Sunday, November 19, 2017

Comments by mah3md

Showing 6 of 6 comments.

  • Mr. Duane, Sir:
    Please read again my posting and respond to the positions I presented. Solipsistic thoughts do not carry any weight.
    I did not say, or even implied, that the so-called minority groups do not adhere to psychiatric treatments “due” to lack of support but “because” of lack of support in the community. “Non-adherence” is not only with Psychiatry treatments in particular but with Medical treatments in general and thus not adhering to different treatments: Cardiovascular (like hypertension and cholesterol control,) Metabolic (diabetes, obesity) Eye and Ear (glaucoma, retinopathies, decreased hearing,) Gastroenterological (from perforated duodenal ulcers to bleeding hemorroids,) Infections (from complex dermatological suppurative lesions to HIV advancing into AIDS) and so on and so forth. These minorities that refuse every kind of treatment have shortened life spans and, goes without saying, constitute the majority of the homeless and street people that present with severe untreated illnesses, both mental and physical (a silly difference but that is vastly used) and populate the emergency rooms. The “right” to refuse treatment should not stop with Psychiatric treatments but with ALL treatments. Is it not true?
    There is no question that everybody, patients or not, must be protected in their rights and nobody denies that. You do not need to quote every Constitutional amendment to support this notion. But as important as the protection to refuse treatment is so is the right to be treated and when a person lacks the ability to understand this need then the society must intervene to facilitate treatment, at times above the wishes of the patient. Mentally ill patients can certainly be dangerous TO THEMSELVES, and they are unable, in many cases, of controlling their impulses and their lack of insight supersedes rationality and that that takes them to refuse treatment and therefore put themselves in a vulnerable state. To obtain a permission to treat above objections under the AOT guidelines (Kendra’s Law) a lawyer is assigned to the patient to defend his/her right to refuse treatment, the Psychiatrist presents the case and requests treatment over objections based on three main instances: Dangerous to self, dangerous to others, inability to care for self. A judge weights the arguments and issues a decision. Yes, to obtain an order of treatment over objections the Psychiatrist must PROVE in court any or all of the above mentioned three instances.
    You should witness these court procedures and see how many times the Psychiatrist fails to PROVE his/her case for treatment over objections and the request is denied.
    I agree that the rights protected by the Constitution applies to the mentally ill and should be defended, including the right to vote and to redress grievances in court, like refusing treatment. But then the resulting questions are:
    – Should we defend the right to own a gun for protection under the second amendment as the NRA interprets it or, as the NRA states, we should deny it to people with mental illness.
    – If a mentally ill person commits a crime, should we do away with the M’Naughten rule (ability to tell right from wrong)? Well, if the patient refused treatment and the society does not consider him mentally ill and he is considered able to refuse treatment then the society can refuse to consider that any crime he commits in the absence of treatment has been done with total free will and years of legal proceedings that protect the mentally ill will be trashed.
    – If the patient can refuse psychotropics, so can the Psychiatrist refuse to administer them without fear that the results of The Osheroff vs Chestnut Lodge case applies to him/her?
    – If a Psychiatrist learns of the threat on somebody’s life verbally made by a patient under his/her care, should the therapist forsake warning the potential victim, without suffering consequences from cases like the Tarasoff vs Regents of University of California because the patient is exercising unimpeded free will and you are violating the patient’s rights to conduct treatment and to privacy?
    These arguments, directly or indirectly related to the right to refuse treatment, can be even more complex and extend forever and cannot be encapsulated in ideological bromides.
    Finally, let me say that the implications of “racism” of the AOT program are totally false. The program was based on the outrage generated by one very white paranoid schizophrenic that, having refused treatment and following command hallucinations, pushed a very white person into the path of the subway, producing the death of the person.
    Are there psychiatric abuses being committed? Yes. Should we ignore them? No. Does this mean that all of Psychiatry is abusive and should be dismissed? Absolutely not, but Psychiatry has to be corrected, not eliminated.
    Forums like this one are good to discuss issues, but people should not argue with vacuous diatribes and set forth arguments based on what one thinks has been said and not to what was actually postulated. This distortion of thought belongs to the Beck/Limbaugh School of Willful Distortions and not to what should be a civilized exchange of ideas.
    I do not think that I am correct in every aspect that I present and I find that starting a polemic in sites like this could be useful to develop common understandings. As it stands, pseudo-arguments do not protect psychiatric patients but make them more vulnerable.

