Antipsychotics Lead to Worse Outcomes in First-Episode Psychosis

Those who did not get antipsychotics in the first month were almost twice as likely to be in recovery after five years.


What happens when you give antipsychotic drugs at the first sign of psychosis? Worse outcomes, according to a new study in Schizophrenia Bulletin Open.

Those who did not receive antipsychotics within the first month after being diagnosed with their first episode of psychosis were, on average, almost twice as likely to be in recovery five years later than those who did immediately receive the drugs. According to the researchers, this means there are many patients who do not need antipsychotics, at least not right away.

The authors of the study were Tomi Bergström at the University of Jyväskylä and the Wellbeing Services County of Lapland, Finland, and Tapio Gauffin at the Wellbeing Services County of Lapland, Finland.

“Immediate antipsychotic medication was associated with a poorer 5-year outcome compared to a 1-month antipsychotic postponement, after controlling for observable confounders. These findings align with previous research on need-adapted approaches and recent controlled trials, suggesting that there is a significant subgroup of patients with acute psychosis who do not require immediate antipsychotic treatment, and postponing medication, particularly in first-episode cases, may help identify those patients,” they write.

Young man refusing to take prescribed pills in clinicBergström and Gauffin used the Finnish National Health Registry to identify all those who met the study criteria. This included 3714 adolescents ages 13-20 who received a diagnosis of a psychotic disorder between 2003 and 2013 and had never before taken antipsychotic drugs. The researchers followed their records for five years (or until death). During the first month after diagnosis, 1549 (42%) did not receive antipsychotics. Over five years, 29% ended up never taking the drugs.

The researchers found that, on average, those 1549 people were 1.8 times as likely to be in recovery after five years.

Those in recovery, in this study, were defined as those who were still alive and had not received any form of psychiatric treatment, supportive housing, or disability allowances at five years. The researchers note that these services are provided to the entire population as needed and recorded in the registry based on their universal healthcare system.

Next, the researchers wanted to see if those who eventually did end up on antipsychotics fared worse if there was a delay. That is, is there a subset of patients who need to be put on the drugs immediately and who will be harmed by waiting a month?

To test this, Bergström and Gauffin looked at only the patients who took the drugs by the end of the study and compared those who started immediately with those who ended up taking the drugs later.

They found that there was no difference in most outcomes—recovery and mortality rates—but that those who started the drugs immediately were more likely to receive disability payments and to die younger than those who delayed taking the drugs.

The researchers write:

“Since there may still be a subgroup of psychosis patients who require immediate or preventive antipsychotic treatment to prevent a deteriorated course of [first-episode psychosis], it was hypothesized that postponement of antipsychotics for those who eventually used antipsychotics would be associated with poor outcomes. However, the findings did not support this hypothesis. There was no indication that antipsychotics initiated prior to the formal diagnosis of psychosis or immediate antipsychotic treatment for those who eventually required antipsychotics would improve treatment outcomes.”
They add, “In fact, contrary to our hypothesis, the time to death after [first-episode psychosis] was found to be significantly longer for individuals whose antipsychotic medication was postponed. Furthermore, after controlling for confounding factors in both sub-samples, immediate antipsychotic medication was associated with a notably higher disability ratio at the end of the 5-year follow-up period.”

One explanation often floated against this type of study is “confounding by indication”—that those who have the most severe baseline symptoms are the ones who receive the drugs and also the ones who would be expected to have the worst outcomes. Thus, those who receive the drugs would have worse outcomes not because of the drugs but because of baseline severity.

To account for this, the researchers used a statistical model called stabilized inverse probability of treatment weighting (SIPTW) to control for these possible confounds. After their analysis, all of their results remained the same, indicating that the finding was not due to confounding by indication.

This latest study builds on Bergström’s previous work, particularly a 2020 study that looked at cumulative exposure to antipsychotics for all patients with first-episode psychosis over 19 years. That study also found that those who took the most drugs for the longest period had worse outcomes, including higher mortality rates. And the researchers controlled for confounding by indication in that study as well.

“Moderate and high cumulative exposure to antipsychotics within the first five years from FEP was consistently associated with a higher risk of adverse outcomes during the 19-year follow-up, as compared to low or zero exposure,” they wrote in that 2020 study.

