How Little We Really Know About Psychiatric Drugs

Joanna Moncrieff reflects on what has and has not changed in the field of psychiatric drug treatment in the years between the first and newly published second edition of the Straight Talking Introduction to Psychiatric Drugs.

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A Straight Talking Introduction to Psychiatric Drugs cover art

The second edition of my Straight Talking Introduction to Psychiatric Drugs has just been published, 11 years after the first. Some progress has been made in that time. Services for people with early psychosis now routinely prescribe low doses of antipsychotics and frequently support people to come off them.

The UK government funded the RADAR trial that is evaluating a gradual programme of antipsychotic reduction and discontinuation in people with long-term psychotic disorders or “schizophrenia” and several other trials of this sort are going on around the world involving people with a first episode of psychosis.

This research is being conducted by psychiatric researchers who recognise that psychiatric drugs can be harmful, and that their use needs to be minimised. From my experience, most psychiatrists are now aware of the evidence that long-term antipsychotic treatment causes brain shrinkage (although many are also enamoured with the misleading studies on antipsychotics and mortality produced by the Finnish group, which have been helpfully deconstructed in this blog by Robert Whitaker).

The fact that antidepressants can cause severe and prolonged withdrawal effects has now been widely recognised, although not without the concerted efforts of those who have suffered these problems.

The drug-centred model of drug action (the idea that psychiatric drugs change normal brain functions and mental states, and that these changes inevitably interact with the “symptoms” of mental disorders) is now established in some circles. It is recommended in the Power Threat Meaning framework and other convention-challenging texts and textbooks.

I know many psychiatrists who feel that, as well as making sense of the evidence, it provides a useful guide for a cautious and collaborative approach to the use of psychiatric drugs. Yet mainstream psychiatry has ignored it and presses on with business as usual. Prescriptions for antidepressants continue to rise and money is still poured into research trying to locate the specific brain abnormality that produces disorder X or Y.

Despite the failure of this research to provide any conclusive findings, clinicians and much of the general public remain bedazzled by the disease-centred model of drug action—the idea that drugs work by tweaking some underlying brain abnormality, sometimes specified as an imbalance or “dysregulation” of particular brain chemicals.

The few psychiatrists who have engaged with ideas about models of drug action take different positions. As I discussed in a previous blog, some leading academic psychiatrists have re-asserted the disease-centred view (though sometimes denying that this is what they are doing). Others argue that most psychiatrists have an ”outcome-based” understanding of drug action. This means they prescribe drugs because research has shown that they can be helpful, with no commitment to an explanation of why that might be.

We do not ingest a drug or recommend others do so without having beliefs about what it might do, however, and if psychiatrists provide no other explanation, then they are implicitly endorsing the disease-centred model of drug action. This is how they are generally understood nowadays, at any rate.

The drug-centred model obviously touches a nerve among mainstream psychiatrists. This is because it suggests that the way drugs “work” when prescribed for mental health problems is different from what drugs are doing in other areas of medicine. Those who oppose it are keen to defend the medical identity of psychiatry. It is ironic that the drug-centred model demands a much fuller understanding of the whole action of drugs on every aspect of physical functioning, mental states and behaviour, compared with the blinkered approach of the disease-centred model. The drug-centred model is, therefore, a much better basis for a properly scientific, medical training.

Some important research has been published since I wrote the first edition. Further follow-up studies show that people who take long-term antipsychotic treatment for psychotic episodes have worse outcomes than those who do not (e.g. Moilanen et al 2016; Wils et al, 2017). Most importantly, the follow-up of participants in the Dutch randomised trial confirmed that this is not simply a reflection of the more severe profile of those who end up on long-term treatment, but likely to be due to the drugs themselves (Wunderink et al, 2013).

More recently, a small but well-conducted study from Australia showed that antipsychotics had no advantage over placebo in people experiencing a first episode of psychosis who were receiving high-quality psychosocial support (Francey et al, 2020). These studies fundamentally change the way we should approach the use of antipsychotics. Combined with the mounting evidence that these drugs cause serious effects on the brain and other body systems, they underline the need to use antipsychotics as sparingly as possible, and to try to help people come off them where possible. Certainly some psychiatrists have taken this on board.

I have learnt a lot in the last 11 years—much of it from people who have had the courage to share their experiences of using psychiatric drugs and thereby publicise effects that official research has barely tried to address. Perhaps most importantly, I have come to appreciate how little we really know and understand about what psychiatric drugs do, especially in the long-term, and the terrible consequences this ignorance can have.

Take the example of benzodiazepines. We understand the mechanism of action of benzodiazepines better than most drugs. They produce their relaxing effects through modifying the actions of the natural neurotransmitter known as GABA. But we do not know exactly how they affect the GABA system, nor how these or other actions produce the range of disabling withdrawal effects that can occur. We also do not understand the mechanisms underlying the cognitive impairment that benzodiazepines appear to cause both during and after withdrawal from long-term use (Crowe & Stranks, 2017).

Most worryingly, as I highlighted in a previous blog, we have known since at least the early 1990s that some people develop new medical conditions or symptoms while coming off the drugs. These can last for months afterwards, possibly longer, suggesting the drugs have permanently altered the brain in some way. Yet we have no idea what benzodiazepines are doing to the brain that might result in these persistent and often disabling symptoms.

Unfortunately, neither this data nor the evidence that antipsychotics can cause permanent neurological damage (tardive dyskinesia) seem to have made us any more wary of launching new drugs without good data on their long-term effects.

The SSRI “antidepressants” flooded onto the market in the 1990s. At first, they seemed to be relatively innocuous. They are certainly safer in overdose and far less sedating than their predecessors, the tricyclic antidepressants. But then, as I described in my previous blog, withdrawal effects started to come to light, and more recently, persistent sexual dysfunction.  These effects suggest these drugs too are changing the brain in significant ways that we do not understand, and that may take a long time to normalise when the drugs are stopped.

Esketamine is one of the latest chemicals to be aimed at people who are looking for relief from chronic misery. The story of how esketamine was licenced illustrates why we have so much propaganda and so little data on the safety of psychiatric drugs. The FDA and other drug regulatory agencies were easily persuaded by Janssen to relax their criteria for establishing efficacy and did not express particular concern about the natural deaths, driving accidents, and suicides that occurred during or shortly after treatment. They had little curiosity about withdrawal effects and other long-term complications.

