Henry A. Nasrallah talks with
ScienceWatch.com and answers a few questions about
this month's New Hot Paper in the field of
Psychiatry/Psychology. The author has also sent along
images of their work.
Article Title: Low rates of treatment for
hypertension, dyslipidemia and
schizophrenia: Data from the CATIE
schizophrenia trial sample at baseline
HA;Meyer, JM;Goff, DC;McEvoy, JP;Davis,
SM;Stroup, IS;Lieberman, JA
Journal: SCHIZOPHR RES
Year: SEP 2006
* Univ Cincinnati, 231 Albert Sabin Way,POB 670559,
Cincinnati, OH 45267 USA.
* Univ Cincinnati, Cincinnati, OH 45267 USA.
(addresses have been truncated)
Why do you think your paper is highly
I believe the main reason this paper is highly cited is because it reveals
a serious, even shocking, neglect of the physical health of millions of
individuals suffering from chronic
schizophrenia, a disabling psychiatric brain
The data in this paper, based on the landmark NIMH-funded CATIE study
(Clinical Antipsychotic Trials of Intervention Effectiveness) provide an
explanation for the tragically high early mortality in schizophrenia (a
loss of 28 years of potential life, according to a recent study of several
states), predominantly from cardiovascular disease. By pointing to the sad
disparity of care in this seriously mentally ill population, steps can be
taken to address the problem and reduce morbidity and mortality.
Does it describe a new discovery,
methodology, or synthesis of knowledge?
The CATIE study is the largest controlled effectiveness study of
schizophrenia ever conducted. Because it enrolled "real world" patients,
with medical comorbidities, substance abuse, and tardive dyskinesia (all of
whom are excluded from the usual FDA efficacy studies), the study provided
data about the prevalence, and treatments of various medical illnesses that
real-world, community-based schizophrenia patients suffer from.
involved in this research as one of
the investigators in the CATIE
study, which started almost 10
years ago, in 1998, under the
overall leadership of
), the Lawrence E. Kolb Chairman of
Psychiatry at the Columbia
University College of Physicians
and Surgeons and Director of the
New York State Psychiatric
A high prevalence of the metabolic syndrome (42.7%) was found in this
sample that represented 57 treatment settings around the US. In addition,
we discovered that a significant proportion of the serious metabolic
disorders that patients with schizophrenia suffered from (such as
diabetes mellitus, hypertension, and hyperlipidemia)
were not being treated for these illnesses at all, despite the wide
availability of standard treatments of those conditions in the general
population. Thus, the paper was the first to provide an actual
measurement of the percentage of patients not receiving any treatment
for several serious metabolic disorders that increase the risk of heart
attacks and strokes.
Would you summarize the significance of your paper
in layman’s terms?
The American people would find it very disheartening that many young men
and women (average age about 39 years) suffering from schizophrenia and
receiving psychiatric treatments in outpatient settings throughout the US.
were not receiving any physical exams or lab tests to diagnose their
medical conditions which would lead to effective treatment.
Thus, 30% of those with diabetes, 60% of those with hypertension, and 90%
of those with high cholesterol or triglycerides had never received any
treatment for their illness, although such treatments are widely available.
Since these conditions often lead to early death from heart disease or
stroke, such a lack of treatment has grave consequences for this population
of persons suffering from schizophrenia, and significantly contributes to
their high and premature mortality before they reach the age of 50.
How did you become involved in this research and
were there any problems along the way?
I became involved in this research as one of the investigators in the CATIE
study, which started almost 10 years ago, in 1998, under the overall
leadership of Dr.
(see also), the Lawrence E. Kolb Chairman of
Psychiatry at the Columbia University College of Physicians and Surgeons
and Director of the New York State Psychiatric Institute.
The topic of this paper was not even on the radar screen back during the
planning stages, because the main initial purpose of the CATIE study a
decade ago was to compare the effectiveness of the old and new
antipsychotic drugs (as measured by the percent of patients who discontinue
the medication they are assigned due to efficacy, tolerability, safety, or
personal choice reasons).
When the CATIE study approached completion, workgroups were assembled to
analyze different components of the huge CATIE database. Because of my
research interest and previous publications about obesity, diabetes, and
increased lipids associated with some antipsychotic drugs, I chose to join
the metabolic workgroup in 2004—the co-authors on my paper are the
other members of that workgroup, which has been collaborating for the past
four years on analyzing metabolic data in the CATIE.
By examining the tens-of-thousands of pieces of information coded on the
1,460 subjects enrolled in the CATIE study between 1999 and 2004, we were
able to test many hypotheses and to glean highly relevant metabolic and
cardiovascular risk data. We did encounter some challenges such as missing
data or patients who were not fasting when their blood was drawn, problems
that often occur in outpatient studies of the seriously mentally ill.
However, those problems are minor compared to the tremendous amount of
unique and clinically useful information that the CATIE database is
Where do you see your research leading in the
The research in this paper will certainly lead to a vigorous examination of
how persons with severe mental illness are treated for their
non-psychiatric medical problems, such as obesity, diabetes, hypertension,
and hyperlipidemia. Much research is warranted in this area because persons
with schizophrenia are not only at risk for metabolic disorders due to
lifestyle reasons (sedentary, poor diet of high fat/high calories, smoking,
drug abuse, etc.), but they are also at risk of developing metabolic
complications as a result of treatment with some of the widely used
second-generation antipsychotic drugs.
Another avenue of future research is to test innovative models of
comprehensive care for schizophrenia, with a collaborative model of care
linking psychiatrists and primary care providers to ensure 360° of
medical attention for the mind and the body. Such research may reduce the
alarming morbidity and mortality that currently exists among those
afflicted with serious mental disorders such as schizophrenia.
Do you foresee any social or political
implications for your research?
Yes. This line of research straddles the biomedical and health services
domains, and has political, social, and legal implications. Clearly, the
findings of this paper from the CATIE study will prompt a serious
examination of the current healthcare delivery model for serious mental
illness. The presidential commission of the mental health system in the US
described the system as "broken" for a variety of reasons that do not even
include the devastating implications of lack of medical assessment and
treatment of the patients in the system.
Clearly, current outpatient practices must be changed to protect patients
from cardiovascular disease and premature death, not just to help them
avoid psychotic relapses. The VA system is a good example of a
"best-practice" for this area of clinical care because it mandates that
every mentally ill veteran must have a primary care provider who conducts
an annual physical exam and laboratory tests, and also provides medical
management as needed.
Policymakers and legislators as well as health administrators and medical
directors should all join hands to ensure that basic medical care is
provided for people with schizophrenia and other serious mental disorders.
Finally, I hope that psychiatrists in the US would be prompted by the
findings of this paper to make sure that every patient they treat has
access to not only the standard psychiatric care, but also to standard
medical care as well.
Henry A. Nasrallah, M.D.
Professor of Psychiatry and Neuroscience
Department of Psychiatry
University of Cincinnati
College of Medicine
Cincinnati, OH, USA
Keywords: catie schizophrenia trial, hypertension, diabetes
mellitus, hyperlipidemia, early mortality, medical comorbidities,
substance abuse, tardive dyskinesia, community-based schizophrenia
patients, dr. jeffrey lieberman, metabolic data, psychotic