  • Treatment can be enforced through judicial order only in those patients that have multiple admissions due to non-compliance with treatment and/or are deemed to be dangerous to themselves and/or others.
    Blacks and Latinos in NYC constitute the bulk of mandated treatments because they are the groups that due to economical limitations receive the least support from the community to adhere to treatment.

  • Thank you for your considerations. Well… let me see if I can satisfy your healthy curiosity. I am an MD/PhD with degrees in Medicine and in Physiology/Biophysics. For many years I did research in membrane physiology/ biophysics (water and urea permeation, N/K ATPase, K activation of Ca transport, bioelectricity, amnion permeability, and the like) and in the 90s I became a psychiatrist. I was the chief of a medical-psychiatric ward in a large city hospital (while there I took a keen interest in the the treatments of the mentally ill AIDS patients and the elderly demented) and the medical director of a VA Methadone Clinic. I am currently fully retired. I consider myself a Biological Psychiatrist with interests in human rights and the history of Science, Medicine and Psychiatry. I do not believe that the problems of psychiatric abuse (which certainly exist) lie with Psychiatry (in the abstract) but in the way that Psychiatry is practiced, particularly in the USA. The treatments in the hospitals are largely in the hands of rookies with nary an experience in treatments (psychological and biological) and their supervision is largely in the hands of experienced people that barely supervise the residents and also have little understanding of the basis of Psychopharmacology and follow the dictates of the unholy Big Pharma-Psychiatry alliance (the dark side.) Of course, there are genuinely outstanding exceptions to this “rule” and I was fortunately enough to have received training by these “exceptions” and I tried to transmit it to my trainees. I am a firm believer of the great capacity of medications to help in the healing of severe mental illness, when they are judiciously applied. I write (sparely) in this site exactly because its participants and audience are the most vulnerable and sometimes they become easy prey of the mirror image of Big Pharma: the “natural health” practitioners (nutritionist, naturopaths, and the like) that eschew Science in the pursue of big bucks, as much as Big Pharma and its coterie of venal Psychiatrists do. I am NOT an anti-Psychiatrist and I defend diagnostic practices and medication of the disease, when needed, but I do think that Psychiatry, its ridiculous DSM V and the willy-nilly application of psychotropics must be thoroughly revised. And there are serious, honest and intelligent people with a keen interest in the welfare of patients doing so. Psychiatrists like Allen Frances, psychoterapists like Gary Greenberg and jurists like Joel Bakan, to mention a few, are waging a non-strident scientific and well thought out war against the excesses of Psychiatry and Big Pharma and the alliance between them. This “warriors” are not in the “antipsychiatry” movement, like Szasz et al. And I fully support them to the best of my abilities.

  • The categorizations of the normal (adjusts to norm) and the pathological (quantitative and qualitative deviations from norm) is a discussion that goes way back to Hippocratic/Galenic medicine, Pinel, Bernard and everybody else. It was beautifully put together in the philosophical realm by George Canguilem in his 1943 book “The Normal and the Pathological” (published in English by MIT, with a preface by Foucault.)This Dr. Lynch here has rediscovered gunpowder and lollipops. Please, gimme a break!

  • Lithium cannot “cause horrific conditions like CJ (Jakob-Creutzfeldt) disease.” There is one (1) report suggesting CJ-like illness in Li toxicity (plasma level >2 mM), in a 70-some year old patient and then only based on EEG patterns. No brain pathology was reported.
    There is no evidence that Vitamin C reduces any toxic side-effects of Li. I hope that psychiatrists are not recommending Vitamin C to “reduce” Li toxicity. In the not so distant past, psychiatrist used to prescribe Vitamin E to reduce neuroleptic-related tardive dyskenesias, with no evidence whatsoever. Thank god, they have stopped the practice, as it can cause severe bleeding in some patients and nary an evidence that is efficacious.
    There is no evidence that Li orotate is more efficacious than all other Li formulation or that is less toxic. Li orotate manufacturing is not regulated and the advocacy of unregulated medications is irresponsible, to say the least. It is sold as a “dietary supplements” not only in health food stores but also can be purchased on line in Amazon and the like. Li plasma levels have to be followed closely and other laboratories have to be performed. To tout the use of Li orotate with no medical support is the closest thing I have heard to malpractice, though in this case is glorified (with no evidence) by non-professionals.
    Li is metabolized in the body as Na is, and follows the same routes of absorption and elimination. It tends to accumulate in cells because it “leaks” into the cells through Na channels, following activity gradients, but is not “pumped” out back through the Na/K ATPase because the intracellular Na site of the ATPase excludes Li in favor of Na. There is no particular participation of the liver in Li metabolism. What on earth is then the “liver-brain barrier?” Where is it located? How does it work? Sounds like Galenic medicine, not even Vesalius talked like that.
    Please, is anybody there with any scientific background that can spot these dangerous off-the-cuff nonsense?
    And, by the way, what all these “comments” by Ms Mangicaro about Li use has to do with the topic of haloperidol toxicity, the original theme of the posting?

