Comments by Maria Bradshaw

Showing 126 of 126 comments.

  • Thanks for this. I run a suicide prevention charity which responds to suicidality using indigenous and sociological rather than medical approaches. The only thing I disagree with in your article is the statement that we can’t know why some with suicidal thoughts end their lives and why some don’t.

    My child killed himself 15 days after being prescribed Prozac. Both my government and Mylan Pharmacueticals conducted causality assessments and found the drug to be the probable cause of his suicide. In some cases, the reason people end their lives is because of the pharmacological treatment they are given.

    The Joiner model also explains some suicides as being a product of social isolation, a sense of being a burden and the ability to overcome the survival instinct through either the use of drugs or desensitisation to pain and suffering.

    My charity’s work suggests that along with these factors, those who die are distinguished by their lack of self efficacy. They do not believe they have the power to change the circumstances causing their suffering. In our experience, no matter how bad the situation, if people believe they are capable of changing their circumstances through their own efforts, they will survive.

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  • Hi Jolie. Yes my son made a choice. He chose to end the torture of antidepressant induced akathisia. Much as he would have chosen to cut off his arm had it been trapped on a railway track with a train approaching. A choice he would never have wanted to make but one over which he saw no other choice.

    My son did not ‘commit suicide.’ People commit sins or crimes – his taking of his life was neither. My son died by suicide with both my government and Mylan Pharmaceuticals assessing Prozac as “the most likely cause” of his death. He was neither a sinner nor a criminal. He was a victim.

    You suggest my child should not be spoken of in total sympathy. It is hard for me to imagine what about a child being tortured by medical professionals he trusted and going through the terrifying process of making a noose and hanging himself in order to end his pain deserves judgement or criticism.

    I think that you are suggesting that my expressing my love and sympathy for Toran sets a bad example to others. You perhaps believe my message should be that if you kill yourself your parents will stop loving you and will publicly condemn you. You perhaps believe that this would act as a deterrent to suicide. Let me be clear about a couple of things. First, my son is not defined by how he died. He is defined by how he lived. Second, I HATE suicide. I hate what was done to Toran and I hate what he did to himself. My son was a child any mother would be proud of, his death is a death any mother would hate passionately. I will love my son forever. I will hate suicide forever. I will never condemn my son for being a victim of iatrogenic suicide.

    Two years after my son died, my sister died during chemotherapy treatment and a blood transfusion. It has been acknowledged that her death too was iatrogenic. My sister could have chosen not to have treatment for the leukemia she was diagnosed with. Should i also condemn my sister for her choice? Should i stop loving her because she chose to accept treatment that killed her? Am I setting a bad example by publicly saying I love my sister?

    Finally thank you for your good wishes. They are appreciated.

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  • I want to thank Michael for an article that taught me so much and to comment on the concept of failure as a positive.

    As a mother and a teacher I have spent my life promoting the idea that failure is one of our greatest achievements. I have never seen failure as something to be afraid of but rather something to be celebrated. I don’t think it makes us any less worthy of admiration or respect, takes away from our successes or defines us as anything other than brave, forward-thinking and ambitious. Small people set achievable goals, heroes like Thomas Szasz set huge ‘not achievable in my lifetime’ goals and analysis of why they are not achieved overnight and meet so much resistance teaches those to whom the torch is passed how to get closer to success. Failure is our greatest teacher and thanks to Thomas we are all wiser and closer to achieving the change he wanted to see in the world.

    I personally have learned far more from failing to reach an ambitious goal than from succeeding in smaller ones. If I’m not failing regularly, I suspect I am being complacent and not challenging myself enough. I relish failure as presenting me with opportunities and sometimes inspiring more successful efforts in others.

    Of course Thomas Szasz failed. My child would not have been told he had a chemical imbalance, given drugs to fix it and violently killed himself because of those drugs, had Thomas succeeded. I would not have been thrown into a psychiatric institution following his death against my wishes. Had Thomas succeeded, none of us would be here on MIA. Does that make his achievements any less worthy of recognition? Of course not. He failed because he promoted ways of thinking and behaving that will change the world, benefit the masses and undermine the privileged. He failed because he was great and had a vision beyond his peers. As Michael points out, his failure says little about him but speaks volumes about his detractors, our society and what is needed to achieve lasting and effective change. Is changing the world ever achieved in one person’s lifetime or do the big humanity-changing goals have a longer timeframe before they are truly bedded in?

