The Reiner family tragedy continues to unfold. A few weeks ago, we learned that Nick Reiner, who was indicted for the gruesome murder of his parents on December 14, 2025, had been diagnosed with schizophrenia. Days later, we learned that drug use may have aggravated his mental illness. The latest update reveals that doctors changed his medication just a month before the murders––and that this change was followed by an increase in erratic behavior. As Nick Reiner’s terrible story develops, more about his troubled past will undoubtedly come to light––as well as the degree to which his schizophrenia diagnosis may have prompted his heinous act.
Tragedies like that of the Reiner family are painful to hear and can only fill me with sympathy. I could comment on the numerous ways in which Nick’s treatment regimen likely failed the Reiner family, but I neither have sufficient information to be certain nor the license to be an armchair quarterback.
So I will confine myself to musing on how yet another preventable tragedy serves to remind me how little the public understands about mental illness in general and schizophrenia in particular.
Some Background on Schizophrenia
Schizophrenia is neither new nor rare. It has likely existed for centuries, if not millennia, and remains one of the leading causes of disability in the world, with a lifetime prevalence of about 1% of the population. More than any other mental illness, schizophrenia is synonymous in the public’s mind with madness: the homeless person standing barefoot in the cold shouting at no one, the family member who suddenly believes the neighbors are sending poison gas through the walls, the friend who is convinced that the government had planted cameras to spy on him, and the perpetrator of irrational acts of mass violence. A particularly cruel aspect of the illness is that it manifests in late adolescence and early adulthood, just as young people are coming into the prime of their lives.
My fascination with schizophrenia began before I knew its name. As a child who loved stories of the ancient world, I read the tale of a religious recluse called Symeon Salus, who lived in the sixth century AD. After years in the desert, Symeon heard a call from God to save human souls, and so he traveled to Emesa (what is now the city of Homs, in western Syria) to do God’s bidding. On his way there, Symeon found a dead dog in a dunghill; he loosened the rope of his tunic, tied the dog’s paw with it, and entered the gates of the city dragging the carcass behind him. Children chased and taunted him. At church, Symeon cracked nuts noisily and snuffed out the candles; when people ran after him, he pelted the women violently with nuts, then overturned tables of food. The crowd beat him nearly to death. He drank copiously in taverns, defecated publicly, appeared nude in the streets, and entered the baths of women.
At the time, I regarded Symeon as a historical anachronism. Only years later would I realize that he, among many others like him who pepper the pages of history and literature, were ordinary people exhibiting the symptoms of schizophrenia: bizarre, irrational behavior; disconnected from reality; hearing voices and seeing visions. Moreover, Symeon’s conduct looks suspiciously like many of the homeless people that inhabit the streets of our cities.
It wasn’t long after such literary encounters that I saw up close what madness looked like. When I was in the seventh grade, my class took a field trip to—of all places—a mental institution as part of my school’s health and hygiene course. I can still recall vividly the noxious sensory experience of that visit. The patients had strange postures and mannerisms, made bizarre gestures, and wore remote expressions. When they walked, it was with the stiff, shuffling gait of the elderly. Periodically, someone would burst into laughter or unintelligible shouting, noises that punctuated the background institutional din.
My childhood brush with the world of the mentally ill might have deterred me from having anything to do with their troubles, but by the time I was in college, my interest in the brain and behavior—and in the causes of aberrant behavior—had deepened, so much so that by my third year of medical school, I had decided to go into psychiatry, even though the prognoses for people with schizophrenia were bleak.
Treatment Shortfalls & Pervasive Pessimism
However, everything changed with the wonders of psychopharmacology and the emergence of neuroscience. The advent of these scientific disciplines loosened the grip that Freudian theory—with its emphasis on unconscious conflicts, dreams and early-life traumas as causes of mental disturbances—held on psychiatry for much of the twentieth century. Unfortunately, it was replaced with a new theory that, while scientifically based, offered even less therapeutic optimism for those suffering from schizophrenia.
This neurodevelopmental theory, which was conceived and gained influence in the 1980s, postulated that genes and environmental factors that impacted gene expression, like birth trauma and exposure to toxins, caused abnormalities in brain development that later gave rise to schizophrenia—similar to autism, fragile X, Rett’s, and Down syndromes. The idea was that schizophrenia was caused by genes that affected brain development and inexorably led to the onset of illness and chronic disability. This theory gave rise to an attitude of therapeutic nihilism in which those who suffered from schizophrenia were, in the words of a prominent British psychiatrist, “doomed from the womb.”
I saw this pessimism in practice—and had a front row seat to the self-fulfilling bad outcomes predicted by the neurodevelopmental theory. One patient in particular—a young man named Jonah—stands out in this respect. Jonah was a gifted, intelligent, and ambitious student who began to show symptoms of schizophrenia shortly after he began his freshman year of college. Always diligent, impeccably groomed, and well mannered, Jonah began missing classes, appearing disheveled, and acting in a strange and self-absorbed manner. Alarmed, Jonah’s parents brought him to Mount Sinai Hospital in New York City, where I was a junior faculty member in psychiatry on night call. Jonah was experiencing his first episode of psychosis and, based on his history and symptoms, was likely developing schizophrenia. He was admitted to the inpatient psychiatric service and treated with antipsychotic medication.
