Optimal Use of Neuroleptic Drugs: An Introduction

Sandra Steingard, MD
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I have recently put together a talk in which I summarize my current thinking on the optimal use of neuroleptic drugs, primarily focusing on the treatment of individuals who are experiencing psychotic symptoms.  In order to foster conversation on this topic, I will be posting the content of this talk in a series of blogs.

First of all, I stipulate two points:

  • These drugs can be very effective for some people in the short term in reducing symptoms of psychosis.
  • Once someone is started on these drugs, the risk of relapse is much higher when they are stopped than when they are continued.

Current treatment standards suggest that:

  • Antipsychotic medications are critical to the treatment of schizophrenia.
  • Antipsychotic medications should be started ASAP.
  • Long term maintenance medication is recommended.

In addition, current treatment practice is:

  • When a person does not respond, dose is increased.
  • Dose is often increased faster than drugs typically work.
  • Additional medications are added fairly often.
  • An enormous amount of resources are devoted to insuring that patients remain on medications.

These are questions that I want to address:

  • When should we begin/what is risk of waiting?
  • How much drug is needed?
  • Should everyone remain on these drugs indefinitely?
  • Is it appropriate to consider relapse as a uniform phenomenon with uniform risks?

This is the argument I will put forth in future blogs:

  • The impression of short term efficacy tends to be inflated.
  • The impression of long term risk tends to be minimized.
  • The impression about the risks of delaying treatment (Duration of Untreated Psychosis) with antipsychotics is inflated.
  • Although antipsychotics are sometimes remarkably effective in reducing psychotic symptoms, this does not mean that they are always required.
  • Compliance is low despite our recommendations so it is almost impossible to comply with recommended guidelines.
  • Relapse does not carry the same risk for all individuals.
  • In the early 1990’s, there was a growing recognition that only minimal D2 blockade was needed to produce optimal results.  This concept got lost in the years when the newer antipsychotics were highly promoted but concept remains valid.
  • Joe McEvoy and colleagues (Archives of Gen Psychiatry 48:739-745, 1991) conducted a study in which they determined the minimal dose of haloperidol needed to produce very slight extrapyramidal symptoms, i.e., muscle stiffness.  In a carefully controlled study, he found that low doses of haloperidol (on average about 3.5 mg) were just as effective as the higher doses that were commonly used that the time (10-20 mg).  Raising the dose above that was only likely to produce more side effects without further clinical improvement.

I come to the following conclusions:

  • Since many people choose to stop, since some may get better without medications, since some may be able discontinue with slow taper, since relapse is not universally a disaster, we should revise our practice standard to try to wait before starting drugs and consider discontinuation in a controlled manner.
  • Since these drugs are not as effective as most people think, we should approach failure to respond with more judicious use of drugs rather than by adding on more drugs.
  • The current practice of recommending that almost all individuals remain on these drugs indefinitely should be challenged.
  • We need to reconsider what we consider informed consent.

In the next blog, I will provide the data that support these assertions.  I will provide references for specific articles but at the beginning, I want to cite several books which  have had a big impact on my thinking in recent years.  Each of them has informed me in important and sometimes profound ways.

Marcia Angel’s The Truth About the Drug Companies.  In the 1990’s, I began to notice a disconnect between the published data and the perception of the efficacy of the new drugs.  However, I did not have enough data to fully understand this. Dr. Angel who was then the (first female) editor-in-chief of The New England Journal of Medicine began to write about this.  She was in a position to understand how profound the influence of Big Pharma was on the practice of medicine and she tracked this story with a directness that took courage given her position at the time.

Irving Kirsch, The Emperor’s New Drugs.  Dr. Kirsch is a psychologist who has written extensively about the efficacy of the antidepressant drugs. This book reviews not only his own work but also the larger topic of placebo.

Daniel Kahneman’s, Thinking, fast and slow.  Professor Kahneman is a Nobel Laureate in economics. His work is in cognitive psychology. This book elegantly summaries research conducted over the past 50 years and gives us insight into how we think, form opinions, and make decisions.  Humans have remarkable abilities of intuition but these abilities can also lead us astray in ways that are surprising and unsettling.  It seems critical for anyone who ever has to make a decision to understand what Dr. Kahneman has to tell us about ourselves.

David Healy, Pharmageddon.  Dr. Healy is familiar to readers of this website. This work is important in many ways but one critical message in the book is its discussion of the limitations of randomized clinical trials and the ways in which these can be distorted for commercial purposes.

Wendel Potter, Deadly Spin.  Mr. Potter was a high level executive for a major health insurance company. Although, his book’s topic is not directly relevant to this discussion, I found it important because it sheds light on the ways that corporations invests huge resources into spinning their message not for the sake of the public good but to advance the financial interests of the corporations.

Robert Whitaker, Anatomy of an Epidemic.  This needs no further explanation.  This book directly influences this talk and I refer to some of the articles that he cites in his writing and talks.  However, I cover some areas not directly addressed in the book, specifically the short term efficacy of these drugs and the question of the impact of not using drugs to treat psychosis.

I look forward to reading your comments.

 

160 COMMENTS

  1. Dr. Steingard,

    I’m fairly impressed with what you’re offering here.

    Generally speaking, what you say throughout makes sense.

    Speaking as a former “patient,” who (back in the late 1980’s) was taking such drugs, it all resonates and is in accord, with my own experiences *and* my observations of many others’ experiences. It’s very well done – for what it is.

    But, one or two things are missing, I feel.

    First of all, there’s no mention of *akathisia* (let alone any description of what akathisia is).

    Nor is there any mention that these drugs can create horrible dysphoria.

    As I’ve said elsewhere, if I could recommend just one online article to all psychiatrists (and to others who are keen on recommending these drugs), it would be this one article (“Unravelling Madness”), which briefly describes such effects, as experienced, by Richard Bentall, years ago, in an experiment led by David Healy:

    http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10565099&pnum=0

    [Note: I tend to be extremely critical of Healy, for he promotes ‘shock treatment’ (ECT) and denies the reality of its negative effects; but, he does a good job emphasizing the dysphoric effects of neuroleptics.]

    From the point of view, of knowing, that such effects can result from prescribing such drugs, I wonder: Is it ever ethical to force them on people?

    (I will tell you here, frankly: I don’t believe it is ever ethical to force them on anyone. Such is my conclusion, for I know, first hand, what it feels like, to have them forced on me… into my veins and my nervous system, my brain. They created the sorts of effects that Richard Bentall describes, in that article. I was so deeply disturbed by those effects, I could hardly function; yet, no one would ascribe my distress to those drugs; instead, those effects were interpreted, by everyone, as ‘proof’ that I was supposedly “mentally ill”.)

    Often, there is mention of weight gain and other effects metabolic effects. Sometimes, there’s mention of tardive dyskinesia, which ostensibly develops only after many years of being on these drugs.

    There is virtually never any mention, anywhere, of what extraordinarily *negative* effects these drugs can have on people, when administered by force.

    My experiences with psychiatry led me to realize, that: as soon as they’re forced on a so-called “patient,” these drugs can be torturous; and, those effects put an end to all possible, reasonable objections, to the ‘treatment’ itself.

    So, what you’re saying in this blog is all quite meaningful, and I do appreciate what you’re saying…

    But, in my humble opinion, if you are to cover this subject well, you’ll need to address these further issues, which I’m raising, in your subsequent blogs.

    Respectfully,

    ~Jonah (@BeyondLabeling)

    http://twitter.com/beyondlabeling

    • Jonah, thanks for the link to the NZ Herald article. Very interesting.

      I watched this Ted talk two days ago

      https://www.youtube.com/watch?v=L8Bd_p8pbQI

      It’s about an experiment with fruit flies, where they stress the flies with an air puff and look how long it takes the flies to calm down. Then they found a fly that took much longer to calm down than the other flies. They found a mutation on a gene that encodes the dopamine receptor.

      If I understand it correctly it means, that if you block the dopamine receptors, it is very likely that you get some (at least very mild) form of akathisia. Worst case scenario: The psychotic symptoms don’t go away with the neuroleptics and they make you constantly stressed (not calm / hyperaroused / fight or flight state), which makes it even harder to cope with the psychotic experiences.very

      Now there is also the theory that hyperarousal plays a role in the development of psychosis.

      Which doesn’t mean that neuroleptics don’t work for some people, but I find it plausible that they could be psychological very harmful for some others.

  2. Hi Sandy-
    Thanks for the post. I do remember attending a lecture years ago by Herb Meltzer (who is probably retired by now.) He indicated that antipsychotics don’t achieve reduction of symptoms by sitting on the receptor site. Rather, the pre-synaptic dopaminergic neuron will increase its release of dopamine in response to the antipsychotic occupation of the receptor site. Eventually, the presynaptic neuron exhausts its supply of dopamine. This is the point at which a reduction in symptoms is observed. According to Meltzer, it takes time for this exhaustion process. If the clinician increases the dose, nothing is achieved in terms of symptom amelioration, which is a function of time. Increasing the dose just augments the EPS. Who knows if Meltzer was right?

    I’m wondering about the use of omega-3s (see J.R. Hibbeln on omega-3s for ameliorating all kinds of distress; recall: omega-3s are the only treatment that decreases the emergence of full-blown psychosis in youth at risk.) I’m attaching some notes on N-acetylcysteine, which is pretty benign, and some comments heard at Emory Frontiers in Neuroscience on Zinc. Since none of these interventions are harmful, why not give them a try.