    My goal is to eradicate suicide. I will be remembered as a failure. On the back of my failure though, lasting rather than superficial, short-lived change may be made and as such my failure and my success are intertwined. I’m no Thomas Szasz and no one will write such a thoughtful, thought provoking article when I die as Michael has but if someone talks about my failures, I’ll feel like I’ve succeeded because my work and ideas will have outlived me.

    I think it is imperative that we recognize that as a movement aimed at ending coercive psychiatry we are failing. Yes we need to celebrate our successes and acknowledge our heroes but if we are afraid of admitting that we are not achieving the change we seek or critically appraise the efforts of our leaders, then I don’t think we’ll ever get there. Let’s not delude ourselves or be afraid to honestly evaluate progress towards our goals. Being afraid to acknowledge that we have not yet succeeded would, in my view, be our biggest failure.

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  • I agree. The state has too much vested in keeping patients vulnerable and afraid to have any interest or ability in the empowerment of those involved in the system. Demand for change would need to come from the public and be driven by those of us who have been harmed. Sadly the myth of the violent, irrational mental patient who is a risk to society and the myth that psychiatrists are practicing evidence based medicine serves to make the average person on the street comfortable with human rights abuses within psychiatry.

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  • Hi Alix
    I accept totally that people make mistakes and psychiatrists are no different from anyone else in that respect. What I’m concerned about is that many standard practices in psychiatry are nothing more than abuse and many psychiatrists routinely engage in abusive practices for which there are no challenges and no accountability. Making mistakes is one thing…deliberate abuse is another and that’s what I think needs addressing.

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  • I couldn’t agree with you more. The New Zealand police are currently reviewing the evidence in relation to my son’s death as I have submitted it constitutes manslaughter. I’m waiting for the police to complete their review and advise whether they are laying criminal charges against the psychiatrist. Cross your fingers for me πŸ™‚

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  • Hi Iarmac

    One of the problems with censoring the media around suicide is that the associations with both SSRIs and cannabis are not highlighted. I think of you (and so many other mothers) every time I see the claim that cannabis is not associated with any harms. I know that is not your experience or the experience of the mothers of so many other children who have died from suicide after using the drug.

    Much love to you and the memory of your lovely son.

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  • Hi Bipolardoc

    I’m familiar with the studies you mention but don’t consider they establish a causal relationship between suicide reporting and suicide deaths. They fail to control for a number of factors that could affect suicide rates – social and economic factors as well as factors Niederkrotenthaler has identified in more recent studies including train speed and frequency and the use of stations for drug deals. Correlation is not causation.

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  • Hi there

    The countries where I found guidelines around not mentioning specific drugs or brands are Korea, Japan and Australia but there may be others.

    I guess we will have to agree to disagree on whether the evidence for suicide contagion )the Werther Effect) is convincing. My view obviously is that it is very flimsy and that theories such as homophily are far more convincing.

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  • Just wanted to say that many of us who are survivors of suicide loss are also survivors of our own suicide attempts. After my son died as a result of prozac induced suicide, I made three medically serious suicide attempts. It would be a shame to suggest that those of us who watched our children tortured and killed by psychiatry and in the aftermath were forcibly detained and medicated and attempted suicide do not have a ‘survivor’ perspective to offer. We have had to fight very hard to be heard. In my country it is perfectly legal to speak out about attempted suicide but an offense to talk about the medication induced completed suicides of our children.

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  • Thanks for this Sera. My suicide prevention organisation CASPER has a policy of not only not accepting Pharmaceutical company funding but not accepting government funding. Few people would understand how hard this is – not being paid for months and having to sleep on other people’s floors to survive – but this article highlights how important it is and why we make the sacrifice. Funding influences philosophy and practice and can corrupt the best of intentions.

