Transcript of Talking Heads with Dr. Noosha Niv – Episode 3

Advancing Schizophrenia Treatment: Dr. Steve Marder on Medications and Recovery

Announcer: This is Talking Heads. Explore the latest in research and policy about serious mental health disorders with Dr. Niv.

Dr. Niv: Hi, this is Dr. Niv and today’s guest is Dr. Steven Marder. Dr. Marder is professor of the SEML Institute of Neuroscience and Human Behavior at UCLA, director of the section on psychosis at the UCLA neuropsychiatric institute. He’s also the director of the VA vision 22 mental illness. research education and clinical center which focuses on improving functional outcomes in individuals with psychosis. His research focuses on the treatment of schizophrenia and the pharmacology of antipsychotic drugs. He has authored or co-authored more than 200 journal articles and chapters and has won a gazillion awards for his work. In short, he’s a very busy man and I’m really grateful that you’re here. Welcome, Steve.

Dr. Marder: Glad to do this new show.

Dr. Niv: Thanks. Um, what led you to psychiatry and more specifically the focus on schizophrenia.

Dr. Marder: Well, I mean in in medical school, you know, I got enchanted by psychiatry and particularly the kind of attitudes of of psychiatrists who seemed more humanistic than uh some of the other clinicians that I saw. Many schizophrenia researchers have uh a relative or someone who suffered from psychosis. That wasn’t my story. My story was when I went to the uh NIMH after residency. I was assigned to a schizophrenia research unit which was fine for me and it sort of set off my career.

Dr. Niv: Well, we’re lucky it did. What are the biggest waves you’ve seen treatment change over the course of your career?

Dr. Marder: You know, a number of things happened during the first decade at UCLA. I became aware that there were limitations to what drugs can do. Antipsychotic medications attenuate psychotic symptoms, but But they really didn’t help people recover and and return to work or school. So uh those limitations got me focused on psycho-social treatments. And I was influenced by a a recently deceased colleague Bob Liberman uh at UCLA and he persuaded me to become involved in studies that included antipsychotic medications as well as psycho-social treatments. I also spent spent uh a number of years going to state hospitals as a consultant, particularly Tuscadero State Hospital, which is a hospital for the criminally insane. There I also realized that there were many patients who had really sad histories because they had illnesses that didn’t respond well to antipsychotic medications. And I also saw that in my work as an inpatient psychiatrist at the VA in West Los Angeles. Then when Clozapine was introduced and I treated my first patient with Clozapine. I saw what was something remarkable which was that a young woman who had uh who was 34 years old tormented by a psychotic illness suddenly improved and suddenly got better and was able to return to her goals from a decade before. Interestingly enough, after graduating from UCLA getting her masters. She just retired after a career as a teacher in the uh Los Angeles school system. That showed me that the right treatment for patients can really change lives and made me much more optimistic. You know, when I visit with her, both of us so appreciate the fact that uh our lives were influenced by the other. Sadly, something that happened around 1989 or 19 90 was the sort of last major uh advance in pharmacotherapy. There’s a generation of newer antipsychotics but they weren’t uh game changers like uh the introduction of Clozapine but what’s happened over the years has been the development of better psycho-social treatments and improved rehabilitation which made me optimistic about the ability to of people to recover and also substantial advances in the treatment of uh young people with schizophrenia. People during their first years of the illness that frontloading treatments aggressively treating them with psycho-social treatments and the right kind of pharmacotherapy can change the trajectory of the illness. That people who in the past would sort of move towards disability could uh change that trajectory and move towards recover. Y and that made me again more optimistic about uh treatments for schizophrenia. And of course the results from the large NIMH raise study uh show that that that could happen in very typical psychiatric settings if we have the right resources at the right time. So I would summarize those as the major advances during my time as somebody focused on the treatment of psychotic illnesses.

Dr. Niv: So the development and implementation of psycho-social treatments and then meant establishment of treatment early on. So the earlier people get treatment the better the outcomes.

Dr. Marder: Right. Right. And and that we can change the trajectory away from disability towards recovery.

Dr. Niv: And you you mentioned Clozapine. When is it appropriate to use Clozapine and why is it so underused?