  • I read Dr. Nasrallah’s opinion on haloperidol and his indirect support for the use of the so-called second generation neuroleptics (SGNs) that he acknowledges are no more efficacious than the first generation neuroletics (FGN.) Though it must be emphasized that this distinction between “first” and “second” generations is rather week as the grandmother of the SGN, clozapine, was “generated” by the great-grandmother of all of them, chlorpromazine, already in 1970.
    First of all, let’s be clear on the fact that Dr. Nasrallah operates with BigPharma on the dark side of Psychiatry. Among many examples, Dr. Nasrallah, based on flimsy evidence, a great ignorance of receptor occupancy rates and eyes firmly planted on the prize that follows the promotion of brand names, sang the praises of the concomitant use of 2 antidepressants (SSRIs and SNRIs) for poorly responding depressions.
    Second, his opinions about haloperidol are totally biased and partial.
    The real biggest problem with haloperidol arise when you examine the doses at which it is used and its half-life (t.5).
    Haloperidol is always dosed at extraordinary large doses, ≥ 20 mg/day. For example, in the first head-to-head comparisons between SGNs and first generation neuroleptics (FGNs) haloperidol was invariably administered at 40 mg/day while the SGN was given at the lowest dose possible, generating large side-effects for haloperidol and lower ones for the SGN. The large haloperidol dosages have been in use forever and, like with every neuroleptic used at large dosage, being either FGN or SGN, the long term effects are unpredictable but mostly bad. When you run lab experiments with haloperidol on isolated neurons you get a lot of effects that run from vacuolizations to activation of caspases and what not. Always calculate the concentrations employed in these experiments (always read the Methods section of the papers) and you will almost invariably find that they are enormous thus obtaining effects that are actually impossible to translate to clinical practice with any significance. Haloperidol, like many, or most, neuroleptics, activate NMDA receptors, and give signals of Ca release in Fura-2-like experiments, but what is important is to determine if the cellular Ca-buffering systems are functioning adequately or the drug overrides them. For example, ketamine is neurotoxic, promoting neuronal vacuolization (Olmney’s lesions) and apoptosis and mimics psychotic symptoms in humans (and monkeys.) Everybody knows that, but it has not stopped psychiatrist to study its potential as an antidepressant and even a psychiatrist applying for a patent under his name for the use of Special K as an antidepressant. And not a peep about this from the good doctor, Nasrallah. Moreover, said doctor lists “depletion of gluthatione” as problem with the administration of haloperidol. But, without going any further, a drug that does reduce gluthatione activity, and in a significant way, with the potential for causing liver failure, is valproate. Where is the chochem of Dr. Nasrallah denouncing the dangers of using of Depakote® and Depakote® ER when we need it? The symbol ® is meant to be tongue-in-cheek, as Dr. Nasrallah would never, ever, give any grief to Abbot or any cause for Abbot to be angry at him.
    As to the t.5 of haloperidol, it is several days or weeks. If you recalculate the t.5 of haloperidol in the brain from the published washout curves you will see that it stays in the brain for a long, long time. Therefore, haloperidol might be simply given every third day or even once a week.
    So, when you add large accumulating doses, you may expect large, accumulating side effects.
    If you examine the old Wolkin’s haloperidol D2 occupancy curves you realize that the system saturates at the equivalent oral dose of 2.5-5.0 mg; so, why give more than 5 mg every third day, for example, or use decanoate at doses greater than 50 mg once a month? Because a drug as effective as haloperidol and that costs so little but comes without the benefits of a pen and sandwich and with no speaker’s fee is not in the realm of Dr. Nasrallah’s sphere of interest. Use haloperidol judiciously, an advise that you can extend this to every generic neuroleptic and to one of the best mood stabilizers: Lithium, that also comes without pens, pizzas or speaker’s fees.
    If you read the science-free articles by Dr. Nasrallah, only one advise: Caveat emptor. He is the friend of Pharma, not yours.
    So much left to analize and to say in Psychopharmacology!