If drug regulatory agencies are not interested in data on immediate and long-term safety, then clearly there is no incentive for drug companies to produce it. Government funding agencies are also focused primarily on establishing the effectiveness of interventions, rather than exploring their harmful effects. Hence it is left to users themselves to highlight the adverse effects of drugs—some of which will only come to light after years of use and after thousands, maybe millions, of people have been exposed.

I am not opposed, in principle, to the use of psychiatric drugs. I believe, as I say in the book, that “some psychiatric drugs do help some people in some situations.” Having said this, I think it is likely that the vast majority of people who take psychiatric drugs derive little or no benefit from them, and yet are susceptible to all the harms they can induce.

It is people’s right to know how little we really know about these drugs. People should be informed that the story they have been told, implicitly or explicitly, about having an underlying chemical imbalance that drugs can correct is just that—a story—with very little evidence to back it up.

They need to know that these drugs are doing things to the brain that we do not understand properly, and people should be aware of how little research there has been into the long-term effects of the drugs and the difficulties of coming off them. I hope the second edition of A Straight Talking Introduction to Psychiatric Drugs will enable people to make better-informed decisions about whether to start or continue these sorts of drugs.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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69 COMMENTS

  1. Some progress has been made in that time. Services for people with early psychosis now routinely prescribe low doses of antipsychotics and frequently support people to come off them.

    Yet mainstream psychiatry has ignored it and presses on with business as usual. Prescriptions for antidepressants continue to rise and money is still poured into research trying to locate the specific brain abnormality that produces disorder X or Y.

    Can you clarify this? It’s confusing.

    “Perhaps most importantly I have come to appreciate how little we really know and understand about what psychiatric drugs do, especially in the long-term, and the terrible consequences this ignorance can have.”

    And this always peeves me, and I’ve said this to you before. You, we, science, fully knows what the drugs do to people long term.

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    • I agree, we know what we need to know about them. We know: 1) They mess with our brain chemistry, and indirectly, our brain structure, just like any “psychoactive drug,” including heroin, meth, alcohol, LSD, etc.; 2) there is no identifiable “illness” being treated, no means of distinguishing the “ill” from the “well,” so at best, these can be considered palliative drugs, similar to heroin for pain or aspirin for headaches; 3) all of these drugs have serious and in some cases deadly adverse effects, such that people taking the APs die 20-25 years earlier than the average person in society; 4) they all have withdrawal effects that generally lead to MORE of the “symptom” they are supposed to be suppressing; and 5) whatever unstudied long-term consequences exist, the evidence suggests that they are not good or helpful.

      What more needs to be known? A simple cost-benefit analysis says that we’re “treating” an unknown condition (if it even is a condition) with a drug that has largely unknown long-term consequences (other than early death and diabetes) and known short-term adverse effects which can be severe, and known withdrawal effects which can be worse than the “condition” being “treated.” The only benefit appears to be a temporary lessening of uncomfortable “symptoms” for an unknown proportion of the population using them. What argument is there for their continued widespread use? What happened to “first, do no harm?”

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      • And how long must we discuss the fact that we are constantly discussing the known neurotoxic effects of psych drugs, and repeatedly coming up with the same conclusions, yet that’s as far as it goes?

        Another study, yeah, that’s the ticket.

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        • “more research is needed”, always. Delay conclusions, bring in more and more money for research, spread that money around to their colleagues and themselves, “We don’t know the long-term effects of these drugs.” “We don’t know how these drugs work.” or “We don’t know how these drugs work in this group of people or that group of people, or for this disorder or that disorder, etc.” and one way or another, “Clearly more research is needed.”

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  2. Thank you Joanna for a great article.
    It is difficult, very difficult for people within the MD community to speak up.
    It’s shocking really since MD’s are supposed to protect patients from harm by informing
    them and offering solutions.

    It would be a grand day when all MD’s get balls and speak the truth to their patients and the
    media.
    It needs to start small, have meetings. If you guys want to believe in “mental” problems, fine.
    But one thing you should all agree on as docs is that the chemicals are harmful.
    IF all docs were in agreement and simply no longer involved themselves and stuck to
    informing, psych would have nothing to go on.
    They have been riding on MD’s coattails for so long that MD’s finally gave in and now
    are some of the biggest subscribers.

    I’m glad you are not one of them. I hope you inspire other MD’s.

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  3. Johanna Moncrieff is the transatlantic conscience of psychiatry who has pioneered the Critical Psychiatry Network (www.critpsynet.freeuk.com) to counter the dominant paradigm about psychiatric drugs. As outlined in her books and blog the evidence for the limitations of psychiatric drugs is now irrefutable. She joins an impressive list of truth tellers including, Peter Breggin, Peter Gøtzsche , David Healy and Robert Whitaker who have followed the science about psychiatric drugs rather than the myths perpetuated by academic psychiatry in cahoots with the pharmaceutical industry.

    I am a retired psychiatrist and I found the first edition of her book “Straight Talking Introduction to Psychiatric Drugs” to be a most useful clinical guide, accordingly I highly recommend the second edition. It should be required reading for trainee psychiatrist residents.

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    • And yet I am absolutely and sadly sure that No ONE reads it!
      The Bitterest Pill by the same Johanna the sad accurate story about antipsychotics and their short and long term effects no one cares and poor sad people like me have to live with and manage the life long effects and sequale to a casual prescription by a cruel MORON.. In someone they love not me because I would stick pins in my eyes first before I took any off this crap or whatever word suits the referee for the site

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      • agree boans beautiful west Australian day today all that smoke from the burn off and then the smell of the rotting sea weed off the beach privileged indeed.. How lucky are we..today someone threatened me a broken bottle at the train station
        But none of it impacts me at all I just laughed..come live at my house then you would get it…

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        • “How lucky are we..today someone threatened me a broken bottle at the train station”

          No copy of the Criminal Code, left to threaten citizens with broken bottles for not having tickets for the train, what has policing come to lol. The lack of resources surely to be discussed at public forums before the election?

          Seriously though, matters seem to be deteriorating at a rapid rate. The hospitals now dumping grounds that are nowhere near as safe as they used to be (and that was a stretch at the best of times)

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      • It’s great to see some progress. The mental health system in UK badly needs a reform. Starting with community treatment orders, they are not even being used for their supposed intended purpose, but completely abused as a means to control the vunerable or those who even just fall outside of social norms. I had no idea such a disgusting breach of human rights existed until I was subjected to one despite not being ill, the forced medication proposed to keep me well just in case. My crime?disagreeing with my psychiatrist at the time, I was misdiagnosed with schizophrenia, he wanted me to take antipsychotics despite me being completely functional and suffering no hallucinations or hearing voices. I was told my cpn thought I was hearing voices. Sounds like she had a delusion, not me.