Dr. Marder: Initially Clozapine was a medication that was reserved for the most severely ill patients. What’s happened recently is is I think that we’ve begun to appreciate that Clozapine is also effective for people who are outpatients living in the community but still tormented by psychotic symptoms. So I consider it a medication that’s appropriate for a large proportion of patients much larger. I direct the psychosis clinic at UCLA and there we have something around 40% of our patients on Clozapine because we don’t accept limited outcomes. If somebody even if they’re working and going to school, but they still have uh psychotic symptoms, we move towards Clozapine. So, I I think it’s a medication for a much broader population of patients than it’s currently utilized. To your other question about why it’s so underutilized, that has tormented me for years. You know, I considered one of my goals when Clozapine was first produced as how to get psychiatrists more used to using it. And sadly, it’s really challenging to do that. Prescribers will choose things that are easier to do than Clozapine. They’ll add medications. They’ll use high doses. They’ll, you know, add two or three antipsychotics and it seldom makes a difference. And then Clozapine is like the last thing that they’ll do. And and many people are unfamiliar. It’s the most difficult drug in psychiatry to prescribe because almost every patient has a substantial side effect burden and the uh blood test is the least of the problem. It’s the sedation and weight gain and other things but when it works it can really change lives in in a substantial way. It’s hard to get clinicians to use it but I think you know we’re making some progress. I think as you look at some of the way American Psychiatric Association, the VA, others are really convincing many clinicians to use Clozapine and to use it at an earlier stage of the illness, not to wait until a patient becomes hopelessly psychotic where it’s very difficult to get get them out of that disability.

Dr. Niv: Given the side effects, are patients resistant to using it or are the benefits so good that they tolerate the side effects?

Dr. Marder: It’s a very mixed bag. You know, you know, for some pat will tell you that they’re better, but they they’re sleeping 14 hours a day and it’s really hard to get work done and they have to make a difficult decision. That’s for a minority of patients and I I think we need to respect that for some patients. It’s not the right drug, but I think for others they appreciate the fact that they could live in the community even with that substantial side effect burden.

Dr. Niv: So, how might a patient or family member advocate to receive it.

Dr. Marder: Well, what I tell patients and and families and uh you know, loved ones is things in your life aren’t going so well. Now, there’s only one way to tell whether Clozapine is going to make a difference and that’s to try it for a few months. You know, I I think we need to convince patients that they’re in charge of their lives and and their treatment. And and I think that one of my goals in treating people with schizophrenia is that patients take ownership of their illness. So it’s not their family members and their psychiatrist and others who are telling them what they need to do. And for them, I really suggest that they make an informed decision and to make it based on an experience and that a few weeks or months of side effects and inconvenience is a small price to pay for being able to make an informed decision about whether or not this drug is good for them. Uh it’s sort of, you know, give it a cry. I don’t think you have that much to lose.

Dr. Niv: And how do they convince a psychiatrist to put that time and effort in?

Dr. Marder: Well, that’s very that that could be more of a problem. But I do think that more psychiatrists are willing to give it a try and some of them need help in doing that. You know, within the VA, we have a consulting service where where we help psychiatrists learn how to use Clozapine and sort of uh give them advice on how to address side effects, you know, some of the other challenges uh about administering Clozapine in a way that patients are likely to accept it and where it’s safest.

Dr. Niv: So, psychiatrists might need other supports,

Dr. Marder: right? That they’ll need supports for uh prescribing it and uh you know, advice as things happen.

Dr. Niv: Okay. Um going back to what you were saying about antipsychotics not assisting with recovery, um can we talk about about what symptoms antipsychotics actually help improve and why that’s not impacting recovery.

Dr. Marder: To make it clear, uh antipsychotics don’t lead to recovery, but there’s a large literature suggests that they’re an important platform on which to build recovery. It shows that uh patients who are on an antipsychotic drug and stabilized are more likely to benefit from from uh psycho-social treatments and and rehabilitation. So what I tell psychiatrists sometimes when when I when I talk is that sometimes recovery begins once a patient is on an antipsychotic and what they do is they attenuate psychotic symptoms like hallucinations and delusions and disturb thought process and an inability to carry out a logical train of thought what they also do is they prevent relapse. So if a patient has been stabilized in their psychotic illness where their symptoms are minimized, they’re able to live in the community perhaps to go to school or work, remaining on an antipsychotic uh makes it much less likely that they’ll have a psychotic relapse which in turn can lead to sort of a loss of some of the gains that people make and a loss of self confidence that people have when they pull their life together, have a relapse, and then lose their job. Relationships can get destroyed. So, it’s important to emphasize how relapse prevention is really an important part of promoting recovery.

Dr. Niv: And do they affect negative and cognitive symptoms of schizophrenia?

