Medications in Psychosis- Paula Wadell, MD


So I’m going to talk about medications. I
am a child and adolescence psychiatrist and I’m the medical director for our early
psychosis programs here at UC Davis. I have no disclosures. All right, so today
I’m gonna focus in on oral medications and then really sort of spend some more
time talking about injectables, specifically long-acting injectables and
then covering what we know about nutritional supplements. And the spoiler
on that is, not a lot. So all right, before I launch into the oral medication
piece I just want to give out this resource. So the RAISE early treatment
program is a research study it supports coordinated specialty care which you’ve
been hearing about today and this was a really comprehensive research program. So
they looked at 34 community mental health centers and hospital outpatient
mental health facilities in 21 states. That’s pretty impressive, that’s a pretty
diverse group and when they looked at at these folks what they found was
that they did better with this type of treatment. Now as you might imagine
that’s a pretty diverse group and so in order to sort of ensure that everybody
was getting the same type of evidence-based medication treatment they
came out with a really useful manual so it’s called the NAVIGATE Psychopharmacological Treatment Manual. It has a lot of really great details in it. I’m not gonna go into all of that today, because I’m gonna focus in on some other
things, but if you are a prescriber if you are somebody who’s monitoring
medications or if you just want to learn more about it it’s available for free
you can download it. It’s like 60 pages so it’s a little bit lengthy but it’s got a
lot of really nice details about how to make decisions, about when to try
different medications, how long to wait, what to do when certain side effects
come up. So, I’ll be referencing that a couple times but just wanted to make
sure I gave that reference right off the bat.
All right, so when we talk about oral medications in psychotic disorders we’re
really talking about antipsychotics and they generally have sort of similar
efficacy it’s it’s hard to really get an excellent group of head-to-head studies
comparing all of these antipsychotics. So I can I say for sure that they’re all
generally the same with regard to their efficacy? Well, it’s kind of hard to say. The exception is clozapine which I’ll talk about in a minute. But in general
they all tend to have the same benefits. They’re pretty good at treating positive
symptoms– delusions, hallucinations, disorganized stuff. Now you notice I
didn’t put in negative symptoms and unfortunately these medications are not
particularly helpful when it comes to negative symptoms. So it’s certainly a
limitation. They’re quite good at improving mood stability. They are often
used actually as mood stabilizers. They also decrease anxiety. The first
antipsychotic– anybody know without that was? Thorazine, right. So the first
antipsychotic if you go back and look at these really fun ads from the 1950s it
was marketed as an anti-anxiety medication that you would just feel
wonderful and you wouldn’t care about anything if you took this medication. So
it definitely I think all of these medications have gone on to show pretty
good effect when it comes to the treatment of anxiety. They tend to
improve sleep, sometimes a little bit too much. Sometimes they can be fairly
sedating and lead to lots of sleep. But for many people it really is very
helpful and very powerful. And then very importantly– relapse prevention. So sort
of florid episodes requiring more intensive treatment. These really reduce
the risk of that happening again. So lots of benefits. I’ll just briefly outline how we categorize these medications because
I told you already but they’re all kind of the same when it comes to efficacy. So
what tends to drive our decision-making is more the side effect profile. And the
side effects, again I’m not going to go into the exhaustive list of that, but you
can kind of break it down into two main groups. So the first antipsychotic,
Thorazine, was called a well later on became known as a first generation
antipsychotics or a typical and what that means is that it worked in a way
that followed the dopamine hypothesis. There’s this idea that dopamine was very
important in in psychotic disorders and if you blocked dopamine receptors that’s
what would treat a psychotic disorder. And so Thorazine and then all of its
kind of relatives all followed that pattern. The idea was to block the
dopamine receptor and when you do that there’s a risk of abnormal movements and
so that’s kind of one of the defining features of this subgroup of
antipsychotics. The second-generation antipsychotics which are far more common
