A Guide to Long-Acting Neuroleptics: Education or Promotion?

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Several weeks ago, I received a number of emails notifying me of a new pamphlet released by the National Council for Behavioral Health titled “Guide to Long-Acting Medications for Providers and Organizations.”

The pamphlet begins:

“This Guide to Long-acting Medications (LAMs) is a Call to Action for psychiatrists, other clinicians and behavioral health organizations to increase the use of LAMs.” It goes on to suggest that psychiatrists and their organizations (which comprise the membership of the National Council) rally resources to make these drugs more readily available as “first-line treatment.”

The authors opine upon “What Science Tells Us,” namely, that “there is enough science to demonstrate the degradational effects on brain tissue of each psychotic episode.” Moreover, we are informed that — when started early — the neuroleptic drugs will “avert progressive neurodegeneration and subsequent disability.”

The pamphlet is designed as a public health promotion with this message: If we can stop the progression of schizophrenia, we will improve long-term outcomes. This is purported to be based on science. I would argue that if one follows the science, one might support instances in which long-acting drugs are useful but not necessarily to the extent suggested in this pamphlet. In addition, one would not promote the newer drugs as first-line treatments. By downplaying some aspects of the available science, the pamphlet implicitly is acting as a promotional tool for the pharmaceutical industry. Furthermore, this pamphlet serves as an example of why simple disclosures of conflict do not adequately address deeper issues of bias and influence in our field. While the authors correctly state that this was not funded by pharmaceutical companies, it is nevertheless influenced by their interests via the incursion of commercial interests into academia over the past few decades.

Some history:

Long-acting neuroleptics are drugs, in this case given by injection, that remain in one’s system for up to 4 weeks. This allows a person to avoid taking a pill daily. This type of drug is not new. Fluphenazine decanoate (a form of the drug initially branded as Prolixin) was approved in 1966. It was developed as a response to the observation that while many people seemed to improve when given the drug in the hospital, their problems returned after discharge. This was thought to be due to poor adherence; long-acting injections were hypothesized to improve adherence and, therefore, outcome. It was thought this would be especially helpful in the outpatient clinics where those discharged from hospitals were to be treated. Haloperidol decanaote — which has an advantage over fluphenazine in that it can be given every 4 rather than every 2 weeks — was approved around 1990.

When the newer drugs — risperidone, olanzapine, aripiprazole, among others — were introduced, many clinicians waited eagerly for these drugs to be available in long-acting forms. CONSTA — long-acting risperidone — was not introduced to the market until 2009, about fifteen years after the release of Risperdal (risperidone). We now have long-acting forms of several “newer” neuroleptics. The long-acting formulations were approved as the short-acting versions were going off patent. Although there are still some new short-acting neuroleptics on patent, long-acting neuroleptics comprise a significant share of the patented neuroleptics drugs marketed today. This is obvious when you look at any journal or online site that accepts pharmaceutical advertising; this group of drugs is highly promoted.

But we know what happened after fluphenazine decanoate was marketed. We continued to observe the “revolving door” where people discharged from the hospital frequently returned. While there are deep disagreements over how to fix the community mental health system, it seems clear that long-acting neuroleptic drugs did not offer the kind of benefits that were anticipated in the 1960s. Contrary to popular belief, there is a lack of evidence in support of the core hypothesis that these drugs improve adherence (Leucht 2011).  Since improved adherence is presumed to be the mechanism by which they improve outcome, this raises a serious challenge to the advantages of these drugs. In 2015, Castillo and Stroup published a paper in Evidence Based Mental Health reviewing this topic. They admit “the evidence [in favor of long-acting formulations] is conflicted and weaker than expected.” Of note, they point out that there does not seem to be any advantage for the newer rather than the older drugs. So while the National Council pamphlet promotes “What the Science Tells Us,” the authors appear selective in what they seem to hear.

However, there is a broader implication of this kind of pamphlet that goes beyond my arriving at different conclusions regarding the role of long-acting neuroleptics in clinical treatment. In Psychiatry Under the Influence, Cosgrove and Whitaker offered a model, called economies of influence, for understanding the complex forces that might lead academic and guild institutions of psychiatry to act in ways that are not consistent with their stated missions. I believe those influences are at play here.

To make this point, I will stipulate that improved adherence is an advantage for at least some people. I suggest, however, that the science would lead us to conclude that the advantage rests with haloperidol decanoate rather than the newer drugs. While the pamphlet does not discourage the use of haloperidol and appears to be neutral on this topic, there is a failure to address the underlying structural reasons why far more people will be prescribed the newer long-acting drugs rather than haloperidol. This constitutes an implicit promotion of the newer, patented drugs. While this position may seem inconsequential to those who do not like the use of neuroleptics in any setting regardless of formulation, for me, this is important. It addresses deep structural problems in psychiatry (and medicine) and the influences that have distorted clinical practice. Moreover, the pamphlet promotes shared decision making (SDM) which encourages a process in which a person is “empowered to make decisions about their care and experience the clinician as a recovery partner.” I do not believe SDM can occur when the biases of the clinicians are unacknowledged.

More history:

In the 1990s and early 2000s, a number of new antipsychotic drugs were introduced and highly promoted. They quickly became first-line treatments based on the belief that they had fewer side effects. The marketing of this era is what led me down the path towards critical psychiatry. It was clear to me that the promotion did not match the data. For instance, the main finding of the premarketing studies that led to their approval was that the new drugs caused fewer parkinsonism symptoms than the older ones. However, in these early studies, the drugs were compared to haloperidol prescribed in very high doses.  There were other claims that the newer drugs had benefits for cognitive problems and motivation but these claims were both generally lacking substantial evidentiary support and, to the extent there was support, likely secondary to the very high doses of haloperidol used in the studies (high doses of haloperidol would be expected to cause cognitive problems and apathy so the newer drugs would appear to be better by comparison). The effects the newer drugs had on weight gain were obvious to me after a few years and are now widely recognized but these effects were downplayed in academic and marketing circles for many years. In fact, what was disconcerting is that the separation between marketing and academia became so close as to be undetectable.