Dr. Marder: If you look at it carefully, they have some effects on improving cognition and negative symptoms and by negative symptoms I mean the kind of apathy and disinterest in things that really torments both patients and family members but they only do it to a minor degree. That is one of the challenges to find other solutions to those problems in schizophrenia. The uh you know you know the lack of motivation as well as the cognitive disturbances and for those I think we need to look at at this time to look at psycho-social treatments to those challenges.

Dr. Niv: So something like cognitive training,

Dr. Marder: right? Right. Cognitive rehabilitation, cognitive training can be very effective for both cognition and sometimes for negative symptoms as well.

Dr. Niv: As well as cognitive behavior therapy.

Dr. Niv: You’ve been involved a lot in trying to at least develop medication to address the cognitive part. What What’s been the progress that you’ve seen?

Dr. Marder: There there’s been a a number of studies of very promising drugs that sadly they look very promising in early stage studies when they went to very large international studies they failed. We still have a number of studies there are a couple of very promising drugs that are in development for uh both cognition and uh negative symptoms. So I’m still optimistic that in in the near future we’re going to have drugs that you can add to an antipsychotic that will be more effective for negative symptoms. There’s also a couple of antipsychotics that are very close to FDA approval that act differently than all of the other antipsychotics and those drugs also seem promising for cognition and negative symptoms. So, it’s it’s likely I believe that during the next few years we’re going to see substantial advances in uh drug development. It’s very exciting, but you know, until it actually happens, I’ll believe it. But I’m I’m I’m still optimistic.

Dr. Niv: So, at this point, the reality is someone gets a diagnosis of schizophrenia, they are likely to be on a medication for a very long time, if not the entirety of their life.

Dr. Niv: Um, you’ve written a lot about side effects and that most patients don’t like to be on these medications because of some of these side effects. What are the major ones you think people should be aware of and be watching for and talk to their psychiatrist about.

Dr. Marder: You know, one of the problems is that antipsychotics attenuate psychosis. They don’t make people feel better. So, the things that I focus on the most are neurological side effects, a feeling of restlessness that or we call it akathisia that patients may experience. Sometimes they cause uh stiffness uh where where patients they don’t feel as agile as they did. The other thing is metabolic side effects. Antipsychotics can increase the risk of developing diabetes and they can also cause weight gain. That’s not true of all antipsychotics, but it’s true of of some of them. And this is a substantial problem because people with uh schizophrenia, even before they get antipsychotics, are more likely to develop diabetes than people without schizophrenia. Probably because of a shared genetic risk and they’re more likely to die sooner. The life expectancy for a person with schizophrenia is something like 20 years briefer than that for uh people without schizophrenia. And this is largely due to heart disease. You know, antipsychotics and weight gain and you know effects on lipids. All of those things add up to an increased risk. And of course, people with schizophrenia are somewhat more likely to smoke cigarettes. which also increases risk. So psychiatrists should talk to their patients about these risks. They should be more aware of the risk for weight gain and uh together you know we strongly recommend that psychiatrists and patients really watch their weight and uh that psychiatrists look for uh clinicians I should say because many patients aren’t being treated by psychiatrists being treated particularly by uh advanced practice nurses who really do a wonderful job watch their weight and and to look for signs that have symptoms of pre-diabetes and to intervene you know you know relatively quickly to that.

Dr. Niv: So what are some of the options to protect patients from these side effects?

Dr. Marder: The one thing that uh works very well is lifestyle changes. Every study that has looked at lifestyle interventions that uh include exercise and and nutrition advice have shown to be highly effective. Those kinds of interventions are very effective. Other things that that help uh we often add a medication patients are having these side effects. Metformin which is a drug which could be used for prediabetes but also uh helps patient lose weight is something that we often prescribe. And uh there’s this new generation of drugs that help people with weight weight loss and they are highly effective for weight reduction and preventing diabetes or treating pre-diabetes. So I I think we’re at a stage where there are more options and the other thing of course is to change the antipsychotic you know if somebody there are some antipsychotics lanzipene which is called zyprea Clozapine cerakquil also called quutiapin really are uh promote weight gain but there are anti other antipsychotics where there’s much less risk so changing the antipsychotic can also help so I think there are a number of interventions but I I think the first thing that I recommend to clinicians and patients is to look early on what antipsychotics tend to do is there’s a normal satiety response a sense when we eat that we’ve had enough to eat and uh it seems that antipsychotics sort of decrease that satiety response. So what we tell patients is, you know, patients who’ve never had a weight problem who gain before they would stop eating when they’ve had enough, we emphasize portion control, things like that to help them not gain weight. And and I think this is advice that we should give to patients all of the time. Uh because again, this problem is so common in schizophrenia that we need to be aware of it right at the beginning of treatment. Part of the stigma of schizophrenia is this kind of trope of the good patient, bad patient. You know, you’re the good patient if you take your medication and go to treatment as expected and you’re the bad quote unquote bad patient if you don’t do those things. Um you in that case the attributions that family members may have is that you’re responsible for your illness. You’re responsible for the symptoms that you’re experiencing. What would you say to someone particularly a family member who holds this you know, an unfortunate perception of what schizophrenia is.

