Psychiatry & Psychotherapy Podcast - Schizophrenia with Dr. Cummings: Controversies, Brain Science, Crime, History, Exercise, Successful Treatment

Episode Date: March 6, 2018

In this episode, Dr. Puder addresses the fascinating realm of schizophrenia with Dr. Cummings, a previous guest in the show. Dr. Cummings is a psychiatrist with a wealth of experience from working at Patton State Hospital in California, one of the biggest forensic hospitals in the world. -Defining Schizophrenia -Living with Schizophrenia and Perception of Reality -Are Negative Symptoms in Schizophrenia Precipitated by Medications? -Emil Kraepelin, and the Early Studies on Schizophrenia -The Pathology, Biology, and Genetics of Schizophrenia -Cannabis Use and Risk For Schizophrenia -The Loss of Brain in Schizophrenia -Counter-arguments Against Robert Whitaker's "Anatomy of an Epidemic"         -Schizophrenia Prevention in High Risk Population -Australian Study on Children of Schizophrenic Parents -Crime, Violence, Mass Shootings and Schizophrenia -Medical Management of Schizophrenia -1st Break Psychosis -Long-acting Injectable Antipsychotics in Early Illness -Medication Adherence -Exercise, Lifestyle, Diet Optimization By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder CV of Dr. Michael A. Cummings Assistant Producer: Arvy Wuysang Editor: Trent Jones

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Okay, so I am back here actually at Patton State Hospital with Dr. Cummings, and today we're going to be talking about schizophrenia. We're first going to go over, you know, what is schizophrenia,

what are characteristic of the hallucinations, delusions, the negative symptoms of schizophrenia. How do you differentiate this from other things? You know, what do we, how do we make sense of the different environmental factors that increase the rate of schizophrenia? We're going to look at the why of schizophrenia, the genetic influences, the brain changes, we're going to look at the rates of crime in schizophrenic patients and, you know, do people with

mental illness commit a lot of crimes? Do they, are they responsible for a lot of the violent crimes going on? We'll also talk about medications and discuss some of the controversy over, you know, is it good to leave someone on medications long term for schizophrenia? we'll talk about a little bit on the research that's out there on long-term studies, and if it is a good idea to treat someone inevitably, or, I mean, not inevitably, but continuously, and how to best sort of optimize someone's long-term trajectory with schizophrenia. So I'm here with Dr. Cummings.

Okay. Schizophrenia is essentially a cluster. or spectrum of illnesses that are related to each other genetically that are characterized at their heart by psychotic symptoms psychosis being defined as a loss of ability to test reality all of us as we get sensory input kind of automatically in the background check our senses against our past experiences and make a judgment as to whether what just happened, such as hearing your name called in a room where no one else is present, or interpreting something as an

animal in dim lighting is real or whether it is an error in our sensation. in this illness and all psychotic illnesses, the core symptom is really a loss of ability by a part of the brain called the dorsolateral prefrontal cortex or the working memory area of the brain to take the current experience, compare it to past similar experiences, and essentially make that judgment. Is this something that was likely to have happened or not?

if that ability becomes impaired, people then have great difficulty distinguishing between reality and events that may be based on abnormalities in their own biology that are giving them essentially false signals about themselves and the environment. And that can indeed lead to delusional thoughts or fixed false beliefs about themselves or about the environment. There are also changes in the brain that bring about the negative symptoms such as blunting or flattening of emotions and affect, a loss of language abilities, and certain cognitive deficits such as a loss of verbal fluency that are characteristic of the schizophrenia spectrum disorders. So what you're saying is that, so let's say a normal person hears something in their brain like you're stupid or you're ugly, they might say, well, that's part of me that's sort of, you know,

maybe a little bit critical, but that's not the reality, whereas someone was schizophrenia when they hear that in their brain, they think that that's the reality? Is that what you were saying? Very much so, yes. In fact, not just in the brain. A survey done in, I believe it was Sweden, found that roughly half of the population acknowledged that they had occasionally had misperceptions of the environment that could be considered psychotic in nature, for example, being fatigued and hearing their name called when there was actually nobody there, or seeing a shadow in the dark and thinking it was an animal, turned out to be a potted plant. Those people, though, however, did not have a psychotic illness because their brain said,

no, not likely. You know, this is not normal for reality. And they just reject it out of hand and go on with their lives. What's different in the person with a schizophrenic brain is they lose that ability to make that judgment. And like all human beings, if we have an experience, that's unusual or fascinating, you know, such as hearing your name in a room that's empty, if you can't distinguish that as not being real, well, then you're left with, well, how do I explain that? And that often leads to delusional thoughts.

