Preface

The gap between research evidence and clinical practice remains substantial in psychiatry. The poor application of findings from research in clinical work is probably due, in part, to the tradition of distance between those engaged in academic pursuits and those working in the service institutions. This separation is not characteristic of psychiatry alone, but is more dangerous in the field of mental health — a field that has been, as a whole, separated from the rest of medicine for a long time. The popularity of psychoanalysis as a self-contained method of thinking about health, illness, social structures, history and other matters may have also contributed to the reluctance to use findings obtained in neuroscience laboratories, and through genetic epidemiology. Other factors might also have been of importance; however, the search for such other reasons must not postpone the effort to bridge the gap and ensure that the vast amount of knowledge is considered and applied in the provision of services to people suffering from mental disorders and in teaching psychiatry to students of medicine and of other health professions.

The diagnosis and treatment of schizophrenia illustrate the gaps existing between currently available knowledge and its application in mental health services. Research in this field has been remarkably active during the last decade: new drugs have been developed which have shown an innovative therapeutic profile; new psychotherapeutic techniques have become available, directly targeted to psychotic symptoms; and new rehabilitative techniques and family interventions have been empirically tested and proposed for clinical use. However, these advances are not adequately reflected in clinical practice. Novel antipsychotics remain underused, and several clinicians feel that clearer guidelines are needed concerning their indications and the choice among them. Cognitive-behavioural psychother-apies, in spite of the empirical evidence of their efficacy, are unknown or ignored in several countries, whereas psychodynamic psychotherapies, whose efficacy is not supported by research findings, remain widely used. Rehabilitation has indeed emerged as a priority in the clinical management of psychotic patients, but the techniques that are used in clinical practice are often different from those that research has validated. Furthermore, several clinicians are dissatisfied with the concept of schizophrenia itself, and feel that the primary psychoses which are seen in clinical practice, especially in outpatient or community settings, are unlikely to represent a single illness.

Yet, all these issues do not emerge from current psychiatric literature. The experience of skilled clinicians is only rarely published in psychiatric journals, while the best of scientific evidence is only infrequently presented in a manner and in a place that would make it immediately accessible to clinicians. Reports on clinical practice in different countries — possibly enriching knowledge by providing a range of experience and a powerful commentary on the applicability of research findings in everyday work — are not easily found in accessible psychiatric literature. In the current era of promotion of evidence-based medicine, these separations between research evidence, experience, and practice are a dangerous anachronism.

The series Evidence and Experience in Psychiatry has been initiated as part of the effort of the World Psychiatric Association to bridge gaps within psychiatry and between psychiatry and the rest of medicine. The series aims to be the forum in which major issues for psychiatry and mental health care will be discussed openly by psychiatrists from many countries and different schools of thought. This second volume of the series compares research evidence and clinical experience concerning schizophrenia, with contributions from about one hundred psychiatrists representing twenty-seven different countries.

Mario Maj Norman Sartorius

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