The neurodevelopmental theory of schizophrenia gave rise to an attitude of therapeutic nihilism in which those who suffered from schizophrenia were “doomed from the womb.”
Jonah’s symptoms receded, and, within four weeks, they had almost disappeared. But after a few weeks of sporadic attendance at his aftercare appointments, Jonah believed he was well again and abruptly terminated treatment. Predictably, his symptoms soon recurred, and by the time his parents called me, panic stricken, Jonah was on the verge of a full-blown psychotic relapse. Voices were telling him that the world was on the precipice of disaster. He saw portents of danger everywhere; he worried that God’s will was being defeated, and the world would end.
We readmitted Jonah to the hospital and prescribed another antipsychotic with a different side effect profile, thinking that perhaps unpleasant side effects had contributed to his discontinuing his medication. Fortunately, his symptoms responded well to treatment, and he was given another chance to resume his life. But Jonah stumbled again. He felt that his ability to study was impaired by the mental fogginess and physical shakiness that the medication caused. And so, buoyed by his second dramatic recovery and impelled by youthful imprudence, Jonah decided after six months to once again stop taking his medication. Two more relapses and hospitalizations later, Jonah finally had to drop out of college.
Feeling frustrated and helpless, I asked a former supervisor for advice. How could I help Jonah break this cycle of relapse and hospitalization? Rather than offering words of wisdom or empathy, he said blithely, “You just have to let some patients suffer and learn the hard way by having multiple relapses before they accept the need for treatment.”
I was stunned. He was speaking about someone with schizophrenia the way people spoke of drug addicts or alcoholics who needed to hit rock bottom. Jonah’s life was at stake, and the supervisor’s attitude was shockingly callous. Imagine an oncologist saying something similar about a cancer patient who’d stopped chemotherapy because of the noxious side effects. “You just have to wait till the cancer spreads before they learn to accept chemotherapy.” To my mind, my supervisor’s comment was no different.
I had a front row seat to the self-fulfilling bad outcomes predicted by the neurodevelopmental theory of schizophrenia.
For a time, Jonah largely escaped the consequences of stopping his medication by responding well to re-treatment and recovering from relapses. But his luck finally ran out. After his third relapse, Jonah’s symptoms no longer responded to antipsychotic medications. Persistent delusions, hallucinations, and disorganized thinking, combined with an inability to manage the tasks of daily life, rendered him a veritable invalid. Gone were his plans to complete his education, pursue a profession, marry and have a family.
In fairness to this young man, how could he have been expected to know about the potentially devastating consequences of schizophrenia? While most people have some understanding of cancer, heart disease, and diabetes, their knowledge of schizophrenia is likely vague or nonexistent. Sadly, those of us treating Jonah did not take the initiative to explain this to them until it was too late. In fact, our training had actively discouraged us from doing so; educating patients and their families about an illness such as schizophrenia was thought to be inappropriate and even detrimental—potentially compromising the effectiveness of the treatment.
Modern Developments & Effective Treatments
My supervisor’s comment sparked my commitment to study schizophrenia, because I believed there had to be a better way to treat this dreaded disease. This career decision led to my life’s work and a body of work that has changed the perceptions, prognoses, treatment strategies, and outcomes of schizophrenia patients. Research has revealed the links between the clinical manifestations and course of the illness and the underlying biology symptoms. These discoveries have informed treatment strategies that now enable us to think realistically of symptom remission, recovery, and even the prospect of prevention. The reality is that evidence-based, state-of-the-art treatments exist that enable physicians to control the symptoms of schizophrenia, prevent their recurrence, and preempt their destructive consequences.
As a result of this progress, so much of the suffering and disability that have afflicted people with schizophrenia can now be avoided. What once defined the fate of those with this illness—the consuming torment of symptoms, the massive disruption to their lives and families, the irreparable intellectual deterioration, and the potential for violence—is no longer inevitable and should not be regarded as an acceptable outcome.
Evidence-based, state-of-the-art treatments exist that enable physicians to control the symptoms of schizophrenia, prevent their recurrence, and preempt their destructive consequences.
Now, the difficulty is to get people into treatment in a timely and affordable manner. Despite the relative frequency of schizophrenia, its enormous cost to society, and the availability of effective treatments, schizophrenia has still not received attention and funding on par with that of other scourges of humanity. Much of this inattention has been due to stigma—the prejudice that was formed when there was absence of knowledge.
The time for this to change is long overdue—so that the countless current and future victims of this horrible disease will have the opportunity to reclaim their lives, so their families can be relieved of the burden of this devastating illness, and so we can put an end to the potential for tragedies like the one that befell the Reiner family.
Thank you, Dr. Lieberman, for another great article. It provides a lot of encouragement.
Are there any books out there that can be recommended, if one has no or limited “professional“ support? When an adult child has Medicaid/Medicare care is severely lacking—we only see psychiatric nurses (NO psychiatrists in current county) or fresh out of school jr doctors, well meaning as they may be (who constantly change). How should families respond? NO guidance, because there is NO time.