I am a psychiatrist and direct the MGH Center for Addiction Medicine and Addiction Research Fellowship Program. I teach residents, fellows and physicians about neurobiology and treatment of addiction in those with serious mental illness, particularly nicotine dependence and schizophrenia. I train post-doctoral research fellows. I serve as a peer reviewer of NIH grants, as a teacher at continuing education courses and conferences, as an editorial board member and as a reviewer for a number of journals.
In a series of clinical trials, I demonstrated that nicotine dependence treatments are effective for smoking cessation for those with schizophrenia, that high-dose, combination pharmacotherapy is superior to monotherapy for smoking cessation in schizophrenia, that rates of relapse to smoking are high in this population after discontinuation of nicotine dependence treatment, and that extended duration pharmacotherapy for 52 weeks dramatically improves long term abstinence outcomes. The impact of this research has been to change clinical recommendations. 2010 and 2013 Cochrane Reviews are based largely on this work and the 2010 NIMH PORT Evidence Based Guidelines for Treatment of Schizophrenia included a recommendation for the first time for smoking cessation treatment in schizophrenia and cite this work as primary evidence that smokers with schizophrenia who wish to try to quit smoking should be offered pharmacotherapy and behavioral treatment for smoking cessation. This has the potential to reduce the heavy burden of smoking-related disease in this population.
In a related series of trials I have focused on study of innovative treatments for negative symptoms and reward processing and cognitive dysfunction in schizophrenia and in developing treatments for nicotine dependence in this population. Our group has demonstrated that agonists at the strichnine-insensitive glycine site of the NMDA glutamate receptor complex improve negative symptoms of schizophrenia. Inter-individual variability in clinical effectiveness of these agents called into question their clinical utility, so we applied magnetic resonance spectroscopy techniques to correlate change in brain glycine concentration with improvement in negative symptoms, cognitive function and smoking. We demonstrated that brain glutamate concentration can predict smoking cessation outcomes. Our group also showed that transdermal nicotine improves cognitive function and nicotinic receptor antagonists worsen cognition in non-smokers with and without schizophrenia, but to a greater extent in those with schizophrenia.
In addition to research, I perform clinical work, with a caseload of 150 patients from 1995-2001. Since 2001, I have performed consultations on diagnosis and pharmacological management with a focus on treatment of those with bipolar disorder and schizophrenia, with or without co-occurring substance use disorders. The inspiration for my clinical research has come from these clinical interactions and the desire to improve clinical outcomes in patients with serious mental illness. There were no standard treatments for negative symptoms, cognitive dysfunction or nicotine dependence in schizophrenia when I began my career. I co-founded the Wellness Program in the MGH Schizophrenia Program in 1997 to develop treatments for nicotine dependence and obesity in schizophrenia. With support from the Massachusetts Department of Mental Health, I developed a Tobacco Treatment Network at 8 sites in New England to implement and test smoking cessation treatments for patients with schizophrenia.
My clinical teaching contributions include co-authorship of the DMH ‘Guidelines for Psychiatrists for Preventive Medical Management of Patients with Major Mental Illness’ and ‘Guidelines for Management of Bipolar Disorder’. In addition to individual supervision of psychiatric residents, I have contributed to ongoing courses for medical students, residents, fellows on schizophrenia, nicotine dependence, and co-occurrence of addiction and major mental illness at the local level. I have taught practicing health care professionals at regional, national and international levels through courses and webinars.