This was a general phenomenon in that era. New drugs were presented as “breakthrough” medications with claims of greater efficacy than older ones. Over time, there were expanded indications — either by identifying new disorders for which they are effective or by expanding the boundaries of the initial target condition. In later years — often coincident with the drugs no longer having patent protection — there is a retrenchment; the drugs are found to be not as effective as initially thought. Problems with the drugs gain wider attention. By that point, however, the drugs are entrenched in clinical practice. Despite emerging evidence questioning their efficacy and highlighting worrisome side effects, they continue to be widely prescribed.

All of this happened with the neuroleptics. In 2005, a study funded by National Institute for Mental Health was published. Called the CATIE study, it compared most of the newer neuroleptics to perphenazine, an older drug. It found no advantage for the newer drugs. However, clinical practice changes slowly or promotion is hard to ignore; by the time CATIE was published, the older drugs were rarely used as first-line treatment. This has not changed.

Before it was approved, when risperidone was tested against haloperidol, various doses of risperidone were compared to 20 mg of haloperidol. Risperidone is now considered to be dose equivalent to haloperidol. In the initial studies, researchers concluded that 6 mg of risperidone was optimal but over time, average doses of risperidone used in clinical practice more commonly range from 2-4 mg. In the late 1980s, I participated in a study examining optimal doses of haloperidol. The study found that on average 3.5 mg was as effective as higher doses; the higher doses only produced more neurologic symptoms but conferred no clinical advantage. Many of the worst problems associated with haloperidol are moderated by dose — parkinsonism, tardive dyskinesia. If used in low doses, a strong argument could be made that it has less toxicity — particularly with regard to obesity and metabolic problems — than the newer drugs.

Aside from cost, there is another technical advantage to haloperidol decanoate. One of the recommendations of the pamphlet is to “start low and go slow.” This is possible with haloperidol but not with the newer drugs. Haloperidol can be dosed with infinite flexibility. The newer drugs come in fixed doses and reducing to very low doses is impossible. In addition, the manufacturers of the new drugs suggest starting with loading doses. There are essentially no guidelines available for starting low and going slow with these drugs.

By not directly addressing the pros and cons of the various long-acting drugs available, the pamphlet implicitly endorses the newer drugs. This is why: since one needs to first try the short-acting version before taking the long-acting one and since many more people are treated initially with either risperidone or aripiprazole than with haloperidol, it stands to reason that the newer forms of the long-acting drugs will be prescribed far more often than haloperidol. In fact, the pamphlet implicitly acknowledges this. There is the suggestion that doctors tell patients that “this form of medication ‘is more expensive for Medicaid/Medicare/insurer but you deserve the best treatment available and we will work hard to get it for you.’”

Economies of influence seem to manifest in this pamphlet. While not being funded directly by the pharmaceutical companies, the pamphlet quotes psychiatrists who have major ties to them. National Council receives at least indirect support from the pharmaceutical companies; their ads adorned the halls at the recent national meeting.

The pamphlet suggests that educational material created by the companies that make the drugs are offered to patients to enhance the decision making process. The pamphlet also suggests a specific name change for this group of drugs.  The authors suggest that one “Use language that is less frightening and stigmatizing such as long-acting medications rather than ‘the IM,’ long-acting injectables or ‘the needle.’”  I wonder to what extent this is done for the comfort of the patient and to what extent this is done for the comfort of the clinician. I find it hard to believe that this language switch did not originate with a marketing executive.

Finally, there is the promotion of these drugs as a first-line treatment for individuals who have experienced a first episode of psychosis. This constitutes a major expansion for the use of these drugs. The pamphlet cites the science but again it appears there is, at least to some degree, a conflation with improved adherence and improved outcome. The Castillo and Stroup article, which is overall restrained in its discussion of the advantages of these drugs, does suggest their use in those with recent onset schizophrenia. However, in their conclusion, they point out the disadvantages of the newer drugs for reasons I mentioned above: “we caution that this [new onset psychosis] is also a time to use medications judiciously . . . as dosages of LAI antipsychotics are not immediately changeable, they are less convenient.” Oddly, despite this article making it clear that there is little evidence suggesting the newer drugs have any advantages over the older ones, the authors fail to point out that haloperidol does allow for flexible dosing.

How could my colleagues do a better job of addressing these problems?

An immediate answer would be that my colleagues would need to share my concerns about the nature of the problem. I suspect there will be some disagreement.

But while the National Council might contend that their pamphlet does not promote any particular drug or group of drugs, I would argue that by not acknowledging some of the biases present in the field — particularly the bias to use the newer drugs as first-line treatments — they are indirectly aligning themselves with the interests of the drug companies.

To be clear, while I am addressing these issues with one particular pamphlet, I am using this as an example. I receive emails frequently from various sources that contain this kind of information. It is a low-level drum beat of marketing dressed as education that has an insidious effect on clinical practice. As with this pamphlet, this kind of promotion is no longer just addressed to clinicians — it goes to organizations that have influences as well as various advocacy groups.

My profession has an obligation to address this directly. Ignoring the problem implicitly favors practice as usual which is a practice that favors the financial interests of the pharmaceutical companies over the interests of our patients. Those interests will hopefully align at times but, given their vast influence, we need to be proactive, cautious, and vigilant. It seems that is the only way we can we have any credibility as being true partners in the sort of shared decision making process that the National Council and many other well-intentioned organization professes to support.

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61 COMMENTS

  1. If this is actually the goal, “If we can stop the progression of schizophrenia, we will improve long-term outcomes.” Then the goal should be to stop the psychiatrists from prescribing the neuroleptics/antipsychotics altogether.

    Since the neuroleptics can create the negative symptoms of schizophrenia, via neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    “This can easily lead to misdiagnosis and mistreatment.” Especially since NIDS is not a billable DSM disorder.

    And the antipsychotics can also create the positive symptoms of schizophrenia, like psychosis and hallucinations, via antipsychotic induced anticholinergic toxidrome.

    https://en.wikipedia.org/wiki/Toxidrome

    “The symptoms of an anticholinergic toxidrome include … hallucinations, … psychosis, … Substances that may cause this toxidrome include antihistamines, antipsychotics, antidepressants, ….”

    And this too gets misdiagnosed, again because anticholinergic toxidrome is not a billable DSM disorder.

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    • The data suggests strongly that anyone interested in increasing the long-term rate of recovery from “schizophenia,” whatever that may actually be in each case, would do best to minimize the use of neuroleptics in every possible way. It is clear that the more neuroleptics are in use, the more chronic the “condition” becomes.

