David Pickar, MD

is Adjunct Professor of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD. He is also Former Chief, Experimental Therapeutics Branch, Intramural Research Program, NIMH, and Former Director, NIH Clinical Center 4-East Research Ward for Schizophrenia

The prevalence of schizophrenia in the US is 0.3%. Really? I thank the Treatment Advocacy Center and Dr. Fuller Torrey and Elizabeth Sinclair for bringing attention to the NIMH’s website, which states just that.

A schizophrenia prevalence of 1% of the US population is a foundation fact that has wide implications.

 Torrey and Sinclair discuss this odd error with characteristic pith and accuracy in the 

 The “disappearance” of 2 million patients with schizophrenia is certainly an effective way to bring home the implications of the NIMH error.

response of NIMH Director Dr. Joshua A. Gordon

 to Torrey and Sinclair’s piece does little to persuade that the NIMH is on point. Pardon this 21th century cynicism, but was there an interest in reporting a lower prevalence figure for the most serious of mental illnesses? Might a lower prevalence suggest that it is less a problem? That we have somehow been successful in reducing its occurrence?

The NIMH error is particularly noteworthy in light of recent Congressional efforts to bring attention to persons who suffer with serious mental illness. The Helping Families in Mental Health Crisis Act approved by the House in 2016 and later incorporated into the 21th Century Cures Act in 2017 highlighted the need for renewed, effective attention to this population by Federal agencies. Does NIMH research meet this challenge?

NIMH Intramural Research beds for schizophrenia at St. Elizabeth’s Hospital in Washington, DC and those at the NIH Clinical Center in Bethesda together numbered in the range of 35 to 45 in the 1970s through 1990s. Research into schizophrenia at the NIH Clinical Center today (there are no longer beds at St. Elizabeth’s Hospital) limps along with few inpatients and lacks supporting energy from “above.” Inpatient research beds represent a national resource for families of patients with schizophrenia. No one has used research beds better than The NCI in its Intramural Research Program.

The NIMH website highlights 2 clinical studies, CATIE and RAISE.CATIE, completed in the 1990s, brought home the fact the new generation of antipsychotic drugs is no more effective than older drugs, leaving clozapine, first used in the 1970s and FDA approved in 1989 for patients with treatment resistance as the only antipsychotic drug with enhanced efficacy. RAISE further demonstrates the limitation of current treatment. Unfortunately, the NIMH has never followed up its own leads to improve the treatment of schizophrenia. Dr. Gordon correctly mentions the importance of neurocognitive deficits of schizophrenia, an area pioneered by Intramural NIMH Clinical Scientists. Despite considerable academic and industry efforts, drug development for these deficits has been entirely unsuccessful. A fresh look is in order.

Perhaps just an oversight, the NIMH error about schizophrenia prevalence prompts a closer examination into NIMH’s attention to schizophrenia. I support the suggestion by Torrey and Sinclair for a new study of the prevalence of schizophrenia. It is also time for an independent review of the NIMH’s research efforts into our most serious mental illness.

Dr. Pickar reports no conflicts of interest concerning the subject matter of this article.

 Regier DA Narrow WE, Rae DS, et al. The de facto US mental and addictive disorders service system. 

Hocus Pocus: How the NIMH made 2 million people with schizophrenia disappear

 Gordon J. On the prevalence of schizophrenia-and on the NIMH. 

Articles

Might a lower prevalence suggest that it is less a problem?

The Prevalence of Schizophrenia in the US

Throughout my medical career as a researcher and clinician I have studied and treated serious mental illness (SMI) and the people affected by it. The film, 

 grew out of a desire to have factual perspectives about mental illness accessible to a broad public audience. In recent years, violence has unfortunately become the tragic touchstone that too often draws the public’s attention to mental illness. Despite the fact that the majority of individuals with SMI are not violent, the potential for violence is a reality for some people and situations.

 is a uniquely human disorder. There are no diagnostic tests, including modern brain imaging techniques or genetic screens, that can make a diagnosis of schizophrenia: it is a clinical diagnosis. In the film, Michelle graciously shares her experience with the onset of hallucinations and delusions, diagnostic foundations for the disease. Michelle’s story illustrates a key fact: schizophrenia begins in late adolescence/early adulthood. The illness occurs with a similar prevalence around the world, across races and cultures. Approximately 1% of the population suffers from schizophrenia. It is a common disorder that lasts a lifetime.

The introduction of antipsychotic drugs in the 1950s and 1960s was a landmark, not just for psychiatry but also for all of medicine. The exodus of patients from mental hospitals was principally related to the ability of these drugs to reduce core symptoms, less a function of change in social perspective. Statistics in today’s world are anything but comforting: more patients with schizophrenia are in jails than hospitals, and 40% of patients with schizophrenia are untreated. While the patient bears the greatest pain and hardship from the illness, it is family (eg, parents, siblings), who suffer and hurt along with them. An informed and dedicated mother provides her perspective on the illness and its realities in the film.

In searching for policy that could make a difference I found my way to Rep Tim Murphy (R-PA) whose 

Helping Families in Mental Health Crisis Act

, after a long and grinding path in Congress, was signed into law by President Obama. Funding for these reforms to “our broken mental health system” now awaits House Appropriations Committee action. I am grateful to Rep Murphy for his generous time with us in the film.

The film does not focus on science, in large part because there are not many factual scientific “realities” regarding SMI. I touched on two: affinity and partial blockade of the dopamine D

 receptor, a pharmacological effect shared by all known antipsychotic drugs; second, the fundamental genetic underpinnings to these disorders. I will leave it to a future film to sort through scientific “advances” of our era looking for emerging realities.

Dr Pickar is Adjunct Professor of Psychiatry at Johns Hopkins Medical School and the Uniformed Services University of the Health Sciences. He has founded three companies related to drug development for CNS disorders and serves as a member of the Food and Drug Administration (FDA) Psychiatry Advisory Committee. He is in private practice in Chevy Chase, Maryland. The author reports no conflicts of interest concerning the subject matter of this article.

http://therealitiesofseriousmentalillness.com

In recent years, violence has unfortunately become the tragic touchstone that too often draws the public’s attention to mental illness.

Author | David Pickar, MD

Articles

The Prevalence of Schizophrenia in the US

Putting a Face on Serious Mental Illness