Researchers have found that cognitive-behavioral therapy without antipsychotics is just as effective for first-episode psychosis—that adding drugs provided no additional improvement.

Previous research has also found that interventions for those considered at ultrahigh risk for psychosis, including antipsychotic drugs, can lead to worse outcomes.

And decades of research by luminaries like Wunderink, Harrow, and Jobe have found that those who stop taking antipsychotics have better long-term outcomes.

Researchers have increasingly identified childhood trauma as the primary cause of psychosis, even as biological theories involving dopamine and genetics have been debunked. This is consistent with previous studies that found that experiencing childhood trauma, not heritability, was associated with psychosis.

Thus, interventions that focus on healing from trauma and those that foster empathy, empowerment, and human connection—and respect those with lived experience—may be a more successful route to recovery.




Bergström, T., & Gauffin, T. (2023). The association of antipsychotic postponement with 5-year outcomes of adolescent first-episode psychosis. Schizophrenia Bulletin Open, 4(1), sgad032. (Link)


  1. This is a poor/bad paper. The numbers in table 1 have errors, apparently, it is a telltale of bad science. And it omits analysis of the basic demographic baseline variables that are statistically significantly different between having a poor vs good outcome.

    It is also misleading:

    The context is that basically this paper looked at “minors” who were not treated with antipsychotics, and had not had their first episode of psychosis, yet…

    To note: 41% of the enrolled minors received an antipsychotic BEFORE having their first episode of psychosis. These minors were excluded from the rest of the study. After “baseline”, apparently…

    It says “kids” who had antipsychotics after their first episode of psychosis were younger. That in reality means younger by 2 months and 1 week, or 10 weeks younger. Exactly, apparently, the same as ALL the kids enrolled: with or without antipsychotics BEFORE their first episode of psychosis. That I think it’s misleading: a 10 weeks difference out of 17.4 yrs is around a 1.1% difference in age…

    The use of antipsychotics in minors not previously treated with antipsychotics after their first episode of psychosis was in great part, apparently, explained by HOSPITALIZATION of those minors. That’s a 72% difference in rate, which, cursorily, it’s the largest of the study…

    Two percent, 2% of the minors, regardless if antipsychotics were delayed, who were, apparently, not exposed to antipsychotics BEFORE their first episode of psychosis, died within 5yrs after their first episode of psychosis, apparently. That is HUGE, huge, 1 in 50 kids died in these competent hands, admitedly, apparently, half after turning 18yrs…

    Only 230 of “minors” who had not received antipsychotics before their first episode of psychosis, in whom administration of antipsychotics was DELAYED after their first episode of psychosis, after their first episode of psychosis received one ONLY during the first year of their post first episode of psychosis.

    Between table 2 and table 3 there is a difference of 7 out of 29 kids, that presumably were not exposed at ALL to antipsychotics, that is a 1.5% fatality “rate” (7/456), not very different from the 2%.

    Now, whether 7 out 456 minors passing away after their first episode of psychosis, but apparently within 5yrs, who did NOT received at ALL, apparently, antipsychotics is STATISTICALLY different from 22 out 1093 who did received them but “postponed, is beyond me… thats a 1.5% vs 2.0%, rounding, difference in minors who did not, versus those that were administered antipsychotics, postponed or not…

    Translating: one could pressumably save 1 in 200 minors by not using antipsychotics after their first episode of psychosis. A 25% difference in mortality rate by not using them… chessy,but hey…

    Speculating, from personal experience not with minors, minors who had not been exposed to antipsychotics, or were postponed in their administration, or were administered it ONLY during their first year might actualy have been at risk of passing away if administered antipsychotics (!?). I have not read THAT hypothesis…

    That is: the reason antipsychotics are NOT used in some people, minors, adults or the elderly might actually be the opposite from the common rhetoric: they might be perceivably, somehow, at HIGHER risk of DYING if administered such drugs, and not because they had a BETTER prognosis or MILDER “disorder”.

    The infamous “confounding by indication” might be confounding, but of CONTRAINDICATION…

    And that, not necessarily will be in the clinical record, particularly if they already suffered akathisia, for example, not exclusively, recorded as something else, or not recorded at all… you know: clinical “intuition”… experience not otherwise specified, whatever…

    However, again, between table 2 and table 3, there are 23 “minors” missing, 7 in the postponed antipsychotics, and 16 in the not posponed antipsychotic treatment. What happened to the 16 minors?, dunno…

    But another bad flag: it reports the same 2% demise out of 2165 with a difference of 16, which is a 0.74% difference, actually, when comparing the fatalities in the non-postponed antipsychotics.