today, we tend to use these more. They’re called atypicals. And the very first
atypical or second-generation–does anybody know? Clozapine. That was the first one, it’s from
quite a long time ago. Although, it was sort of recent there’s been a more
recent proliferation of all of those those medications. They’re called
atypical because they didn’t work in the way that we thought they needed to
everybody thought you had to have these really potent blockers of dopamine
receptors and then clozapine came along and sort of put that theory
to the test. So everybody thought great this is wonderful this is a wonderful new
solution, we’re not gonna have to worry about abnormal movements anymore. But
unfortunately what we found was that it increased the risk of weight
gain and then associated metabolic problems. So specifically, hyperlipidemia
increased risk of diabetes, abnormal fasting blood sugar. Which you know has
serious consequences. I didn’t put in here another category which is kind of
emerging now, broadly called third generation antipsychotics. I’ll mention
one of them later, aripiprazole, or abilify. The reason it’s considered kind
of distinct is because unlike first generation and second generation it
actually partially stimulates the dopamine receptor and so aripiprazole, brexpiprazole, and now cariprazine, those are
all medications at work in a slightly different way. They seem to have the same
side effect profile as the second generation, so they’re sort of lumped in
with this newer generation in terms of side effect profile. Alright, so that’s kind
of like a broad background. Let’s take a minute and talk about clozapine and
when we might use it. I already told you that of all the antipsychotics there is
one that shows higher efficacy kind of clearly and that is clozapine. And the newest guidelines which come out of the NAVIGATE psychopharm manual which I told you about is that we should probably be considering this sooner. Maybe after just two trials of antipsychotics. If somebody’s having what
we call treatment resistant symptoms at that point that we should really
consider clozapine and certainly after three trials of an anti-psychotic it
should be the treatment unless contraindicated or refused. And I’ll
often put it that way. Now the reason I want to really provide the the strength
of this recommendation is because it is not without burden, right. So the big
risk is agranulocytosis. Granulocytes are neutrophils or type of white blood
cell, and this medication can cause a rapid decrease in those particular white
blood cells which limits the body’s ability to fight an infection. So
for that reason, you actually have to get a blood draw every single week for the
first six months then every two weeks for six months and then every four weeks
as long as the medication is taken. So as you might imagine this is a really high
burden. This is really hard. I mean how how many people are willing to go to a
lab without fail every seven days so that they can then get their medication
for seven days? That’s all you get until you go again to the lab. So this is this
is a pretty high bar to get over. The other two kind of big medical things we
worry about our myocarditis, an inflammation of the heart, and that can
be very dangerous. The highest risk is in the first four weeks and so now actually
the newer recommendations are to also monitor measures of heart inflammation
in the first four weeks as well. And then there is an increased risk of seizures.
So for all these reasons clozapine is not first-line. But for
treatment-resistant symptoms it really can be life-changing and we certainly
see that in our clinic. It does have a special indication in people with
persistent suicidal ideation and so sometimes we’ll consider it earlier on
if that’s what’s going on. And there’s this hint coming out of the literature
now that although I told you all of the antipsychotics are roughly equivalent
risperidone and olanzapine are sort of emerging as maybe a little bit more
effective when it comes to treatment resistant symptoms. And so if somebody’s
like no, no, I’m not gonna try clozapine I will often say okay let’s make sure
we’ve at least tried these: risperidone olanzapine. And then of course if you’re
if you think the medicine is not working because the person is not taking it then
then you would want to have that conversation as well. Just a word about
antidepressants. Depressive symptoms are really common in the first episode of
schizophrenia and and they may be a core part of the acute illness, but generally, those symptoms tend to resolve with
anti-psychotic mono therapy. And so our recommendations in the first phase of
the illness is to really try and focus in on making sure the anti-psychotic
that’s been chosen is appropriate, it’s at an effective dose, and is being taken
