Dealing with mental illnesses in our societies is fraught with uncertainties. At one time, psychiatry and neurology were two approaches to understanding the same health threats. Over time, however, the two disciplines split off with neurology focusing on mental conditions known or thought to be determined by measurable conditions in the brain such as dementia. Those for which there were no known physical indicators of disease, including schizophrenia, depression, anxiety, and others were left to psychiatrists who drifted toward treatments with medications in hopes not of curing a disease but of managing symptoms of the various conditions.
Rachel Aviv provided an interesting article for The New Yorker that indicates neurology is back in the mental health business: Mary Had Schizophrenia—Then Suddenly She Didn’t.
Some conditions such as depression and anxiety are relatively easy to identify, but schizophrenia is an example of a disease that is less easily diagnosed.
“For decades, scientists have been searching in vain for a biological marker that would confirm whether someone has schizophrenia. Last year, in a paper in Schizophrenia Research, seventeen international experts concluded that schizophrenia was defined by no single etiology, symptom, or biological mechanism. “It is prudent to wonder if the construct around which we are organizing this information is fundamentally flawed,” the authors wrote.”
Recently, some startling medical turnarounds have been observed for people diagnosed as suffering from schizophrenia.
“A 2017 study in Frontiers in Psychiatry described a woman with a twenty-five-year history of schizophrenia. She also had a skin disease, for which she was given drugs that reduced inflammation and suppressed her immune response. Her doctors noticed a pattern: when they treated her skin lesions, her psychosis went away. They hypothesized that the rash and the psychosis had been caused by a single autoimmune disorder, and were cured by the same drugs.”
“Another paper in Frontiers in Psychiatry described a man with ‘treatment-resistant schizophrenia’ who developed leukemia. After a bone-marrow transplant, which reconstituted his immune system, he startled his doctors by suddenly becoming sane. Eight years later, the authors wrote, ‘the patient is very well and there are no residual psychiatric symptoms’.”
“…a Washington Post article from 2023 about a woman named April, who had fallen into a catatonic state at the age of twenty-one and been diagnosed with schizophrenia. Sander Markx, a professor of psychiatry at Columbia, first encountered April at a psychiatric hospital on Long Island when he was a medical student; twenty years later, he was dismayed to find her at the same hospital, in the same condition. ‘She has not been outside for twenty years—out of sight,’ he said, at a symposium at Weill Cornell’s medical school. He and his colleagues gave her an extensive workup and found that she had lupus, an autoimmune disorder that, in rare cases, can induce inflammation in the brain, causing symptoms that are indistinguishable from those of schizophrenia. After undergoing immunosuppressive therapy, including rituximab, April emerged from, essentially, a ‘twenty-five-year-long coma, and was able to tell us everything,’ Markx said. ‘We don’t have a script for this. We don’t see patients coming back from this condition’.
Aviv identifies April’s case as the one that finally got neurologists back in the mental health business.
“April’s case helped give momentum to the founding, in 2023, of the Stavros Niarchos Foundation (S.N.F.) Center for Precision Psychiatry and Mental Health, at Columbia, which is working to uncover biologically distinct subtypes of illness that have been obscured by the broad categories in the DSM.”
DSM stands for the Diagnostic and Statistical Manual for Mental disorders, a handbook published by the American Psychiatric Association.
Neurologists are on the move proposing a new category of mental illness labeled “autoimmune psychosis.”
“The S.N.F. Center is embarking on a project, beginning this fall, to screen all the patients hospitalized in the New York State mental-health system for autoimmune, metabolic, and genetic disorders, to see if there are people whose symptoms can be traced to a distinct biological mechanism.”
Considerable progress has already been made, but there is likely a long way to go.
“…scientists have identified more than twenty new antibodies linked to psychiatric symptoms… Christopher Bartley, the chief of a unit at the National Institute of Mental Health which investigates the role of immune dysfunction in mental illness, said that the twenty known antibodies may be a ‘drop in the bucket.’ There could be countless targets in the brain that antibodies attack, some subset of which may alter people’s perceptions and behavior. ‘We have to have epistemic humility and accept that there are alternative models of disease,’ Bartley said.
This new focus on autoimmunity as a source of psychoses has produced dramatic improvements in the health of affected persons. There are two questions still too early to answer. First, how prevalent is autoimmune psychosis, and how many other physical conditions will be found to contribute to psychoses.
“Bartley estimates that between one and five per cent of people who have been diagnosed with schizophrenia actually have an autoimmune condition—a figure he based on his own lab’s research, which has not yet been published, and also on a German study of a thousand patients, the most extensive study of autoimmune psychosis so far. ‘Even one per cent ends up being almost a million people in the world who should be treated with a different kind of medicine,’ he said.”
This development in the field of mental illness reminds
us that in the fields of medical science there have been endless numbers of
surprises and there are many more yet to come.
We need to encourage our best people to participate and provide them the
resources to continue to extend our knowledge.
