This multi-author volume suffers from both the fragmentation and the duplication to which such works are prone. It begins with accounts of several cognitive domains thought to be relevant to schizophrenia but there is no section that places these separate domains within an overall context. A structural format for each domain would have been useful and might have brought these chapters up to the standard of Richard Keefe's excellent contribution on working memory in schizophrenia. The chapter on frontal deficit is surprisingly short given the enormous amount of interest in dysexecutive syndromes, and the chapter on the course of cognitive dysfunction is curiously simplistic, failing to consider the effects of treatment on course, or the phenomenon of dementia in chronically untreated patients. There is hardly any reference to the now extensive literature on the cognitive deficits of first-episode patients.
Subsequent chapters consider schizophrenic symptoms and cognitive impairment, including accounts of functional outcome, comorbid substance misuse and insight. These are of more immediate relevance for the clinician and cover the territory well.
The final section, on treatment, contains excellent theoretical accounts of the cognitive consequences of manipulating those receptors that are relevant to antipsychotic drug treatments. Curiously, the account of the glutamatergic contribution to cognitive dysfunction in schizophrenia is found in the first section, on different cognitive domains. The work on the cognitive effects of ‘typical’ antipsychotic treatment is particularly sensible and thorough, drawing much-needed attention to the methodological inadequacies of many studies in this field. The chapter on cognitive enhancement as a treatment strategy in schizophrenia, written by the editors, reads like an advert for atypical antipsychotics. In the current climate, where first-line use of atypicals is being seriously questioned despite their superior tolerability, it is important not to be overoptimistic about properties that remain incompletely investigated and poorly understood. The editors rightly stress the importance of effective treatment during the first episode and point out that such early treatment may actually change the trajectory of the illness by preserving cognitive function. Unfortunately, this disregards the possibility that factors intrinsic to the illness, such as significant and irreversible premorbid cognitive deterioration, may be so closely associated with lengthy duration of untreated psychosis that it will not be possible to intervene early enough; another triumph of hope over experience?
The final chapter, on cognitive remediation, is somewhat limited and does not address the issue of whether improvement in task performance is capable of generalising to real-life situations. Neither does it consider supposed mediators of cognitive dysfunction on functional outcome, namely affect, perception and insight. This is perhaps one of many instances where material from separate contributors might have been integrated across chapters to produce a more satisfying whole.
Overall, this is a useful and up-to-date volume, which anyone with an interest in schizophrenia would do well to possess, despite my caveats.
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