consistently, before you consider adding anything else. Right, we always want to do
less medication. It decreases the risk side-effects, decreases lots of things. So
now let’s talk about long-acting injectables. So, we’ll start with the
benefits. The first one is kind of obvious, right? So up to 50% of people
will stop taking oral medication. This is just reality. This is reality for
everything. Who has ever been told you should probably take this medicine,
and has then forgotten to take it. I mean this is just the reality. And so
we’re asking young people, generally young people, please take this without
fail it will affect your long-term ability to function and the better you
are at taking it every day the better you will do. That’s really hard, that’s
just the reality. And when I’m talking to people–
first of all I’ll preferentially choose something, an oral medication, I will try
to choose an oral medication that is available as a long-acting injectable,
and right off the bat we’re having that conversation. I get a lot of–I don’t want
an injection, and I don’t like the idea that I can’t sort of titrate or
adjust it in real time. Right, because you you’ve committed to that and it’s gonna
be 30 days before you can really adjust the dose of your medication, give or take, it
varies on on the medication. But really, these are clearly very helpful. They
decrease rates of hospitalization and when compared to oral medications they
are superior. If you want to be on the best treatment for this, choose an
injection. And you know one idea is that well it just takes the adherence
question out the window. You know for sure that the medication is being
delivered every single day without fail. And so in somebody who just takes
their oral medication with a really really high level of commitment maybe
they can achieve the same outcome. Well maybe, but keep in mind that the
injection is being metabolized through a different pathway.
So when you take an oral medication it goes into your stomach and it’s absorbed
into your liver and it goes through what we call a first pass of metabolism and
so what actually enters your bloodstream for then delivery to your brain is
something that’s already been altered by your liver. When we give an injection,
it’s going into the muscle tissue and slowly being released directly into the
bloodstream. So it’s not going to participate in first pass metabolism. So
that’s a fundamental difference in how the medication is delivered. There is at
least one antipsychotic that’s and a couple that are available in sublingual formulations. Same idea, if it’s sublingual it’s getting absorbed
directly into the bloodstream and that changes how the medication sort of the
concentration of it and the state it’s in when it’s delivered to the brain. So
it may be that by avoiding the first pass effect the injections end up being
more effective as well, we don’t really know. So let’s talk about what the
options are. So first of all, like I’ve said before they all appear to be
roughly equivalent in terms of their efficacy. So again, we’re gonna be looking
at their side effect profiles and then the frequency of the injection. So that’s
a big one because there’s one injection that has to be given every two weeks.
Again, that’s that’s kind of a hard sell. So, the first generation antipsychotics,
the ones that we tend to use are going to be fluphenazine or haloperidol. Those
are both given every four weeks and they’re first generation antipsychotics. So
they’re gonna have that higher risk of abnormal movements. And then, the second
generation or as the case of aripiprazole, if you want
to call it a third-generation, now we have the proliferation of a lot of
different options. So aripiprazole exists in two different formulations, the
maintena one is given every four weeks, there’s a newer one called Aristada, that one can be given up to every six
weeks in the highest dose. And then risperidone is given every two weeks, so
that one is less popular because it’s twice the injections. Paliperidone
is probably one of the most popular ones. Paliperidone is the active metabolite of
risperidone, so risperidone turns into paliperidone. So this is available as Sustenna and that’s given every four weeks. But it has
another advantage, the way you start this medication is different than the others.
You give a loading dose on day one and then another sort of loading dose on day
eight and then every thirty days thereafter. And what that enables is that
you don’t need the sort of oral medication overlap that you need with
some of the other ones. So if you’re gonna switch somebody to haloperidol decanoate you’re talking about at least two weeks of oral medication
before that injection is effective enough to kind of fully take the place.
