Jeffrey Lieberman, MD is the chairman of psychiatry at Columbia University College of Physicians and Surgeons and on the scientific council of NARSAD. As a clinician and chairman of the preeminent department of psychiatry in the world, Dr. Lieberman is unrivaled in his ability to speak to a lay audience on complex psychiatric issues, ranging from chemical systems in the brain to the traumatic effects of natural disasters.
Dr. Lieberman’s own research focuses on the neurobiology, pharmacology and treatment of schizophrenia and related psychotic disorders. His work has advanced our understanding of the condition and the pharmacology and effectiveness of antipsychotic drugs. Recently we spoke with him on the phone about his April 10th talk in New York for the Healthy Minds Across America series entitled Treatment for Schizophrenia: Current Limitations and Future Promises.
Thank you for speaking with us, Dr. Lieberman. Can you share with us some of what you spoke about at the Healthy Minds Across America program?
I spoke specifically about the current and future status of the psychopharmacology and the psychosocial treatment modalities for schizophrenia and related psychotic disorders. I outlined the fact the cornerstone of treatments are antipsychotic medications and that though we have numerous forms of these medications, what differs isn’t so much the therapeutic efficacy but in the differences in their side effect profiles and level of safety.
There is one, real outlier medication—Clozapine—which is more effective in treatment resistant patients, but also has more serious side effects. Other than that, they are very similar.
Clozapine is often perceived as a “last-resort” medication for treatment resistant schizophrenia…
Actually, though the side effects of Clozaphine may be more serious, they are relatively infrequent. Only one in a hundred patients may have the severe side effects. Nevertheless, this fear has kept doctors from prescribing it and Clozapine is vastly underutilized.
If I were to tell doctors what three things they could do to make a difference in treating their patients with schizophrenia fastest, I would tell them to
- Consider useing Clozapine as soon as a patient shows signs of treatment resistance
- Consider useing more long-acting injectable medications, such as Haloperidol Decanoate, Paliperidone Palmitate and Olanzapine extended release injection in patients who have difficulty adhering to treatment.
- Practice early intervention. It is important try to identify people who are experiencing symptoms of psychotic disorders as soon as possible and begin in treatment—this will improve their chances of recovery.
Those are excellent points. A comprehensive evaluation (that rules out other mental illnesses), and an expert diagnosis are an essential part of a mental health evaluation.
What do you mean by recovery?
There is a chance for recovery at every stage of illness. People with mental illness can lead a meaningful life even though they are having some symptoms. In terms of remission of symptoms this can happen if there is an early enough intervention in many cases. And that is a more complete recovery.
You mentioned the psychosocial component to treatment.
We know that medication alone isn’t sufficient to foster recovery. There are a range of different psychosocial interventions that have been shown to be effective but unfortunately are not as frequently a part of a treatment regimen as they should be. These include
If people with severe mental illness have nothing else other than meds, they should have a concerned caregiver; whether it is a therapist or a family member who supports the person through the bureaucracy of the system and helps them secure a stable lifestyle.
These should all be part of any treatment plan.
The absolute essentials for people with chronic schizophrenia are maintenance medication (in an effective/tolerable dose) and having a concerned and committed caregiver.
What message would you like to share with people with schizophrenia and their families?
Despite the frustrations and limitations of treatment, the reality is that a person with a mental illness such as schizophrenia is far better off today than at any point in history—the knowledge and the capacity we have to treat people is greater than it ever was.
Also, there is tremendous momentum in terms of research and better quality of care.
We have noticed certainly at the state level that there have been severe cuts to services and that some predict Medicaid cuts to only grow in the next several years.
Yes. We are lacking the political will to provide the necessary services.
That is really a philosophical issue—who counts, whose life has value, who deserves medication and treatment. What can we do about that?
There needs to be a larger grass roots effort on the part of mental health care providers, patients, families, and advocates. A coalition of all these individuals and groups can [make a difference]. In lieu of that we will have to wait for a crisis to happen that will force changes to be made.
Has your research led to pharmaceutical interventions or other discoveries for the treatment of schizophrenia?
Yes, the use of clozapine, adjunctive treatments to antipsychotic drugs to enhance efficacy and safety and the finally the need for and strategy of early intervention.
Thank you for your time, Dr. Lieberman.
Jeffrey A. Lieberman, MD, is a physician and scientist who has spent his career caring for patients and studying the nature and treatment of mental illness. Dr. Lieberman is currently the Lawrence C. Kolb professor and chairman of psychiatry at Columbia University College of Physicians and Surgeons, and director of the New York State Psychiatric Institute. He also directs Columbia’s Lieber Center for Schizophrenia Research and is chief psychiatrist at New York Presbyterian Hospital-Columbia University Medical Center.