Well, maybe God is talking to me or maybe angels are talking to me or maybe demons are talking to me. Or maybe it's space aliens, you know, so you can develop. elaborate belief systems to try to explain these experiences. Now, those have varied over time depending on the cultural context and history. And before people, before the modern era and spaceflight and airplanes, people did not develop delusions about UFOs, for example. Oh. You know, one thing that comes to my mind is a patient who would be taking showers

and then would see like spiders on the ground. And the person who brought this patient in said that he would be in a shower and would start screaming and start stomping on the ground. And it was just incredibly frightening for him. And so that kind of difficult, like extremely, you know, agonizing sort of type of hallucination, I think is common in this population,

which it really does, you know, disturb and conflict with them. Yeah, certainly the human beings are prone to at times frightening or disturbing images and thoughts. I think everyone has had anxiety dreams or nightmares where they often perceive horrific images or ideas or sounds. For the person with a psychotic illness, that can occur during, wakefulness and indeed if they've lost the ability to distinguish reality from non-reality then for them it's a very real experience and is often a very disturbing experience the most common type of hallucination in schizophrenia is auditory that is people hearing things that aren't real people do however

have a full range of sensory experiences that can be hallucinatory and that can include, of course, seeing things that aren't actually there or misperceiving things that are there, but not being perceived accurately, smelling or tasting things that aren't really there, or feeling things that aren't really there. People sometimes experience tactile hallucinations where they feel like they're being touched. And, of course, people, whisk as a phrenia spectrum disorders,

can have multimodal hallucinatory experiences where they essentially all of their senses have become engaged in experiencing essentially a non-reality. Reminds me of a patient I was called to in an ER once who thought that worms were crawling all over her legs. And after telling the ER physician that the ER physician, you know, paged psychiatry. And I ended up looking at her legs and she had cellulitis. But for her, you know, in her description and because she had schizophrenia, at baseline, she sort of put the two together that there was something other than just, you know, salewitis, which is kind of an inflammatory disease going on in her legs. And so we were able to,

you know, get her the antibiotics for treatment and the sort of psychotic sequela died down in that process. Yeah. Well, it's certainly true. People can have hallucinations, which are defined as there's essentially, it's a false sensory signal. There are either. is nothing in the environment that's related to it. Or people can have illusions, which are distortions of perception. There is actually something in the environment, but it's being misperceived as something else. The classic example among healthy people is catching something out of the corner of your eye and dim lighting, such as a plant or a rock or something, and momentarily thinking that

that it's an animal of some kind or something threatening. Largely, that comes from the fact that as a species, we and our ancestors have at times been prey, and it's good to pay attention to things in the environment, otherwise you might wind up as lunch. But a lot of it, if our information from the environment is partial, our brain fills in the gaps, and we make our best guess as to what it is that,

might be out there looking at us or watching us in psychotic illness that grows from being vigilant about the environment to being paranoid about the environment so what are some common like hallucinations the auditory hallucinations that men and women have often the auditory hallucinations are of multiple voices sometimes familiar voices such as family or friends sometimes stranger voices they often take on two types, one in which the voice speaks directly to the person, sometimes giving them commands, such as giving them command hallucinations, do this, do that, which can be a risk if the instructions are to do something violent to themselves or someone else, or often voices

that carry on a running commentary about the person's actions, where the voice. will be quotes talking to each other about what the person is doing in some ways that's a variant of what everyone does in terms of thinking about their own actions and healthy people if you ask them well when you've been talking things over in your mind now you're aware it's your own mind who are you talking to in the psychotic person that talking to becomes perceived as other or not part of the self. You know, in essence, this comes back to something that's characteristic of all illnesses.

The symptoms of an illness are distortions or aberrations of what were normal physiologic functions. Hallucinations are essentially aberrations that occur in the sensory systems. delusional thoughts or an elaboration of our normal vigilance about the environment and trying to explain what's happening to us. Okay. And let's talk a little bit about negative symptoms. Is that from schizophrenia itself or is that from the medications? It can be from both.