    By the way, omega-3s are anti-inflammatory. There is a huge literature (see Charles Serhan) on how omega-3 are converted into resolvins, which function to curtail an inflammatory response. They also increase vagal tone and PFC function. However, my guess is one can wipe out the beneficial effect of omega-3s by washing them down with inflammatory high-fructose corn syrup, transfats, or foods with a high glycemic index.

    Hope these notes make some sense. If they don’t give me a call. 770-939-7409.

    N-aceytl-cysteine
    Ketamine is known induce both positive and negative symptoms of schizophrenia. Work on animals has determined the mechanism through which ketamine operates. Ketamine influences the behavior of inhibitory interneurons which function to place a break on glutamate releasing neurons. Ketamine will increase the production of superoxide by an enzyme called NADPH oxidase. Both antioxidants (glutathione) and inhibitors of NADPH oxidase will abrogate the impact of ketamine. In terms of the mechanism, superoxide will decrease the function of interneurons and reduce the amount of an enzyme (GAD) which produces GABA (the neurotransmitter released by interneurons). Genes associated with this circuitry (genes producing glutathione) have been linked to occurrence of schizophrenia. All of this explains why N-acetyl-cysteine (an amino acid which gets converted to glutathione) is efficacious in reducing symptoms associated with schizophrenia.

    Behrens, M. M., Ali, S. S., Dao, D.N., Lucero, J., Shekhlman, G., Quick, K. L., Dugan, L. (2007). Ketamine-induced loss of phenotype of fast-spiking interneurons is mediated by NAPH-oxidase. Specific developmental disruption of disrupted-in-schizophrenic-1 functions results in schizophrenia-related phenotypes in mice. Science, December 7, 318, 1645-1647.

    Lecture at Emory-Zn++ will block signaling at NMDA receptor

    • Hi Jill,

      I always appreciate your intelligent comments on many issues of interest to those challenging biopsychiatry.

      However, your above response citing genes linked to schizophrenia is appalling to me based on all the junk science psychiatry has produced so far with a zillion different theories at about one new one per week to justify their bogus disorders invented and VOTED IN by the white old boy network of psychiatry in bed with BIG PHARMA to push the latest lethal drugs, ECT and other tortures on patent. Books like PSEUDOSCIENCE IN BIOPSYCHIATRY and books/articles by Dr. Mary Doyle make it all too clear that schizophrenia is a bogus stigma with no reliability or validity. She and other experts also make clear that symptoms attributed to schizophrenia or now bipolar, psychiatry’s latest “sacred symbol” per Dr. Thomas Szasz, are mostly if not completely environmental. Books like THE PROTEST PSYCHOSIS make psychiatry’s nefarious goals in creating such stigmas with varying symptoms and targets like young angry black men depending on the perceived need for increased social control all too clear.

      Anyway, Dr. Jay Joseph has written some great posts on this site recently and other great articles and books like THE MISSING GENE and THE GENE ILLUSION among many others to totally debunk any claim for genes causing bogus stigmas for the junk science DSM billing bible, which Dr. Loren Mosher exposed as far more political than medical.

      I find it offensive that you would post such THEORIES about schizophrenia when NONE have been replicated or proven!

    • Omega-3s are good, but it’s also important to lower omega-6 intake. The amount of omega-6s in the normal diet is inflammatory. Better to replace oil high in PUFA (polyunsaturated fatty acids) with oil high in in monounsaturated fats or saturated fats. Especially avoid sunflower, soy and corn oil.

  3. I am quite sure the rate of relapse after discontinuation of any psychiatric drug is inflated by the almost universal misdiagnosis of withdrawal symptoms as relapse.

    There are virtually no guidelines for tapering; we can be sure some of those who were observed to be relapsed in studies were discontinued too fast for their individual tolerances.

    In addition, of all the hundreds of clinical trials that involved observation (lasting only weeks) after discontinuation, I’ve seen exactly one that included a protocol to distinguish withdrawal symptoms from relapse. All the others — 99%+ of studies — use psychopathology scales for assessment. Any symptomology at all is going to be reported as a psychiatric condition rather than withdrawal symptom.

    The statistics for relapse are likely all incorrect. I would like to see some reporting based on slow discontinuation and careful observation of withdrawal symptoms during the process, and observation for at least 6 months post-discontinuation.

  4. “Once someone is started on these drugs, the risk of relapse is much higher when they are stopped than when they are continued.”

    Trouble is EVERYONE gets started on the drugs. Of course some people are more vulnerable to being screwed up by them than others. Any study is only going to discern that some people will be more or less screwed up by them. Not who should never have been started on them in the first place. That should be the focus.

  5. Sandra,

    Welcome back. You know I don’t agree with stigmatizing people with bogus DSM VOTED IN labels that do a huge amount of harm or subjecting people to toxic drugs and other types of lobotomy that damage their brains, make them far worse in the short and long run and destroy their lives in countless other ways.

    At the same time, I give you a great deal of credit for continuing to engage in the learning process along with us at this site and doing your best to help people as much as you can while doing the least amount of harm given the less than ideal environment in which you work. Richard Lewis helped me to understand that many patients at Community Mental Health Centers may be poor, on Medicaid, under a great deal of stress and have few options. I apologize if I have misunderstood your situation, but I realize at times one has to do the best they can under the circumstances.

    I think you may have been misunderstood in one post in that it appears that you are stating what the current standard practice or protocol of mainstream psychiatry is and you are challenging some of that based on your own experience, research and increased knowledge including the fraud of BIG PHARMA now exposed by many experts like the brave, honorable Dr. Marcia Angell in books and articles.

    One of the problems that doesn’t get addressed enough here especially is those MISDIAGNOSED with bipolar for abuse related trauma, bullying and other crises for very nefarious reasons like drug company profits and higher incomes. People so stigmatized do not have psychosis or delusions though they can be falsely accused of having them and others due to their stress and trauma per Dr. Carole Warshaw and many other abuse/trauma experts with horrible consequences to women and children especially. Does that happen much in Community Health Centers? Do you deal with domestic/work/school abuse/violence/bullying issues in your work? If so, how are they handled?

    Obviously, anything like giving lesser stigmas, smaller doses of toxic drugs and tapering people off them as soon as possible, considering nutritional and better substitutes for drugs and other changes based on your increased knowledge is very beneficial to your clients.

    Did you ever get around to checking out Dr. Mark Hyman’s books and/or web sites like THE BLOOD SUGAR SOLUTION and the functional medicine approach he and others advocate that I suggested in an earlier email to you? He also has many good videos on the web where he suggests holistic and nutritional approaches to maintain a healthy mind, body and spirit. I highly recommend his approach.

    Sandy, You are a brave woman too!

    • Sandy,

      Thanks for your response. Unfortunately, you totally misunderstood me when I pointed out the huge harm by psychiatry to abused women and children by giving them bogus bipolar and other misdiagnoses for their all too normal stress reactions to abnormal, abusive, often psychopathic, narcissistic, misogynist men with psychiatry having far more than their share of them.

      This reference source, THE ENCYLOPEDIA OF DOMESTIC VIOLENCE, is one of many sources exposing the huge harm psychiatry does when invalidating the victims while aiding and abetting the abusers with bogus psychiatric stigmas with the worst and most common fraud being bipolar now.

      Although PTSD was added to the DSM to acknowledge combat and domestic violence related stress and trauma as normal reactions to abnormal events, many psychiatrists are publishing bogus data about many being predisposed to PTSD so they can blame the victims and deny them any justice, safety, military benefits, etc. I think this is despicable and all too common for the top dogs of psychiatry to collude with the power elite, BIG PHARMA and other self serving interests as you have acknowledged to your dismay, which adds all the more to the victims’ suffering when those who are supposed to help cause the most harm. Dr. Aphrodite Matsakis exposes the shock and misery created by such betrayal by so called legal, medical and other “professionals” who retraumatize trauma survivors.

      Here is an excerpt from THE ENCYLOPEDIA OF DOMESTIC VIOLENCE showing the harm of bogus bipolar and other stigmas for abused women and children, which is all too common:

      http://books.google.com/books?id=OcDBZ0uNNVIC&pg=PA694&lpg=PA694&dq=abused+women+misdiagnosed+by+psychiatry&source=bl&ots=6zZ4YwmNLv&sig=7NlV1qkNScLARf7N5H6NmMl1XMw&hl=en&sa=X&ei=CjVIT4zjCePq0gGMp6yzDg&sqi=2&ved=0CC4Q6AEwAg#v=onepage&q=abused%20women%20misdiagnosed%20by%20psychiatry&f=false

      I am not sure what you mean by extreme states. Abused women and children are not psychotic, delusional, paranoid or making things up in any way, shape or form. They will show signs of great PHYSICAL and emotional stress while being INVALIDATED and falsely accused of being crazy (bipolar) is certainly crazymaking at best and plays right into the hands of her abuser that can include family, community and other bystanders in a patriarchal world.

      So, I will let Dr. Carole Warshaw, Psychiatrist, and nationally recognized Domestic Violence expert speak on the huge harm done to abused women and children by psychiatry out of ignorance, malice, fear or indifference:

      Psychiatric News | July 19, 2002
      Volume 37 Number 14 page 8-8

      Psychiatrists Urged to Ask About Domestic Violence

      Carole_Worshaw.jpeg

      Carole Warshaw, M.D.: “We are trained to diagnose psychiatric disorders without looking at the social context that might have generated the patient’s symptoms.”

      In addition, she noted, research shows that 43 percent of women seen in outpatient mental health settings were sexually abused as children, and 35 percent were otherwise physically abused.

