Editors’ Note

Clinical neuroscientist, psychiatrist, and author, Dr. Jeffrey Lieberman’s groundbreaking research on the neurobiology & pharmacology of behavioral brain disorders has advanced the understanding and treatment of mental illness and pioneered a transformative strategy for the early detection and prevention of schizophrenia. He is a past president of the American Psychiatric Association, a member of the National Academy of Medicine, and the recipient of many academic awards, including the Brain & Behavior Research Foundation’s Lieber Prize. Over his 40-year career, Lieberman has treated thousands of patients with serious behavioral brain disorders and his research has been published in more than 800 scientific articles. A frequent public spokesperson on mental illness and psychiatry, he has contributed to healthcare policy and federal legislation – including the Mental Health Parity and Addiction Equity Act, the Patient Protection and Affordable Care Act, and the Helping Families in Mental Health Crisis Act – to improve access and quality of mental healthcare while reducing the stigma associated with mental illness. Today, he is actively involved in several initiatives aimed at disentangling mental health and the criminal justice system and reducing the harmful effects of Americans’ unmet mental healthcare needs, including homelessness, incarceration, overdose, and suicide. He is the author of the critically acclaimed book, SHRINKS: The Untold Story of Psychiatry, which became the basis for the four-part PBS series, Mysteries of Mental Illness. His 2023 book, Malady of the Mind: Schizophrenia and the Path to Prevention, has been heralded as “the most important book about schizophrenia in decades, and perhaps ever” and was released in paperback in April 2024.

Will you discuss your career journey?

My career began at the time when little was known about schizophrenia, and psychiatry’s predominating belief was that those afflicted with the disease were “doomed from the womb” due to genetic factors that altered brain development and left them resistant to treatments. I was not only offended by the implication that nothing could be done for these patients, but found this notion implausible. I believed that modern medicine had the capacity to not only suppress the symptoms of schizophrenia, but potentially prevent its progression and disabling effects. I was motivated to challenge the dogma, but what galvanized my intellectual questioning into action was the plight of one patient.

He was 20 years old, intelligent, charismatic, with limitless potential. As a college freshman, he started behaving strangely, missing classes and eventually was admitted to the hospital with his first psychotic episode. He was diagnosed with schizophrenia and treated with medication, to which he responded well, but soon made the common mistake of stopping medication, thinking his bout with psychosis was a one and done experience. When his symptoms predictably recurred, I asked my supervisor for advice – but instead of offering wisdom or empathy, he told me, “You just have to let some patients learn the hard way by suffering multiple relapses before they accept the need for treatment.”

I was stunned. A patient’s life was at stake, and the supervisor’s response was not only shockingly callous, but entirely misguided, as though my patient with schizophrenia was an alcoholic who just needed to hit rock bottom.

This experience prompted me to pursue research that would elucidate the underlying pathology of schizophrenia and determine if treatment could not just alleviate symptoms, but also prevent its devastating progression. Thirty years later, I’m pleased to say that we have changed the perspective and paradigm of treating people with schizophrenia, and now have the capacity to modify the course of the illness and avert the persisting symptoms and lasting disability. Moreover, through emerging strategies for early detection and intervention, we are on the brink of being able to prevent its onset altogether.

Did you know at an early age that you had a passion for the field of psychiatry?

No, I was initially inclined to be a heart or brain surgeon. Two things led me to focus my medical career on the brain, and psychiatry in particular, which studies disturbances in the brain affecting mental functions and behavior. The first was Freud. As an undergraduate, I read Freud’s seminal work, Interpretation of Dreams, and was captivated by his explanations of how the mind works. I was able to see myself through the lens of Freud’s model of the mind and found answers to questions about my inner self – my tendencies, relationships, struggles – answered through his teachings. The second thing that set my path toward psychiatry was really a matter of timing. As a child of the 1960s – the era of recreational psychoactive drugs, psychedelics in particular – I was profoundly impacted by the notion that a small dose of a chemical substance like LSD could induce such a powerful, altered state of consciousness. Based on this, it seemed possible that abnormal behavior associated with mental illness could be due to inborn errors of neurochemistry. Therefore, in medical school, I studied biochemistry of the brain and how psychotropic drugs could affect therapeutic changes in persons with mental illness – and thus, the focus of my professional path was defined.

You pioneered a transformative strategy for the early detection and prevention of schizophrenia. Will you highlight this work?

I began my research in the 1980s by studying patients at the beginning of their illness and characterizing the course of the disease. This research demonstrated that schizophrenia was a progressive disease, characterized by a worsening of symptoms and deterioration of cognitive function caused by brain volume loss over time.

From there, we determined that treatment intervention at or soon after onset can alleviate the symptoms and limit the disabling effects of brain volume loss. In fact, most patients who are promptly treated with antipsychotic medication after their first psychotic episode will experience substantial or complete remission – which can be sustained with ongoing medication and psychosocial therapies in conjunction with a supportive family environment.

Today, we’re developing strategies to prevent the onset of the illness altogether by early detection and intervention during the prodromal period, when symptoms begin to develop.

What are your views on the mental health crisis occurring today and what are the keys to effectively addressing this crisis?

