The National Alliance on Mental Illness recently gave its 2011 Scientific Research Award to Dr. Jeffrey A. Lieberman who has a long and impressive resume in researching schizophrenia. Among his many titles, Dr. Lieberman is chairman of Psychiatry at the Columbia University College of Physicians and Surgeons, and is Director of the New York State Psychiatric Institute. 
Before he accepted his award, Dr. Lieberman gave an hour long lecture about his research. I want to share some key points with you that he made about current medications commonly prescribed for mental illnesses.
First, some background.
Dr. Lieberman was the principal investigator for the Clinical Anti-psychotic Trials of Intervention Effectiveness Research Program, better known as the CATIE study, that caused an uproar in 2005 when its results were published. The reason the CATIE study was controversial was because it compared older, cheaper anti-psychotic drugs –the so-called first generation of drugs used to treat mental illnesses — with the newest generation of anti-psychotics, sometimes called a-typicals, which were and are much more expensive.
Everyone thought the newer drugs were both safer and superior to the older medications based largely on claims by the pharmaceutical industry. What the CATIE study revealed was that the newer drugs were not substantially better than the older drugs at treating symptoms, although some had fewer side effects. This finding led to charges that drug manufacturers had hoodwinked doctors and their patients. An editorial published in 2005 by the New York Times was typical of the public reaction:
“A government-financed study has provided the strongest evidence yet that the system for approving and promoting drugs is badly out of whack. The study compared five drugs used to treat schizophrenia and found that most of the newest, most heavily prescribed drugs were no better than an older drug that is far cheaper. The nation is wasting billions of dollars on heavily marketed drugs that have never proved themselves in head-to-head competition against cheaper competitors.”
In his lecture, Dr. Lieberman repeated much of what he has said before — that media outlets sensationalized the CATIE results. In the American Psychiatric Journal in 2005, Dr. Lieberman summerized what the CATIE study had actually revealed:
The essential import of the CATIE study can be summarized as follows. Anti psychotic drugs, both old and new, are clearly effective and have been a boon to the treatment of schizophrenia. However, they have substantial limitations … The numerous anti psychotic drugs, however they might be classified, are more similar to than different from each other. To the extent that anti psychotics differ, it is more in their side effects than therapeutic effects. ..What works for one person may not work for another. Consequently, treatments for schizophrenia must be individualized.
In his lecture, Dr. Lieberman elaborated on the CATIE findings. He said there are currently about 20 different drugs on the market for treating schizophrenia. Although they are different, all of them work the same way — by blocking how much dopamine is released inside the brain through what is commonly called the D2 receptor.
Simply put, all of them focus on blocking dopamine. Switching medications, doesn’t change the process. The only difference between the medications is the side effects that they may cause and those vary from one individual to the next.
In 2007, the sale of these dopamine inhibitor drugs accounted for about $30 billion in sales worldwide. But many of these drugs are now coming off their patent protections. What this means is that they are going to begin being sold as generic drugs and less profitable. Because of this, Dr. Lieberman said several big pharmaceutical companies are no longer interested in investing in research for new anti psychotic medications. The dopamine ” gold mine” is thought to be empty.
A handful of companies, however, are preparing new anti-psychotic medications. In the 1970s, emergency room doctors noticed that patients who had been using PCP — “angel dust” — mimicked the same symptoms as someone who had schizophrenia. By the 1980s, scientists had learned that PCP interferes with brain receptors by way of an amino acid called glutamate. Now scientists are trying to determine if regulating glutamate, rather than dopamine, might be a safer and better way to control the symptoms of mental illnesses.
Dr. Lieberman said some of these new glutamate drugs with be on the market within two to five years. The question is whether they will be any better than the dopamine drugs — or will they just a substitute?
During his lecture, Dr. Lieberman used the term, “schzophrenia has run its course” when talking about patients who had gone untreated for years. When it was time for audience questions, I asked him what he meant by “run its course.” He said that studies have found that the best time to treat someone with schizophrenia is when they have their first episode. With each episode that happens after that, there is more and more damage to the brain. Eventually, there is so much damage that a patient reaches a ”plateau.” Hence, the illness has “run its course.”
Dr. Lieberman said we need to develop medications that will not only control the symptoms of schizophrenia but also help a person who has reached a “plateau” actually “regenerate” and regain their loss of capacity.
Here’s what I took away from his lecture.
(1.) Our current drugs — older ones and newer ones — only help regulate symptoms and all work the same. (2.) Each person is different so they need medication that is tailored to their individual body with the fewest side effects possible. (3.) Dr. Lieberman said, “Medication is not enough.” Persons need psycho-therapy and other wrap around services to fully recover. (4.) Glutamate inhibitors that are being invented may introduce a new “pathway” for doctors to use to treat symptoms, but whether there will be fewer side effects is still unknown. Glutamate drugs may be just another way to do what dopamine drugs now do. (5.) Despite everything that we know, scientists still don’t have a clue about what actually cause severe mental illnesses, nor how to cure them. (6.) There are blood tests being marketed that can identify people with schizophrenia but these tests are not generally reliable.
Dr. Lieberman ended his talk on a hopeful note. Progress is being made, he said, but it is coming at a ”glacier rate.” Slow, slow, and slower.
On that, I certainly agree.
About the author:
About the author: Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.