    Which in the world of rounding numbers, trimming them down, might come to ZERO, but when compared to 2% is like saying: “You know in some column, between tables 2 and 3 there are 37% of the fatalities in those columns missing” (!?)…

    Of note, among those postponed antipsychotics, there is a difference in 316 minors between table 2 and table 3 in the “Good outcome” row.

    And the final row of “Good Outcome” in table 3, is actually not statistically different between postponed and not posponed: CONTRARY to the conclusion of the reviewed article (!?). In fact, after their, I asume, fancy “statistical weighting”, IPTWS, the P is larger, that is, less significant difference in THOSE rows of just table 3…

    How?, does that lead to an adjusted odds ratio of 1.8 in favor of postponing, is beyond me…

    But hey!, I am not a PhD!… I’m an ignoramus…

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    • “The numbers in table 1 have errors, apparently”

      I didn’t find any. Could you point them out?

      “To note: 41% of the enrolled minors received an antipsychotic BEFORE having their first episode of psychosis. These minors were excluded from the rest of the study. After “baseline”, apparently…”

      This is a complete none issue, as demographic factors are given again after their exclusion.

      “It says “kids” who had antipsychotics after their first episode of psychosis were younger.”

      It does not say that. There is no direct had antipsychotics/did not have them comparision in the paper whatsoever.

      “The use of antipsychotics in minors not previously treated with antipsychotics after their first episode of psychosis was in great part, apparently, explained by HOSPITALIZATION of those minors. That’s a 72% difference in rate, which, cursorily, it’s the largest of the study…”


      “Only 230 of “minors” who had not received antipsychotics before their first episode of psychosis, in whom administration of antipsychotics was DELAYED after their first episode of psychosis, after their first episode of psychosis received one ONLY during the first year of their post first episode of psychosis.”

      I don’t understand where you get that number from.

      “And the final row of “Good Outcome” in table 3, is actually not statistically different between postponed and not posponed: CONTRARY to the conclusion of the reviewed article (!?).”

      This is not contrary to the conclusion at all. Postponement has a significant association with good outcome, unless you exclude those who never get antipsychotics, which is what table 3 does.

      There definitvely are some wrong numbers in table 3, tho. It’s impossible that of the 1093 with postponed treatment 1310 had treatment contact after 5 years.

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      • The 230 number is a substraction from the data in table 3 and table 2, 1549 – 456 – 863. First I got it differently, but I forgot how, both ways add to 230. 🙂

        The evident “errors” in table 1 are in the rounding, some are rounded up, others are rounded down, when in fact they are closer to the rounding up, or the rounding down, oppposite to usual rounding practice. And it does have a tendency, a bias, towards minimization,I think.

        The 41% administered antipsyhcotics without actually having psychosis is not a none-issue. It is useful for comparison of outcomes when delayed vs immediate and it does speak of the “generous” use of, say antidiabetes medication when the person has no diabetes, yet, for example.

        And it did use that data, number, in the paper: ” In the multivariable regression model, statistically significant baseline predictors…prior antipsychotic treatment (OR: 1.6, 95% CI: 1.3–1.8)”.

        60% higher chance of a poor otucome is close to TWICE the benefit of antipsychotics in adults: around 35% in the best benefit metanalysis, if I am remembering correctly, just meassuring improvement in psychosis scales, not disability, demise, etc, mere improvement in the severity of symptoms. Which the paper did not address, but it is a useful anchor for comparison, since the paper questions a more relevant outcome: disability and fatalities.

        So it might lessen the severity of symptoms, but antipsychotics do cause more fatalities and disabilities, at least in minors.

        And: “There was no indication that antipsychotics initiated PRIOR to the formal diagnosis of PSYCHOSIS … would IMPROVE TREATMENT OUTCOMES. On the CONTRARY, ANTIPSYCHOTIC TREATMENT PRIOR TO PSYCHOSIS WAS ASSOCIATED WITH A POORER LONG-TERM OUTCOME…”.

