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The widespread availability of the new generation of atypical antipsychotics offers the clinician valuable new opportunities to prescribe effective and well-tolerated drug treatments for schizophrenia. As a group, the atypical antipsychotics are distinguished from the conventional agents by their lower propensity to induce extrapyramidal symptoms (EPS). In addition, some of these agents seem to be less likely to cause hyperprolactinaemia; this may contribute to a lower incidence of sexual and hormonal side-effects than with standard treatment regimens. EPS and sexual difficulties cause considerable distress to patients; there are grounds for predicting that better tolerability will lead to better compliance with treatment and thereby better long-term outcome. There is accumulating evidence that the atypical antipsychotics are more efficacious than the standard treatments; this may reflect greater tolerability and enhanced compliance with treatment, in addition to intrinsic efficacy. But, at the same time, the new treatments pose fresh challenges to the clinician. These agents differ from one another and the traditional antipsychotics in their pharmacology, side-effects and dosing requirements; clinicians are thus required to develop new treatment strategies, if these drugs are to be deployed to best effect. In particular, it is important that the new treatments are given rationally. Polypharmacy should be avoided, as this is unlikely to be more effective, and may lead to the tolerability benefits of the new agents being lost. Although clozapine is, rightly, reserved for treatment-resistant patients, on grounds of haematological safety, the practice of reserving other atypical antipsychotics for specific groups of patients, such as those with severe illness or established EPS, is misguided and results in the advantages of the atypical agents being denied to many patients who might otherwise have benefited greatly. These newer agents are best used within the setting of a strong therapeutic alliance between clinician and patient, in which an ongoing dialogue regarding symptoms, side-effects and treatment expectations is an important element. Used rationally, they offer new opportunities for clinicians and renewed hope to many patients.

Providing optimal treatment for people with schizophrenia is a difficult long-term problem for clinicians and healthcare providers. Over the years a variety of approaches to treatment have evolved and, until now, there have been no widely accepted standards for care. To determine the principles underpinning the best practice for schizophrenia treatment, an Expert Panel of European psychiatrists and psychologists has worked to distil current theory, collective practical experiences and published literature into 17 basic Principles of Practice . These are not intended to duplicate or replace local treatment policies or guidelines. Instead, they describe best practice in diagnosis, patient assessment and long-term treatment of schizophrenia as it exists at the beginning of the 21st century and is likely to exist in the near future. The Principles of Practice broadly fall into four main categories: (1) assessment, diagnosis and care provision; (2) treatment in day-to-day practice; (3) building a positive therapeutic alliance; and (4) a long-term clinical commitment. Running through all the Principles are several common threads - the fundamental importance of the therapeutic alliance between the clinician and the patient, the need to plan both for treatment efficacy and avoidance of side-effects and the importance of long-term treatment planning. It is intended that psychiatrists and other healthcare professionals can use the Principles as a benchmark for optimum patient management, and as a tool when negotiating the future of local and national schizophrenia management services. Furthermore, the Principles of Practice represent a first step in the development of a new patient-centred philosophy for the care of people with schizophrenia.

Between 20% and 40% of schizophrenic patients are thought to be resistant to conventional antipsychotic therapy, although this may be an underestimate of the scale of the problem. The causes of nonresponsiveness are likely to be multifactorial, and there have been reported associations between refractoriness and neuropsychological impairment, negative symptoms, and abnormal brain morphology. For some patients, treatment resistance may in fact represent an intrinsic part of the schizophrenic illness. Treating the refractory patient should begin with a full, preferably multidisciplinary, review of diagnosis, symptoms, and side effects. Although an increased dose of a conventional antipsychotic agent can be effective for some patients, consideration should be given to reducing the dose and combining treatment with psychosocial management, or switching to one of the newer atypical antipsychotics.

Two experiments are described in which the performance of schizophrenic subjects was investigated, using tests of affect judgement and recognition memory for faces (Warrington), words, and semi-abstract patterns. Schizophrenic subjects were impaired in their ability to describe the emotional states portrayed by actors and presented on video and were more likely to comment on the physical description of the actor or to fail to comment on the emotion at all. Performance on the Warrington Recognition Memory Test for faces suggests a marked impairment in schizophrenia, although impaired performance on recognition memory tests for words and patterns indicates that this abnormality may not be specific for faces.