        There is no fair trial or safeguards for the patient as they claim, whatever I had written in my statement was said to be “clouded by mental illness” therefore unreliable. The psychiatrist and cpn were said to be reliable witnesses, who had both gone out of their way to lie to secure the cto, even completely fabricating a delusion which I apparantly held, that I heard nothing about until the tribunal. I was never questioned about any beliefs or views by the psychiatrist beforehand, he never asessed me, seeming to come to assumptions that I did absolutely nothing and couldn’t function. He would also receive information from the cpn, who would tend to pathologise every normal human emotion I experienced as psychosis. With absolutely no evidence of a break in reality. When I later questioned her about what psychotic symptoms I had she said worrying about judgement from others indicated psychosis. Only to find out on her cto report that I did not occasionally worry about what people think but apparantly heard their thoughts and believe they can hear mine. I wonder why they can’t just leave someone with trauma alone and instead pathologise their every feeling into a problem, going as far as to lie so that they need medicated into complete disfunction for life instead.

        It was mentioned on my cto report that I was emotionally flat and emotionally unavailable to my children and thought to be incapable of day to day activities, as if antipsychotics has any way to remedy this even if this was the case. Before antipsychotics I was extremely fit and active, managed to engage with my children, have fun and imaginative play daily.
        Afterwards I couldn’t partake in previous interests and completely lost my ability to take care of or interact with my kids, this is the only effect that can come from blocking dopamine receptors. For example I couldn’t still still or focus enough to play a board game or even watch a movie. Antipsychotics were presented as a magical cure all at the tribunal, improving functionality, life, motivation, safety of my children and myself and all sorts of ridiculous things. I’m sure the psychiatrist wasn’t so stupid that he didn’t know that blocking 90% of dopamine creates lesser functioning, loss of independence, loss of interest, flattening and all sorts of other detrimental effects.
        But this is how he get’s away with his abuse and the panel and mho lapped up all the unscientific rubbish. I don’t know how they get away with presenting antipsychotics as having the complete opposite effect to that which they have.

        Although I have been off medication for months thanks to a new psychiatrist actually doing his job correctly. I am traumatised everyday and for life likely by my experience. I know what true mental torture is and can’t get over how many people were complacent in destroying my life and future under the guise of helping. I know these drugs made me extremely ill, the worst I have felt in my life and most disfunctional I have ever been in my life. And when I felt this way, it was even noted that I had improved, I saw no way out apart from killing myself, this was the polar opposite of my previous life and not a life I wanted to live, they backed off and didn’t care when I was suffering the most, or that my children did not have a parent anymore, proving none of this is about helping anyone. Only in dealing with the undesirables like me the only way they see fit.

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        • “the only way out” is the responsibility of shrinks. Not only they, but the Medical system can drive such fear into people, traumatize them that they will do anything to escape. Of course, this all works out perfectly for their security. I hope you can find some relief from the trauma.

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        • How unusual to find a psychiatrist who won’t prescribe these “drugs” and even understands how these awful “drugs” affect you. From my experience here in the US, even the psychiatrist who claim they are not for “drugs: in treatment, will finally admit, “Oh yes, I do sometimes prescribe them.” And these are psychiatrists who take no Medicare or Health Insurance. Almost all psychiatrists, in my experience, when the patient has a bad reaction or complains about some side effect, it is usually the patient’s fault for not taking the drug as prescribed, being sick without accepting it or we are just going to add more drugs to your drug regimen. “Let’s schedule another med review!” the psychiatrist says in happy glee like the Witch in Hansel and Gretl before she puts the vulnerable children in her boiling hot cauldron. Thank you.

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        • Hi Nihil, you write;

          “The psychiatrist and cpn were said to be reliable witnesses, who had both gone out of their way to lie to secure the cto, even completely fabricating a delusion which I apparantly held, that I heard nothing about until the tribunal.”

          Another victim of a ‘verballer’ eh?

          “Verballing is the false attribution of a confession or admission to a suspect. On the evidence before the Royal Commission, the practice of verballing ranged in degree between the fabrication of an entire record of interview or statement, in which a full confession is made, to a subtle change of words to cast greater suspicion on a suspect. Ultimately, if the verbal were contested in court, the police officer involved might commit perjury in support of the false statement.”

          “It was explained to the Royal Commission that an officer might verbal a suspect whom he believed was guilty in order to secure a conviction and that, on other occasions, an officer might verbal a suspect in order to disguise a breach of policing procedures or a failure to take adequate notes of a conversation.”

          “The practice of verballing has some serious implications for the administration of justice. An accused may be convicted wholly or in part on the basis of fabricated evidence, bypassing the checks and balances of the law designed to ensure that each accused has a fair trial.”

          It’s a disgusting practice and the people who engage in it are a danger to themselves and others. It is unfortunately considered to be “noble corruption” by those in authority and is provided support by ensuring that the victims do not get access to legal representation, or if they do that it is compromised. Or in my instance via the negligence of the Chief Psychiatrist who pretends to be asleep at the wheel , and fails to recognise the protection of the laws he has been charged with administering.

          The above quotes (from Vol. 1 Part 1 of the Kennedy Royal Commission) deals with the practice in policing. If they were ever to take a look at the use of the practice in mental health, AND God forbid see the consequences of the corruption (ie brain damage) there would be an outcry. Fortunately for some there is no avenue for this to occur, and if you complain about being verballed you are accused of trying to offer “justifiable explanations” (letter of response by the Chief Psychiatrist detailing why the events listed as being “observed matter” would require the ability to time travel and read minds. Copies available on request) for behaviours which could not possibly have been “observed” or which actually occurred (i’m sure from your description you know what I am saying)

          It’s a shame that the authorities charged with the “protection of consumers, carers and the community” allow this practice to occur with their negligence, because there is a significant amount of damage occurring as a result. No one in my community trusts these filthy verballing bastards as a result, and they thus need to be a little more ‘aggressive’ with their interrogation techniques (eg they torture people where I live by having police ‘rough em up a bit’ before interrogations and then ‘verbal em up’)

          This methods provides a means to enable arbitrary detentions and the use of torture for both mental health AND police. The protections afforded by the law of “reasonable grounds” undermined by the corrupt practice, which allows the fabrication of the grounds to remove the burden of proof for incarceration and forced drugging. (careful who you do it to though, easier to do to black people than whites for sure)

          Still, I guess they do not believe in a God and that they will ever be held accountable for their “bearing of false witness”. Which should protect them from the fear of what they are about to be faced with for their human rights abuses. Because while people like our Chief Psychiatrist and Minister may be prepared to conspire with criminals to ensure a lack of accountability (and only do their mandatory duty when they find out the ‘cover up’ has failed and police didn’t retrieve the proof of the misconduct). God doesn’t.