The illness itself does have a tendency to cause negative symptoms. which are characterized by a lack of motivation or initiation, a flattening or blunting of affect, sometimes abnormal affect where the person's thoughts and words don't go together with what their emotional expressions are. The antipsychotic medications, however also, particularly the dopamine antagonists, can worsen negative symptoms.

as well as can also cause some impairments in cognition as well. So if it's a strong dopamine blocker, like Haldall, I've seen the sort of flattened facies, you know, like where the face doesn't have as much expression. Yes. Well, the effect of dopamine is to increase motor activity, including expressiveness and the facial muscles and activation. If you're looking at a particular molecule or a compound

and you want to know if it's a dopamine agonist, something that promotes activity and dopamine circuits in the brain, if you give it to an animal and the animal increases their physical activity, they move around more, they walk forward, it's likely a dopamine agonist. And the inverse of that, of course, is if you give them an antagonist, they become still more quiescent. If they have much facial expression, they have less facial expression. And does the negative symptoms get worse over time? They do.

One of the things that has occurred since Creppelin in the 19th century first described schizophrenia is that the antipsychotic medications have stretched out the progression of the illness. And if you go back and read his descriptions of his patients, most of them were described as essentially being vegetative by the time they were in their 40s. You're going to need to define vegetative. Vegetative, sitting, staring into space, not interacting very much with the environment, largely inert, being a lump.

Yeah, so just more like catatonic, would you describe that state? Catatone is a somewhat specialized sub-state. It's also characterized by lack of movement in at least the stuporous form. The person appears stuporous. They don't move very much. They exhibit what's called waxy flexibilitus, which means if you hold their arm or their hand up and you turn loose of it, it will stay there for the most part.

It will gradually drift down. due to gravity, but they largely look kind of like a waxy statue. The people who are blunted or have prominent negative symptoms basically just don't interact very much. Okay. So when I was overseas in Haiti, we would see some homeless, the homeless population that was obviously psychotic and psychotic for a long time. and I think it's just rare in the first world to see that in the same way.

It is. It's unusual for people in the first world countries to go for as long a period without treatment. Although even in first world countries, by and large, schizophrenia is undertreated, this might be a good area in which to talk a little bit about the pathophysiology or the biology of schizophrenia. Yeah. Although we think about this as an illness in adults, the truth is the abnormalities, the expression of the abnormal genes, of which there are some 106 candidate genes that have been identified as contributing, begins in the second trimester of pregnancy. In the healthy brain, very young nerve cells or neurons are actually modal. They can crawl like amoeba do. Wow.

And in the second trimester, those cells divide largely down in the central part of the brain near the ventricles. And then they literally crawl along pathways that have been laid down by the brain's structural cells, glial cells, to where they're supposed to be as adult neurons or nerve cells in the brain. In the schizophrenic brain, many of those nerve cells don't make it to where they're supposed to go. so you'll find them down in the white matter in the brain. Those that do make it to where they're supposed to go don't show the nice, neat, and orderly organization

that are characteristic of healthy neurons. So this is an illness that starts before birth. So it starts in the second trimester, and it seems to progress from there. How is that discovered or what is, like, how do you make sense of that? Okay, well, the discovery was largely based or has been largely based early on on post-mortem studies, people with schizophrenic brains. For example, the abnormal migration, they initially found that there were clumps of neurons down in the white matter where they weren't supposed to be,

which means that they basically never made it to their target. They also, in looking at post-mortem, schizophrenic brains and looking at the organ, organization of the neurons found that spatially, normally neurons, particularly in the cortical layers, line up in very nice neat rows, sort of like somebody with a highly organized kitchen cabinet. In the schizophrenic brain, though, the cells are kind of disoriented. They're not lined up in neat rows. They're kind of jumbled. The number of connections between neurons is decreased and the number of neurons is decreased. Over time and with the addition of imaging and pet studies to look at metabolism, schizophrenia has largely become characterized as a

developmental dementia. In some ways, resembling the dementias that occur at the end of life like Alzheimer's disease or Lewy body dementia, but in this case being a developmental dementia in which there's first abnormal neuronal development, and then across the early part of the life childhood and early adolescence, there tends to be an excessive loss of the connections between nerve cells, as well as an excessive death rate for neurons themselves.