      The psychiatric impact of domestic violence is great. Women with a history of childhood abuse are more likely to be abused as adults than women without that history, said Warshaw. “Rates of posttraumatic stress disorder are also higher in adults with childhood abuse than without childhood abuse,” said Warshaw.

      However, symptoms of severe childhood trauma including flashbacks, dissociation, mood fluctuations, and impulsive behavior are often misdiagnosed as hallucinations, psychosis, and bipolar disorder, leading to treatment that doesn’t address the underlying issues, she said.

      Warshaw directs the Domestic Violence and Mental Health Policy Initiative at Cook County Hospital in Chicago, which brings together more than 70 domestic violence, social service, and mental health agencies in a collaborative partnership to identify common goals, barriers to services, and gaps in services to improve and provide integrated services for victims of domestic violence and their children, according to Warshaw.

      Domestic violence survivors who participated in a 2000 survey conducted by the Domestic Violence and Mental Health Policy Initiative reported feelings of sadness, loss, despair, depression, loneliness, shame, isolation, confusion, guilt, loss of identity, fear, anxiety, stress, insecurity about their capabilities, and somatic symptoms, said Warshaw.

      Moreover, studies of women victims in shelters and clinical settings have reported that about 60 percent had PTSD, 50 percent had depression, and 20 percent had suicidal thoughts or had attempted suicide, said Warshaw.

      “PTSD increases the risk that a victim will develop major depression and diminishes her ability to seek help, make decisions, and mobilize her resources to leave the abuser. It also increases her risk of being isolated and controlled by the abuser,” said Warshaw.

      Missed Opportunities

      Psychiatrists may be unaware that abuse can precipitate a patient’s psychiatric symptoms. “We are trained to diagnose psychiatric disorders without looking at the social context that might have generated the patient’s symptoms,” said Warshaw.

      Psychiatrists fail to ask about abuse because they don’t think it is prevalent among their patients, don’t have the time, and don’t know what to do if they identify it. They may also find it difficult to tolerate the pain and helplessness they feel when patients talk about their experiences of abuse or when their own traumatic experiences are evoked, said Warshaw.

      In the eyes of domestic violence survivors and victim advocates, labeling survival strategies as psychiatric disorders is a barrier to mental health care. “It is important to acknowledge to survivors that dissociation, self-medication, appearing passive and compliant, and self-blame are understandable responses to terror and entrapment,” said Warshaw.

      Additional concerns regarding mental health care identified by domestic violence survivors and advocates in the 2000 survey were not receiving comprehensive mental health services, the abuser’s controlling the victim’s health insurance, initiating couples counseling before knowing the risk to the victim, and not informing the victim that psychiatric diagnoses can work against him or her in child custody battles, said Warshaw.

      Screening and Documentation

      Psychiatrists often find it awkward to raise the topic of abuse, especially when there are no obvious signs. Warshaw recommended asking abuse-related questions routinely and framing them in a way that shows interest and acknowledges that it is a common experience, said Warshaw.

      A sample statement is “I don’t know if this has happened to you, but because so many women experience abuse and violence in their lives, it’s something I always ask about,” she said.

      Warshaw cautioned against asking a patient about abuse in the presence of a potential perpetrator and to be aware if a perpetrator seems “psychologically healthier than the victim. Abusers know how to manipulate the mental health system to further control the victim,” she said.

      If a woman says she is being abused, Warshaw suggested asking her about specific acts of abuse and documenting as many facts as possible, including when and where the abuse happened. She also recommended asking detailed questions about patterns of abuse, tactics of control and intimidation, level of fear and entrapment, sexual coercion, and the impact of the abuse on the woman and any children.

      “Documentation is critical for women seeking legal protection, redress, or custody and provides a safe opportunity to examine the ongoing nature of abuse and its impact,” said Warshaw.

      In addition to obtaining a history of abuse, a causal relationship between domestic violence and mental health issues or diagnosis should be established, said Warshaw. She also recommended documenting the patient’s strengths, coping strategies, and ability to care for and protect her children.

      The patient should also be informed about the limits of confidentiality and the risk that her medical records could be subpoenaed in a court case involving child custody, said Warshaw.

      Assessing the patient’s safety is a critical part of treatment planning, said Warshaw. These are some questions that psychiatrists can ask their patients:

      • Is the abuser present or likely to return to the clinical setting?

      • Is the victim afraid to go home?

      • Is the abuse escalating?

      • Are there weapons present?

      • Is substance abuse a problem?

      • Is the victim planning to leave?

      Warshaw urged psychiatrists treating victims of domestic violence to give them information about domestic violence and local advocacy resources, including shelters, support groups, and national advocacy resources.

      “Victims may need to call a local domestic violence program, the National Domestic Violence Hotline [(800) 779-SAFE], or develop a safety plan before leaving the clinical setting,” said Warshaw.

      A list of state domestic violence coalitions and their telephone numbers is posted on the Web site of the National Domestic Violence Hotline at http://www.ndvh.org/helpstate.html. The Domestic Violence and Mental Health Policy Initiative Web site at http://www.dvmhpi.org should be live in the next month, according to Warshaw. Posted items will include “Recommendations for Addressing Domestic Violence in Mental Health Settings.” ▪

      Sandy, With all due respect, you really didn’t answer my question about how much you encounter domestic/work/community violence and bullying and the fate of the victims. Whether the victim is validated as Dr. Warshaw and other domestic violence experts recommend while avoiding harmful, bogus labels like bipolar or if she is just callously given a bogus stigma with lethal drugs that will hinder her ability to focus and create an escape plan for herself and children is a matter of life and death. Although it is taken for granted that domestic violence takes place in lower income groups, the book, NOT TO PEOPLE LIKE US: HIDDEN ABUSE IN UPSCALE MARRIAGES, shows that such violence against women is alive and well at all income levels with those in higher income marriages the most invalidated of all.

      Again, though I don’t agree with all of what you do and say, if I HAD to be under the care of a psychiatrist, I would hope to get someone like you who tries her best to first do no harm or at least minimize the harm as much as possible when one is faced with people causing great harm or being subjected to great harm themselves. And I hope you see that giving an abused woman a bipolar stigma plays into the hands of the abuser while robbing the woman of her children while further endangering them, her fair share of the home and assets, career, friends, community and all else she holds dear, which is totally unconscionable if one considers these horrific consequences.

      I’m glad you are checking out Dr. Hyman’s book, which can be helpful to your own health and well being too. You might find it quicker and easier to check out his online videos. I’m sure you know a great deal of this by now anyway, but I was very impressed with an example Dr. Hyman provided online of functional medicine being applied to find the causes of symptoms given the bogus ADHD stigma.

      You are making a wise choice eliminating sugar because many doctors/experts are exposing sugar is poison and sadly, corporations covered up this dangerous fact exposed by courageous scientists in the past just as they do with toxic drugs, pollution and junk food today. We must all be our own “doctors” in the sense we need to do lots of homework before automatically trusting someone just because they claim to be experts, doctors or scientists who may have huge conflicts of interest that don’t include our interests at all.

      Again, I give you a great deal of credit for struggling with such difficult issues for the best interests of your patients and society while I won’t deny that some day I hope psychiatry as it now exists with life destroying stigmas and lethal treatments will be replaced by a type of holistic treatment for mind, body and spirit that enhances health rather than destroying it.

      • Donna, thanks for the awesome post! The quotes from the “encyclopedia of domestic violence” were particularly good. I had never heard of that book, despite my working in the field of social work. And it’s good to know that this stuff does get published in mainstream journals, even though I don’t see anyone in the psychiatric field paying much attention to it.

        — Steve

        • Steve,

          Thanks so much for the validation and encouragement. I do feel quite alone and unsupported expressing these critical views by very caring psychiatrists and mental health experts who actually address the victims’ toxic environments, the real cause of severe emotional distress that is falsely attributed to bogus claims of “mental illness” to fuel the biopsychiatry global money machine for the power elite at the huge expense and harm to the majority.

          And to be honest, it takes a great deal of hard work and time to ferret out this information, but fortunately I have degrees and lots of experience in research areas that have been a great asset in this long term endeavor of seeking the truth about many things I learned that I had been grossly misled about in my youth. Dr. Thomas Szasz warns that it is our responsibility to learn about such social institutions as psychiatry to avoid harm. I have found out that is also true of the legal profession, government in general, main stream medicine, corporations and other institutions I naively trusted before they proved they were totally unworthy of such trust as a whole.

          That does not mean that everyone is included in such a critique. The problem is that those controlling main stream medicine and psychiatry in power structures like the AMA and APA and other professions make decisions they force on the rest of the profession that are not in the best interests of patients or consumers since they exist to gain more money and power for their profession and not on behalf of their clients. Though the majority do go along to get along, fortunately, there are always those mavericks who act as whistleblowers for the rest of us and I am eternally grateful for them. Society owes a huge debt for those who take risks to protect the rest of us. I greatly admire Dr. Carole Warshaw, Psychiatrist, who is a domestic violence expert and the subject of an article I posted above. I tout the huge contributions of Dr. Peter Breggin frequently too since he has been a lifesaver for many.

          Thanks again for your comment. It made my day.

          • I also want to express my appreciation for your contributions to the conversation, Donna. I can assure you that the trauma-informed perspective is more than welcome here. I keep an active eye out for trauma-informed research that is pertinent to the MIA mission, as a means to encourage that dialogue. I am more than grateful for your perspective and knowledge base.