          At some point someone is going to start to unravel the lies and see these corrupt public officers for what they are, and the damage they are doing. And aren’t they in for a surprise when they find out complaining about public sector misconduct results in you and your family being ‘fuking destroyed’, and an ‘unintended negative outcome’ in the Emergency Dept with a ‘hotshot’ (negligence a tool that can be used in a number of ways. Especially with a public that has been ‘groomed’ to expect their failures, and make false attributions regarding those failures). THATS how desperate they are to ensure they are not exposed with their ‘help’.

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  4. “Take the example of benzodiazepines. We understand the mechanism of action of benzodiazepines better than most drugs. They produce their relaxing effects through modifying the actions of the natural neurotransmitter known as GABA. But we do not know exactly how they affect the GABA system, nor how these or other actions produce the range of disabling withdrawal effects that can occur.”

    The two DO NOTs of “acute stress reaction”

    DO NOT prescribe benzodiazepines
    Do NOT force the person to talk

    Let me say that there was nothing ‘relaxing’ about being ‘spiked’ with this drug without my knowledge, and then being jumped in my bed by police to cause an ‘acute stress reaction’. I assume I am supported by the victims of Nite Club rapists in this assertion, that the ‘spiking’ does exactly the opposite.

    We could perhaps set up an experiment where we ‘spike’ people in Police Stations before interrogations and then put a gun to their heads and pretend we are going to execute them if they don’t answer the questions, and see if they remain calm and relaxed? And don’t give me that torture rubbish, if we are not actually going to shoot, it is simply a coercive method because police are allowed to lie to suspects during interrogations (okay, so the ‘spiking’ is a physical assault on the person which does actually meet the standard of ‘hard torture’, but we can get doctors to sign off on the ‘spiking’ after it is done and then slander the victim if they complain about being drugged without their knowledge. Send them off on a police referral to mental health services to be ‘treated’ for their “hallucinations”). It would be at best “a poor choice of words” to quote our Police Commissioner.

    Maybe the dosage was a little low in my instance, and of course I had never taken these drugs before. Though the prescription written to conceal the ‘spiking’ (12 hours after it was done) did make them into my “Regular Medications”. Who’d a thought eh? How fortunate police can conspire with criminals (disguised as doctors) to pervert the course of justice.

    The way you get ‘treated’ for not wanting to speak to a psychologist (note a psychologist, not MY psychologist). The lie that I was a “patient” simply a trick of the light to enable me to be ‘cared for’. 9 years and I hope my daughter and grandchildren are safe, and the threats to harm them weren’t carried out. Because when the State threatens to ‘fuking destroy’ you for complaining about the standard of care, they really mean it.

    Interesting though that the four intoxicating drugs (Benzos, ketamine, GHB and Rohypnol) are considered ‘medicine’ if they are prescribed by a doctor and you take them of your own volition, but are ‘stupefying drugs’ if you are ‘spiked’ with them on instructions from a psychologist with no prescribing rights [my husband is a psychiatrist and i’ll do whatever I want, any problems and it’s off to the E.D. for a ‘hotshot’ unintended negative outcome for you] (though I didn’t know doctors could write prescriptions for them administered to people they didn’t know, and 12 hours after they were administered Something new every day huh?).

    Well, in a place where police can find their copy of the Criminal Code that is.

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    • agree boans beautiful west Australian day today all that smoke from the burn off and then the smell of the rotting sea weed off the beach privileged indeed.. How lucky are we..today someone threatened me with a broken bottle at the train station
      But none of it impacts me at all I just laughed..come live at my house then you would get it…

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  5. “Yet mainstream psychiatry has ignored it and presses on with business as usual”.

    Given the current circumstances it’s more important than ever this information on psychiatric drugs keeps getting out there. Thank you Dr. Moncrieff for continuing to make people aware of the harm that awaits so many once they start these drugs and that the drugs don’t “treat” or “cure” anything, they simply numb your feelings, turn people into zombies and change the brain in ways that make them extremely difficult to ever quit taking. I wish I’d known this twenty years ago and may have been able to prevent my brother’s death.

    Kudos on putting out a second edition. I look forward to picking it up once it’s on Amazon.

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  6. Thanks for people’s comments and good wishes! In response to the idea that psychiatry cannot reform, I agree that an institution that is founded on the idea that distress is a disease may always be compromised. However, in my view, there is a need for some sort of service for people who ‘lose their minds’ from time to time, beyond simple therapy (because there are times when people are not in a state to be able to take part in therapy). I have thought this might be best placed as a branch of social work, because people who are confused and mentally incapacitated almost always have ‘social problems’ of one sort or another, and sometimes they cause social problems too. Someone else I know suggested ‘mental health services’ should be part of housing provision. Maybe pure Szaszians would argue that such a service should only be for people wo break the law and should be a branch of the prison service. What do other people think?

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    • Joanna, I’m the last person on earth to suggest that we don’t need “services”. And if we had no psychiatry, the psychiatrists could be employed operating those services if they hate being out of a job. Somehow though, I don’t think they could possibly be felixible enough to change jobs.
      Losing one’s mind to not be able to function as is laid out for us, or as we compare Jim to Bob, obviously happens and so we need to find out if said person can function in another setting. And if they remain somewhat crippled by fears and need support, ALL these things we do NOT need psychiatry and that is where a new brand of social workers could come in. Hopefully informed, not trained social workers.

      In fact, I am thinking that if psychiatry was gone and if we could actually find those who want to work to help enrich the lives of those in need, we could build a much better society.
      And no, it’s not a utopian idea. It is common sense. But there we have it, if you remain the only voice willing to face the firing squad, it is not moving fast enough.
      I hope your colleagues join you in your efforts.

