Reintegration & Recovery >> First Person

Dr. Ralph Aquila shares his perspective on some recent research

Psychiatrist Dr. Ralph Aquila, executive editor of this magazine, is a leading expert on schizophrenia-spectrum disorders and the reintegration process.  He is chairman of the Center for Reintegration, director of Residential Community Services at St. Luke’s-Roosevelt Hospital Center in New York City and Assistant Clinical Professor of Psychiatry at Columbia College of Physicians and Surgeons. He is also a consultant to New York City’s Fountain House and is the 1999 recipient of the NAMI Exemplary Psychiatrist award.

As a psychiatrist for the past 20 years, I have treated patients both before the availability of atypical antipsychotic medications and after the introduction and widespread use of these drugs. In my experience the newer agents have been a tremendous boon to people with schizophrenia-spectrum disorders. 

The new drugs have provided significant improvement around cognition while lessening the negative symptoms of schizophrenia-spectrum disorders—domains we could only dream about improving until most recently. As a result, the medications worked to raise the level of expectations for persons with serious and persistent mental illness, as many of these people can now hope to live independently and productively. 

Unfortunately, there was and is a persistent spate of misinformation about side effects of these newer agents. Specifically, glucose dysregulation, dyslipedimia (high cholesterol or tryglycerides) and obesity have been identified as concerns in several recent studies that were prominently featured in the news. However, it’s important to point out that there have been no studies showing any direct cause and effect as far as glucose dysregulation and dyslipedimia are concerned, though there is some evidence pointing to appetite increase with the atypicals that may lead to obesity.

What is unquestionably true is that persons with serious and persistent mental illness have a greater prevalence of other medical disease states than the general population, and this important factor is often ignored by the recent studies. The pre-existing disease states are most likely due to genetic factors, lifestyles and lack of access to primary care.  We know, for example, that many persons with serious and persistent mental illnesses have not seen a primary care doctor in many years or, in some cases, ever.

A recent Veterans Administration study warrants our scrutiny. The study investigated the supposed link between atypical antipsychotic medications and diabetes.  The study showed that in 12,235 patients taking the newer antipsychotic medications there was a greater incidence of Type II diabetes compared to the older medications. Of the three newer agents, Seroquel, Risperdal and Zyprexa (made by Eli Lilly and Company, which funds this magazine through an unrestricted educational grant), Seroquel had the greatest percentage of reported diabetes, followed by Risperdal and Zyprexa. 

Despite these findings, many psychiatrists, including myself, maintain that there is no direct cause and effect between diabetes and the atypical medications.  In fact, it is my opinion that the study is flawed, as it did not take into account family history, the number one risk factor for Type II diabetes according to the American Diabetes Association.

Studies such as this one that are based on questionable methodologies endanger access to valuable medical care for persons with severe and persistent mental illness, a group that has already been marginalized by our health care system.  There is a risk that third party payers and financially strapped states may use the Veterans Administration study, and others of its ilk, as an excuse to withdraw atypicals from the field to save dollars.  Using bad science to justify financial, let alone medical, decisions is a mistake.

The fact  is that atypical antipsychotics have opened a new world of hope for a large number of people with schizophrenia, effecting transformations that I am grateful to have witnessed in my work as a psychiatrist. It is time we place efficacy as our goal in the treatment of schizophrenia, and work to ensure that consumers have access to appropriate medical care.

Readers with questions or concerns about their medication should share them with their healthcare provider.