hopeful. The caution comes from the reality that, "We don’t even understand schizophrenia at the biological level," as Thomas Laughren, the FDA’s director of psychiatric drugs, notes in a news feature by Nature writer Alison Abbott. The article also points out that the recent history of clinical schizophrenia research is, in the end result, not much different from that of the previous century: much hope for new ideas that have not panned out (see SRF related news story; SRF news story). One difference, however, is that the newer research is built on a greater understanding of how the brain works, and this, along with some new data, methods, and collaboratives in schizophrenia research, is what lies behind the optimism evident in some of the pieces.
News and commentary
The issue leads with features from Nature writers David Dobbs and Alison Abbott. Dobbs discusses how the disorder seems to strike during adolescence, but also explores the work of David Lewis, who has taken a rigorous approach to a circumscribed topic—the basic neurobiology of cortical microcircuits and evidence that it is perturbed in schizophrenia. Abbott traces the history of drug development in schizophrenia, and notes that the current state is not a promising one, with several companies recently pulling out of psychiatric research altogether. The one hopeful ember in the ashes is an effort put together by the pharmaceutical company H Lundbeck and the Institute of Psychiatry in London, which will pool previously proprietary data from different drug makers and allow industry and academic scientists to comb them for something that could spark new research.
In the commentary section, researcher Norman Sartorius, now president of the Association for the Improvement of Mental Health Programmes, Geneva, Switzerland, describes the continuing stigma associated with schizophrenia. He cites research showing that three-quarters of people with schizophrenia conceal their diagnosis, and argues that the biggest problem with anti-stigma campaigns is that they tend to be too short: if they last less than a year, he writes, they tend not to have a sustained effect, and thus they leave those who did the work feeling let down at the end.
Noting the recent evidence for the effectiveness of cognitive behavioral therapy for schizophrenia, Til Wykes of the Institute of Psychiatry, London, contrasts this with the miniscule amount of research funding the method receives. The remedy for this, she suggests, is for researchers in the area to buttress the experimental evidence. "It is time to develop models of how the training works, analyze how basic cognitive improvements help patients, and discover how best to implement the therapy and to whom it should be offered. DSM diagnoses are discrete entities." Wykes writes.
In the books section, Roy Richard Grinker, an anthropologist at George Washington University, Washington, DC, takes a historical look at the Diagnostic and Statistical Manual (DSM), particularly its treatment of schizophrenia. He notes that there is a trend toward returning to the earliest formulation of the manual—begun as a project by the U.S. Surgeon General to diagnose World War II veterans—wherein there was more emphasis on identifying individual symptoms, many of which are shared by different disorders, than on providing a false sense that diagnoses discrete entities.
In the first of three longer Perspectives articles, Tom Insel, director of the U.S. National Institute of Mental Health, Bethesda, Maryland, gives a synopsis of just about everything we know about schizophrenia, and then focuses on the hypothesis of neurodevelopmental origins. Viewing schizophrenia through a neurodevelopmental prism, Insel describes the interventions that one can imagine someday making at each stage of life, though he notes that lack of diagnostic specificity of early symptoms will likely complicate any attempts at early treatment. He does venture to predict that 20 years from now, some avenues of prevention might lead to lower rates of schizophrenia. He also has hopes for strategies to address cognitive deficits and for better, more integrated care of patients. Finally, he predicts that increased knowledge of the genetic and biological bases of the "schizophrenias" might allow us to lay that term, and its attendant stigma, to rest.
Andreas Meyer-Lindenberg of the University of Heidelberg at Mannheim, Germany, picks up where Insel leaves off, expanding on what we know from structural and functional imaging of schizophrenia, both of the apparent structural pathology and connectivity disturbances between brain regions, as well as insights into acute psychosis. He goes into detail on the promise of looking for disease-associated genetic variation on brain function during various cognitive tasks. Meyer-Lindenberg also discusses the possible synaptic, local cortical circuit, and long-range axonal connections that might underlie the observed functional imaging alterations in schizophrenia.
Jim van Os and colleagues at Maastricht University Medical Centre, the Netherlands, and at the Institute of Psychiatry in London, review the varying levels of evidence for environmental factors asserted to raise the risk for schizophrenia, and also explore the questions of what cognitive processes and biological systems might channel these exposures into the psychopathology that is deemed schizophrenia. Finally, they enter the more complicated territory of gene-environment interactions.—Hakon Heimer.
Abbott A. Schizophrenia: The drug deadlock. Nature. 2010 Nov 11;468(7321):158-9. Abstract
Dobbs D. Schizophrenia: The making of a troubled mind. Nature. 2010 Nov 11;468(7321):154-6. Abstract
Grinker RR. Nature. In retrospect: The five lives of the psychiatry manual. 2010 Nov 11;468(7321):168-70. Abstract
Insel TR. Rethinking schizophrenia. Nature. 2010 Nov 11;468(7321):187-93. Abstract
Meyer-Lindenberg A. From maps to mechanisms through neuroimaging of schizophrenia.Nature. 2010 Nov 11;468(7321):194-202. Abstract
van Os J, Kenis G, Rutten BP. The environment and schizophrenia. Nature. 2010 Nov 11;468(7321):203-12. Abstract
Sartorius N. Short-lived campaigns are not enough. Nature. 2010 Nov 11;468(7321):163-5. No abstract available. Abstract
Wykes T. Cognitive remediation therapy needs funding. Nature. 2010 Nov 11;468(7321):165-6. Abstract