      There is no doubt in my mind that psychiatry as did religion has made more people sicker than they needed to be. So even the “lost my mind for now” people are much better off without more mind losing garbage.

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    • What you’re essentially saying is that people supporting people in times of crisis must be construed as a “service,” rather than a basic human capacity — from which we have been alienated in a society for which the bottom line is measured in dollars and cents and not human values. Helping one another through the storm until the storm is over should not be a “specialty.”

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    • Maybe part of Finance and Treasury?

      When the new Mental Health Act was proposed here there was a provision for the forced sterilization of children without parental consent. The draft Act was written by an epidemiologist and it was fairly obvious that he was taking into consideration the fact that there were a whole bunch of aboriginal children that were going to cost the State a whole lot of money. This due to the increases in Foetal Alcohol Syndrome (FASD).

      So I am wondering if the bean counters do the numbers and decide that certain groups of people are no longer economically viable in a cost benefits kind of way, then those groups could be ‘flagged’ for treatments and dealt with in the most humane way possible. Perhaps we could even make some ‘tweaks’ to our new Euthanasia Act that might be of use? Rather than hospitals having to rely on “editing” legal narratives to conceal what it is they are really up to.

      And given the ability of the State to use mental health services to extract confessions and then use the proceeds of crime legislation to remove their property and rights (where have I seen this before?) the ability to fill the coffers of the State in this time of need may be of great benefit to us all (that is “us” as in those who have not achieved the legal status of “mental patient”. Which was a little easier than I thought, a telephone call? You know, humans).

      All said tongue in cheek Dr Moncrieff, though there is an element of truth in what I am saying. The attempt to force sterilize here was based on an economic decision alone, the Hansards show this. Glad to say that 40% of our psychiatrists have left the public system as a result of being requested to perform the dirty work of the State. Some of them simply don’t have the stomach for it. (I got the impression that it was mainly the removal of the drug addiction exclusion, shuffling the problems of drug addiction from police to mental health services. You want drugs? We got drugs lol)

      As economic decisions the methods of dealing with these issues could be ‘farmed out’ to the various bodies. Sterilized, snuffed, given a tent to live under a bridge, ‘medicated’ or electro shocked into compliance, subjected to arbitrary detentions and torture, imprisoned in your own home [if you have one left by the time they ‘fuking destroy’ you] for eternity …. etc.

      In fact, may I suggest a really good paper about the use of Psychiatric Diagnosis as Political Device to you? (Loved the article, disappointed you didn’t cover the ability to use it as a Criminal Device. eg ‘flagging’ citizens on the system to use police as a personal kidnapping service) The ‘pathways’ available are left or right as you step off the train. Arbiet Macht Frei

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    • My response is to recommend *The Careless Society: Community And Its Counterfeits,* about which Goodreads says: “John McKnight shows how competent communities have been invaded and colonized by professionalized services — often with devastating results. Overwhelmed by these social services, the spirit of community falters: families collapse, schools fail, violence spreads, and medical systems spiral out of control. Instead of more or better services, the basis for resolving many of America’s social problems is the community capacity of the local citizens.”
      (https://www.goodreads.com/book/show/635872.The_Careless_Society)

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  7. I have no real answers, but the therapist’s in most “community type” settings are nothing but LCSW’s. Therefore, I am unsure if a degree in social work is the answer. There are those who might argue that this is more of a moral or theological problem. There could also be an issue of motivation. The main thing, I think, is there is “no one size fits all.” This is perhaps the biggest problem in America and probably the “Western World.” I could say, “all we need is love.” But, that may be too simplistic. But, then maybe the other issue is our natural human error to make everything too complicated. In my dealings with the “mental illness industry” they were always looking for some hidden, forgotten agenda or trauma I supposedly had that had impacted my now adulthood. They even tried to make me think that I had been “mentally ill” since almost before I could walk or talk and that almost all my childhood experiences were now misconstrued to show that, yes, I was “mentally ill” from childhood. This is dangerous nonsense; probably used as an excuse to ply me with evil, dangerous drugs and complimentary therapies, etc. Thank you.

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    • The “degree” is never an answer. The most unsuited people go into “jobs”. It happens more than not. Because we have 6 year olds being groomed for production. Most people’s motivation to work is money. The success of a service is seen in it’s ability to lift people up, to make them feel they count.
      The dangerous nonsense you were told, does EXACTLY the opposite. What you experienced was not a “service”, it was a denigrating power. Most “services” have lost the meaning of what it means to “serve”

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  8. We are too large and complex a society to leave this to the kindness of family or neighbours – who may not be in a position to provide the level of care necessary, and even if they can, with the best will in the world, sometimes become worn down. As soon as the State steps in, it becomes a ‘service’. However, I take all your points about how this does not need to be a specialist activity. Indeed, this reminds me of the principles of the Soteria house and the emphasis on simple human contact and unintrusive support for those who were in a very disturbed state of mind, and the recognition that this could be provided by anyone with patience and commitment. I agree to some extent, but also feel that this can be challenging work, and there needs to be a structure to support people who are doing it.

    Also agree that each person is an individual with distinctive needs – this is partly what is wrong with diagnosis. It obscures this and encourages us to see people as representatives of a group label. Also agree this is a significant problem. Indeed, the other aspect of this is how does society justify welfare payments for the millions of people currently classified as ‘mentally ill’ if this is no longer considered a medical sickness. Doctors have been nominated as the gate keepers of welfare benefits, a job I am sure they would happily relinquish, but we have no other system to replace this. Studying the history of welfare in England over the last few hundred years shows it has been done differently, but also that it has always been a highly contentious issue. These problems attract me to the idea of a universal basic income, but this is not perfect either.

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    • We are too large and complex a society to leave this to the kindness of family or neighbours

      This is a cynical and negative assessment of what people are capable of, and I see the whole idea of “services” as akin to prostitution.

      I do support a basic universal income, pending total revolution, as this would eliminate the need to identify or present oneself as “ill” to survive.

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    • “Indeed, the other aspect of this is how does society justify welfare payments for the millions of people currently classified as ‘mentally ill’ if this is no longer considered a medical sickness.”

      and conversely how would we justify a person being paid tens of thousands of tax payers money every year when they write this:

      “I’ve been practicing psychiatry for 20 years, and in my experience antidepressants don’t do any good at all. I wouldn’t take them under any circumstances – not even if I were suicidal.”