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        • Not at all. I’m saying that if you really want to bring someone to a different place, you need to meet them where they are and understand why they believe what they do rather than starting off by telling them that they’re making bad decisions and should change their minds. I’m by no means tolerant for a second of the concept of “pill shaming,” as it was invented for the purposes of stifling discussion. I’m merely saying that an approach that recognizes the person being harmed as a victim of the system who needs some gentle guidance, vs. someone who needs to be rescued or fixed by again doing what someone else says they should do. What I want from these encounters is to maximize the odds that the person’s going to be able to hear what I’m saying. Anything that smacks in any way of me judging the other person’s decisions as being “bad” or “wrong” or me “correcting” their views generally leads me no where at all. I learned this by much trial and error, and believe me when I say, I have had plenty of time to discover what works, and telling people they’re wrong doesn’t do the job.

          Again, very different from how I’d approach someone accusing ME of “pill shaming.” No need for gentle measures there generally, though there are those who are brainwashed and don’t really believe it themselves who still engender my compassion, even though I have to call out their judgmental behavior. But if I want to be in a position to call out judgmental behavior, I kind of have to avoid it myself, don’t I? Or I end up being way too similar to those whose behavior I am trying to stop.

          Hope that makes a little more sense this time. It is a kind of subtle point, but as far as dealing with domestic abuse survivors, it’s tried and tested over hundreds and hundreds of people who have found my interventions generally very helpful, once I figured out what NOT to do. I haven’t done half bad with psych survivors, either, based on what feedback I’ve gotten. I’m not talking through my hat – I’m sharing what I’ve found to work best for those I’ve worked with.

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          • I know, I said that to tease you. But “to minimize the drug” is ambiguous: it can mean zero drugs, or just a little drug.

            Moreover, in France, the “pill shaming” does not exist, or rather is not a subject of society, because everyone is already ashamed to take drugs. On the other hand, there is the “no-pill shaming”, to shame someone who does not take it, while he “should”. To this, we can answer that the one who do “no-pill shaming” is a mentally retarded, a sheep, a doggie to his psychiatrist; which is usually the case because he has actually accepted drugs out of ignorance or submission.

            We also have the masochists, for whom drugs are the proof that they are inferior, and sometimes we attend strange debates where polytoxicomaniacs dispute the golden palm of the sickest and the most dependent: “– Ho yes, I’m taking this and that, what am I sick, and you? — I’m taking this, and even I’ve asked my psychiatrist for more drugs and he’s refused! Yet I need it! — We’re really sunk! We’ll take drugs all our lives! We’re the sickest and the most compliant patients of the service, we’ll take everything our psychiatrist gives us and more!”

            Finally, we have the full fascists for whom “no-pill shaming” does not exist because you are an animal and animals are not ashamed. For them, drugs are an instrument of coercion, as the stick or the whip may be, and they are far too much penetrated by the conviction of your inferiority to take the least interest in your feelings.

            And then, it’s still funny the concept of “pill shaming”. In reality, you can not shame someone who is not ashamed, you can only shame someone who is already ashamed in his heart. And why is he ashamed? Because taking drugs is naturally shameful: it is the proof that you are inferior, that you are a “mentally ill”, a subhuman.

            And the psychiatrists may say, “No! You are not subhumans!” It does not prevent them from locking you up, tying you up and drugging you like a subhuman, and even as a subanimal. In pig farming, are pigs tied to a stretcher for days and days, with a haldol sting in the thigh? Butchers would be shocked. That’s why psychiatric hospitals and slaughterhouses are still separate institutions.

            This whole discussion of “pill shaming” is a sign that there is a shame somewhere, but nobody wants to take it.

            In conclusion I will say that it is not desirable to drive someone into more shame, but it would be counterproductive to act as if it did not exist. In my experience, tell someone:

            “You do not need drugs. Your psychiatrist is a mentally retarded and a fascist, and here is the scientific proof. I will help you to make a rational withdrawal. Surround yourself with people who respect you and who value you; and find strength in you to free yourself. ”

            is much more favorable to the ego than to say:

            “You still have a little need for drugs.”

            Which means nothing but:

            “You still are a little lower than me.”

            And there, without doing “pill shaming”, you multiply the shame by ten.

            –

            Note that I know you do not say that, and that I write to you to give you my opinion.

            There are many ways to approach the problem and I think yours is very good.

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          • That is such a good point! The shame is what comes from the system labeling someone and exerting power over them. Then the system comes and accuses anyone who wants to tear the veil of secrecy over their own shame and tries to project it onto those who is trying to get the facts on the table. It’s classic projection.

            I also agree that “no-pill shaming” is a lot more common, and yet no one seems the least bit disturbed by “did you take your meds?” humor or the pressure that people come under to give in to the psychiatric worldview and accept their shaming label without complaint.

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    • There was much I could have addressed in this pamphlet. It is interesting that just this week, much has come out about the cognitive impairing effects of drugs that act on acetylcholine receptors. This includes many antipsychotic drugs. Henry Nasrallah has argued that the newer drugs are much safe in this regard but I think his argument is flawed. Here is my blog and I now realize I need to follow up!
      https://www.madinamerica.com/2013/07/haloperidol-in-neurotoxic/

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      • I agree, it sounds like extreme psychiatric propaganda, when will it end? Thank you, Sandra, for speaking out about this continuing “promotion” of this neurotoxic drug class. I know from personal experience that the atypical antipsychotics are NOT safer, in regards to causing anticholinergic toxidrome. As a grown adult .5mg, a child’s dose, of Risperdal caused me to suffer a terrifying first ever “psychosis,” two weeks after it was prescribed, and just when I was told “the med will kick in.” Obviously, my medical records now say I’m allergic to the anticholinergic drugs. What’s sad is I had to do the medical research myself. All doctors do is misdiagnose the adverse effects of their neurotoxins, as the “invalid” DSM disorders.

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      • Some people commenting on this site have mentioned the harms of anticholinergics for a long time. They were most likely introduced to the atypicals to hide visible movement disorders. I wonder if there is any information on chronic blocking of the 5HT receptors (I know it’s related to concentration and the forming of new memories). The antihistamines are linked to sedation, chronically blocking that would mean the whole wake / sleep cycle is damaged. Then there is the benzo-effect, also related to cognitive impairment, lack of drive, indifference, sedation. It’s no wonder the best psychiatry can do is a 15% recovery rate with maintenance treatment. It used to be 40% or more, depending on where you look.