So that it's a bit like reaching into a computer and slowly clipping away a few too many wires. And as you might guess, using that analogy, eventually the processing of information becomes disorganized and abnormal. And in many ways, that's often what you see then when the person has onset of overt psychotic symptoms in their late teens or early 20s, which is characteristic for schizophrenia spectrum disorders. Yeah. Regarding the second trimester, I was reading about, you know, there's different stressors that can sort of increase the rate of schizophrenia, such as higher, it's higher in urban

environments, when there's birth complications with hypoxia, greater paternal age, prenatal adversity, stress, infection, malnutrition, maternal diabetes. So, and it's not like the association is really strong between those. No, I, you know, in large parts, schizophrenia is a, is a genetically determined illness. The worldwide risk of schizophrenia is about 1%. That does vary, and the lowest rate on the planet is in Taiwan at 0.4%. The highest rate on the planet is in the Irish population in Ireland at about 2%. Wow. So it does vary, but by and large it centers right around 1% across most of the world. There are things that can increase that.

As you pointed out, there's several factors. Childhood adversity, insults or stressors during pregnancy, including things like viral infection during pregnancy. I think it's important to say, like, what, you know, how strong is that a predictor of developing schizophrenia? Is it, is it, are we talking about, like, if this happens, then you will develop schizophrenia? Well, not completely. It's a combination like many illnesses are of genetic risk plus enough

environmental insult to bring about the illness. Now, if you are just a general person in the environment and on the planet Earth, your overall risk is about 1% of developing schizophrenia. if you have one parent who is schizophrenic, it bumps up that risk about tenfold to about ten percent or one chance in ten. If you have a sibling, a brother or sister who is schizophrenic, then your risk is up around 13 to 15 percent. If you have both parents are schizophrenic,

then you're talking about a risk of 40 to 50 percent. So almost half. And if you have an identical twin, who has schizophrenia, your risk is about 70%. So that does two things. One, it says it's a very strongly genetic illness because identical twins have exactly the same genes. Well, they also have exactly the same womb environment, though.

They have the same womb environment, but they don't have the same postnatal environment. There are things postnatally that can, of course, increase risk as well, such as childhood adversity, abuse of some illicit substances, in particular the stimulants or other drugs that impinge on the dopamine system, can promote the development of schizophrenia. What about, since we're talking about drugs that promote schizophrenia, what are your thoughts on marijuana promoting psychotic illness or schizophrenia?

It appears to do so in a minority of people, and we actually know that. the gene association for cannabis or marijuana-induced psychotic or psychotic responses, it occurs in those people who have a variation in the gene that codes for a brain enzyme called catechol-o-methyl transfraise. It's one of the enzymes that breaks down neurotransmitters like dopamine. Wow. If the 151st position in the amino acid chain that makes up that enzyme has a replacement of methionine by valine, that occurs in about 8% of the population. That person, when they smoke marijuana, rather than getting a pleasant high and a relaxed

feeling is likely to become acutely paranoid. Those also appear to be the people in whom cannabis may be promoting the risk of developing a permanent psychotic illness. So before you smoke weed, ask your marijuana dealer to run a genetic test. Either that or certainly if you experiment, as many people do in adolescence with marijuana, if your response is different from that of your fellows, that is, they become relaxed and you become hypervigilant and paranoid and begin to feel like things are after you, that may suggest that you should definitely thereafter stay away from marijuana or hashish

or any of the other cannabinoids. Let's talk a little bit, any other brain abnormalities that are present in schizophrenia that you want to touch on. Yes. One of the things I wanted to touch on that's very important, and this will get us into the area of treatment, clearly this is not. an illness that has effects from the second trimester onto when it becomes obvious that the person has a psychotic illness. One of the things that's very important at that point is that the rate

of loss of neurons and connections between neurons accelerates with the onset of overt psychotic illness when the person starts hallucinating, having delusional thoughts. And in fact, Henry Nazarala has done a very nice series of brain imaging studies in which he demonstrated that on average people with schizophrenia lose 2% of their brain mass for the per year for the first five years of suffering from schizophrenia. Well, that's 10% of their brain that's gone. The more relapses they have of psychosis during that time, the more severe the loss is. Has anyone been able to differentiate medication use versus no medication use in that brain loss? Yes, those people who are more adherent to their medications, to the antipsychotics, are less, they still lose brain, but they don't lose as much.

Okay. Every relapse of overt psychosis, the person has, worsens the biology of the illness. It progresses more, which gets to the question you had about continuous versus non-continuous treatment. Yeah, maybe I should pose like the sort of a context. There was a book, Anatomy of an Epidemic by Robert Whitaker. And he basically argues that, you know, medications long-term make people with schizophrenia worse. And he says there's no, like, long-term studies that show that medications actually help people compared to people not being on medications. And so I really think that this is out there in the culture and the milieu and people wondering, you know, should we be on antipsychotics?