Whereas with Invega Sustenna you’re not having to do that. Olanzapine is
available in a long-acting depo but we essentially don’t use it because it
requires three hours of monitoring post injection. The risk of this post
injection syndrome is quite low it’s at like 0.7 percent and it includes
confusion, sedation, agitation, and sort of acute extrapyramidal symptoms. But that
three hours of monitoring post injection is a is a really high barrier so it’s
really hard to find somewhere where that can be done. And so sort of practically
speaking that one is it’s hard to to access. Oh and then I forgot to mention
about haliperidone, one of the newer ones Trinza is now
available and that actually given every 12 weeks. So we’re
talking about only needing an injection four times a year, that’s it. So that’s
another benefit of Invega Sustenna just sort of practically speaking. So if
somebody has been on Sustenna they have the opportunity to switch over to
Trinza. They have to be on Sustenna first before you can make that move to Trinza. What I hear from people when they switch over to an injection is that it’s
liberating. They don’t have to carry pill bottles with them, they don’t have to
worry about it, they don’t have to think about remembering this and making sure
it’s all lined up. They’re not engaging in the sort of back and forth with their
loved ones, did you take your medications, stop bothering me. That conversation is over. And so what I hear from from so many people who decide to go this route, is
that they really really like it. Not everybody does.
Some people they really have an intense fear of needles or they just don’t like
the medication or the side effects for other reasons. I want to just take a
second to talk about what we call sub-threshold psychosis, which I’m sure
Dr. Niendam touched on. This idea that there’s people who are experiencing kind
of psychotic like experiences, so not fully psychotic, but a bit unusual. And
so I think for practitioners the idea is you know what’s the best approach? What
what should we do? Should we be offering low-dose risperdal? And the
answer in that is, no. So antipsychotic medication is not effective enough at
preventing the transition to psychosis to justify its use with all the
associated side-effects, which is really important. So whenever this medication is
being prescribed we need to make sure that it’s appropriately being used. And
it’s not any more effective than therapy in reducing psychotic like symptoms. So
we always want to make sure the appropriate therapy is going on. Omega
fatty acid. So now we’ll transition into the sort of the supplements and
and the different things that have been in the news lately. So omega fatty
acids have gotten a lot of press. What are they? So they’re essential fatty
acids that are needed for brain development. And so the term essential,
whenever you see the term essential in front of a vitamin, a mineral, or a fatty
acid like this it means that your body cannot make it on its own. Much of what
our body needs we can actually make, out of whatever we’re eating. But there are
exceptions to that and these are one of them. So particularly when it comes to
omega fatty acids the best sources of this are going to be fish and in the
U.S. we just don’t really have a very marine based diet for a variety of
reasons and so most people in this country are probably not getting the
recommended amount of omega fatty acids. What is the recommended amount? Hard to
say. Again, there’s sort of some guidelines that have come out of the
Institute of Medicine and from the WHO, but in general the idea is
something like two to three meals of containing fish in a week. So how many
people get that? Very few. In terms of looking at this in the treatment of
psychosis; there was excitement that maybe it could help. It helps the brain,
maybe it’ll help with psychosis and it doesn’t, but it might maybe help reduce
the side effects to antipsychotics. But it very clearly decreases the risk of
cardiovascular disease. So, when I talk about omega fatty acids I’m always
encouraging it. Absolutely, that’s a good idea.
But don’t think that it’s going to do something that clearly it’s not
going to do. Now there was a lot of excitement about fish oil preventing
psychosis. This came out of a study that was done in 2010 and then a follow up of
this same group of individuals that showed–it was 76 individuals, they did a
12-week intervention and there was a dramatic reduction a very exciting
reduction in the number of people who transitioned to psychosis.
And when they did a follow-up study later that difference held up. And
so that was very very exciting and so Medscape put out in August 2015 this
very exciting headline “Omega-3 treatment shows long-term psychosis prevention.” So
pretty exciting, right? Well then we had a replication study and this is why it’s