Dr. Niv: Well, I I you know, you know, I think one thing to do is to have them understand the problems that uh their loved one has. That being suspicious, being irritable is is a symptom of an illness. Just understanding and empathizing with them. The other thing is that uh sometimes families get really really uh annoyed at patients who have deterioration in their hygiene. They they don’t take care of themselves. They’re late. They’re more difficult to understand that that’s not something intentional. That’s again part of their illness. That the cognitive disturbances, the things that we do easily can suddenly become more difficult for them. That this is part of the illness. That blaming them is is a problem. The other thing is that people with schizophrenia are sometimes much more sensitive to criticism than others. As I’ve talked to families that have a number of children, one of whom developed schizophrenia, they will talk about from a very early age, they realize that their son or daughter was uh more sensitive to criticism than the other. And and to make them aware of this so that they’re less blaming So that that’s the kind of advice that we try to give to families. It’s uh to empathize with them that this is very difficult to see this change in their son or daughter. It’s just a very emotional response. It could be a sense of loss that they need to deal with. Uh absolutely. So so these are very difficult conversations that that we have all the time.

Dr. Niv: Okay. Yeah. There’s a lot of grief in being a family member and grieving the person. they had

Dr. Marder: right and and sometimes what I I tell people is that particularly early on in the illness you know one don’t give up on your goals because a lot of people can recover with proper treatment but it may be longer and it may be that uh it’ll take them longer to get through college because they’ll need to take fewer courses and it may be that their career goals will uh change the things that they’re more able to do Sometimes families once once they accept that and and support it that they really help patients reach their goals with an understanding that their life will will be you know like anybody who has a chronic illness whether it’s diabetes or rheumatoid arthritis or that uh there are challenges with having an illness but it really doesn’t define who that person is.

Dr. Niv: And at the core of that uh being able to be empathetic for family members is for them to understand these symptoms are of an illness, not purposeful. They’re not

Dr. Marder: um you know the it’s not that they’re trying to hurt family members.

Dr. Niv: It’s not trying to hurt family members, right?

Dr. Niv: Um so can we talk about you know patient shows up in your clinic for the first time. What what can they expect? What happens?

Dr. Marder: Well, in our clinic, uh they’ll be evaluated. We’ll do a history. We’ll find out what treatments they’ve had because we’re often a referral source. from other clinicians who aren’t as familiar with the illness and then we’ll sit down and we will give them an assessment. The thing that we always ask is we try to emphasize that we want to be behind the person’s goals. That the goal isn’t to be a remitted person with schizophrenia. The goal is what are your personal goals? Well, uh what kind of life are you looking for? or it could you know girlfriend or Okay.

Dr. Niv: Right. Right. Right. Right. We define ourselves and and that the treatment is uh part of that. I think as mental health providers we see treating their mental health as a road to help them reach their own personal goals. So so we emphasize that and and that treatment is is a part of that. We often emphasize for patients who are resistant to taking medications are getting psycho-social treatments. We try to emphasize that we’re on their side because they’ve had uh people breathing down their neck, family members, other people. We try to sort of change that relationship. What we want is for the person to take ownership of their illness and to understand that once they can manage that, it becomes easier to reach their personal goals. So, we’re all ways sort of focused on their own we can call it a recovery plan or sort of uh helping them reach their personal goals. So it it I I I think we try to change the narrative of treatment away from just managing symptoms towards lifetime management. In in our clinic we often get the question you know doctor do I need to be on these medications for the rest of my life and and we address that question you know very honestly which is who knows we we’ll have to see but but we need to learn this together in in our clinic and the way we work is we try to work together to understand the illness and sometimes ness something uh very magical happens when all at once a patient understands oh when I reduce my medication or I stop taking it actually things fall apart a little bit that’s when the person appreciates why they’re getting treatment. If we um involve them in cognitive behavior therapy for psychosis, they can see that they learn how to manage their symptoms that it sort of gives them a feeling of having more control of over their symptoms.

