A reduced niacin-mediated flush is increasingly accepted today as a positive diagnostic indicator for schizophrenia. Schizophrenics that were successfully treated with high dose niacin (nicotinic acid) therapy by Dr. Abram Hoffer in the 1950s recovered from their otherwise previously reduced flush response simultaneous with recovery from schizophrenia. Significantly, some schizophrenics also recovered after high dose nicotinamide treatment, a different nicotinamide adenine dinucleotide (NAD) precursor that does not cause a flush response. Whether the niacin-flush response is first due to replenishment of NAD deficiency or due to a restoration of polyunsaturated fatty acid levels thus restoring niacin-flush competence is not mutually exclusive.
It is possible that nicotinic acid is first dedicated to intracellular NAD synthesis at the expense of the flush response until the schizophrenic's immediate needs for NAD are finally met. Then the nicotinic acid, rather than entering the cell through transporters, instead becomes available to bind GPR109a, on the surface of the cell thus mediating the flush pathway. Moreover the restored NAD levels may also revive the biosynthetic pathway required for generation of the known niacin-flush vasodilatory molecules PGD2, PGE2, PGI2, and thromboxane A2.