so important to wait for those replications, because when they did a
bigger study at multiple sites. So this time 304 adults they did kind of a
similar distribution of essential fatty acids with their supplementation but
they did it for six months so a little bit longer and everybody received
cognitive behavioral case management. So that was different from the original
because we knew by then that you really needed to offer that because there were
such strong evidence to support the use of cognitive behavioral case management.
So what happened? No difference, no difference at all between the two groups.
So, “Final word? omega-3s don’t prevent transition to psychosis,” that’s the
article that we got. You know, I don’t know that I’m that confident. I mean, I
think we don’t really know. These were adults, not kids. How adherent were they? Were they really taking this? I mean it’s hard to
say. So, I don’t think we have definitive evidence supporting its use, that’s
for sure. Although we have evidence for other health-related outcomes, right, that I
talked about earlier. What I hear a lot though after I sort of point this out
that there’s no replication of this is this– but it’s natural. Okay, but
how do we define that? How do we define natural? And does natural mean
that there’s no harm? And the answer to that is, no, right? I I wouldn’t go out and
eat poison oak. It’s natural, it’s readily available, but you should not
eat it. That’s a bad idea. So just because
something is sort of so-called natural does not mean it’s safe and in fact if
you look at animal studies of large doses of oxidized lipids may cause organ
toxicity, growth retardation, and accelerated atherosclerosis. And this is
a big issue because these supplements are not always highly
regulated and so what I’ve cited there is a study from New Zealand where they
found that the majority of the supplements available in the market were
highly oxidized and therefore potentially harmful. So this is not
something that is without harm. And I corresponded it with Dr. Amager who did
the original fish oil study and asked him, “well what are you doing for your
patients?” And he said, “well I’m telling them to eat fish twice a week.” So that’s
sort of what I say. I think for people who absolutely will not eat fish, then
it’s okay to kind of go out try and find an omega fatty acid supplement. Try and
make sure it’s reputable, the FDA has nice guidelines on which supplements are
more likely to be sort of contain what they say they do. And then follow the
guidelines on the bottle so in general these have to be like kept in a cool
place or refrigerated and you really have to adhere to the expiration date
because they do oxidize. So that’s kind of the fish oil story. Let’s talk about some
sort of vitamins. I like this ad a lot. If you google Sarcosine this is one
of the ones that comes up, this is brain vitamins. It sounds so promising, right? It
says right there in big font, ‘promotes brain cell function,’ but there’s a little
asterisk there and so if you sort of lean in and read that it says these
statements have not been evaluated by the Food and Drug Administration this
product is not intended to diagnose, treat, cure, or prevent any disease. So, huh, hard to know what to make of that, right? And what is this Sarcosine anyway?
It is an NMDA receptor modulator. And so without going on into the weeds there’s
lots of different theories about the origins of psychosis and how it happens
at the level of receptors and NMDA receptors seem to play a role. So there
was this idea, well maybe we could take some NMDA receptor modulators and maybe
it would have some impact. And it seems like it might. So these are four sort of
commonly used ones where there’s some research available and all of them seem
to lead to small improvements when added to an anti-psychotic,
but again we’ve got an exception for clozapine. It didn’t provide any benefit
when added to clozapine and worse if you added glycine to clozapine the symptoms
worsened, more evidence that just because it’s over-the-counter and natural
doesn’t mean it’s not harmful. So when do we use these NMDA receptor modulators?
When does a small improvement lead to a meaningful significant gain in
functioning? These are really hard questions to
answer. I try to really focus on choosing the right antipsychotic and making sure
that it’s actually being taken. Those are my priorities. In someone who feels
like they’ve gotten some benefit from their medication, they don’t want to
change it, they don’t want to up the dose because then they have more side effects,
and there’s very like sort of small minor things that are bothering her, I’ll
have a conversation then about some of these supplements and we’ll talk