        And it does cause psychosis, so… it speaks of the millieu in which the study was conducted: a bias towards administering antipsychotics even when there is no psychosis, in minors. To poorer outcomes, as per the authors.

        And more broadly, it supports, I think, the claim that those cases are, at least now malpractice, admiting I am not an expert, not a lawyer, and it’s my personal opinion.

        As to “younger”, you are correct, I made a mistake, it actually says the opposite: “The group whose antipsychotic treatment was postponed was also younger…”, by 0.1-0.2 yrs… still irrelevant, I think, when the person is close to 18yrs of age… but statistically meassurable.

        Not an excuse, but “after the party” at 3am analysis/reading of a paper does lead to poor outcomes 🙂

        Now, the last row in table 3 says this:

        Good outcome: (postponed) 229 (21%),(not posoponed) 476 (22%), p=0.498.

        After “adjustment”: (postponed) 252 (24%), (not postponed) 513 (24%), p=0.796.

        A 1% difference without adjustment and a ZERO % difference with adjustment, I think, can’t convice anyone that delaying/postoponing statistically significantly changes the likelihood of a good outcome. And, stated thus, I think it’s opposite to the conclusion of the paper.

        Which essentially, as I understand, was about the effect of delaying, not only antipsychotics vs no antipsychotics, even if as I quoted, and as follows, does reach the conclusion that NO antipsychotics is better than antipsychotics at some point. Since the difference in the last rows of tables 2 and 3, the 35% vs 22% in good outcome of table 2, and the 22% vs 21% of table 3, of postponed vs not postponed is explained, I think and as you seem to imply, by the kids not given antipsychotics at ALL.

        So substracting them from table 2, to table 3, does demerit the conclusion of postponed vs not postponed, and it lends weight to NEVER antipsychotics vs AT SOME POINT.

        And as I said, the P is higher after adjustment, making it less statistically significant.

        So, as to confounding by indication, it does say: “However, the proportion of adolescents with previous treatment contact and a longer time from the onset of psychosis, as well as a higher proportion of prior mood, psychological development, and behavioral disorders, was higher in those whose antipsychotics were postponed after the onset of psychosis.”

        And confounding by indication does sound suspicious to me when 41% were administered antipsychotics when they had no psychosis, where is the indication for that?, specialy if/when the clinicians doing such hadn’t realized those kids had poorer outcomes… what sort of indication is that when the paper shows, apparently, current “best”practice should have been contraindicated.

        So, great comments, thanks. What do you think of the apparent demises missing?. Particularly: ‘The outcome was considered “good” if adolescents did not die…’

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  2. They kind of leave out their most important finding, but it can be reconstructed from the given data.

    Out of 456 people who never got antipsychotic treatment 69% (316) had a good outcome compared to 22% for people who received antipsychotics.

    No time to check whether these groups were different in any way before “treatment” atm, I’ll come back to that.

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  3. I’m at a loss and I don’t understand how a statistical method could control for something like the severity of psychosis.

    The article asks an important question: how do we know those who did receive an AP weren’t the ones with more severe psychosis, and presumably at risk for a worse outcome?

    According to the article, a statistical method was used. How. Is. This. Possible!?

    I would think if you could use stats to rule something out like that, then you could do away with the gold standard of research: randomized controlled trials.

    I don’t have the stat background to adequately assess the SIPTB or whatever the acronym is, but I’m highly suspect of it.
    The reality is, this is a cohort study. It may have intriguing findings, but it doesn’t definitively prove anything.

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    • The problem you point to…how does one
      * define psychosis
      * quantify the severity of psychosis separate psychosis from other mind states like disassociation (just one example)
      * make certain that the subject is not acting, a la the Rosenhan experiment,
      * make certain that the “psychosis” as it’s being defined by the people running the experiment is not being caused by a physical problem…

      I could go on…but what I’m getting at is, there are always too many variables to make any study in psychiatry pass muster, and that’s before you add in things like confirmation bias, conflicts of interest, the fact that some (like drug makers) are allowed to throw out studies until they get a study with results that they like. Really, you can’t trust any study, whether it’s pro pharma, pro psychiatry, or against.

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    • “I’m at a loss and I don’t understand how a statistical method could control for something like the severity of psychosis.”

      Apparently they didn’t measure the difference in severity of the first episode of psychosis. Or the severity of the prior diagnoses.

