The goal of Society and Psychosis is ambitious but necessary: to illuminate the path of future research regarding psychotic illnesses—in the editors' own words, “…to reflect these current trends in the study of society and psychosis, and to contribute to developing an agenda for future research” (p 6). The primary audience would be those who conduct and fund research on psychotic disorders; however, the clinician will find many worthy pearls in this collection of essays. The editors begin by asserting that psychiatry has now “rediscovered its roots,” accepting and exploring social and environmental factors in the etiology and course of psychotic illness and establishing a backdrop of tension between pharmacologic and social research. Society and Psychosis is organized into 3 main sections—theoretical foundations, social factors and the onset of psychosis, and social factors affecting the course and outcome of psychotic illnesses. Several of the nuggets unearthed through this comprehensive review are worth highlighting: childhood adversity and trauma are known risk factors for psychosis, and perhaps the mechanism involves the development of oversensitive threat appraisal resulting from the maltreatment. Children who live in single-parent homes or who spend time in institutional care are also at higher risk, but the question remains unanswered whether this correlation is the result of parental separation or some other set of associated risks, such as socioeconomic status or family conflict (chapter 7, “Childhood Adversity and Psychosis”). Many clinicians who treat psychosis recognize that cannabis will indeed trigger a psychosis that will result in an eventual (if not immediate) diagnosis of schizophrenia. Recent evidence indicates that cannabis interacts specifically with gene coding for the catechol-O-methyltransferase (COMT) enzyme, which is relatively restricted to the prefrontal cortex and involved in the metabolism of dopamine. Adolescent-onset cannabis abusers have an overall increased risk of adult psychosis, with the greatest risk in the Val/Val genotype of the COMT gene. Further, cannabis abuse and COMT genotype also interact in predicting later depression. This genetic-environmental risk factor interaction is validating for the clinician who had observed it previously, and this understanding potentially opens many doors for further study (chapter 5, “Genes and Social Environment”). But the main premise of Society and Psychosis, that pharmacology is by definition at odds with social and genetic study, is flawed. This premise leads to the omission of any consideration of the new field and literature on pharmacogenetics, the area that tracks genetic markers associated with medication response and the genetics associated with medication side effects. Another shortcoming is the structure of such a book—specifically, a collection of separate articles culled and pasted together (from 26 authors in total). This format presents a challenge for distilling out a set of conclusions or determining a path for future research. The editors rightly point out in their summary the risk of reducing the book's recommendations to a set of cliches such as “protect the children” or “create programs for those at risk.” The main disappointment of Society and Psychosis is that, with so many questions and issues not fully resolved, the editors chose caution over courage. Understandably, caution is the norm in scientific discussion, but caution's twin is hesitancy. The ship moves on. Yes, to know where we have been is good, but to have new waters charted and to point out the unknown is better. Editors as knowledgeable as these now need to demonstrate courage. There is far too much valuable data to waste on cliches. A follow-up publication that gives specific directives would be welcomed. Andrew Farah, MD, FAPA High Point Regional Health Systems, High Point, North Carolina
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