about taking them. Generally they’re not super expensive. The pills
tend to be kind of large, particularly for N-Acetyl Cysteine, it’s a large
pill so in somebody who has trouble swallowing things it’s not a very
popular choice. So those are options. I want to take a minute though to talk
also about vitamins. So there was this idea of mega vitamins. This was
introduced in the 1950s and then really pushed by a couple
of psychiatrists. There was this idea that if you gave people with
schizophrenia extremely high doses of vitamins that this would treat the
underlying problem. There is no evidence to support this claim. It’s been sort of
debunked multiple times. It’s still out there.
I certainly still get questions about it. But there is no evidence to support the
use of B vitamins. Now, natural sources of B-vitamins are good for you and you
should eat them. But in terms of taking high doses I don’t recommend that.
The vitamin D story is a little bit more interesting. So when you look at vitamin
D there’s some type of association. Individuals with schizophrenia are more
likely to be deficient in vitamin D. That does not mean that if you give somebody
vitamin D supplementation it reduces their symptoms of schizophrenia. There’s a correlation we don’t know really truly the relationship here.
So there have been a couple attempts at this trying to treat people with
vitamin D and it didn’t lead to any benefit. So, again, there’s lots of healthy sources of vitamin D
that can be consumed. I encourage people to eat them. But there’s no
evidence for vitamin D supplementation. And then vitamins A, C, and E. More of the
same. So there’s really no current evidence to suggest that these vitamins
reduce the symptoms of schizophrenia. That does not stop the propagation of
articles on the internet suggesting otherwise. But really there is no
reputable evidence to support those claims. And again, harm is possible. So
toxicity can occur with vitamins, which sometimes people don’t realize.
Particularly with vitamins that are fat soluble which means they accumulate. So
vitamin A you can see headaches, nausea, blurred vision, hair loss. Vitamin C again nausea, diarrhea, kidney stones. And vitamin E
nausea and digestive problems. And I didn’t even put on here with vitamin E
and people who are on anti-clotting medication it can increase the risk of
bleeds. So certainly, again, not without harm. I think there’s been a
proliferation of these different kind of ideas about vitamins. We’ve had some in
our clinic. I had somebody come in with a list of 10 supplements he was supposed
to take, many of which I had never heard of and I had to look them up and each
one contained multiple compounds. Some of which that interfered with the
liver metabolism of his antipsychotic. So I called up the person who had
recommended these many things because I was curious and I wanted to learn about
this and what I was told was that she could tell by looking at the iris of his
eyes that he was deficient in a wide variety of things and that this would
really be very helpful at great expense both of the visits and the supplements,
which she conveniently sold. And they provided no benefit and there was
no evidence to support them and worse they actually there was potential
for harm. So we really have to be very mindful about what kind of information
might be provided to the people we work with, to our loved ones. There are people
who will try to sell these things and it can really cause a lot of problems. So,
what’s the bottom line? I think there’s limited evidence to
support the use of vitamin supplements in schizophrenia if you consider the
amino acids I talked about I talked about vitamins you could you could say
well those supplements have a little bit of evidence to support their use.
A healthy balanced diet that limits processed foods is a good goal for
everyone. So absolutely, let’s talk about making sure you’re getting dietary
sources of omega fatty acids but you’re getting enough vitamin D that you’re
getting outside to get some sunshine so you so you have that opportunity to make
vitamin D, right, because that’s you get it from the sun. So those are good
goals, but that does not mean people should take a bunch of supplements. I did
have a question once. Someone approached me saying that sometimes this illness
can drive really selective dietary intake especially when there might be
delusions associated with the food supply or different things like that and
those cases are a little bit different and in those cases I will recommend just
a good balanced multivitamin to make sure people are getting the essential
vitamins and minerals they need. And then as I said before, NMDA receptor
modulators such as sarcosine and N-acetyl cysteine, often abbreviated as NAC,
can provides some benefit when added to an anti-psychotic.