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        • “Some people commenting on this site have mentioned the harms of anticholinergics for a long time. They were most likely introduced to the atypicals to hide visible movement disorders.”

          Some of the older low-potency antipsychotics such as chlorpromazine, the first neuroleptic drug, have much higher anticholinergic effect (block muscarine) than haloperidol. While the anticholinergic drugs can prevent (block? hide?) the effects of dopamine antagonism related EPS symtoms, drugs such as chlorpromazine also have a smaller affinity to dopamine receptors, so I’m not exactly sure how much it is about anticholinergic effect and how much about less dopamine antagonism.

          “I wonder if there is any information on chronic blocking of the 5HT receptors (I know it’s related to concentration and the forming of new memories).”

          I personally don’t really have opinion, or don’t understand properly how the 5HT blocking actually works. I don’t know what it feels like subjectively, or the clinical implications from any proper studies. Some studies with drugs majorily blocking the 5HT have been quite disappointing to the industry if I recall correctly.

          “The antihistamines are linked to sedation, chronically blocking that would mean the whole wake / sleep cycle is damaged.”

          On the other, I think I understand the antihistamine effect a lot better. A very low dose of Seroquel (quetiapine) is a very potent antihistamine, acting on H1 receptors. It’s what makes you drowsy and sedated. It also gives you “munchies” and may be one major factor why some of these drugs make you fat. Taking the traditional US variety of OTC Benadryl (diphenhydramine) would give you much of the same effects as a low dose of quetiapine. In Europe they often sell the same trademark Benadryl with another active ingredient, but the point is that the original Benadryl blocks highly the histamine H1 receptor just like quetiapine at a small dose.

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          • Incidentally when I was looking at the low dose haloperidol studies, some stated that the haloperidol group got more additional anticholinergic drugs compared to controls… this may imply it was still blocking the dopamine receptors too hard, or other drugs mitigated to that issue with more anticholinergic effect (or perhaps with other receptor activity)

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    • Tardive psychosis is real.

      Mine was iatrogenically caused by massive quantities of Haldol and Stelazine. Along with Parkinsonism, mini-seizures, and OCD I had not exhibited before taking psychiatric drugs.

      I started out depressed and anxious because I feared social rejection. Psychiatry made my fears come true and almost drove me to suicide.

      My tale is all too typical.

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  2. Since neuroleptics are intended to be used for life, that is, nearly 50 years for someone starting at age 20, the short-term effectiveness of these products is of no importance in relation to their long-term effectiveness.

    If neuroleptics reduce the symptoms of psychosis for 1 to 2 years, but they increase them during the next 48 years, not to mention the side effects of these products, the therapeutic balance is negative, and these products can not be called medecines, but poisons.

    Even after weaning, one to three years later, the rate of relapse is higher with neuroleptics, compared with placebo (Schooler, 1967; Rappaport, 1978), which means that the therapeutic balance is negative even in case of planned weaning.

    Throughout the life of the subject, the therapeutic balance of placebo is always higher than that of neuroleptics, notwithstanding an illusory improvement in the short term with neuroleptics: with and without weaning.

    In other words, giving neuroleptics to someone means nothing more than lending him 6 months of non-psychosis, to make him pay for 60 months of psychosis throughout his full life, not to mention the other side effects.

    It’s an usurer and mafioso behavior, and it’s not doing any favors to someone to lend him $60,000, and then force him to repay $600,000 by blood and sweat, and by locking him regularly into the psychiatric asylum, which is nothing more than a metaphor for the prison for debt.

    Long-acting neuroleptics have only one acceptable use: withdrawal (Viguera 1997). Long-acting neuroleptics provide safe, independent withdrawal, without much dependence on a psychiatrist always ready to postpone or stop weaning at the slightest incident.

    Bibliography:

    Rappaport M, Hopkins H, Hall K, Belleza T, Silverman J. Are there schizophrenics for whom drugs may be unnecessary or contraindicated?. Int Pharmacopsychiatry 1978 ; 13 :100–11.

    Schooler N, Goldberg S, Boothe H, Cole J. One year after discharge : community adjustment of schizophrenic patients. Am J Psychiatry 1967 ; 123 :986–95.

    Viguera A, Baldessarini R, Hegarty J, Van Kammen D, Tohen M. Clinical risk following abrupt and gradual withdrawal of maintenance neuroleptic treatment. Arch Gen Psychiatry 1997 ; 54 :49–55.

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  3. So, if you ignore visiting the doctors after psychosis (because instead of medications they give poison), they will diagnose you with schizophrenia, and give that poison by force rest of your life.
    Note that each non-attendance = new psychotic episode.

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    • I relocated. I promised to find a new “mental health” center and then didn’t.

      Off my bipolar inducers now. Building my health up and looking for work after 25 years in the Madhouse Without Walls!

      No one knows I’m supposed to be an “unmedicated bipolar” since I don’t act the part, not being on the drugs that caused my psychosis/mood swings anymore.