      Imagine if an architect were to say: I’ve been an architect for twenty years and I would never live in one of my building under any circumstance – not even if I were homeless in my experience my building don’t do any good at all, in fact I’ve done so much research it’s clear – the longer you live in them the more harm to your health there will be.

      It’s an utter nonsense, no real professional could not survive 3 months. People who design and make buildings and say airplanes do real science and engineering. Psychiatry is evil, this is clear in it’s history and you are part of that – you’re a psychiatrist, you drug people, even though you know full well the harms of what you put into people you decided to continue to do it for decades. People on here should be asking themselves – how many people, over those decades, due to your actions in subjecting them to psychiatric drugs ended up unable to function and how much you profited from that.

      Menschen für Freiheit

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    • I agree that we cannot always leave this to family and friends. People are often overwhelmed by working long hours in insecure work places these days to provide care for anyone, never mind people who are going off the deep end.

      However DP Hunter in there book Tracksuits, Traumas and Class Traitors https://www.theclassworkproject.com/product-page/tracksuits-traumas-and-class-traitors-by-d-hunter puts forward the idea that all state, “Support,” services (psychiatry, benefits, social services, children’s services etc) are about control of the working class and are evermore likely to be so. In the book he describes how as an adult, when he had a breakdown, his friends supported him by sitting with him on a round the clock rota for several weeks. He was insistent on them not calling services and he had been through them, which large sections of the book are about.
      We know it is possible to support people through crisis, but we also know that people are often overwhelmed by the demands of our increasingly unequal society, ill equipped with the patience or knowledge of how to deal with someone in crisis, or might have contributed to it.

      I suspect DP Hunter, as an anarchist, would call the support they received as Mutual Aid. While I cannot see many people setting up mutual aid collectives to support those in crisis I can see that it would be possible to do. The principles of Soteria House and even Open Dialogue are reproducible by unpaid volunteers with a little training.

      If services were to be run by the state, before or after any revolution (I for one see the world moving away from communism and whatever people may consider the left to be that it is getting progressively weaker) they would have to have a high degree of user/survivor/community input and control for any coercive, medical based model to not be instigated.

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      • Yes John, it is totally possible to set up supports. And before that was ever done, hopefully we could have an overseer and not have some help entity become it’s own watchdog, with it’s own colleges and associations.
        Why does it go sour? People when they are 18-25 look for “jobs”. Of course they need money. Most want a LOT of money. To get the stuff they deserve.
        To not be embarrassed.
        There would be a lot of money to play with if psychiatry had to give up theirs.

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    • Joanna,
      as a husband who has been doing this very thing for my wife the last 12 years, what you say is correct. It takes way more than kindness and it is exhausting, and yet, we, the family, are simply put in the very best position to do what is needed. It’s a 24/7 ‘job’ especially in the beginning. Our son was attending a local college while at home. He took the night shift, and I took the dayshift (since I worked nights) helping my wife, keeping her safe. We did that for nearly 5 years until he moved out to do his graduate work by which time my wife was in a much better place.
      I love what Open Dialogue seems to be, but there is no one like that here in the Midwest states. I would have loved someone to help me learn the ropes, but in the end only I can be her primary attachment figure and do the hard work of helping her heal all the attachment issues she suffered from severe trauma and dissociation 5 decades earlier…and helping her tear down the dissociative walls so she can be whole again.
      Sam

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      • I have enormous respect for what you do, and you should not be left alone! When I had psychosis nr. 2, not so long after I was hospitalized for the first time, I had been seeing a psychiatrist as an outpatient. I had told both him and my family about the disasters and mistreatment at the locked ward I had been hospitalized in. I had their support, but I was very broken and maybe not so surprisingly this resulted in another psychosis (that and the medicine they had been forcing me take, that I dropped right after I was discharged). But this time my parents came and brought me to their home. I am so lucky to have them! It must have been very difficult for them, but they were also talking now and then to the to the psychiatrist I had seen and so was I, so in that way they had some support. This happened in Finland, but in a system that was not familiar with Open Dialogue. Still, as things happened, the method we together invented resembles something like Open Dialoge.

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        • Hi A.S.!
          I always feel a special affinity toward Finland because of the exchange student from there that we had in our family 35 years ago. We still keep in touch with her via Facebook.
          I’m so glad your parents rallied to help you. I hope some day there is far more help offered to the families who want to help a loved one in distress but don’t know where to start and don’t want to go the NAMI route.
          Sam

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  9. And, as Peter Breggin says in his videos, we know very little about the human brain too. Mainstream psychiatry would have us believe our brain chemistry consists of only two chemicals. Serotonin and dopamine. To be “tweaked” with those “life saving meds” they hand out like office mints. (At least they won’t force feed you their stale office candy if you decline.)

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    • It is also not known or readily forgotten that these “neurotransmitters” affect a lot more than the brain. 90% of the serotonin receptors in the body are apparently in the gut. We are doing more than messing with people’s brains here. Hence, the obesity, diabetes, and early death figures.

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  10. This is an amazing article, considering how long these “psychiatric drugs” have been out and available to be prescribed to the public. I have read various articles on “ECT” and it seems that the only real difference may be that the “psychiatric drugs” chemically induce many of the same effects and side effects as “ECT”; maybe at a much slower and sustained rate. I wonder if that could explain the issues in withdrawal. But, as someone who as endured these “drugs” for many years at a time, there is life after “withdrawal” even as my case; it was intentionally abrupt and some of this was partially caused by inept doctors. Still, one must know that after “withdrawal” in some to many ways, one’s life is forever altered. First, I was “disabled” by this alleged diagnosis. Now, I am disabled by the effects of that diagnosis; i.e. the “drugs and therapies, etc.” Thank you.

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  11. Dr. Moncrieff, please keep writing and educating. Like so many others who frequent this site, my life has been irrevocably changed and harmed by psychiatric drugs. I have been further traumatized by the treatment I received when I tried to complain of side effects and also while tapering. I have permanent issues that have never resolved or improved after years of being off all medication.