4 comments

  1. I assess Paula as extermely dangerous to human beings. She is suffering from SIRDPD "Socially Induced Robot Dissafective Psychopath Disorder". This is a state of mind Psychiatrists are often left in after academic brainwashing They see humans as "things" – only see their outer characteristics and have no understanding of human consciousness – a type of extreme selfish solipsism .They are socially induced murderous psychopaths.
    This condition is incurable. I recommend a prefrontal lobotomy and lifetime imprisonment in the deepest darkest dungeon where she has no power to hurt a human being again.

  2. Well to sum it up. There are no objective criteria for schizophrenia. Its diagnosis and treatment are based on subjective evaluations and impressions of mortal beings who 're prone to make mistakes. This makes it open to all sorts of abuses. We can't know if the patient responds well to the treatment as the evaluation of the improvement or retrogression of the patients too is again based on subjective impressions.

    Actually we can't distnguish a person who really suffers from schizophrenia from a person who pretends to be schizophrenic and vice versa. Thus we can't know if this condition is a temporary one which will disappear by itself in time just like flu or a permanent one like diabetes. Actually according to World Health Organization data the ones who don't receive any treatment for schizophrenia in underdeveloped countries are doing much better than the ones recieving aggressive drug treatments in developed countries in the long run.

    Those symptoms could well develop in prolonged stays in coercive environment of psychiatric hospitals and the ensuing uncertainity emerging in the minds of the patients, and actually mental health professionals could well be the main culprit of the aggravated symptoms of this condition which would otherwise disappear completely when they're treated in noncoercive and compassionate environments. We need transparency and accountability in mental health facilities
    .

    Antipsychotics?

    How do antipsychotics treat hallucinations and delusions? How does it work? You give antipsychotics and as soon as these drugs start to kick in suddenly all the hallucinations and delusions disappear. Is it the case? No it is not. Even after being discharged those hallucinations and delusions linger in those people. So in reality they really have no impact on the positive symptoms. They worsen the negative symptoms only. The benefit of these drugs is for hospital staff only as these drugs make those unfortunate people docile and more manageable only. Is it ethical to risk the physical as well as mental health of those indivduals simply to increase the comfort of hospital staff?

    According to the researches almost one third of those people start to suffer because of the side effects and crippling, disfiguring and irritating irreversible adverse effects of these substances within 2-3 years time, and it's estimated that in life time use all recipients will experience all these rreversible adverse effects which would make their life unbearable.

    According to the international conventions that aim to prevent torture, cruel, inhuman or degrading tretament and punishment "medical treatments of an intrusive and irreversible nature, when lacking a therapeutic purpose, may constitute torture or ill-treatment when enforced or administered without the free and informed consent of the person concerned"

    Take a look at the link below.

    http://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf

    Is Psychotherapy Effective on People on Drugs

    I really wonder how you hope to help those doped people whose cognitive abilities severely impaired? In order to be able to help those people their hippocampi should be active. Hippocampus in the brain needs emotions in order to be able to tag the informations to learn. That's how we can learn and keep or record the informatons and knowledge in our brain and process them when we need. Yet, as their emotions are seriously blunted due to the drugs they receive their hippocampi have no avail. Most probably most of your efforts with them completely disappear within a couple of hours time altogether. Psychotherapy programmes with schizophrenics on drugs are doomed to fail.What you say here that you can help those suffering individuals has no scientific basis what so ever. That defies logic and neuroscience

    What is the Succes Rate of the Proposed Treatment

    I really don't understand how she can confidently say that treatment works while we know that average recovery rate for alcoholics and drug addicts altogether is as low as 4 percent? Why does she think that the revcovery rates for this mental health problem should be higher than this despite the fact that the treatments offered to those people are pretty much same? Remember that this woman earns her living from that profession. Is it possible for her to be impartial in that particular matter? Is she really a reliable source of information regarding the success rates?

    Is This Really a Success

    Many of those unfortunate people treated with drugs after being labeled schizophrenic can't see their mid forties as those drugs irreversably wreck their physical health. Those unfortunate otherwise very healthy individuals (who could well see their eighties hadn't they forced to take those drugs) die at early ages mainly because of the drug induced health conditions such as liver or kidney failure or heart problems. It's important to note here that they don't die in peace. On the contrary they die in great physical and emotional pains.

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  3. You can also apply the arguments she uses against vitamin supplements as identical reasons to not take anti-psychotics …there is also very limited evidence to suggest that anti-psychotics are even effective for anything other than creating zombified, easy-to-manage patients in psych units. it is widely known that they are not safe and cause extremely detrimental side effects in a vast majority of those taking them. The harm from anti-psychotics is substantially greater and much more prevalent than cases of vitamin toxicity, which is rare. Yet she still has no problem pushing the anti-psychotics.

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