      But they did meassured the frequency of the F20 diagnoses, that speak of “psychotic disorders” to try to put a weight on severity. Some folks before the FEP had several F20s, so to say. Some are more frequent with a poor outcome, some with a good outcome.

      And they did meassure how long those minors were in treatment, medications, before their first episode of psychosis. With the implied assumption that younger folks or with more medications could have had a more severe disorder…

      Well, I am no expert, but I think grossly, the statistical correction does assign a number to the “relevant” factors, say age, time under treatment, use of antidepressants, use of anxiolyticis, etc., to try to explain the difference between 2 groups of people for a single relevant factor. When there are differences in several.

      Like using medication X does increase the likelihood by 20% of a poor outcome. Medication Y by 15%, etc.

      Then, adding those up, you can correct,in principle, the differences in use of medication X, Y and both, between group A and group B. That’s grosso modo, a regression analysis. Of which linear regression is the most commonly used, since it is simpler in it’s math.

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  4. As someone with psychosis, I find this information incredibly misleading and harmful.

    A “good outcome” is receiving NO treatment at all? That’s ridiculous when talking about chronic conditions that are best managed with antipsychotic medication. According to this study, I wouldn’t have a “good outcome” despite the fact that I haven’t had a psychotic episode in years, am now able to maintain a job, and healthy relationships.

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    • Whether or not someone receives treatment is not an “outcome.” An outcome is a result of the treatment approach. The study does not state or claim or suggest or imply that no one has a good outcome using antipsychotic drugs. It suggests that ON THE AVERAGE, those who receive light or no intervention are more likely to have a better outcome at two years onward. A better outcome ON THE AVERAGE. There can be plenty who got a better outcome with drugs or a worse one with drugs as well. Your story is one story of millions. Yours can be 100% true and yet the average person can still be worse off in the long run on antipsychotics. You are one data point. A scientific study is made up of hundreds or thousands of data points. It’s not the same.

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    • As someone who got brain damage from ECT and is still disabled, I find the claim that ECT “is the most effective treatment for depression” incredibly harmful and misleading. Unfortunately for me, I have to encounter statements that I find incredibly harmful and misleading every day, everywhere I look. That’s the dominant narrative: “Psychiatry is good and scientific and helps people and everyone who’s having a problem should seek help and get diagnosed and treated because psychiatry is life saving and scientifically based and thank God for psychiatry!”
      You are lucky that you only need to avoid this website and a couple others if you don’t want to hear things that don’t reflect your own experience.

      I’m very curious about your username.

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    • Who said psychosis is a chronic condition best treated with “antipsychotics”? Pharma and psychiatry said that, and the mainstream media said that because pharma pays their bills.

      Anyone who studies the history of psychiatry will get a lesson in “misleading and harmful”. It’s their specialty.

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      • There might be some trolling going on too, or genuine incomplete/missguided information.

        Or, as I loved to say in my old days: We are not being suspicious enough, it might be an “inside” job to make us more likely to argue MORE in favor of NO psychiatric treatment. And NO psychiatric diagnoses…

        So, as I used to say, it might actually help to strenghten our beliefs in a rational, usefull, and justified way. Instead of just propaganda, even if at first might look like it.


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    • Well, when prescribed by a health professional, no treatment is a treatment 🙂

      The typical: “Don’t worry, your runny nose and sored throat require no medication, you’ll be fine in 5-7 days. Just, if after 2 days you feel the same or worse, or this happens, check back with me”.

      And, strictly speaking, I think, the paper did not meassure no treatment, it meassured treatment with antipsychotics vs never antipsychotics vs postponed antipsychotics after the first episode of psychosis.

      And no treatment when 41% of minors were given antipsychotics when they had no psychosis sounds, stated thus, without further qualifications or clarifications, clearly OVERtreatment, to me.

      And your experience is the opposite of the conclusion in the paper: no antipsychotics are better than at some point. Not using them leads to less fatalities and disabilities.

      And just consider 1 in 50 minors died during the study. One in fifity when the fatality rate of minors according to UNICEF IS 17 per 1,000. Or 1 in 59, in 5-24yrs old.

      Might not look like much of a difference, but oddly, some folks never administered antipsychotics had a fatality of 1in 67, smaller than UNICEF’s number (!?).