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  4. Sandy thanks for the discussion but a very hard read for me on the psych survivor side of my life and also as a past professional in the field.
    This discussion is flashback city. But there it is and the last section about the insidious low drumbeat should have been first out of the door.
    But here are my thoughts
    1) Having developed Parkinsonism and told by a neurologist to stop well yeah but after inpatient experiences that out fear into my soul marrow- it would have helped for him- oh my – to actively advocate for me.
    In a different world we’re my father and other folks practiced it would have been a no brained call and write a letter to document your medical assessment .
    I had to stop on my own violation and it took years and I still carry the burden of weight.
    So maybe a team approach?
    2) The discussion of Haldol is chilling to read with current prescription practices and advertising being totally marketed as the real thing.
    As you may know Haldol was a go to prescription for the elderly who exhibited so called problematic behavior.
    On the medical unit we had folks thinking they were at a restaurant, someone circling the floor thinking she had lost her flight in the airport, and more.
    Nursing staff and residents were doing the right thing just trying to go with the flow and reassure as much as possible.
    Medical students however would be alarmed and would order Haldol but they weren’t always good about knowing the right doses for certain populations or the concept of mileu and now today Improv work with the confused elderly so danger for patients st times.
    When I was in crisis and inpatient I begged for 5 mg Haldol but no and proof positive I was really “ crazy”
    So this is a sad confirmation, I was right. I knew the dangers, saw the Code Blue but also aware of the new drugs- did not trust since 1981 biomarkers for depression- Never found.
    3) The issue of advertising and guild protection circling the wagons subtle but there and yes. The same folks who created the opioid crisis in many ways also as a precursor similar to the Nazi early experiments with the handicapped and homosexuals laid and profited off ALL of these chemical formulas.
    Also the end of patent copyright and more tools for them. The pain scale developed at from a Pain Management Department at Tufts by Aa very very generous grant by the Family of psychiatrists who created their own chemical company.
    4) The concept of choice and informed concent in my time as patient clearly did not have that nor was I seen as a human being with any type of a personal or famial narrative. I was a mere cog who happened to have skin and bones and private insurance.
    You might be different and it certainly seems you really have tried to be open and see what lies beneath the psychiatry family room carpet. But one also must believe and respond to the horrors of personal experience. Just like sexual abuse survivors.
    How considering the muck of s—- not sure.
    5) Choice – on the medicalfloor there was a Type I diabetic of legal age who wanted to stop her insulin. She was allowed almost died then changed her mind. The idea of noncompliance was always at issue for all patients – the forcing of those who at the heart of it all are trauma from life folks is beyond chilling.
    The biopsychistry approach deliberately and willfully due to greed quashed any information on trauma and the history of alternative treatments that were used in the past. Check out Trudy Schoop/ never heard of her I bet —-yet she was there on the wards and many others ground into oblivion.
    So these are my thoughts. Since I worked in the field like you I have flashbacks for those times when I was blind and unaware. I went into the field because it did not make sense and it was such a large part of helping professions. The only positive in any of this is my hope for the truth and some sort of restorative justice.
    Leon Uris in one of his novels on the Israeli – Palestine conflict has a page or two on a psychrists suggestion for peace there
    It deserves reading and distribution.
    Basically own your mistakes, accept them, and apologize and then do what one can to restore the error. All of this in a framework of—— imperfection apologies will always miss the mark, owning up will always involve a but but but, and restoration really only a sembalabce or symbol.
    But there it is a guide for a very very imperfect world. And even tribunals cannot undo the horror and tragedy.
    But those who actually performed and profited from crimes against humanity that is also part of restorative justice.
    May the dialogue continue and please speak truth to power you can do it.

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    • Cat, I have said it for years, we need truth/reconciliation.
      That does not happen, unless the oppressors fear death/annihilation.
      Unless the majority of the public gets the shame of it all. But even then,
      the pain continues.
      Best thing we can do is hope to illegalize it, so kids are safe from these criminals.

      I completely understand how triggering it is, and so sad, that we feel sad for others, and want it to stop.
      I have realized we are dealing with mental wretchedness and it is much worse than psychosis.
      To be of clear mind and promote such garbage and discrimination can only come from deep injury.
      So I realize every shrink has been harmed somewhere. I’m not sure I want to call it “harmed”, as I get older I realize we all have ‘stuff’, we leave ‘stuff’, and that ‘stuff’ might be a desperate need to balance the world?
      I am thankful for the so called MI, because otherwise we would all be apathetic, harsh jerks.

      We have less than 100 years here. There are those who create poisons for people and make them swallow it, then go home and celebrate Christmas with their kids.
      Their kids grow up with the same mindsets.
      If that is a good life, they can keep it.
      There is something missing in them and some of us have it. I have ZERO desire to be such a horrid being.
      And thus, I have 2 kids who could NEVER be horrid beings, but I did educate them about those types.

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    • Madmom this is a brilliant point.

      The folks I know who had “depot” – towards the end of the weeks, would start to flutter around in distress, until they got the shot again.

      I think I’ve seen studies which show that the decline of the depot shot over the last week is equivalent to withdrawal. At the very least, cutting the dose in half for a number of days.

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      • @JanCarol – this effect is exploited in clinical trials to rig the results in favour of the drug. A classic example is the trial for “Invega Trinza” which is now being heavily promoted by Janssen. Do psychiatrists ever take a close look (or even a cursory look) at the design of these phoney Randomised Controlled Trials? I guess not – they must have to keep their eyes tight shut to avoid seeing the enormous hoax they have been conned into believing. If any of you are reading this, I’d love you to take a look at my cartoon version of the Invega Trinza trial – here is the link…
        http://www.auntiepsychiatry.com/red.aspx?ha=rigging

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  7. Haldol has a very long half life wrt it’s binding with the dopamine receptors. Above 4mg given daily your bound to eventually develop movement disorders, which suggests brain damage even before it’s visibly obvious. A lot of the so-called atypicals have a lower affinity to dopamine at therapeutic doses. They mask the movement disorder by adding an anticholinergic component. The anticholinergic on it’s own can lead to early onset dementia. Clozapine works best for “psychosis”, and probably not due to it’s antagonistic effect on dopamine. It has a very short half-life and probably for that reason isn’t as likely to cause tardive dyskinesia.

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    • Clozapine has a low affinity for dopamine D2 receptor which explains why it doesn’t cause tardive dyskenisia and other similar issues as easily. I think it was sometimes though in the development cycle of SGAs that it was effective because of its HT2 effects. Not sure, but I guess much of its effect (for good or bad) may come from its antihistamine actions. Some people with actual experience taking the drug don’t always talk so favourably about it, so not sure if it’s the best.

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  8. Any education that doesn’t take a careful look at the potential harm of these drugs is miseducation based on misinformation. One of my great fears, in treatment, way up there with non-consensual ECT, was the possibility of being put on a long acting injectable. I’ve seen what I would consider bad outcomes that resulted from the use of long acting drugs. My feeling is that doctors really don’t need long acting medications, and that they shouldn’t be used at all.

    Logically, withdrawal effects are going to be much more severe from long acting injectables than from your standard dose pill. This is something that doctors need to consider, and it is something that your “Guide” doesn’t even acknowledge, withdrawal being conflated with a bad outcome.

    The newer drugs are more deadly than the older drugs. We know this. That is the big point in the argument between the use of the newer drugs and the older ones. That Haldol is the drug used in testing their efficiency is not a great argument for the use of Haldol in any dose.