            The MIA mission is a delicate one, as I see it; to work from within the psychiatric theory and research. Robert Whitaker has accomplished what he has by doing this scrupulously; avoiding stands on what “psychosis” or what-have-you is or is not, and looking at outcomes. Within that framework, yours and others’ perspectives on the implications are welcome and necessary.

            I see Sandy’s reserve on the subject as appropriate. Within what she is saying there is room for discussion of alternate perspectives. More than that; alternate perspectives are called for, and we are all the beneficiaries of yours.

            You are every bit as essential and integral a participant in this website’s mission as is Sandy, Bob or myself. Thank you for staying engaged.

  6. When I stopped all the psychiatric drugs I was put on cold turkey (at the time it was a cocktail clomipramine/sertraline but I had been in the past on Zyprexa, Risperdal, Dextroamphetamine and Lorazepam that I had previously stopped with supervision) I felt terrible for a couple of weeks. Terrible as in “brain zaps”, nausea, general bad feeling. So bad that I even thought about going back to them. Fortunately, I was able to resist the temptation, encouraged by testimony of people who had gone through the same process who said that eventually those withdrawal symptoms go away. They do go away, and with them the extra pounds, the skyrocketing cholesterol levels and the kidney/liver malfunction. It’s been a long time that I have been off drugs and I doing great.

    I was diagnosed with OCD, a diagnosis that I consider as fake as all DSM diagnoses. Yet I was put on all kinds of drugs of the psychiatric arsenal: antidepressants, antipsychotics, anxiolytic and stimulant. Because my cholesterol level skyrocketed my psychiatrist wanted me to be put on cholesterol drugs as well (but I refused). So!

    I think that psychiatric drugs should be banned, period. Psychiatry should be declassified as a medical specialty and be given the same legal status as astrology or homeopathy. Period.

    • CannotSay,

      What if I need a psych med to resolve being able to stay asleep on my apap machine?

      Just so folks know, I have suffered months of insomnia that was most likely due to undiagnosed sleep apnea made worse by being on psych meds. Unfortunately, I feel that being on them. has made me hypersensitive to being able to tolerate the treatment that I need.

      I intend to explore many other avenues before I resort to taking a med. But I may have no choice as I can’t function on little sleep on a daily basis. No one can.

      Sorry, it may seem like I am getting off topic but in a way this relates because Sandy’s point is that antipsychotics do benefit some people and Bob has said the same thing. They just don’t benefit as many people as psychiatry thinks they do.

      But still, to deny even a small percentage of people something that would benefit them them simply because we hate psychiatry for legitimate reasons would be wrong.

      • As I said, I have no problem with voluntary relationships. It’s the coercive aspect that I find despicable. I also think that psychiatry is, for the most part, as nonsensical as astrology or homeopathy but I have nothing against people who voluntarily use their services. Imagine for a second how our life would be if astrology had the power of preemptively locking in an individual because some astrologer looking at the natal chart of said individual believed that there is 75% chance that said individual would become violent tomorrow. There would be an understandable outrage against such power. Yet, that is the power that psychiatry has here in America today (75% is equivalent to “clear and convincing evidence” which is the standard required by the courts to commit people). We know that psychiatry has no ability to predict who’s likely to become violent (several studies attest to that), yet our society gives psychiatry the power to preemptively locking people based on the assumption that it can do so.

        If I were an astrologer, I would sue the government for discrimination: a psychiatrist and an astrologer practice the same type of nonsense, yet the first is given a lot of legal power while the second is ostracized.

        • Hi Can’t Say,

          Thanks for clarifying.

          Actually, I would be using a regular doctor as I have no intention of ever setting foot in a psychiatrist’s office again. No disrespect to Sandy and the ones who post here by the way.

          • :D. I advise you to stay as far as you possibly can from a psychiatrist. They will only bring hell to your life. If you need some drug of the psychiatric arsenal, get it from your GP.

            See, I am a very strong defender of individual freedom, which is why I feel so strongly on the matter of coercion. Some people don’t value their freedoms as much and see no big deal in getting locked in for “medical” purposes. I do.

            If one day I have the resources, I will support any astrologer who wants to sue the government for discrimination :D.

      • I support letting people choose whatever treatment they want, AS LONG AS THEY’VE BEEN GIVEN TRUE INFORMED CONSENT. The problem with these toxic drugs is that it’s the rare psychiatrist or GP who truly informs the person about the effects of the drugs and whether the benefits of taking the drugs outweighs the problems that they cause. People in state hospitals are essentially forced into taking the drugs before the psychiatrists even consider discharging them. If you don’t comply with the drugs you don’t get loose, plain and simple. Many times people are taken to court and have their time extended, against their will. This is done as an effort to force them into taking the drugs.

        So, if you want to take them by all means do so, but no one should be forced to consume them against their will and they should be informed as to what will happen to them if they take the drugs.

        • Stephen, absolutely no arguments whatsoever as you’re preaching to the choir. Long before the UN labeled forced drugging as torture, I called it that on the Shrink Rap Blog. I am sure they weren’t happy about that.

          Can’t Say, we agree about psychiatry. But be careful about assuming that GPs can’t do any harm with psych meds. I saw a story yesterday on NPR about one giving an 80 year man an AD because he was upset about cognitive issues. He tragically committed suicide with a gun which I feel was the result of a reaction to the med even though obviously, I can’t prove it.

          I know I am getting off topic but needless to say, I was quite disgusted since NPR as usual didn’t ask the tough questions and just automatically made it about guns and suicide. I derisively call them National Psychiatric Radio.

          • National Psychiatric Radio! That’s hilarious. I’m a daily listener, and have often heard they are funded in part by the Robert Wood Johnson Foundation. I hear that’s related to Johnson&Johnson, the drug maker. This new joke name may beat the one, “National Propaganda Radio.” It’s funded somewhat by individual donations, but not entirely! Still, I like hearing how the information is being presented. That’s information in itself.

  7. Duane, the issue isn’t that Alto is against alternative med. It is that just because they aren’t mainstream psychiatry, doesn’t mean you should be any less skeptical. Sadly, while there are good folks out there, there are also some scam artists who can also be quite harmful. True, they can’t force you into treatment against your will but they can still cause alot of harm.

    Sandy, I tapered at the 10% rate using a compound pharmacy. When that got to be too expensive, I used a digital measuring scale, empty gel caps, and a pill crusher, to measure out my doses. Yes, it is a pia big time but it was the only way for me to safely get off of my meds.

    Not sure how that would work for your patients so perhaps finding a compound pharmacist you could work with might be your best bet. But I definitely agree with Alto that tapering them by 25% of current dose is way too fast, particularly for antipsychotics that are quite powerful. In fact, some of your patients might find they need to taper at 2.5 to 5% of current dose every 4-8 weeks.

    Yes, it will take them a long time to get off the drugs at that rate but better they increase their chances of success and maintain their quality of live vs. a fast taper that will most likely cause a relapse and set them up for failure.

  8. In some circumstances the question comes down to: what is better the padded cell or a tranquellizer when a person who has “completely lost it” and is trying to kill himself or somebody else, arrives in A&E. I am talking about my son here. I am glad they coerced him into taking Haloperidol at the time; what I object to though is that the psychiatrists continued to tranquellize him against his will afterwards instead of talking to him and helping him to solve his psychological and emotional problems that brought him to his knees in the first place.I think that people break down for a good reason and psychiatry is ignoring this. I am looking forward in reading more of what you have to say.

  9. Hi, Sandra,
    I’m going to jump in on this discussion with anecdotal information re my son’s tapering. I think you are doing an excellent job of keeping track of the complexity of the situation and reminding us that no two people are alike. My husband and I hired an well-qualified holistic psychiatrist to very slowly taper my son off the two low dose meds he was on. The taper was supplemented with all kinds of vitamins, minerals, immunity boosters, etc. And, he was getting psychotherapy twice a week from a different psychiatrist. Surely, I thought, he would not relapse given all the support (physical, mental, emotional) he was getting. Wrong. Within a couple of months of finally getting off them, he was showing signs of psychosis. We delayed putting him back on the drugs until it became clear that he may not survive crossing a street. We tried again two years later, after different holistic therapies had been used and twice weekly psychotherapy. Same ending. Slow taper, but soon showing signs of psychosis. These drugs, as much as I dislike them and see how crude they are, were invented for a reason, and that reason was to stop psychosis. I’ve chased all kinds of interventions, and, while my son is really on an excellent path now because of these interventions, I wish we could find out what his particular medical problem is that keeps him dependent on the meds for the time being. It could be his immune system (that’s my latest thinking)but where are the answers? “Science” hasn’t bothered looking too hard past the dopamine theory until fairly recently and I don’t want a drug in 10 years time, I want a natural remedy now. This is my long-winded way of saying, yes, it’s complex. Sometimes I fear that people now believe that relapse is only because the med tapering was too quick. Also, it is well known that as a person gets older, the symptoms tend to diminish or disappear, so a lot may be explained by the age of the patient.
    Best regards,
    Rossa

    • Hi Rossa, it’s very complex indeed. If there is an illness that causes the psychotic symptoms, than it’s quite possible that the symptoms return, after tapered off the drug that suppressed the symptoms (on the other hands there are people who had a psychological crisis that was caused by social circumstances, who where put an psychiatric medication and they were ill just because of the medication and become well after withdrawal).

      I have no medical education, but there is more and more evidence, that the immune system and autoimmune responses play a role in mental disorders. I never had any psychotic experience, but after I went on a gluten-free diet my anxiety dropped to a normal level and nightly panic attacks just disappeared.