Dr. Niv: So, they may need to experiment a little to really gain the appreciation,

Dr. Marder: right? And it’s not something it’s a long-term process. Sometimes if a person is drug reluctant, they’re not taking it regularly. Some psychiatrists will throw them out of the clinic and we don’t do that. We try to work with them to uh understand why they’re not doing it and to sort of gain their trust. As you could imagine, suspiciousness is a often a core symptom of the illness and how to sort of address suspiciousness is a it’s an art at Nia. It really requires a a particular kind of skill. Our clinic is a place where we train clinicians and and we try to get them to understand that.

Dr. Niv: Yeah. What we what I’m hearing from your clinic is that you really partner with the people who come through your door rather than I’m the doctor. I’m going to tell you what to do. And and when you’re suspicious, someone telling you what to do,

Dr. Marder: right?

Dr. Niv: Doesn’t work so well.

Dr. Marder: Right. And sometimes it’s hard not to because you know when people are suspicious they could be unpleasant. Yes.

Dr. Niv: You know they they could be very challenging. So maintaining your posture as a uh an empathetic clinician can be difficult and I think that’s part of the training to kind

Dr. Marder: ego aside a little

Dr. Marder: Right. Right. Right. Right.

Dr. Niv: Um is it helpful to you as a physician for for a family member or close friend to come in with someone and those initial visits?

Dr. Marder: Yes. Yeah. Absolutely. Uh you know in contrast to other psychiatric disorders the family can be the most important ally. Most studies have shown that patients who have supportive families do better and they do substantially better. So getting the family as an ally is is really vital and letting them understand their role and and and also having family members feel free to contact the clinicians as long as the patient understands that that relationship is there because you know sometimes patients don’t want that. But you know getting kind of a a free flow of information and sometimes uh family members are aware that somebody’s getting worse or having a problem before the patient is being able to exchange that information without sort of offending confidentiality and having the patient understand can can be very very helpful.

Dr. Niv: So they obviously your clinic will give them medication but we’ve talked about um the proliferation of psycho-social treatments. Which ones do you you find are available to your patients. I mean that’s the real challenge right is that these treatments are not widely available.

Dr. Marder: They are not widely available. You know in our clinic we we have uh you know psychology trainees and uh psychology supervisors and we can provide uh treatments like cognitive behavior therapy for psychosis and uh cognitive remediation and other treatments. is yes social skills training but in the community at large it could be very hard to provide to to find a a clinician there are lots of people who are trained in CBT but very few who are trained in CBT for psychosis this is a major problem and I’m hoping that the availability of remote treatment will make this more available so for example in in the VA now we’re able to uh deliver uh CBT for psychosis remotely. Cognitive remediation can be uh done through websites. Metacognitive training for people with delusions can be delivered through uh web-based treatments. So, I I agree that that we have a mental health workforce that’s really deficient in being able to provide these treatments. There just aren’t enough trained providers

Dr. Niv: that that we have to find other ways to do it. And for us to train more clinicians

Dr. Niv: and technology is really changing how we can

Dr. Marder: Yeah, I I think there I think we have a number of new opportunities for providing these uh treatments.

Dr. Niv: Okay. Um I want to switch gears. I in some Facebook groups I had some patients ask questions just patients family members as well. Is it okay if we talk about those?

Dr. Marder: Sure.

Dr. Niv: All right. Um the first one is what is the pans and how can consumers make sense of it?

Dr. Marder: Well the pans is a research instrument. It’s the positive and negative symptom scale. It’s the most commonly used scale in drug trials. I don’t think it’s something for uh patients to be concerned about. As a matter of fact, most clinicians haven’t been trained in the pans. Patients should understand what symptoms are and be able to describe them. But I don’t think that the pans is the right way to do it. It’s really not an an instrument that patients need to become familiar with. On the other hand, learning to describe their experience whether they’re hallucinations or uh distortions can be very very helpful. It’s one of the things that a good psychotherapist and a good clinician will do is helping patients be able to describe their kind of uh internal experiences so that the psychiatrist can understand them and treat them.