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  10. ‘I do agree that much harm can be mitigated by trying to use the lowest amount of drug possible – with both dose and length of exposure.’
    ‘Cat night,
    Thank you for sharing your reflections – and your pain. I do agree that the field would benefit fro. Some sort of truth and reconciliation, an acknowledgement of past errors.’

    There is no ‘drugs’. There is no ‘field’. There is no ‘past’.

    Enlightened minimal prescribing does not exist. These people (how to call them? Minimalist nazis?) have not the slightest beginning of an idea of what those products are capable of doing to people.
    They really need to take them , get lobotomized and tortured, and then they could be taken seriously.

    The psychiatric entreprise is a strangely ointed abberation towering in the preposterousness of its conceptualization and praxis.

    These people dont understand the brain, neither the mind, and even less the people who they purport to help.
    That their primary resort consists of crude psychotropics speaks volumes about the pathetic of their achievement in helping people. A made up dictionary and neurotoxins are the incredibly pathetic extent of the ‘field’, begetting terrible woe in the present, not just in the ‘past’.

    Terribly simplistic, invalid, self-serving and harmful conceptual and therapeutics protocols are what the ‘field’ has ever been able to produce.
    In other words: a lame and absolute zero.

    Lawrence Kemelson posted a clown as an illustration of his latest article, which is an other way to frame it.

    —

    I just find it appaling and terribly sad that progress and the only way to help people seem only to be able to be conceptualized as some kind of enlightened and soft minimalism of an incredibly destructive and pathetic paradigm.

    Drugging less is still drugging. It is still pathetic. And it is still sad

    ‘

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    • Alessa well yes of course the ice of using other alternatives to chemicals even of short duration is the primary goal.
      Thequqmire is most so called places of help only have chemicals are are basically prison barracks.
      One would hope there could be a sea change with trauma centers and if needed smallsmall units until all the support systems and alternatives could be put in place.
      Still some folks may still want a chemical option and again choice even a choice oneself disagrees with is paramount. If they have true informed consent and know the risks of addiction and withdrawal – there problem.
      But still there is the issue of forced treatment

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  11. i managed to duck and dodge depot injections, thank goodness. i remember going into a nurse’s office, at a clinic…she had the Haloperidol vial, in a box, on her desk…she was chatting me up, she was supposed to do an AIMS test, didn’t happen. seeing the long acting vitamin H vial on her desk kind of…made me realize how cruel psychiatry can be, how harsh and controlling.

    my problem with advocating minimal use of neuroleptics is -not- that it is ‘bad advice.’ the ‘issue’ i have with such advice is that…in psychiatry, there always seem to be ’emergencies,’ ‘unusual situations,’ etc. there was always a reason to do a lobotomy (‘better to operate than to wait!’), always a reason to push the dosage higher (‘dosage optimization,’ is the going term, I believe), always a reason to disregard whatever common sense recommendations are/were in place…

    ‘give an inch, they’ll take a mile.’ Dr.Steingard and psychiatrists like her are rare…and I kind of sense that the younger generations of psychiatrists lack the thoughtfulness, the nuance, the finesse, of some of the older set. of course…the elites in today’s America have thrown noblesse obllige out the window, now its all about Ayn Rand…maybe that’s why psychiatrists now are so much more dogmatic, controlling, and cruel? class warfare, playing out in clinics all over America? maybe that explains this growing interest in depot injections, the hi-tech Abilify that tattles on the ‘non-compliant,’ etc…

    control of the growing under class, the alienated, the unemployed and/or under-productive. something like that, anyway. 🙂

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    • I dont really believe it. I think most psychiatrists, even though they de facto are terribly misguided and incredibly harmful, pursue and foster an image, both internally and externally, of benevolent and helpful expertise.

      They need technologies and innovations to sustain their illusion of toiling and glorious technicians,, which is why they play with whatever form the technology of the time can dress up the ‘treatments’.

      IMHO most of them are not evil, just delusional. They are just humans riddled with biases (like every human) pandering to a core identity and very profitable position.

      They play their role, the way they invent themselves, the way society let them dream up, in utter impunity, most of the time at the expense of the ‘patient’, who is then enslaved to whatever madness the biases and fantasies of the delusional pseudo healer sculpt the masquerade

      One could talk about theatrical slavery. Or Labour of delusion.

      How much ironic is it that the so called doctors of madness wallow in delusional slavery, which is the pathetic circumference of their rotten priesthood.

      But the truth is that it is a delusion.
      Psychiatrists are misguided, harmful, and above all , (worse than) useless.

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  12. Shared Decision Making (SDM) in this context is a disingenuous ploy. The pharmaceutical industry knows more about how this plays out in the doctor’s office than it lets on. It knows that people with schizophrenia (for example) are notoriously compliant due to flat affect or apathy, and may willingly go along with whatever the doctor or family member recommends, not having the means or the energy to self-advocate. I encountered this problem recently when my son, who had been off drugs for several months, had his first appointment with a new psychiatrist. By “appointment” I mean a 15 minute med check. The doctor had never met him, knew that he had in the past been taking oral Abilify, but nonetheless tried to talk him into taking Abilify as a long term injectable. To his credit, my son said he would “think” about it. This doctor in one fell swoop would have introduced him to a form of drug that my son would have had no control over how often or how much he ingests it. Who is in control is critically important, and IMO, long term injectables hand over control to the psychiatrist and the pharmaceutical companies, not the patient.

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    • Very true. In the world of mediation/negotiation, it’s long been recognized that “shared decision making” is impossible in the presence of large power disparities. It’s hard to think of a greater disparity than a person who is highly distressed talking to a person with high social standing who has the back pocket option of imprisoning them if they don’t go along with the program.

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        • Yes, it is extremely dangerous, as are any 1-1 clinical meetings with that kind of power disparity–where the subjective “truth” of the clinician is considered gospel and that of the client is always suspect, at the very least. That is obviously a recipe for disaster, and it’s exactly what this paradigm has produced and perpetuates without blinking. Really shows how toxic the situation is for clients. It’s utterly powerless-making and pure human rights denying oppression.

          Worst of all, it is fertile ground for insidious abuse, often covert because it fits the unfortunate “norm,” so it is a program which needs to be challenged. In fact, I believe some kind of abuse–and not necessarily intentional–is inevitable, in this scenario. Nature of the beast.