      Many of the non-neuroleptic (experimental) treatments are linked to the immune system:

      Omega-3 supplements (reduction of omega-6 in the diet)
      Probiotics
      Vitamin B12 / Folate
      Vitamin D
      NAC
      Gluten-free / casein-free diet
      Mindfulness based stress reduction / yoga

      • I have had good results with all the supplements Oli suggests (except NAC, which tends to upset stomachs), plus magnesium citrate, taurate, or glycinate.

        I suggest omega-3 be supplemented to at least 3,000mg EPA plus DHA per day — usually about 6 capsules of good-quality fish oil.

      • Thanks, Oli, for your taking the time to respond. I confess that I am quite jaded now about medications, vitamins, psychotherapy, and mindfulness, even though I am giving more thought to the immune system. My son, at one point, was swallowing 35 vitamin and mineral supplements a day, taking into account all the supplements you listed, and he still relapsed after going off the meds. I guess I was looking for a quicker fix than was actually the case. It is a hard slog for the “correctly diagnosed.” By “correctly diagnosed,” I mean, people in the traditional age groups (15 to 25 for men, 25 to 35 for women) who are NOT at the mercy of nurse practitioners and doctors who actually believe that there is a compelling need to medicate children showing signs of mental illness. My humble opinion, based mainly on extensive reading personal experience and other people’s testimonies, indicates that people outside of this age range are the most likely to be “misdiagnosed” as bipolar or schizophrenic. “Correct” diagnosis doesn’t mean much, since the diagnosis has no verifiable scientific underpinning, but it does mean that if you exhibit certain behaviour and beliefs within these age ranges, you’ll get the label that reflects the behaviour. I do believe, however, that an all encompassing approach to treatment, that does not rely on meds exclusively, gets wonderful results over time. I have always noticed improvement in my son, with each new intervention tried, and these improvements are cumulative.

  10. Duane,

    Why the anger when people like Alto and I express concern about alternative medicine practices?

    Essentially, my message is that when dealing with mainstream and alternative health professionals, you need to be very cautious. That is just common sense and has nothing to with any agenda.

    • AA,

      I have experienced unspeakable trauma in my life.
      Two saving graces were Neurofeedback and Cranial Osteopathy. They helped *much more* than “talk therapy”.

      We have injured soldiers who would greatly benefit from Hyperbaric Oxygen Therapy – for both “PTSD” and TBI.

      Re: Being “very cautious”

      Water soluble vitamins are extraordinarily safe.
      So is neurofeedback.
      So is deep breathing and relaxation.
      So are *many* non-drug approaches.

      I can understand being *cautious*, but *very cautious*?

      Are you comparing using a neuroleptic to having an osteopathic physician perform a cranial adjustment? Taking antidepressants to learning to pray and meditate?

      Is there *some* inherent risk involved in these approaches?
      Sure.
      But a pretty strong argument could be made that there is *significant risk* involved in psychotherapy – not the least of which is that most folks who reveal their souls to these folks know *nothing* about their therapist – including their beliefs and values.

      Re: Alto
      Let Alto speak for Alto.

      Duane

  11. While some “alternative medicine” has significant side effect risks, as a rule, most are less than those of conventional medicine, which is used with so little consideration. The concern for the use of any “unproven” remedy should be proportionate to the risk. For instance, certain herbs can have significant and even deadly side effects if used in high dosages. Folic acid, however, has almost no risk, as excess B vitamins are excreted in the urine easily. As another example, homeopathy may be seen by many as hokey and unscientific, but the side effects are essentially nothing more than a very temporary discomfort at the very worst, and the costs are minimal. If someone wants to try it out, why not?

    We ought not to be viewing “alternative medicine” as a monolith, but should look at each intervention with an eye to cost-benefit analysis, just as we ought to be doing with conventional medicine. Most of the time, doing that analysis honestly brings “alternative medicine” out on top, mostly because the risks, as a general rule, tend to be so much smaller, even if the benefits may be inconsistent or difficult to determine.

    —- Steve

    • I agree that, by and large, taking a supplement is a lot less dangerous than taking a psychiatric drug. (However, I’ve got a couple of cases of people having difficulty withdrawing from SAM-e….hmmmm….)

      I get outraged about any kind of dishonesty in health treatment, alternative or allopathic.

      Some people just don’t have the money to waste on misrepresented treatments. For example, many naturopaths will order urine tests that purport to measure neurotransmitter balance from a company called NeuroScience. The lab reports come complete with recommendations for NeuroScience’s pricey supplements formulated to correct whatever neurotransmitter imbalances are found. How could this possibly be valid?

      I wish now I had the several hundred dollars I wasted on that bogus testing and those supplements when I was much more naive.

      (Many people have adverse reactions to NeuroScience supplements, which contain various neuroactive ingredients.)

      Like TrueHope’s EmpowerPlus, Immunocal is another supplement for which the manufacturer, Immunotec, generated studies and a lot of scientific-sounding blather supporting its use. Immunotec also got Immunocal approved as a prescription “medical food” reimbursable by Medicare. Immunocal is a whey protein isolate. Unlike other whey protein isolates, supplement composition for Immunocal is held secret.

      From what I can glean, Immunocal is roughly equivalent to NOW Whey Protein Isolate, which lists its composition on its label and is available without prescription. The difference: Immunocal is 15 times more expensive. You (or Medicare) pay $85.00-$99.00 for 300 grams of Immunocal; for the same amount of money, you can get 4536 grams of NOW Whey Protein Isolate.

      Beyond cost, there are real dangers in supplement manufacturer misrepresentations. Neurocritic discusses TrueHope’s liabilities in this post http://neurocritic.blogspot.co.uk/2012/07/empowered-to-kill.html , which includes some very interesting transcripts of TrueHope support calls with people desperate for solutions to their health problems.

  12. Hello Sandra,

    great post. Just some additional points I find important:

    – It is thought that delaying treatment with neuroleptics is harmful. As far as I know there is no proof this assumption.

    – It is still argued that loss of brain tissue over the years is mainly caused by the illness, but we know that antipsychotic treatment is associated with brain tissue loss.

    – Side effects of neuroleptic drugs are often battled with additional drugs, which can be harmful too.

    – Patients should always be tested for B12 and vitamin D deficiencies. They should also be tested for gluten and casein sensitivity.

    • Oli – I spent at least two years kicking myself for not getting my son on medication because I believed (wrongly) the pharmaceutical hype that it was important to get people on medication right away “to protect the brain.” However, delaying treatment has its very severe side effects if the person is exhibiting behavior that increasingly puts their lives at risk. My son got grazed by a car on one occasion, and barely avoided getting beaten up by strangers on another. So, while I agree that the brain isn’t going to stop functioning by delaying treatment, the other side of it is the non-drug risk.

  13. It is so difficult for a psychiatrist to make sense of the conflicting information about what drugs are supposed to do and what we see them do. Medicine is basically a team sport, and any time a doctor disagrees with the ‘standard of care’ then it is an uphill and often career trashing experience.

    I want to praise Dr. Steingard for having the motivation and energy to express her individual opinions, which run counter to the way that psychiatry is practiced. The big problem is that the antipsychotics do clearly help some people, so taking a total antidrug position is simplistic. Unfortunately when a psychiatrist opens up an honest dialogue about antipsychotics, they are quickly marginalized and labelled an antipsychiatrist. Absent a meaningful scientific literature on the risks and benefits of the drugs, there is probably no better source of information than an honest clinician who can draw their own conclusions. I look forward to reading the next two installments.

  14. Dr. Steingard, Thanks for the concise, highly readable article. Would patients’ families be open to using the Open Dialogue approach that is so effective in Finland, as it harmonizes social situations and minimizes drug use? Also, how about using technology that gets real-time feedback on how well-balanced brainwaves are with less medication? When the amplitude of brainwaves is balanced (lobe-to-lobe, left-to-right), the whole brain harmonizes and symptoms of many mental disorders are relieved, pretty much for good. Recent Webinars on this technology mentioned that the objective computer analysis shows that drugs often disrupt the brain’s ability to balance itself. Wouldn’t this provide proof to back a doctor up in choosing to minimize drugs if it enables more mental balance? The unbalance caused by drugs was mentioned in minutes 5 and 7 of the Webinar with “Special Guest Dr. Cronin” and in minutes 12 and 58-59 of “A Conversation with Lee.” They’re under the “Ask Lee Library” at http://brainstatetech.com/webinars I share this unpaid, because I want unnecessary suffering alleviated!

  15. Dear Sandra Steingard, M.D.

    From your tapering post
    “I suggested that we taper by 25% of the initial dose at intervals of every 3 to 6 months”

    May I ask please. Does this mean that you are tapering people off of anti psychotics in the following stages: 100%->75%->50%->25%->0

    Tapering by 25% of the “initial” dose suggests that to me. I’d really appreciate it if you could clarify please?

    Thank you.

  16. Dear Sandra, as a fellow clinician I welcome this and your proposed future posts as I think many psychiatrists who adopt a critical approach are honestly trying to work out how best to use drugs in a way that benefits their patuients while minimising harm. I currently work in Finland and can I say, that sadly it is not all open Dialogue here. Indeed I have seen some of the most terrible polypharmacy I’ve ever witnessed in my clinical life. At the moment I am in a rehab post and nearly every patient I try lowering the dose a bit. Unfortunetely my other colleagues are not of the same mind, saying things like, well if the patient is stable why rock the boat. that is why this sort of guidance for sensible and judicous use of meds is required right now. There are however many thorny issues to tease out. I notice you miss out of your reading list joanna Moncrieff who has written a number of very thoughtful books about psychiatric medication, their history, pharmacaology etc. Worth a read.