Should we get off antipsychotics? So I thought I would kind of bring that up. Well, there are two counter arguments to his opinion. First, there are Crepland's original observations. Crepland lived at a time when there were no antipsychotics. And indeed, by the time his patients were in their early 40s, they had deteriorated to the point of largely being mentally absent or vacant. with antipsychotic medications, we don't see that to the same extent.

People now live into their 70s, 80s, 90s. They do have abnormalities associated with schizophrenia, but they haven't deteriorated to the same degree that Creplins patients deteriorated. The other element that argues against that viewpoint is that it's very, clear that starting and stopping antipsychotic medications promotes progression of the illness. They actually tried antipsychotic holidays during the 70s and early 80s. They would get people into remission. That is, they were not overtly psychotic.

They would take them off of medications and invariably they would relapse. Those people who had antipsychotic holidays when compared over four or five years did much worse than those people who took antipsychotics continuously. And that makes sense if you consider that the underlying pathophysiology of the illness is that relapses produce severe abnormalities in neurotransmitter activity that may produce toxic metabolites of those neurotransmitters. promoting the loss of neurons and the loss of connections between the neurons. And I think just kind of from my own perspective of working in a psychiatric hospital and seeing

these patients, like when patients are psychotic, it's extremely extreme. I mean, this is like a high stress state and it can go on for a long time. And we know that high stress states are really damaging to the hippocampus and to the brain. Yes. And so, you know, leaving someone. in that state is just, it would be torture. It is torture. It is torture.

It's a very difficult, very difficult illness to live with. Most people indeed aren't aware that, although people think about suicide in relation to things like major depression, the suicide rate among schizophrenia is actually higher than that among people with major depressive illness. Lifetime percent. I read it was 5%. Have you, or go ahead. The best figures I've seen out of the World Health Organization, 3.6% completed suicides for people with major depression.

Okay. 3.9% for people with chronic schizophrenia. So it's a very debilitating illness. It's also a very lethal illness for many people. It's been well demonstrated that every time somebody has a psychotic break, they, often don't get back to baseline. At least after the first break, they often can get back close to baseline functioning. Second break, not so much. Third break, less. Fourth break, even less. And indeed, if you take people later in life and you collect a group of people post-mortem and simply weigh their

brains, and you collect a group of people who died with schizophrenia in their 40s, 50s, 60s, and weigh their brains, the schizophrenic brains on average are about 25% less mass. They've lost a lot early in the illness. It slows down, but it doesn't stop. All of those would argue against medication holidays or stopping medication when the person achieves remission. Someone who is maybe educated in this might argue about these studies where they followed patients for, you know, 20 years. like Martin Hollow and colleagues. You know, they followed 139 patients with schizophrenia for 20 years. And this is not a randomized trial.

And there were some patients who were needing less medications or no medications. They actually seem to be doing better versus those on medications seem to be doing worse. And so this is kind of like an argument that the people who would say, no, medications long term are bad. Any thoughts specifically on this argument? and then I'll give some of my thoughts.

Yeah, indeed, that was not a randomized trial, and I think the studies like that tend to select people who have less severe forms of schizophrenia. Probably one of the best studies that looked at this in a more controlled manner was a study done by Michael Gitlin at UCLA. He took a group of schizophrenic patients, got them all into remission, that is no overt psychotic symptoms. These were all first break schizophrenic patients. He then stopped their antipsychotic. 76% of them relapsed within 12 months.

By the time he was at two years, 96% had relapsed. In the third year, only an additional 1% relapsed. And then he had a final 3% who essentially did not relapse, which gets back to the issue that this is a cluster of illnesses or a spectrum, you know, stopping the medication was probably an okay thing to do for that last 3%, but we're talking 3% or 3 out of 100 people for whom that strategy works well. It clearly is not something that suits the vast majority of people with schizophrenia. One of the issues that people have been wondering about,

since one of the reasons we have such a poor outcome in schizophrenia in terms of treatment, only about 6% of schizophrenic persons are able to live independently, have jobs, have families lead what would be considered normal, healthy lives. That's not surprising, given that we have an illness that starts in the second trimester and we don't start treating it until around 20. 20 years later, the illness has been going on unchecked for two decades by that point. There have been studies largely in Australia where they took children of schizophrenic parents. These are people who had a 50% chance of themselves becoming schizophrenic.