Dr. Niv: So really for the general population if they want to understand the pans you maybe they’re reading a research article Higher scores mean higher symptoms,

Dr. Marder: right? It’s it’s a way of if they’re reading the psychiatry literature, which is a little frightening, but uh you’re right. A higher score means that they’re worse and it’s kind of it describes both positive symptoms like hallucinations and delusions and studies may have negative symptoms and other kinds of groups of symptoms that may uh improve on an antipsychotic.

Dr. Niv: Um the next question I got is I’ve read that B I42589 is classified as a breakthrough treatment for cognitive impairment. How effective is it and when will it be released? And I had to look this up, so correct me if I’m wrong. This is a drug called Eclipper.

Dr. Marder: Yeah. Eipin. Yeah.

Dr. Niv: Okay.

Dr. Marder: Yeah. And and we’re actually studying it at at UCLA. It’s a a drug that’s being developed for improving cognition in schizophrenia.

Dr. Marder: It was effective in early you know, in in relatively large trials, phase two trials, and now they’re in a large phase three study.

Dr. Niv: Okay.

Dr. Marder: Uh the company feels very optimistic about it. So, it’s um you know, I think we’re probably going to know relatively soon uh whether or not it gets through this phase three trial, in which case it uh may come to market. You know, there’s a process that could take a a year or more once there’s a positive phase of your trial to get the drug to market internationally.

Dr. Niv: Is this an antipsychotic that also impacts cognition or just a cognitive symptoms?

Dr. Marder: It’s a it’s a drug that would be added to an antipsychotic.

Dr. Niv: Okay. And uh next question and I know I’m going to say the name of this drug wrong. What is ulot ulteradone?

Dr. Marder: Yeah, that’s a a drug developed by a uh a company in uh Italy or Israel I forget but it’s a it’s a promising drug it’s being developed as a broad antipsychotic which may have particular effectiveness for psychosis and negative symptoms so I seems promising

Dr. Niv: so the it’s different than existing ones in that it may

Dr. Marder: yeah right it’s got a different mechanism of action

Dr. Niv: okay are there other medications currently under development for schizophrenia that you said you’re you feel hopeful that in the next few years

Dr. Marder: well yeah There are uh there’s a drug that just passed through a phase three trial. It’s a combination drug, but uh they had a positive phase three study and and that’s from a a press release. I haven’t looked at the data yet, but it’s made by a company called Coruna. It’s a antipsychotic which has an entirely new mechanism of action. And again, I think that’s close to uh being submitted to FDA. for approval. So that could be the first new drug. There’s another drug that’s called a tar one agonist that’s uh made by Sovian which has had very strong um data from phase 2 trials and again it’s a broadspectctrum antipsychotic entirely new mechanism. It looks very very promising. We’re optimistic that that will come to market but but we’re just waiting for the phase three study to to see you know you know whether or not that that’s been verified.

Dr. Niv: That’s exciting times.

Dr. Marder: Yeah, it’s very exciting. It’s very exciting.

Dr. Niv: Another question. Um my friend told me to try transcranial magnetic stimulation. Does that help symptoms of schizophrenia?

Dr. Marder: That’s unknown there. There have been studies of transcranial magnetic stimulation. It’s kind of something where you go into an office, they put something on your head and they do magnetic stimulation. There are some studies that show that it can be effective for voice hearing. It could decrease you. They apply it to the part of the brain that affects speech and that it seems to decrease uh voice hearing. That’s those are very small limited studies. There are other studies that suggest that it might be effective for negative segments. Again, those are very small studies. So, it’s promising, but I I I think it’s too early to say.

Dr. Niv: And last question. If you had a magic wand and could change anything in the field of psychosis, what would you change?

Dr. Marder: I it’s hard to think of one thing, but I I would one an antipsychotic drug as effective as Clozapine without the horrible side effects, you know, that works through a different mechanism. I would want to rename the disorder so that people understand that uh people with schizophrenia vary as much as people with diabetes from people who are highly functioning accomplished people to those who have a horrible disease burden to take away the stigma that’s associated with that diagnosis. Thirdly, to just have a health system that makes these treatments, effective treatments, more highly available that uh it’s an illness that’s uh greatly uh undertreated

Dr. Niv: and we have the treatments that can improve outcomes.

Dr. Marder: We we have the tools for patients to do much better.

Dr. Niv: We just don’t have a health care system that able to deliver them.

Dr. Niv: And with that, we’ll say thank you so much. I really, really appreciate you joining me today.

Dr. Marder: Okay,

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