  17. Sandy,

    As Robert Whitaker says, the point of this web site is to air different views.

    I have cited many experts including psychiatrists with many alternative views than yours, so I believe these views are just as valid as yours, so I don’t see the point of your dismissive responses or ignoring me to avoid these issues, but if that makes you more comfortable that is all right with me. We are talking about the same issues and people, but our views about how these issues and fellow humans should be treated are quite different if not opposite at times.

    Obviously, you are under no obligation to share any information with me about your background, your work or opinions in general though I appreciate your efforts to do so.

    I think you should reserve such power tactics for your practice rather than this web site.

  18. Hi Sandy,

    Thanks a lot for your kind, empathic response. I guess I felt hurt by some of your responses that did seem to me that they were dismissive, so I am relieved when you say that is not the case. I literally felt like I got a slap in the face from your last comment where it seemed you were saying I shouldn’t make any more comments about this topic with which I probably agreed for this particular entry, but I felt that you were angry with me for seeming to push the matter too far. So, perhaps I overreacted because I felt literally dismissed by you to the point I wasn’t going to dare share another comment with you on this post other than to let you know I felt bad reading your last comment.

    I admit that I am very passionate about these issues like many people here. I clarified above that when I make critical comments about mainstream psychiatry that does not include my heroes like Dr. Peter Breggin, Dr. Carole Warshaw and others like you who try to struggle with these issues for more helpful, safe outcomes rather than just maintaining the status quo that can be very harmful to people.

    Any type of communication that doesn’t take place face to face can be easily misunderstood since about 90% of communication is nonverbal, so I don’t think blogging etiquette is the issue.

    Anyway, I have come to like and respect you quite a bit though you knew from the start we disagreed about many things while I also admire you for having an open mind and being receptive to new ideas and practices as I have said before. But, maybe I don’t know enough about you, your work and what you think about such issues as trauma to necessarily assume we disagree on such issues. You mentioned you have more counselors than psychiatrists where you work.

    Also, as I admitted before, you were amazing in your patience for dealing with people like me who made undeserved horrible remarks on your blog about you and main stream psychiatry that has caused many of us great suffering that you took in stride while earning everyone’s respect including mine in spite of us. If you recall, I apologized and told you that although we still didn’t agree on several issues, I do respect your hard efforts to learn new things, to try to do as little harm as possible while dealing with the biopsychiatry paradigm, seeking healthy, holistic, nutritional approaches, reading books like ANATOMY OF AN EPIDEMIC, learning about Open Dialogue and many other
    positive things. So, I have to admit that given the unjustified hard time I gave you when you started blogging here, you owe me some payback. I’m saying this tongue in cheek, but it’s all too true.

    Although it seems we agree that psychiatric diagnoses are not too relevant but just a necessary evil for billing, given the current paradigm, I think there is a huge difference between giving someone a PTSD or related diagnosis as opposed to the life destroying bipolar stigma especially for abused women and children since the former at least validates what they’ve experienced to a certain extent while the latter designates them as severely mentally ill for life and supposedly delusional and psychotic when they try to protect themselves and children from the abuser. The same is true for soldiers suffering PTSD in my opinion.

    I don’t want to push my luck, but I really would like to hear how you and your colleagues deal with trauma in your future blogs if you can fit that into your agenda since experts like Dr. Judith Herman (author of classic, TRAUMA AND RECOVERY) claim that most mental health experts know that most if not all of those they encounter have been abused in some way and/or suffered other traumatic events. And you said above that trauma issues are receiving more focus though I fear from some of my reading that some of the supposed research seems to be another attempt to blame the victims to justify more stigmatizing and drugging. Some experts say the better approach is “What happened to you?” rather than “What’s wrong with you?”

    I am learning from you and I am honored when you say that you might learn some things from me too. I have felt somewhat invalidated when raising abuse/trauma issues on this web site since not everyone caught up in the system is psychotic by any means. So, by focusing on abuse, trauma issues along with psychosis, I think that would expand the usefulness of this web site to many others and attract a greater following. As a matter of fact, I have thought about disengaging from this site for that reason since it doesn’t seem applicable to my life and the many people I’ve known seeking help from psychiatry.
    Anyway, I hope we can be friends and I will try to tone it down in the future.

    Again, I appreciate your compassionate response and I regret if my response felt like an attack on you when it was an expression of my hurt at feeling rejected by you.

    Thanks a lot for clarifying your comments.

    Sincerely,

    Donna

    • Donna, I agree with you that the usefulness of this web site would be expanded to many others by focusing on abuse ,trauma issues (betrayal trauma) along with psychosis.Also that there is no ones posts on this entire web site more important and accurate then your own ,please don’t disengage from this site and please don’t tone it down.Sincerely, Fred

      • I would like to echo Fred here. I’ve only taken the time to read through this post today (and I don’t have the time to do it today, either, but I’m glad I have). I responded to Donna earlier in the thread, not realizing all the ground that has been covered up until this point since then. It’s very edifying and gratifying to see all this.

        I do not think we have shied away from trauma issues on this site. It is certainly an important part of my perspective, and I seek out research to post that bridges the worlds where I can find it. I am grateful for all that anyone can bring to the discussion.

        • Thanks Kermit for your encouragement. It’s nice to hear from you. I learned some of the information I posted from your great articles on things like the failed attempts by the military to treat PTSD with psych meds and other important issues of great interest to me. So, I appreciate your contributions too.

          Given what you said about Robert Whitaker’s approach, I worry about focusing on any one drug or treatment as the enemy to be exposed or attacked or even improved for that matter like the “judicious use of neuroleptics.” I think this misses the big picture. Given Bob’s books including MAD IN AMERICA, psychiatry is well known for coming up with never ending ways to damage the brain and perform new types of lobotomies whether chemical, electrical or surgical as so called treatment.

          I think most of the psych drugs being used have gotten some pretty bad press and though many in psychiatry are still fighting to make a last stand, I think some very scary things are happening.

          As you know, there was a great controversy on this web site about ECT known to cause brain damage, permanent memory loss and even death. Experts like Bentall & Read summarized their extensive study by saying that based on their findings, ECT could not be recommended at all. Even lifelong promoters of ECT have come out and admitted the brain damage and permanent amnesia and even death it causes.

          Yet, ECT seems to be making a huge comeback along with cingular lobotomies, brain transcranial stimulation (found useless I believe)(not sure I have the terminology exactly correct here) and other dubious treatments that may be as bad and even worse than the horrible drugs.

          I was appalled that the great Dr. Oz even had a program on ECT recently and I had a fit that his program presented it as a very safe and effective treatment for depression, which all those with huge conflicts of interest pushing it also say because it has been very lucrative. That’s when I had to agree with many people that Dr. Oz is a fraud like the Wizard of Oz. I have seen articles saying the same thing in the media and in so called science publications. So, this nasty practice is being pushed as a great safe substitute for the toxic drugs as Dr. Breggin exposed as well while they obfuscate the brain damage it causes.

          So, the handwriting is on the wall. I think psychiatry is pretending to maintain the status quo while bringing back their old brain damaging “treatments” in “new clothes” or “sheep’s clothing” while inventing new ones since they know they can pretty much get away with anything on the so called “mentally ill” as long as they have the latest junk science and paid shill KOL’s to back it up.

          Although I think Bob Whitaker has made an immense contribution to exposing the huge damage done by biological psychiatry when focusing on individual treatments like the toxic drugs, it appears that a more “big picture” approach is needed to challenge biopsychiatry’s bogus stigmas, constant junk science, fraudulent focus on genes and brain wiring and the huge amounts of wasted tax dollars on this fascist eugenics agenda and whatever brain damaging, life destroying treatments they push now and in the future. Also, the fact that most people caught in the web of psychiatry’s deceit are not psychotic, bipolar of delusional and a danger to themselves and others as psychiatry pretends needs to be exposed too.

          I realize that creates a conflict for Bob and others because of Dr. Healy’s great contribution to exposing the problems with psychiatric drugs that cause brain damage and other life threatening effects. At the same time, Dr. Healy engages in an ECT practice that he advocates in his book and articles and refuses to acknowledge the brain damage and other lethal effects of this horrible assault on patients exposed in many other studies, web sites and the great book Bob Whitaker recommended, DOCTORS OF DECEPTION.

          As you know there was an obviously planned attack on those protesting ECT on Dr. Healy’s blog, which drove many followers of this web site away. I don’t think this problem has ever been addressed, which makes me uncomfortable and wondering where Bob Whitaker and you stand on ECT and similar brain lobotomies of all types making such a great comeback.

          I know this may seem off topic, but I have been pretty discouraged by the news lately with Chrys posting about lobotomy increasing in Scotland and psychiatry gaining all the more power with the latest public/school shootings they probably caused.

          I realize I am bringing up an uncomfortable topic, but I don’t think the ECT war was ever properly or fairly addressed on this web site. I also thought that those like me fighting against ECT lost big time, which drove me away from this web site too for quite a while.

          When all is said and done, Bob Whitaker has contributed enough to help psychiatric survivors that would make 100 people proud to have accomplished the same thing in their whole lifetimes. So, I don’t want to seem ungrateful or that I’m asking the impossible from him. Rather, when I see psychiatry acting like the best of psychopaths when one lie like the “chemical imbalance of the brain claim” is exposed and they smoothly move on to the next lie with no shame, embarrassment, remorse or admission of wrong doing, I think the whole concept of psychiatry’s fraud, fascist powers and assault on humans needs to be addressed along with their gross violation of human and democratic rights.