They put them on low-dose antipsychotic medications, Resperadone, half a milligram, olanzapine, a milligram and a half. Doses way below what you would use to treat active illness, and basically just followed them from throughout childhood and adolescence. The rate of conversion to active illness was about five-fold less in those who were taking low-dose antipsychotics, suggesting that the antipsychotics may have some preventive capabilities, The caveat in this is that at present time, since most cases of schizophrenia are sporadic,

they don't come from schizophrenic parents. We don't have a great way to identify who in the population is at risk, so we wouldn't know who to give the antipsychotics to. Now, one of the questions those studies haven't yet answered because they haven't been going on long enough is if you protected people long enough, long enough that is all the way through brain development into around age 25. Could you then stop the antipsychotic and they would be past the point of risk for developing overt schizophrenia? Wow, that is really interesting. Hopefully, once we understand the genetics better, we'll eventually be able to predict who's at risk. And then we could get away with treating them long term with very low-dose antipsychotic medication.

and actually prevent the illness. That would be an ideal outcome because, like most medications at very low doses, the risk of the medication becomes correspondingly less as well. So another sort of line of questioning is, you know, in the news there's been a lot on, you know, these violent crimes and this is a mental health issue. You know, are schizophrenic patients more violent

than the average American? and, you know, what are your thoughts on that? The answer about rates of violence among people with schizophrenia is, yes, they do have a greater risk of violent behavior, particularly if you look at people who have persecutory or paranoid thoughts, they may be prone to behave violently because in their mind they believe they are defending themselves against an active threat. And if their perception is that the threat is acute, it's not uncommon for them to act out by hitting someone

or being otherwise violent. Now, having said that, if you look at the overall crime statistics in the United States that are published by the FBI, the mentally ill, all mentally ill, taken together, they're not just schizophrenics, account for only about 5% of crimes, violent crimes. Which, of course, the inverse is that that means that 95% of violent crimes are not committed by people who are suffering from a mental illness. So 95% of violent crimes are not committed by someone with mental illness.

Right. And indeed, if you look at the phenomena of mass shootings, Some of them are committed by people who suffer from mental illness. It's very likely, for example, that the shooter at the theater in Aurora, Colorado, was suffering from a paranoid psychosis. He had persecutory paranoid delusions. On the other hand, you have people like the shooter in Las Vegas. We don't know what his motivations were,

but there was no overt evidence that he was mentally ill. You have the most recent shooting in Florida in which, while the person may have had some characteristics of autistic spectrum disorder, this appears to have been anger over having lost a girlfriend. Well, that's not a mental illness. I don't know, though, because a year before, he threatened on YouTube that he was going to be a school shooter, a professional school shooter. interestingly he said he was hearing voices but he hit his tracks he hit his gun he tried to blend in with the crowd all of which we would not see if he was truly psychotic if he was truly psychotic he would not try to hide the crime i don't know if you have any thoughts on that it would depend on the nature of the psychosis and certainly people who psychotically believe that they are

defending themselves for example they're paranoid they typically don't try to try to hide the crime. In fact, they may actually themselves call the police to report the crime because they believe they have acted correctly. There are people who commit crimes who are mentally ill, but still recognize that killing people is morally wrong, and consequently they will attempt to hide the criminal act itself. But getting back to the issue of are all people who are mass shooters, mentally ill, the answers is no.

People have a variety of motivations for such behavior, often not associated with mental illness. Is there any research where people have looked at the commonalities in those things in an articulate way and sort of found, you know, common motivations between them? They have. The one motivation they seem to have in common is a desire for notoriety. to have their actions or their cause or their message recognized broadly.

Good example, where in San Bernardino, the San Bernardino shootings were carried out by two people who had a great deal of sympathy for ISIS, terrorist organization, and they planned their mass shooting in response to that political ideology. again, an example of somebody who was acting in this case out of a political ideology, not out of mental illness. Well, maybe in a future episode we'll go into this in more detail, but I want to get back to schizophrenia.