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  13. Hi Sandra. I haven’t visited this site for a while. When I wrote about these issues as a kind of recovering person from Finland in response to your posts several years ago, I perhaps appeared a bit grumpy and not always correct, but I realise even at that time we shared some of the same interest in this issue. Still geeking out.

    It may be that kind of specifically directing dopamine receptors e.g. at a low dose with haloperidol is better than scattering them with drugs that go to dopamine and everywhere else. On the other hand, drugs such as Seroquel sedate people through H1-histamine receptors, etc, so they may may get more sleep and so on, without the need of excessive dopamine blocking, which can lead to nasty stuff. There may be some kind of a bike stabiliser effect with drugs such as Seroquel in the sense that the doctor cannot block the dopamine really hard even if she tried to, because of the receptor affinities involved. I mean, you can block dopamine really hard with increasing doses of haloperidol, but it’s much harder to do with say Seroquel. Also if you look at the receptor profiles of some the older neuroleptics such as chlorpromazine or perhenazine, they have less affinity to dopamine receptors and more to others. If you want only to block the dopamine receptors at a very certain amount with haloperidol, you perhaps also need to be really careful not to overshoot it as a doctor. Also there may be some benefits from the other sedating effects of other neuroleptics for sleep, etc. Thoughts?

    (As a personal note, I’d rather not touch any of the drugs of this class.)

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    • Also, I’ve noticed and kind of predicted how over years how this narrative in psychiatric journals and also in places such as patient/carer targeted web sites or public presentations funded by pharma now increasingly talk about the benefits of the injections (the new forms of which have patents).

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      • Hi Hermes,
        My major points are
        1. Haloperidol used in the lowest dose possible – a dose that does not cause neurological effects – and used for the shortest duration possible may be the safest approach.
        2. The long acting drugs are being promoted because the newer ones are on patent.

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        • Yes, I understand the argument that a low dose of haloperidol might be a better alternative for some people. It would presumably block less dopamine receptors than higher doses, and it would have much less effect on other receptors that relate to metabolic issues and so on. I don’t have clinical experience on how injections of haloperidol are administered. A low dose injection of haloperidol might work if it really is administered at the lowest dose for that person in the clinic.

          However, I guess it’s still possible that even with a low dose haloperidol strategy it will create more EPS symptoms over time than some of the other drugs because of its potent dopamine antagonism. After a quick look at articles of low dose haloperidol, some still suggested there was more ESP with low dose haloperidol compared to SGA in those studies. I also understand many of the studies from this field have been convoluted with pharmaceutical interests that are often not very direct, and other issues, as you mentioned. If I had no other choice, I might choose low dose haloperidol injection for its titratability over, say Abilify, provided I was part in the decision making.

          Antipsychotic drugs and extrapyramidal side effects in first episode psychosis: a systematic review of head–head comparisons

          Peter M Haddad1, Amlan Das2, Sarvenaz Keyhani1 and Imran B Chaudhry3

          “parkinsonism and akathisia. Six of athe seven haloperidol studies showed higher rates/severity of both syndromes as assessed by a standard rating scale at one or more time points versus at least one SGA comparator. This included two low-dose haloperidol stud- ies (maximum dose ≤ 4 mg) indicating that this is not simply an artefact of trials using inappropriately high doses of haloperidol. The data is consistent with a meta-analysis, largely in chronic schiz- ophrenia, in which low-dose haloperidol (< 7.5 mg) was associated with a higher EPS risk than SGA comparators (Leucht et al., 2009)."

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        • As for the second point “The long acting drugs are being promoted because the newer ones are on patent.”

          Yes, I’ve followed this progression over the years and I’m frustrated by it. There may be some actually bad guys around, but more often it’s more gradual change in attitudes of all kinds of people. The “low beat drumming” is perhaps a good way to put it.

          For instance, lately there’s been some quite visible “swedish registry studies” come out from research groups which find injections are powerful, and the same persons also publish studies which say injections are the best choice for first episode psychosis, and then other studies which suggest there’s no safe window for stopping an antipsychotic once it’s started. For instance, professor Tiihonen has been quite visible in Finnish public press media, stating that the official national guidelines should be changed to state that neuroleptic injection should be the first line treatment for first episode psychosis.

          They’re not allowed to market medications directly to consumers in TV-ads and such here like in US, but the pharmaceutical companies can create “educational sites” about topics such as schizophrenia and bipolar. When you look at them, they’re doing things such as first giving a short history of neuroleptics; they enabled people to move away from hospitals, then came SGAs, etc. Move to the third page, there’s a kind of a crosswalk sign demonstrating the benefits of oral vs injections (long lasting it states) and lots of talk about this choice. It seems like it’s not direct marketing of these drugs as such, but there’s plenty of commercial interest behind all those sites, the images, words they have in.

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          • It beggars belief that anyone would be so arrogant as to claim neuroleptics increase lifespan. Just based on weight gain, increase in diabetes, and increase in heart disease, it is obvious that these drugs kill people more quickly than if you left them alone. Add in the increase in smoking cigarettes as a means of dealing with “side effects” and you know the death rate will climb.

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          • Not to worry Steve!

            The Mental Illness Centers help with weight gain of 100+ pounds by mocking everybody for how fat they are in day treatment. Some scrawny little case worker with full gym membership who doesn’t take the neurotoxins they’re forced to, lectures “clients” for more than an hour at a time about how “mentally ill” people have no self control.

            Also had a joker who ran the “Club House” ridicule us for sleeping to much and being too thirsty. Accused us of dipsomania because our mouths were dry. 😛

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          • Little irks me more than when they give someone a bunch of fat-inducing “SGAs” and then put the person on a diet because they “make bad food choices.” Saw it happen all the time in the foster kids I advocated for. Then there was the kid who spent two years working through a tendency not to want to eat anything. She was eating well and doing great, then they decided she had “ADHD” and put her on stimulants. Lo and behold, she appeared to “relapse!” I was apparently the only one who saw the obvious causal factor. They were totally ready to see it as a resurgence of her “eating disorder.”

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  14. I am sorry for the double post but since it is not published already for moderation purpose I just want to point out that I made several language mistakes (I am not a native speaker):
    I meant ‘anointed’ and ‘practice’ instead of ‘ointed’ and ‘praxis’ (fourth paragraph).