          Obviously, it is not for me to say what Bob’s agenda should be and I think his latest talk on ADHD is very helpful to parents, but I am wondering if his time and efforts might be better spent on a more “big picture” agenda as I was trying to describe above.

          I would like to know if Bob Whitaker and/or this web site will have anything to say about the great ECT and lobotomy comebacks that are a growing menace to the public. Unfortunately, silence can be interpreted as condoning certain actions.

          I have also noticed that all those who attacked people like me trying to address the ECT issue on Dr. Healy’s web site for depriving them of commenting on the supposed limited topic of SSRI’s (though Dr. Healy touted ECT in his posts too), have all disappeared from his blog, which mostly attracts no comments.

          I am bringing this up because I stressed the fact that abuse and trauma issues are mostly what comes to the attention of psychiatrists in my posts above per Dr. Judith Herman, trauma expert. When psychiatry sold out to BIG PHARMA with its DSM III and the invention of its bogus brain disorders to push toxic drugs and other torture treatments like ECT, it also colluded to ignore all environmental causes of severe emotional distress like domestic, work and community violence and bullying and other crises known to cause trauma. Though they gave lip service to PTSD to pacify soldiers at the time, most people suffering from traumatic events are given the bipolar fraud or other stigmas to blame and discredit them and deny them any justice, compensation or validation since psychiatry sees its role as serving the power elite as Bruce Levine exposes.

          So, I think the very existence of biopsychiatry is a total menace to every person on this planet and people won’t be free of its predation until and unless the whole evil edifice is exposed and abolished like all types of fascism and slavery.

      • Fred,

        Thank you for your kind and supportive comments.

        You speak of betrayal trauma. Have you read Dr. Patrick Carnes’ great book, THE BETRAYAL BOND? He goes into all types of abusive relationships that can cause trauma/betrayal bonds to abusive people due to abuses of power in a wide variety of relationships including work, home, school, churches, medical, etc.

        You make some interesting comments too.

        I also appreciate your empathy in your comment when you probably could see I was feeling somewhat discouraged about my participation on this website.

        Donna

          • Hi Stephen,

            Thanks for your validation. I have read that even psychosis is most often caused by abuse and trauma, so I think it is a critical issue for anyone who has encountered the mental death profession. From what I have read, biopsychiatry knows that people are catching on to the fact that it TOTALLY IGNORES environmental stressors. Therefore, they pretend to address it by fraudulently claiming either that bad genes or some other “blame the victim” flaw rather than the abuse and/or traumatic event(s)is the cause of the PTSD and not the evil situation. Or, as with an article just posted on this web site, they claim after the fact that one’s so called bipolar is far worse due to childhood trauma.

            What is truly evil about such a claim is as Dr. Carole Warshaw, Dr. Judith Herman and other abuse, violence experts expose is that psychiatry does not acknowledge ANY environmental stressors for any of their bogus stigmas for children or adults, but focuses merely on their paper and pencil check lists of normal reactions to life stressors or crises to stigmatize every would be victim they encounter to push the latest lethal drugs and other lucrative tortures on patent while robbing them of any justice, credibility or ability to recover, make a living or survive if they don’t see through and escape this fraud and death trap.

            As now exposed by those like Dr. Warshaw and the ENCYLOPEDIA OF DOMESTIC VIOLENCE ABOVE and many other sources, psychiatry is DELIBERATELY misdiagnosing the abused, bullied/mobbed, traumatized suffering gross injustice and violation of all rights from the original abusers who find themselves scapegoated and stigmatized with the life destroying bipolar stigma so the psychiatry/BIG PHARMA cartel can profit from their suffering while literally killing them by driving them to suicide or early death by about 25 years from the added stress, betrayal, retraumatization and lethal drugs and other so called treatments including constant crazy making bullying invalidation of their reality. Along with the bogus bipolar, the victims of horrific psychological/physical terror, bullying, mobbing and other abuse in homes, work places and the community at large are also subjected to fraudulent claims by the mental death profession that they are delusional, paranoid, hallucinating and other vicious lies to aid and abet their fellow abusers in power. Another bogus ploy is when pushed enough, the mental death expert will admit the person has some trauma as a dual diagnosis with the bipolar fraud stigma. See the work of Dr. Heinz Leymann in THE MOBBING ENCYCLOPEDIA online, BULLYONLINE by Dr. Tim Fields, Dr. Gary Namie’s THE BULLY AT WORK, Dr. Robert Hare’s WITHOUT CONSCIENCE and SNAKES IN SUITS and other sources I cited above along with many others exposing this pernicious collusion of those in power including psychiatry to completely destroy and eliminate anyone targeted by psychopathic, narcissistic serial bullies who are becoming more prevalent in our society every day.

            It is all too clear that psychiatry aids and abets the most powerful, perverse, abusive person, group or entity in every encounter by completely discrediting, silencing, stigmatizing, ostracizing, robbing and destroying anyone who gets in the way of more powerful people including themselves.

            So, helping people see through this evil menace is a first step to escaping this death trap by first unbrainwashing one’s self from all of the lies of psychiatry and their many enablers in power.

            I am glad to hear that others hear want to focus more on the issue of trauma, so maybe it would be helpful if those with such an interest spoke up more and related it to various issues that are brought up here since trauma from abuse and other abnormal events is what lands most people in the mental death system in the first place.

            Again, I have been glad for your many helpful comments and your support when I was feeling alone and discouraged about the trauma and other issues.

            Donna

  19. Jeremy from Finland mentioned Joanna Moncrieff and she’s often very good read. For instance, here’s her presentation paper about Antipsychotics: myths and realities. She has written a lot of different articles, etc, I’ve also read one of her books.

    http://www.linkbristol.org.uk/assets/files/Issues%20and%20Concerns/Joanna%20Moncrieff%20Presentation.pdf

    And the situation in Finland seems to be more something like that Finland was still somewhat independent and distant from the European trends in the earlier part of the 20th century and there were some experiments here and there, but gradually at least the Western world has become and is becoming more and more alike. Same ways of acting, same drugs, etc. Same problems. The thing that those people are doing in Tornio is not so much some new discovery but kind of remnants or one final remote “island” of Finnish national development from 1960’s or 1970’s. During the 1980’s, the USA/Western thinking and media pushed more and more to Finland and replaced the studies on schizophrenia therapy done by this other group. A small number of people in Finland have since then continued with their studies, and those people in Tornio are a great number of those people who are left from this development.

  20. Hi Sandy,
    I do not have time to read all the previous comments so I apologize if I’m repeating a point already made. I feel very strongly about this.
    There is a basic fact about neuroleptics – the most important one – which has been established for some time and which, I feel, you are suppressing in your article. It is that neuroleptics destroy the brain. In the 1950’s, psychiatrists called treatment with thorazine the chemical lobotomy. At the time they could only speculate about the physiology; what they could observe were the clinical facts. With good reason they made the analogy. When computed tomography became available they used the technology to longitudinally study the brains of schizophrenics. The most reputed researcher in field, Nancy Andreasen, and the psychiatric establishment at large were soon trumpeting that they had proved the degenerative nature of the disease. In the long term the brain mass of schizophrenics was decreasing alarmingly compared to healthy individuals. Twenty years later, Andreasen admits she now believes the reason her subjects’ brains were wasting were the neuroleptics they were ingesting, not a natural process of the condition. The establishment does not refute this fact, it only suppresses it. Most everyone who is familiar with the site, knows all this – I don’t like try your patience but diminishing the relevance is even worse.
    I disagree with your claim that the short term efficacy of neuroleptics is inflated. A haldol dose for an acute psychotic episode is just as immediate and as effective as lobotomy. All the “major tranquilizers” and their successors are. I look forward to hearing your arguments on this point.
    Though you will argue how the long term risks are minimized – and the risks are grave and plenty – you don’t have an issue with the long term certainties, brain atrophy and significant cognitive impairment being one of them. A risk is an event that has a significant chance of not happening, that’s why I don’t call brain atrophy a risk. I am curious whether in your clinical experience you know of anyone who has continually taken neuroleptics in a mid range therapeutic dose for more than ten years who is not cognitively impaired.
    I disagree that the risks of delaying treatment are inflated, if by that you mean physiological risks and you believe they are made to be bigger than they actually are, because they don’t exist at all. Insomnia is a condition that causes other physiological ailments, psychosis is not. If you mean the risk of violent acts, I agree with you.
    Morphine and chemotherapy for cancer are accepted as effective short term treatments. There are no good arguments that either should be used long term. The science to justify neuroleptics belonging to the same category already exists.

    • “Though you will argue how the long term risks are minimized – and the risks are grave and plenty – you don’t have an issue with the long term certainties, brain atrophy and significant cognitive impairment being one of them. A risk is an event that has a significant chance of not happening, that’s why I don’t call brain atrophy a risk.”

      PC,
      This is an EXCELLENT POINT (very well put) regarding the so-called “risks” of using these drugs long term.
      In fact, your entire comment is excellent.
      Respectfully,
      ~Jonah

        • 🙂 PC,

          You’re welcome. I like your comment a lot – for the reason I explained – and, especially, for that one sentence, of yours: “A risk is an event that has a significant chance of not happening, that’s why I don’t call brain atrophy a risk.”

          That’s such a great point you make; I’m committing it to memory! (There’s your second comment on MIA!!)

