Lithium treatment in schizoaffective patients

Abstract

Schizoaffective Disorders: The classification of functional psychoses has traditionally been dichotomous since Kraepelin(1) proposed the division into two major, mutually exclusive entities: dementia praecox, currently referred to as schizophrenia, and manic-depressive insanity. The first was seen as inevitably deteriorative, while the latter was seen as leading to recovery. However, the psychiatric literature is replete with descriptions of psychoses with mixed features, so that a plethora of names by various authors has resulted. The term schizoaffective was first used by Kasanin in 1933, when he described nine patients with good premorbid functioning who developed acute psychoses with a mixture of schizophrenic and affective symptoms and recovered after a few months (2). Labeling this entity as schizoaffective was to focus on only a minority of its features i. e. the acute symptom complex. Since then, therefore, there has been a great deal of debate as to its meaning and validity (3) and it has even been suggested that the term has created more mischief than it has resolved confusion (4). Anyhow, even contemporary trends in psychiatry reveal the continued influence of the Kraeplinian dichotomy in the purpose of elucidating the meaning of the concept “schizoaffective”. The disagreement is whether it is a subtype of schizophrenia, a subtype of affective disorder or a distinct entity, and it is reflected in the DSM-III decision not to give operational criteria for schizoaffective disorders (5). Thus a large number of cases is relegated to a mixed or atypical category and the diagnostic system cannot be considered satisfactory in this regard. Unlike DSM-III, the Research Diagnostic Criteria (RDC) by Spitzer et al (6) do have operational criteria for the schizoaffective disorders and have divided the syndrome into manic and depressive type too. However, RDC have the problem of evaluating only the acute symptom complex and not taking into account other factors needed for the schizoaffective state to be considered a valid diagnostic entity. In fact, we need additional data about epidemiology, including sex ratio and age of onset, premorbid functioning, response to treatment, course of illness, family history and etiology with possible biological correlates. The importance of such factors may be underlined by an example: the introduction of lithium salts treatment has not only shown therapeutic implications but has also resulted in diagnostic bias in favour of affective psychoses by American psychiatrists (7).