The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders provides the authoritative list of what are considered to be mental disorders. This list has a tremendous impact on research, funding, and treatment, as well as a variety of civil and forensic decisions. The development of this diagnostic manual is an enormous responsibility. Provided herein are lessons learned during the course of the development of the fourth edition. Noted in particular is the importance of obtaining and publishing critical reviews, restraining the unbridled creativity of experts, conducting field trials that address key issues and concerns, and conducting forthright risk-benefit analyses. It is suggested that future editions of the diagnostic manual be developed under the auspices of the Institute of Medicine. The goal would be broad representation, an evidence-based approach, disinterested recommendations, and a careful attention to the risks and benefits of each suggestion for change to the individual patient, to public policy, and to forensic applications.

Noncompliance with neuroleptic treatment is a major barrier to delivery of effective treatment for schizophrenia outpatients. This article describes the development of a standardized measure for the assessment of attitudinal and behavioral factors influencing patient compliance with neuroleptic treatment. The Rating of Medication Influences (ROMI) scale was developed as part of a longitudinal study of neuroleptic noncompliance in schizophrenia and administered to 115 discharged schizophrenia outpatients. Analyses of the following were conducted to assess the scale's psychometric properties: (1) interrater reliability, (2) internal consistency, (3) principal components, (4) correlation with other subjective measures, and (5) correlation with independent family reports. Most (95%) of the ROMI patient-report items were reliable, whereas rater-judgment items were not reliable. The rater section was dropped. A principal components analysis of the reliable patient-report items yielded three subscales related to compliance (Prevention, Influence of Others, and Medication Affinity) and five subscales related to noncompliance (Denial/Dysphoria, Logistical Problems, Rejection of Label, Family Influence, and Negative Therapeutic Alliance). There were significant correlations between these subscales, and independently obtained family-report ROMI items were significant. The Denial/Dysphoria subscale correlated strongly with two other published measures of dysphoric response to neuroleptics, whereas the other noncompliance subscales did not. The ROMI is a reliable and valid instrument that can be used to assess the patient's subjective reasons for medication compliance and non-compliance. The subscale findings suggest that the ROMI provides a more comprehensive data base for patient-reported compliance attitudes than the other available subjective measures. Indications for use of the ROMI and other subjective measures of neuroleptic response are reviewed.

These findings reaffirm the value of antipsychotic medication in preventing relapse and rehospitalization. The absence of family treatment differences may be because both conditions engaged families.

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Substance abuse among schizophrenic patients is an increasingly recognized clinical phenomenon. The authors review experimental and observed clinical effects of drug abuse and patients' subjective experiences of acute intoxication. Though drug abuse may exacerbate psychotic symptoms, abused drugs may also lead to transient symptom reduction in subgroups of schizophrenic patients. Some patients report feeling less dysphoric, less anxious, and more energetic while intoxicated. Models of the relationship of drug abuse and schizophrenia, particularly the self-medication hypothesis, are discussed in reference to these data.