          Long term use of these drugs leads to measurable brain shrinkage – and will create powerful physiological dependency. Prescribers should explain these facts in no uncertain terms.

          And, about your comparison of prescribing neuroleptics for ‘psychosis’ to prescribing Morphine and chemotherapy for cancer: It’s a fair analogy, in the way you present it…

          (You say, “Morphine and chemotherapy for cancer are accepted as effective short term treatments. There are no good arguments that either should be used long term. The science to justify neuroleptics belonging to the same category already exists.”)

          But, note: I’m not entirely fond of the comparison of ‘psychosis’ to cancer.

          It’s an interesting analogy, in the way you’re using it; there is *wisdom* to be drawn, from such an analogy (in particular, yes, it’s surely a *mistake* to prescribe neuroleptics on a long-term basis).

          But, ‘psychosis’ is a much more *vaguely* defined phenomena than cancer; and, whereas cancer is widely held to be ‘bad’ (and, most people believe that all cancer requires some kind of medicalization), ‘psychosis’ can come in forms, which really should *not* be judged ‘bad’ at all, nor should they be medicalized at all (forms which, when subjected to nurturing environments, will clearly come to reflect a natural outgrowth of developmental processes that are simply bound to *improve* a person’s life, in the long run).

          In fact, many types of cancer exist, but ‘psychosis’ can refer to such a broad array of phenomena, I’d avoid taking any analogy to cancer too far or too literally.

          Respectfully,

          ~Jonah

          • The analogy of morphine with a neuroleptic is that both can relieve insufferable pain but don’t cure anything. The analogy with chemotherapy is that they both kill cells, one quickly, the other slowly. The commonality is that all of them will lead to premature death if taken in sufficient amounts and for sufficient time. There is absolutely nothing in common between cancer and psychosis. One is an illness and the other is not.

  21. “Morphine and chemotherapy for cancer are accepted as effective short term treatments. There are no good arguments that either should be used long term. The science to justify neuroleptics belonging to the same category already exists.”

    Moncrieff also says than in some earlier studies, drugs such as benzodiazepines and even opium have been found to be as effective, I suppose short term, then neuroleptics. (I haven’t read these studies though.) But maybe it is not a good idea to start the neuroleptics in the first place even in many of the acute psychosis, given that their use usually or often simply sticks.

    http://www.linkbristol.org.uk/assets/files/Issues%20and%20Concerns/Joanna%20Moncrieff%20Presentation.pdf

    * Barbiturates: 2 early studies showed chlorpromazine superior
    • Opium: 1 study. Opium equal to chlorpromazine for acute psychosis
    • Benzodiazepines: 6 trials: 3 trials AP=BZD; 2 trials BZD>AP; 1 trial CPZ>BZD=HAL

    • My point is not that a neuroleptic is the best short term treatment for psychotic conditions but that it would be hard to make the case that short term treatment is medical malpractice. As for long term treatment this is what I think: before someone is subjected to neuroleptic treatment, he should have a MRI performed on his brain. If after a few years of neuroleptic treatment the patient’s brain mass has diminished by 5% or the psychiatrist failed to perform the initial MRI, the patient should have an excellent chance of successfully suing his prescribing psychiatrists. Currently his chances are nil. That simple change in legal precedent would have at least as big an impact on global health as the anti-tobacco or anti-asbestos campaigns of the past.

      • “…it would be hard to make the case that short term treatment is medical malpractice.”

        PC,

        In my first comment, to Dr. Steingard (i.e., in that first comment, directly beneath her blog), I emphasized certain risks inherent in *forcing* these drugs upon so-called “patients”.

        I pointed out, that I believe forcing these drugs on people is always unethical – given the risks involved; indeed, it is always bad practice, given the risks.

        But, generally speaking, it is not malpractice – because it is a form of standard ‘medical’ protocol, throughout the land.

        It is essentially impossible to make the case, that any medical practice, which is standard protocol, is malpractice.

        [Important to bear in mind: “malpractice” is a legal term. Though many highly popular (‘standard’) medical procedures are eventually proved inefficacious – and even harmful; they are *not* considered ‘malpractice’ unless or until they are being practiced *after* that time, at which they have been broadly condemned by the field of medicine.]

        So, while I think it is a good idea to develop a standard protocol, of measuring brain mass before and after long-term use of these drugs, I don’t believe it would lead to legal prosecutions of doctors.

        It could lead to prosecutions of pharmaceutical companies – if/when it’s proved that, in the course of promoting these drugs, they have suppressed findings, that these drugs cause such damage.

        Respectfully,

        ~Jonah

        • Jonah, I agree with you that forced psychotropic drugging is unethical; it is also enshrined by law. It is the only medical “treatment” that can be forced on patients. I say that long term neuroleptic prescription – whether voluntarily adhered to or not – is not currently considered malpractice but that it should in many circumstances if not most. Historically many human rights abuses from today’s perspective were enshrined by law, among classic examples are slavery, women and gays rights (rather lack thereof). Things eventually change but not without strife. Though I may sound a little harsh on Sandy sometimes, I recognize she is an agent of change and I profoundly respect that.

      • Hi Sandy,
        I don’t know if in the future you will be engaging any of your patients in long term neuroleptic use but I’m sure you have plenty of colleagues in the Vermont mental health system that will. Would you be willing to urge them to have their patients periodically get a brain MRI? Once a year maybe? Not a bad idea to track their brain mass as a good clinical practice, no?

  22. Why does a psychiatrist put someone who isn’t psychotic on neuroleptics?

    After all the medical training and feed back from other clients how could the psychiatrist not know the drugs were causing at least some terrible side affects??

    That the client’s changed behavior was due to the drugs he prescribed??

    When he does know this then why wouldn’t he admit it and help taper the client off said drugs??

    These are basic questions that psychiatrists should be aware of because they are essentially gate keepers and responsibly prescribe any mood changing drug very carefully.

    • Along this line, Sandy, I’d love for your comments on the dramatically increased use of neuroleptics for “aggression” in children and the elderly. These people don’t even meet the questionable and subjective criteria for a psychiatric diagnostic label, and yet they are given drugs simply for their behavior. Where does this kind of thing stop? Can we drug someone for excessive political protest, or for being too upset about the state of the economy?

      I consider this behavior not only unethical, but criminal. Do we give someone antibiotics without evidence of an infection, or blood pressure medication when their blood pressure is normal?

      What do you think of this trend? Should it be stopped, and if so, how? I work with foster kids and this is done all the time, without the slightest consideration for the long-term impact on the children involved. It makes me ill, but I’d love to know how you view it.

      — Steve

      • Steve,

        It’s good to see you’re pressing these questions.

        I believe no one should be *forced* to take these drugs (made that point, in my first comment), and there should be no way to prescribe them for kids; i.e., doing so should be outlawed.

        Kids who are currently on these drugs should be carefully weaned off them (starting yesterday).

        Of course, I realize that would, at first, seem wholly unfeasible in the eyes of most psychiatrists.

        I recommend they study up, on *behavioral* approaches to parenting seemingly ‘oppositional’ kids.

        There are so many books on that topic!

        Also, I recommend this video,

        “12 year old Testifies in U S Senate Hearing”

        http://www.youtube.com/watch?feature=player_embedded&v=Td7X3yk2UTg

        (Note: At minute 12:30, one piece of advice from 12-year-old Ke’onte Cook… “That meds aren’t gonna help a child with their problems. It’s just gonna sedate them, make them tired, make them forget it for a while, and then it comes back, it happens again. What I learned in therapy is that, when you’re taking therapy, you talk about the deepest thing, it hurts, then it comes back, but you can handle it better.”)

        Respectfully,

        ~Jonah

  23. What is the cause of this so called mental emotional illness ? Either betrayal trauma or drug poisoning, mostly metal poisoning)chemical poisoning, or a combination of 2 or 3 or 4 considering so many abused ,and that just in the USA 78% of the population has at least some mercury fillings.Plus whose gotton away without being vacinated. Google RussellBlaylockMD Mental Health and watch a video of him being interviewed.Also see A Special Interview with Dr. Christopher Shade at Mercola.com on the mental effects and wide range of mercury poisoning. What do you do about all this instead of just trying to make money off of peoples suffering.You force the government to remove all mercury fillings and replace with ceramic restorations ,remove all root canals,check for cavitations.All according to Hal Huggins Protocols. Treat betrayal trauma with enegy medicine like YuenMethod.Every emergency room should be able to make fresh mostly green vegetable juice(also makes weaning off drugs much easier as well as taking 1000 to 1200 mg.niacin followed by a hot bath with Baththerapy (a mineral Powder)rub body with a luffa ,put on inflatable collor as a precaution against drowning. You’ll fall asleep and wake up feeling great.This is my method to replace ect with a modality that that does no harm. you fall asleep in the tub and wake up feeling great.Traditional Naturapathy and Homeopathy can greatly help if you find experienced people to show you what to do like me.Any questions? Go for it.Their is little use for psychiatrists a vestage of the Spanish Inquisition.

  24. Sandy, I’d be interested to see what you think of the new article by Martin Harrow and Thomas Jobe https://www.madinamerica.com/2013/03/do-antipsychotics-worsen-long-term-schizophrenia-outcomes-martin-harrow-explores-the-question/

    As quoted by Bob Whitaker, Harrow and Jobe say: “The discontinuation effect includes the potential of medication-generated buildup, prior to discontinuation, of supersensitive dopamine receptors, or the buildup of excess dopamine receptors, or supersensitive psychosis….” which would suggest some “relapse” is a withdrawal effect.