Governments have a responsibility to provide healthcare to their citizens – and the standard of care should be defined by the current level of medical knowledge. Sadly, the United States healthcare system does not meet this standard, and when it comes to mental healthcare, the situation is far worse.

In the case of people with schizophrenia, the limiting factor is not our level of knowledge, but inadequate financing, lack of infrastructure, and obstructive government policies that limit access to high-quality, comprehensive mental healthcare. This sad situation reflects a discriminatory disregard for a segment of the population affected by serious mental illness, and in my opinion is a civil rights violation.

To improve mental healthcare, we need to have different strategies for different strata of the population and types of illness:

• Screening in schools for intellectual and learning disabilities
• Pre and postnatal maternal mental health surveillance and care
• Protocols for immediate treatment of experiential trauma
• Employment and education-based mental health services
• Expanded clinical infrastructure and trained multidisciplinary workforce (e.g. Residential Facilities, Mobile Crisis Teams)
• Increased funding for mental illness research
• Policy changes including modifying civil commitment and treatment over objection criteria; modifying HIPPA; repeal IMD exclusion; mental health courts and diversion programs; and government legislation informed by public health and safety with regard to recreational intoxicants (e.g. cannabis, psychedelics, MDMA).

Do you feel there has been progress in addressing the stigma around mental illness?

We’ve made some progress in addressing mental health stigma, but we’ve still got a way to go. Stigma persists as one of the biggest barriers to seeking and receiving mental healthcare; many people are still not well informed about the nature of mental illness or how to seek competent care either for themselves or a loved one. The media is starting to bring the topic of mental health into the light, especially as we see more celebrities and public figures speaking out about their own mental health struggles – but we still have a way to go, particularly when it comes to informing the public and reducing stigma around mental illness. Schizophrenia is most often covered in the context of a mass violence tragedy; very rarely do we get to hear about the effective treatments that can control its symptoms and halt its progression.

What more can be done to improve access to and quality of mental healthcare?

This is neither a quick nor easy fix; the bottom-up approach, while commendable, is piecemeal and has a limited impact on population health. A coordinated “top-down” approach is vastly preferable, where federal and state governments work in a coordinated fashion and follow a carefully developed data-driven blueprint based on population frequencies of mental, substance use, and developmental and neurodegenerative disorders. This data would determine the scale of facilities, scope of services, roster of personnel and disciplines, and guide the establishment of infrastructure along with appropriate education and training. Healthcare financing must also be revamped. Currently, private and government insurance benefits rarely come close to covering the cost of high-quality mental healthcare, which requires a disease management approach in which multidisciplinary care is available to cover the range of patient needs. Consequently, psychiatry is the medical specialty with the lowest percentage of practitioners who accept insurance, and most often require patients to pay out of pocket.

Where did your interest in writing books develop and will you highlight the key messages you have wanted to convey in your books?

After writing 800 articles and 11 books on research and clinical psychiatry for medical and scientific audiences, I realized that the major limitation in mental healthcare was not our lack of knowledge and the existence of effective treatments, but the limited awareness of the lay public about what mental illness was, and when and where to seek treatment. In other words, we were not making available, and people were not accessing, the tools we had for reducing the morbidity of mental illness.

Therefore, after 30 years focused on research and clinical care, I began to use my voice in the media, writing op-eds, sending press releases, and appearing on cable news programs where I’d share accurate information about mental illness and mental healthcare with the general public. I also ran, and was elected president of, the APA to expand visibility and awareness beyond the scientific community. It was this leadership experience, serving as spokesperson for the field of psychiatry, that motivated me to write a first book for the lay public, SHRINKS: The Untold Story of Psychiatry, in 2015. In 2023, I published Malady of the Mind: Schizophrenia and The Path To Prevention, with the mission of shedding light on this long misunderstood disease, for which we now have highly effective treatments – and in doing so, offer real hope and answers to anyone who has ever been impacted by this disease.

What advice do you offer to young people interested in pursuing a career in medicine?

The study of medicine is endlessly fascinating and one never stops learning – it can also be at times painful, frustrating, and exhausting. There are long hours, bureaucratic and regulatory constraints, an excessively complex healthcare financing system, and patients that don’t improve despite your best efforts. A career in medicine should appeal to individuals who thrive in the life of the mind, are intellectually curious, and who derive great gratification from helping people and contributing to humankind.

My advice to young people pursuing a career in medicine would be to carefully consider the path you’re best suited to. An academic career, for instance, offers the opportunity to be in an environment of constant exploration and intellectual stimulation – but research is not for the faint of heart; it requires discipline, capacity for rejection, and sufficient valuation of the acquisition of knowledge over grateful patients and a higher salary. Also, as medical careers have expanded in recent decades, options are no longer limited to academia or clinical practice; the private sector offers a diverse array of career paths for physicians who can pursue opportunities with pharmaceutical companies, for instance, or work in financial services as an analyst or investing in new companies, or for insurance companies or healthcare systems as an administrator. Then, of course, there is the matter of which medical specialty in which to train.

After a 40-year career in psychiatric medicine, I can say with complete certainty that I have no regrets. Being a physician has been thrilling and gratifying, and as I often say, “it beats working for a living.”