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  12. In one and the same hospital department several different theories can ciculate, as in the case of my hospitalization for “first episode of psychosis” in 2014. The practice didn’t differ though. One younger doctor under training said, when I asked, “we really do not know much about how the antipsychotics work” and when I asked about side effects she said “the effects can also resemble psychotic symptoms”. Then I said what if I do not want to take them (risperdal)? She replied that then they must inject me. And when I asked how long I need to take them, she said 1-2 years. This was all extremely shocking to me. Even psychiatrists who admit that medicines can have effects like that (and also unknown effects) do not hesitate to force people to take them. At the same time, how would they ever listen to you if you experienced side effects, if those effects could be interpreted as “more psychosis” thus requiring “more anti-psychotics”? I felt trapped in a nightmare. Another psychiatrist at the same department said to me when I was about to be discharged “we know very well how these medicines work” and talked about chemical imbalance, calling me (and others who had doubts) paranoid and believers of conspiracy theories. He said that I will very likely have another pychosis if I do not take the pills. He also said that psychosis is the worst thing that can happen to a person. That sums it up, I do not think that doctor would have liked to try his own medicine. I am very happy I did not follow his advice (or rather listen to his treath).Thank you for your extremely important work! For me personally it has meant a great deal too, and strengthened me in a time when I needed it most.

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    • To the moderator: I didn’t at all mean to sound sarcastic in relation to Moncrieff’s research, but I can see it can be read that way. Could I edit the last paragraph and add something?: “Thank you for your extremely important work, which helped me trust I that I had made the right decision in not continuing to take “antipsychotic” medicine after I was discharged from the hospital. An important question is in what ways psychiatry takes up new research on these medicines and how it shapes psychiatric practice. In the case described above, new information was coming in through a doctor in training to become a psychiatrist, but she probably didn’t have power to change anything in practice and I cannot know if she would have wanted to. She did thank me on the last meeting we had, for “having taught her alot” – I still regret not having asked what exactly she learnt.

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      • No offence taken, and thanks for sharing your experiences. I would think it is still common to be told different things by different psychiatrists, with some asserting unsupported ideas. I am also sure you are not alone in being blamed for (quite reasonably) questioning the medication.

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  13. Rather than opposing disease centred to drug centred treatments, I’d like to see more non-drug-centred treatments.

    You say, “I am not opposed, in principle, to the use of psychiatric drugs. I believe, as I say in the book, that “some psychiatric drugs do help some people in some situations.””

    I wouldn’t go so far as to say that. I would however say, “I am absolutely opposed, in principle, to the use of psychiatric drugs on this particular person.”

    When I first found myself in the psychiatric prison pretending to be hospital that I found myself in, I wasn’t given a choice in the matter. I took their drugs because otherwise I’d get the same drugs through a syringe, under more constricting conditions.

    I learned to submit, and, eventually, I got out. I don’t think the choice, when it comes to dangerous substances, should ever be taken away from the person, or persons, being so substance abused. We’ve had non-drug treatments for some time now. Witness the Soteria Project approach to first time freak outs. I’d like to see more non-drug centred approaches to treatment, even if they occurred within the context of the traditionally oppressive “hospital” environment. At least, it would be something beyond a perpetually drug numbing daze, and the possibility of a drug induced “mental ill health chronicity”. The idea that anyone should be put on these substances for 20, 30, 40, etc., years, and more, without relief, is ludicrous.

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    • I completely agree with you that alternatives should be found to coercive use of drugs, but the Soteria project did not accept everyone – a sizeable proportion of people referred to it were not considered to be manageable in the project because they were too disturbed, and had to go to, or stay in the local asylum instead. The question of how to respond when people are really out of control and not amenable to reason is a really difficult one that I do not think we have yet resolved.

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      • “The question of how to respond when people are really out of control and not amenable to reason is a really difficult one that I do not think we have yet resolved.”

        Put them in a room with a chair each and call it Parliament? lol

        I’d consider drugging me without my knowledge and snatching me out of my bed and taking me against my will to a locked ward being out of control and unreasonable. Especially when I question the ability of a Community Nurse to travel through time and space and read minds as his “reasons” for doing so. Not so our Chief Psychiatrist tells me, logic and reasoning not required, and my “justifiable explanations” for the “observed behaviours” accepted as being “reasonable grounds”. The guy is a filthy corrupt verballer who is completing fraudulent statutory declarations, and harming a lot of people in the process.

        I wasn’t offering “justifiable explainations” I was saying that what he had written could not possibly have occurred if one used a process of logic and reasoning. For example “Not sleeping” (an “observed behaviour”) seems a little rich for someone who knew I had been ‘spiked’ with benzos, was collapsed in my bed and had police jump me with their weapons drawn, thinking what he had said about needing assistance with his “patient” was actually true. Of course I was going to become his “patient” I guess when he had police make a referral to him through his fraud and slander but ….. in the mean time just lie. Okay, a little figurative language in stead of the literal goes a long way when your defrauding the Chief Psychiatrist but …… the whole document could not possibly be defended, so ignore the complaint. They simply don’t like the protections afforded by the Mental Health Act so neglect their duty to examine the burden placed on the filthy scab verballer. mainly because it’s not their lives being destroyed.

        How does one reason with that? Our Chief Psychiatrist thinks the Community Nurse is Dr Who? Care to read his letter?

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      • Joanna,
        Are you talking about people who are using street drugs and alcohol or just people in severe, mental distress? My wife was never the former, but she was definitely the latter, and I never tried to ‘control’ her nor did it really matter if she was ‘reasonable’.
        Think of a person in the water during a hurricane. She was flailing, desperate not to drown. Control and reason are irrelevant in that situation. Validation, engagement and attachment were what mattered. She had to know I was right there with her in the water and even though she felt overwhelmed and out of control, I wasn’t, and I wasn’t going to let her drown.
        When people are ‘too disturbed’ as you put it, that’s when the attachment concepts of affect regulation, safe haven and proximity maintenance can slowly calm the worst of cases like my wife used to be. She didn’t need drugs and never used them. She needed empowered family who knew how to ride the hurricane out with her…and now our seas are much calmer…
        Sam

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  14. Johanna says:
    “We are too large and complex a society to leave this to the kindness of family or neighbours.”

    Oldhead says:
    “This is a cynical and negative assessment of what people are capable of, and I see the whole idea of “services” as akin to prostitution.”

    I believe we CANNOT simply jump from an oppressive Medical Model in a profit based capitalist system to a system where it’s “just people supporting people.” People would correctly view this as “utopian” type thinking.

    There must be a stage in between where there are people (survivors and non-survivors) who are trained in some type of “service” to help people in serious psychological distress.

    We must view this very similar to (and as a part of) a stage of socialism, where there are still some left over divisions of labor and status differences from the old system, as a TRANSITION to the new goal of a true classless society.