You know, I was reading about this and I was thinking maybe it would be worth touching on the medications and your thoughts on where you would start. Like, let's say you had a first break psychosis. what are your thoughts on where you would start? Currently among the antipsychotic medications, we now have a large variety of things to choose from. The good news with first break psychosis is that people who are having their first episode of psychosis

are typically very responsive to treatment. Often modest doses of antipsychotic will put them into remission. from their active psychosis with a response rate to almost all of the antipsychotics that's greater than 90%. Unfortunately, by the time people have had schizophrenia for around five years, that response rate is down closer to somewhere between 50 and 60%. Again, owing to progression of the schizophrenia, most psychiatrists these days would start with a second generation antipsychotic. These are drugs like Olanzapine, acinopine,

quatiopine among the quotes peens or risperidone or one of the other drugs like Zeprazadone or Ilaperidone among the dons or they may start with a partial agonist

like aeropiprosol all of those would be certainly acceptable choices. I think one area that in U.S. psychiatry we don't consider often enough is we should be thinking more often about long-acting injectable antipsychotics earlier in the course of the illness. We tend to view those as a class that are of last resort after the person has proven their non-adherent. Only about 10% of people with schizophrenia receive long-acting medications in the U.S. In Europe, that's closer to 60%.

and they frankly have somewhat better long-term outcomes than we do. 60%? Yes. Oh, wow. Wow, I didn't realize it was that high. They are more aware in Europe that the characteristic history of schizophrenia in the first few years of illness is that the person takes an antipsychotic, they get better, they go into remission, not uncommonly. And then, like, as is often the case, people think, well, gee, I'm feeling okay now.

Do I really need this? Right. Or it wasn't me. It was everyone else who was crazy. And they'll stop the medication, have a relapse. Well, every time they do that, as we've noted, they're losing more brain. One way around that is to give the person a long-acting medication. You know, it's readily apparent if someone doesn't show up for their injection.

whereas if you give somebody a bottle of pills, by and large, you have no way of knowing whether they're actually taking the antipsychotic or not. And in fact, most of the adherence studies that have been done in communities in schizophrenic patients suggest that the rate of adherence defined as taking 80% of the medication is only about 40%.

Now, there's also kind of a delethora of, among psychiatrists, because if you show those numbers to psychiatrists, they'll go, yeah, yeah, yeah, I've read that. But not for my patients. But not for my patients. No, I feel the same way. I'm like, yeah, not for my patients. And then I see one of my patients in the psychiatric hospital.

I'm like, oh, it has been a while since I've seen you. What happened? Oh, I stopped taking my medications and I thought I was doing better. And I'm just like, oh, and I started smoking weed and using meth again. I'm like, oh, great. Yeah. You know, and it's true not only of, um, people with schizophrenia, you know, frankly, people in general, when it comes to medication adherents, there are limits.

Most people don't like to take medications chronically. You know, certainly if you ask, except for those people who are very obsessive, have you ever actually taken all of the doses in a 10-day course of four times a day antibiotic? The vast majority of people have not. They miss doses. Certainly one thing psychiatrists can do about that is to make the antipsychotic regimen as simple and straightforward as possible. The fewer number of doses per day, the more likely it is the person will actually take the medication. Luckily, most of the antipsychotics, the oral antipsychotics, can be dosed entirely at bedtime after titration. There's no reason to give somebody an antipsychotic three years.

or four times a day. Yeah. What do you think about like lifestyle things? Like I was reading an article, two articles on exercise. I'll put the links in the show notes or on the website. And in one study, they found that exercise for schizophrenia increased hippocampal size by 12%. It was 16% for controls. That's people who received exercise but didn't have schizophrenia.

and it was negative 1% for the non-exercising group of patients. Do you think, you know, like this is something that could be helpful in the long-term treatment? Certainly things like exercise, maintaining a healthy diet, maintaining social engagement, all of those are things that are pluses for people suffering from schizophrenia. In fact, if you read the books of those people who suffer from schizophrenia who've been successful in dealing with their illness, people such as Lori Schiller, you'll find that in addition to the medications, they also have made a great deal of effort to maintain exercise, maintain social contacts, maintain a more active life. you know people with schizophrenia on the whole live an average of 20 years less than the general population a good portion of that is because of a sedentary lifestyle often very poor dietary habits concurrent use of drugs and alcohol and as we mentioned previously an elevated suicide risk

Yeah, smoking is like, I think, 50% in one study they found. Yes, and that's actually down over historic norms. If you go back before smoking in general began to decrease in the U.S., the smoking rate among schizophrenic population was often up around 70, 80%. Talk a little bit about, like, advice you would give to families if they had a schizophrenic son or daughter or, you know, let's say who was in their 20s and developing this, what advice would you give them? I think probably the first piece of advice I would give them would to become educated about schizophrenia. And that's an area certainly where mental health professionals can contribute a great deal by helping to educate families about how to manage the individual with schizophrenia.