    There is also a very ugly s after therapeutics (sixth paragraph)

    I will try not to repeat that kind of deformities and annoyances if I am to write again

    Sorry again.

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  15. Sandra, you ask: “How could my colleagues do a better job of addressing these problems?”
    I have two suggestions. The first is to contemplate the words of Phil Hickey… “Psychiatry is a destructive, disempowering, self-serving, drug-pushing HOAX.”

    The second is to share this video of a patient describing her experience of forced depot injections. Not long after this was filmed, she took her own life.
    “They diagnosed her, drugged her, ignored and neglected her. They did not appreciate her as an artist or a person as they did not bother to find out or treat her with respect.”
    https://www.youtube.com/watch?v=BBJBMXw7-fw

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  17. I read one scientific article, I forget if it was about neuroleptic injections in general or specifically SGA injections. It stated that when the oral SGAs came around, injections in general (which were all FGA injections) got general criticism and bad reputation. That is, at that time SGAs had the patent, and the general opinion about injections became more negative. The article then went out to consider the benefits of long lasting injections (LAI). I’m not sure if that article was somehow trying to make the new LAIs more acceptable or if it was more trying to assess the topic in a more neutral manner. I’ve seen many articles though which seem to more clearly to promote the new LAIs (which are on patent of course) as some kind of a next major step in the treatment. Even if they don’t directly focus on SGA LAIs, it’s kind of implicit that they’ll often be of the patented SGA variety rather than haloperidol. Maybe in US there’s still some patient groups out of the insurance system that can’t afford Abilify LAI but can afford haloperidol. In Finland people with severe mental illness diagnoses in public health care get a code with which they can get drugs like this for basically no charge, which means the tax payers pay for it, and they can get really expensive.

    Even if one considers that LAI may be warranted in some situations, there’s clearly this drift on many fronts that turns out the favour the drugs currently on patent, or perhaps coming to patent in next years. I’m not even sure pharma is so much bothered about things such SSRI criticism these days, since the projected future revenue will come patented drugs such as the new LAI and maybe having some patented drugs used of “augmenting” depression treatment. All of this hinders from assessing the risks and benefits for the patient in as neutral or objective manner as possible.

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    • The LAI is a slippery slope. Maybe it is different in Finland, but the LAI’s are used in America in “Mental Health Courts” for forced treatment. Forced treatment is easy when they can give a shot and send you on your way for a month, they don’t have to watch you take your pills every day (like they would in incarceration, er, hospital). Same in the prison situation.

      This is why the aripirprozole now has a tracking device in it – to “ensure compliance.”

      This marketing scheme is especially deadly considering how the courts, prisons, and forced treatment can be involved to drive up sales of these newly patented formulations.

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      • I know the issues with LAIs, and I’d rather fight to the end before accepting them for myself, even if was of the customazible variety. I’d myself try to stay with the oral meds as long as possible for their customability, and I could stop them on my own if the situation insisted that. I don’t recommend it for others, but it’s what I kind of had to do on my own. When looking reasons for LAIs being described or marketed at sometimes less, now more, a large part of that influence does seem to come from marketing department in various ways. But it’s not only pharma, there are various other human interests in the game. Doctors, family members and other people with a stake to hold have also other interests in the products. They often want the patient to be predictably medicated, which can happen with injections. The Abilify with tracking devices for schizophrenia seems like a horrible product.

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        • Here’s the thing, Hermes – neuroleptics are not just for “schizophrenia” anymore.

          They are passing them out like candy for:

          Opiate and alcohol addiction recovery
          Depression (where people don’t respond well to the SSRI class)
          “Bipolar” and related diagnonsense.

          They are pushing the neuroleptics as the “next line of defense” in a world where their “miracle drugs” are not so miraculous.

          When people are rejecting the opiates (addicting) antidepressants (side effects like losing your sexuality, among others) pharma is saying, “BUT WAIT! There’s more! We’ve got these handy neuroleptics that hit on all KINDS of neurotransmitters…..”

          It’s another wave of marketing of questionable “products” and that’s what they are – products. Not medicine. Not healing. Not even a solution. Just a bottom line for the shareholders.

          I think I heard that the neuroleptics are the best sellers and are driving pharma profits now. Abilify is currently the best selling drug in the world. Sigh.

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      • Regarding the situation between US and Finland, well yes, we don’t at least yet have as strick forced commitment laws compared US from what I’ve read. I realise it may change in future. However without those rules, they often find other medias or ways to almost enforce the drugs to the patients they deem need them. There’s can be psychological pressure, and if they think you’re not complying or “treatable” in public, then they can send you involuntarily to a mental hospital for evalution, and often you’ll end up with injections there. Maybe more often these days because of the new patents around. They’re making the injection choice more acceptable among the stakeholders, and with stakefolders I refer to a diverse group of people, not only psychiatrists. Many of those people don’t have any great affiliations with pharma, but the consensus opinion just shifts to prefer the patented drugs over time.

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  19. Lol, “improved adherence”…..definition: improved control by forced injection, forced until enough brain damage occurs that client no longer ‘needs’ to be forced or cajoled (encouraged), for those who really dislike the poisons,

    “improved adherence”….definition for the public: “adherence” meaning the patient likes the drug enough to like taking it.

    “progression of schizophrenia”…..definition: It is a disease that spreads, we are kind to stop this “process”, by forced injection, it is good for the patient’s quality of life, it will ‘stop’ progression, so that the patient may live longer.

    notice what two doctors look like as they speak this kind of speak in public? Whether to audience of their club or family, or the general public/news? One cannot fake BSing, BS is written into the facial expressions, the eyes. It cannot be hidden. It is speech that one tries to convince themselves of at the same time as trying to convince others.

    Put 10 patients on the drugs. Put another 10 on “good” therapy, (ask them which therapist they like after trying a few) interactive woodsy outings, canoe trips, cooking classes, clothes shopping, jobs they can succeed at, at their own pace, any art they like, chatting, hanging out with on their terms, and in 30 years watch the way they walk, talk, interact. Check their brains, their blood, their overall functions.

    I forgot, drugs are cheaper and you don’t have to give your own love and care.
    Please spare me the “docs care”. Doing and caring are worlds apart.

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