    This transitional period could take many decades. One overall goal of such a society would be to gradually eliminate ALL the various forms of trauma and violence, which is fundamentally rooted in poverty and multiple kinds of class based oppression. All of this trauma and violence is the ultimate source of severe human psychological distress.

    The major difference in THIS new kind of “service” is that people would instead be trained to oppose ALL Medical Model thinking and behavior. AND most importantly, they would know RIGHT FROM THE BEGINNING of their “service” that their goal would be to ultimately make their jobs become totally obsolete in society.

    THIS is how we combine both Johanna’s AND Oldhead’s perspective on this vital topic.

    Dare to Struggle, Dare to Win!

    Richard

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  15. I appreciate this article, and all of Joanna’s work. But I’m bothered by one sentence: “Further follow-up studies show that people who take long-term antipsychotic treatment for psychotic episodes have worse outcomes than those who do not (e.g. Moilanen et al 2016; Wils et al, 2017).” The problem is that the Moilanen citation doesn’t seem to support that assertion: instead, that article suggested a mixed result, and reported that people who stayed on antipsychotics with no drug-free periods were the ones with the best scores on the Social and Occupational Functioning Assessment Scale [SOFAS].

    Anyway, if the data really is more nuanced, I think we would do well to reflect that in our statements, so we can so to speak take the “scientific high ground.” Any thoughts about that? Am I misreading anything?

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    • Hi Ron, thanks for making me go back and re-read this paper. The results are presented in a rather confusing way. First they present the proportion of time for which a person took an antipsychotic (which they suggest is more or less equivalent to the notion of ‘compliance’), then they present the average dose people took while taking the antipsychotic, then they present whether or not people had any ‘drug-free periods’ lasting 30 days or more, then whether there was polypharmacy and finally they present cumulative antipsychotic exposure (long-term dose years). Outcomes are SOFAS, remission and CGI (clinical improvement). Having any drug free periods is associated with worse social functioning (SOFAS) scores (just), but so is higher dose and cumulative dose. On the other hand, a higher proportion of drug free time, lower dose, cumulative dose and polypharmacy are all associated with better CGI scores but having or not having drug free periods is not. So it seems that overall, lower compliance is associated with greater improvement and most of the results point in the direction of higher antipsychotic exposure being associated with worse outcomes. They don’t provide data for the outcome of people who discontinued or who used low doses, which would have been more useful. And, as with the other long-term follow-up studies, much of the variation is probably accounted for by variation in severity of the underlying problem.

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  16. Thank you for admitting to the truth about the psychiatrists’ lack of knowledge about the psychiatric drugs, Joanna. I was out and out lied to 19 years ago by a psychologist, who claimed her psychiatrist friend “knew everything about the meds.”

    That psychiatrist knew nothing about the common adverse and withdrawal symptoms of an antidepressant, wasn’t intelligent enough to read his DSM-IV-TR, thus misdiagnosed those symptoms as “bipolar.” Then that psychiatrist proceeded to anticholinergic toxidrome poison me, over and over and over again.

    I hope some day that the psychiatrists garner some insight into the common adverse and withdrawal effects of the drugs they coerce and force onto innocent other human beings. And until more is known, forcing psych drugs on anyone should be made illegal.

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    • Oh that is horrible what they did to this 88 year old woman. The woman had just written very articulate letters and cards to family members and the nurses lied that she had progressed into late stage dementia. Then they claim they injected her with a heavy dose of antipsychotic because this tiny, 4 ft. 11 inch, 88 year old woman threw a nurse against a bookcase. Yeah, that sounds reasonable.
      How do these people who have no conscience and act so dark and sinister manage to work in health care.

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      • “How do these people who have no conscience and act so dark and sinister manage to work in health care.”

        By taking copious amounts of drugs? Drinking themselves into a stupor each night (which was patently apparent with the Community Nurse who tortured and kidnapped me. They had to ‘spike’ me, his was self inflicted).

        https://www.nine.com.au/entertainment/latest/australian-crime-stories-adam-shand-colin-manock/27be09c6-c0aa-4dc6-b5e0-61397a2ac720

        Or maybe like this guy who liked to ‘assist’ in putting people into prison wrongly and no one noticed for 27 years that he wasn’t even qualified for the job, spend a bit of time with Ms Lash to punish you for your wrongdoing? Good to see he finally did the right thing and married her. And was she cheaper than a psychiatrist I wonder?

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      • Well and would it matter if she smeared that piece of paper with feces? Do we pump horrible chemicals into people? Even in a worst case scenario one would use the absolutely most miniscule form of control and NEVER without the knowledge of family. The family could have been notified to watch her behaviour and discuss recourse options. They will use any excuse they can think of so they can drug old folks. The chemical straightjackets are used much more than the straightjackets of yesterday. It is not visible that a person is distressed after their mind has been seized. Nursing homes are not where most want to end up.

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  17. The evidence of the abuse is detailed in the patients notes as was the case in WWII Germany as is the case now in psychiatry and ‘care homes’ and ‘hospitals’. They had the tanacity to find out, it must have been utterly heartbreaking for the family. Hundreds more were killed there over twenty years, watch this to see what they did to cover it all up:

    Bridget Reeves provides Family Statement:
    https://www.youtube.com/watch?v=4Zw9C73TtMo

    Bridget Reeves is in my view a great woman.

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    • These are the people my government is ‘recruiting’, and it explains why our system is being corrupted at a rate the public is going to be shocked by. I guess they have to go somewhere when the UK government is dealing with them, and so hello sunny Australia.

      I sat considering the recruiting of an extra 800 police as a campaign strategy last night. Pictures on the tv of old people being beaten in their homes followed by our politicians telling us how they will make money available for more police. The problem being that those 800 police don’t go far when they are being used as foot servants of the politicians to provide them with ‘security’ for their paranoid delusions that everyone is out to get them, and not to provide protection for these people left to be targets of the thugs who are being dealt drugs by doctors. But it does all sound ‘reasonable’ when they put it like that huh?

      Numbers do not equal quality of service, and in fact may have the opposite effect when human rights abuses are being enabled via the negligence of those charged with protecting the public.

      800 extra police is 800 police to be used to snatch people from their beds and torture them because a doctor wants it done. And the negligence of those charged with protecting the public will ensure that is the task they will be put to.

      Good speech by Ms Reeves there streetphotobeing.

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