how to help that individual stay engaged, stay active, stay on their antipsychotic medication. Often families are very frustrated because they are trying to get the person help and often in our current medical care system have a great deal of difficulty doing that. So there's a great deal of room for improvement and our support of families

because it's often the families that are the primary support for the support for these individuals. Mental health professionals ought to be doing a lot more than we do to support groups such as the National Alliance for the Mentally Ill and to help them manage people with schizophrenia in terms of getting those people to help they need. I've read about decreased emotionality in families can be helpful.

Yes. High expressed emotion, particularly critical or negative, negative emotionality can be a destabilizing influence for the person with schizophrenia. One of the characteristics of schizophrenia in terms of interpersonal interactions is the the person with schizophrenia often does not have a clear sense of the boundary between themselves and other people. And negative or critical comments or emotion often will drive them back toward a psychotic relapse. And indeed, when they've helped families essentially study how to interact with the person with schizophrenia,

it often improves the long-term outcome. You know, schizophrenia is a chronic relapsing illness. And as with any chronic relapsing illness, the goal often becomes to decrease the number of relapses and to increase the duration of stable periods. And certainly family interactions and family support can be a major part of that. Yeah, I think that's so, it's so helpful to have meaningful relationships. And I think, you know, having families get resources that can help them understand schizophrenia and then how to better sort of interact with the symptoms,

when they do happen and how to get good treatment, how to monitor if the treatment's going on. I have one patient who comes from my mind in particular that the family has done a really good job. And this person was psychotic for years before they came to see me in and out of psychiatric hospital. And now has moved on with their life, is applying to a professional school,

is actually worked through college and finished a lot of his coursework, and is doing really, really, really well. And the family is very supportive. Yes, family can be a very important factor in that. It's very difficult for the schizophrenic individual to make that kind of progress, but it is possible. One of the major stumbling blocks and one of the major educational points for families is that one of the common characteristics of the illness is a feature called anosagnosia or loss of insight.

that is the person is not aware of their own illness. Often at the outset, you know, there is a tendency, well, my perceptions are real, my thoughts are real. All of these other people are part of the conspiracy, or it's everyone else who is crazy, or some variant of that. Often those schizophrenics who do manage to get themselves together and to adhere to treatment and to make progress in their life are those. who can get past that to the point where they recognize that they are suffering from a chronic relapsing brain disease and that the best thing they can do is indeed get that disease treated not only by medication but by psychosocial support and by staying engaged and exercising and doing all of the other positive things they can for themselves.

Yeah, I briefly looked up schizophrenia and diet, and there haven't been that many great studies done on this, like how to optimize diet. But there are a lot of studies on how to optimize diet for diabetes and for, you know, a lot of the sort of core morbid things that happen to people with schizophrenia. And so just I think that, you know, a Mediterranean-style diet likely will be one of the ideal diets for this population. Yeah, certainly at least a healthy diet. diet. Healthy diet, right. You know, I can tell you from having worked with a number of schizophrenics over years that when you ask them about dietary habits, often, frankly, they're horrible diets.

It's, you know, a diet comprised of fast food and junk food and everything that we should, that none of us should eat in large amounts. There was one study that looked at schizophrenic brains on autopsy, and they had a lower omega-3 content than the average population. Omega-3s is a healthy fatty acid that's found in things like flaxseed and chia seed and salmon, and it was lower in schizophrenic patients. I don't know if you've seen that one, but it kind of makes me think that either there's something going on

where there's less good fatty acids getting into the brain or there's just a poor diet in that sort of pot. population in general. Yeah. Frankly, we don't know why they have a lower level of omega-3 fatty acids. Certainly the diet for many people with schizophrenia would not provide them with much in the way of omega-3 fatty acids. Yeah.

Well, we've covered a lot of topics today on schizophrenia. And if after reading this, you have any questions? follow the show notes to one of the social media links. And there's going to be a post on this particular episode. If you have any questions, throw them up there. And maybe in a future episode, I'll have Dr. Cummings respond to them or I'll respond to them. And yeah, I hope this was helpful for you. If it was, I really appreciate that you share it.

And we'll leave it there for today. Thank you, Dr. Cummings. Okay. Thank you.