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by Robin M. Murray, Peter B. Jones, Ezra Susser, Jim van Os and Mary Cannon (Editors)
Cambridge University Press, 2002
Review by Mark Welch, Ph.D. on Apr 16th 2004

The Epidemiology of Schizophrenia

This is a most significant book, published at a crucial time and attempting to answer some of the most fundamental questions in research into one of the most pressing of current issues. In 20 chapters some of the most influential researchers across the world canvass the state of the art of the epidemiology of schizophrenia from basic design questions (what can be measured and how is this possible?), to John McGrath's final consideration of the possibilities that accurate epidemiology hold for the prevention of the disorder.

There are five explicit themes in the book: social epidemiology, developmental epidemiology, genetic epidemiology, special issues (such as physical illness, substance abuse and suicide) and future directions on classification, service planning and even prevention. Each section deals with its subject matter in impressive detail, clearly and articulately describes the issues of contention and controversy, debunking unsubstantiated assertions and weighing carefully the best available evidence. Each chapter within the sub-sections is prudent in its claims and careful in its assertions. It may be suggested that the authors would generally agree that while there is much about which we can say we are certain, the most important of these is the knowledge that there is even more that is still to be determined.

There is an underlying critique of much of the conventional approach to epidemiological research in schizophrenia and, in particular, and an emphasis on questions related to the social environment. For example, that the rate of schizophrenia seems to significantly higher in migrant groups, particularly in first and second generation African-Caribbean immigrants, has, of course, been hotly debated for many years. Is it more of a case of diagnostic inconsistency than some real difference in incidence? Is it a function of social values rather than impartial science? Is it more indicative of racial stereotypes or the effects of social circumstances? Jane Boydell and Robin Murray from the Institute of Psychiatry in the UK while dismissing any influence of the season of birth on incidence, despite the great amount of interest the theory has generated, also conclude that the evidence that "social and psychological aetiological factors are operating" and while these may be the same for all sections of the population, migrants and other minority groups are "more exposed to them or less protected against them". Their balanced conclusions reflect a multi-factorial approach that is also found elsewhere in the text.

Hafner, discussing the issue of the prodromal stage and the characteristics of early onset psychosis, argues that the early course taken by the disorder "might be of far greater importance for further illness and social outcomes than any of the later stages" and so although it may not yet be possible to predict outcome from the prodrome, it should be a major focal point for further research. In this, he is supported by the arguments of Clarke and O'Callaghan, but they too are cautious about making claims that the evidence cannot yet support.

There are also significant chapters dealing with the pre- and perinatal risk factors (it is suggested that while there may be some evidence to support the effect of second trimester exposure to some respiratory diseases, low birthweight and retarded intrauterine growth) there remain methodological problems and it is more probable in any case that "we are dealing with interactive effects of prenatal and genetic factors". While genes may "control the development of the brain and the nervous system ... the environment modifies it". As in childhood development, there are pointers and suggestive indications, but looking for single factor relationships will be vain. That, plus the always low relative risk of suffering from the disorder at all, serves to qualify any claim of prediction.

The section dealing with the genetic influence is similarly multi-dimensional. Yes, the genetic factors are undeniable, but No they are not enough by themselves; they are necessary but not sufficient. There is, it is suggested, significant hope that investigation of the gene-environment, not gene mapping alone, may yield clues to the pathways of risk which lead not only to the onset of the disorder, but its persistence.

The penultimate section deals with "special factors" and the relationship to, for example, substance abuse. Here some more provocative claims are made. It is said that while cannabis use, often a contentious issue, can cause brief organic reactions, it is probably also an added risk factor for those already biologically predisposed or significantly vulnerable. Furthermore, it may be an independent risk factor in its own right. That said, the authors, Murray et al, add the caveat that such a claim may not withstand rigorous methodological scrutiny.

It may be fairly said that this volume will become a standard and valued text for advanced students for some little while. It does have a cautious, technical and academic tone, but it is not impenetrable; it just requires close attention. Although it is well written and has admirable clarity, it is dense at times and may not be accessible to the less specialized reader. Nevertheless, it is an important addition to the literature, it summarizes impressively and appraises cogently. Its conclusions are constructive and balanced. It does not venture much into the philosophical debates of the disorder itself, but is still infused with a profound concern for what remains one of the most personally destructive and burdensome of all illnesses. The final word may go to John McGrath who argues in the final chapter that basic strategic research needs to go hand-in-hand with attempts at primary prevention, and the nihilism of the past needs to be replaced by a sense of determination and urgency. He may call the idea of primary prevention of schizophrenia "quixotic", but he might also say that you have to have a dream if you are ever going to have a dream come true.

 

© 2004 Mark Welch 

 

Dr Mark Welch is currently a Senior Lecturer and Postgraduate Coordinator in The School of Nursing at the University of Canberra, Australia. His PhD investigated the representation of madness in popular film, and his other research interests include the mental health of refugees and victims of torture, and the history of psychiatric epistemology.




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