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The epidemiology of schizophrenia
  1. A Munro

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    Edited by Robin M Murray, Peter B Jones, Ezra Susser, Jim van Os, and Mary Cannon. Published by Cambridge University Press, Cambridge, 2003, pp 445, £55.00 (hardback). ISBN 0-521-77540-X

    As a trainee in psychiatric epidemiology 40 years ago, I fervently wished for two things; firstly help to carry out endless statistical calculations and, secondly, a scientifically valid definition of schizophrenia. To a considerable extent computers have fulfilled the former wish. Sadly, neither they nor anything else has come close to achieving the latter, as the present volume repeatedly demonstrates.

    This book is well edited, on the whole well written, and its contributors are eminent in their field. It is impressive in the width of its coverage and it provides a good overview of the discipline’s status at the beginning of the new millennium. Then why, after having read through to the end, do I put the book down with a considerable sense of sadness?

    A statement on the penultimate page of text (p 436) encapsulates the reasons for my unhappiness. The author says “However, history has shown that risk factor epidemiology can sometimes enter cycles of uninformative replications.” He is talking about one area of research, but in chapter after chapter the number of similar conditional statements combines to paint a very negative picture of overall progress in the epidemiology of schizophrenia.

    I do not wish to seem discouraging in my opinions, but a general sense of tasks scarcely begun pervades much of the volume, allied with some rather “pie in the sky” generalisations about the possible outcomes of future research.

    The feeling of incompleteness comes as no surprise. Despite many years of multidisciplinary study, the nature and essence of schizophrenia still elude us. I would contend that this is inevitable because we lack objective markers and the illness category is so over-inclusive and so vulnerable to vagaries of individual viewpoint and cultural pressure. In truly scientific terms, the disorder as currently conceived is virtually unresearchable, or at least research can only yield relatively banal results.

    The epidemiology of schizophrenia gives a highly praiseworthy and up to date account of a multitude of concomitants of schizophrenia, whatever “schizophrenia” actually means. As a mile post of where research on these concomitants has reached, it deserves to be in every psychiatric library. But how can one come to conclusions about a “whatever”? It is only when the book touches upon modern advances in neuroinvestigative techniques and their potential application to the study of schizophrenia that my hopes begin to rise. In my personal reckoning the problems of this enormously important topic of schizophrenia will never be resolved as such. Instead we shall, if we are fortunate, see a gradual whittling away of the concept as scientists and clinicians learn to identify and measure the underlying abnormalities that are hidden by the confusing welter of disorders that make up such a heterogeneous whole.

    How can anyone leave this book feeling happy when one reads (p 44) that “Based on meta-analyses of a large literature on schizophrenic outcomes, improvement in the course or outcome from beginning to end of the 20th century are modest.”? What a condemnation of psychiatry and of society! But how can psychiatry expect society to provide proper amenities for sufferers when we cannot even describe adequately what it is we are dealing with?

    I hope that readers of this book from the wide range of neurosciences may be inspired to collaborate in the introduction of cutting edge technologies into the investigation of schizophrenia. To misquote the old song which said “What is this thing called love?”, it must be a first priority to find out “What is this thing called Schizophrenia?”