      But, per the CDC: “Children ages 5–14 years…Deaths per 100,000 population: 14.3”, or 1 in 6,993. THAT is signficantly different, that’s 140 times more deaths among these psychiatrically treated minors than the average of the US population in that age group.

      Now, according to:

      Finland, more or less has a death rate in under 5yrs of 1 in 500.

      and from:

      is 1 in 2,500, or 50, FIFTY times less than the reported mortality rate in the study reviewed in this MIA piece. Similar to the increased fatality by hospitalization alone, of which 75% can be explained, in this study, more or less, by being in a psychaitrists office, since that will lead, most likely, at some point, to hospitalization, so it’s not independent.

      It makes me think minors under psychaitric treatment are experiencing mortality rates comparable, almost the same, as minors where there is no medical care… and 50-140 times more than without psychiatric treatment, speculatively, in the first world.

      And as per the CDC, the main causes of demise in 5-14yrs old: cancer, accidents, assault and suicide.

      From other studies, just going to a psychiatrists office, or being in a psychiatric hospital increases the chances of suicide by 6-8 times to over 60 times!, sometimes 100 times!.

      Heck, just living in a town or city with a psychaitric hospital increases mortality, I think by suicide TWICE, or 20 something percent?.Don’t remember the number, but it does increase fatalities to live nearby a psychiatric hospital.

      Like having leech treatment accesible in ye old days…

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      • For comparison of mortality rate in a real brain disease, an organic one, with relatively effective treatment, similar in toxicity with psychiatric medication for, uugh, “psychotic disorders”, epilepsy:

        “… In Finland, a population-based cohort of children with epilepsy (245 cases, 61% incident, 39% prevalent) was identified during the period 1961–1964. At follow-up 30 years later, 90% (220 cases) of the cohort could be traced and 44 were found to be dead [18% of 245] yielding a mortality rate of 6.2 per 1,000 patient-years (95% CI 5.7–6.7)…”, or 1 in 161 per year. That was from Finland and in the 1960s!. Or 1 in 31 over 5 yrs, greater mortality than 1 in 50 over 5yrs, but only 40% more, not many times more…


        Same paper, Australia:

        “…, the authors estimated that the mortality rate was 3.1 per 1,000 patient-years”, or 1 in 64.5 in 5yrs, less than 1 in 50.

        Same paper, Canada:

        “In a study from Nova Scotia, Canada, 686 children up to the age of 16 years were followed for a median of 14 years from onset of epilepsy (15). The SMR relative to reference populations from the 1980s and 1990s were 5.3 (95% CI 2.3–8.3) and 8.8 (95% CI 4.2–13.4), respectively.”

        Same paper, England:

        “England, 1995 (21), Special school 15.9 (10.6–23), 5–24 [yrs of age]”. From Table 2. Note: “The higher SMRs found in these selected populations [here England, minors in Special School] indicate that mortality is related to seizure frequency and severity.”

        And minors with epilepsy do have greater probability of having ANOTHER real brain disease like cerebral palsy, brain tumors, or real traumatic brain disease, that actually causes or contributes to epilepsy. In Table 3.

        Unlike psychiatric diagnoses that co-occurring means nothing beyond happy trigger psychiatric labeling.

        How does sound reasonable the mortality rate for minors with epilepsy, a real brain disease is similar, even less, than for minors without actual psychosis diagnosed with a psychotic disorder, or for minors with a first episode of “psychosis”?.

        That does not sound reasonable to me: having similar mortality rate when treated for a “mental DISORDER” than for a real “brain DISEASE” that on top of that, frequently co-occurs with ANOTHER serious brain disease?.

        Unlike psychiatric psychosis that most of the times, and I mean almost all, does not have a DIAGNOSABLE brain disease!.

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  5. psychiatry is fake science. l said to psychiatry ‘l hear a voice’ whereas this was lie.the psychiatry diagnosed with schizophrenia me. the psychiatry said ‘ you is very very very very ill’. this is comic. l laugh to this. If I had cancer it would not be said like that. the psychiatry made drink me clonezopin. l thing clonezopin is poison. rosenhan’s test is very right. science of lies psychiatry. thomas szasz. l am hating from mother and father and brother and family and society and state. the state and society and family and psychiatries in turkey apply pressure to lgbti+.

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