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  • One of the most powerful and effective things psychiatrists could do to educate the public about these drugs is to challenge their colleagues publicly when they state that they do not cause suicide or violence. In Ireland, high profile psychiatrist Patricia Casey who is a paid speaker for Lundbeck Pharmaceuticals, states that there is no evidence these drugs cause either suicide or violence. Mothers whose children have died and/or killed others soon after being prescribed the drugs are left to challenge her while psychiatry is silent. And of course we are dismissed because we are not medically qualified. We need some back up from psychiatrists (apart from Prof David Healy who carries the burden of challenging other psychiatrists almost single handedly) who are willing to make statements such as the one in this blog. Sadly the majority of the over 2 million people who saw Patricia Casey speak about these drugs on Irish television last week will never read Mad in America.

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  • Thanks for your support David. For psychiatrists to conduct a mental state exam the child psychiatry killed is a little like having your child’s rapist criticize her for wearing a short skirt. Neither my son nor Shane Clancy were diagnosed with any mental disorder by the medical professionals who assessed them because they did not have one.

    Its ironic that people tell us “at least they can’t take away your memories.” Well with the benzos they give us after our kids die they can (which of course is another story altogether) but they can also taint those memories with their ‘diagnosis after death’ nonsense.

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  • Thank you both. Dead people have no legal rights – they can’t be defamed nor do they have any privacy rights. That makes them fair game. What was done to our children by psychiatry when they were alive is appalling, to continue to use them to further the agenda of psychiatry and big pharma by suggesting their deaths were as a result of undiagnosed mental illness rather than SSRI induced suiciality, is despicable. As their mothers we will protect them from further abuse until we take our last breath. Your support means so much.

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  • We have so much in common Sarah. I am so sorry. In Toran’s case there were some significant departures from usual practice including telling Toran to stop his meds on a Friday, drink up to six bottles of beer a night over the weekend and resume the meds on each Monday. His doctor also forgot to ask if he had any general medical conditions or was on any other meds – he was on a migraine med that interacts with prozac and can cause serotonin syndrome. The doctor failed to read Toran’s file before medicating him despite the file recording a severe adverse reaction to prozac previously which included suicidal thoughts and behaviours. These along with the doctor admitting Toran was not depressed and his colleagues testimony that when I raised the issue of side effects he told me to ‘stop reading research and trust his professional judgement’ are, I hope, sufficient to prove a significant departure from the practice of other psychiatrists and coupled with the causality assessments from my government and mylan showing the causal link between the drug and Toran’s suicide in my view reach the threshold. I believe a jury would find him guilty – I just hope the police will give a jury the chance to hear the evidence and make a decision.

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  • Thanks Sally. I will never forget how shocked I was to discover, months after my son’s death, that the drug he was prescribed was not approved by our regulator for children. I blamed myself for a long time – why didn’t I ask if it was approved as safe and effective for children – but the reality is that I like most people had no idea that off-label prescribing was legal and pervasive. I trusted my government and my doctor.

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  • Richard I’ve read your paper and wonder if any analysis was done on the proportion of those who died from suicide with a diagnosis of psychogenic pain who were treated with SSRIs or other psychiatric drugs known to increase suicide risk? While it is plausible that the diagnosis led to feelings of hopelessness / worthlessness / sadness that in turn led to depression, it is more plausible that psychiatric drugs caused the suicide as in my son’s case.

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  • Thank you. My son’s death meets all the ingredients of the offence of manslaughter in New Zealand. According to the police though I need a higher standard of evidence given “juries never convict doctors.” I believe the evidence I have provided to the police including two causality assessments showing the drug was the most likely cause of his death meet that standard and want the police to let a jury decide themselves. Should hear soon whether the police are willing to take action.

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  • Hi Peter. I don’t disagree that ecological studies have problems, not only with between country confounding but with issues around the direction of the influence of each of the factors shown to have an association. I note however that across the western world, ecological studies are used to inform policy such as that which governs media reporting of suicide (and in my country makes me a criminal for talking about my son’s suicide). This evidence is at least as strong as the ‘copycat suicide’ evidence and yet is being ignored by governments in developing suicide prevention policy. I, like you, hope that more robust studies will be conducted but in the meantime, and in the spirit of the precautionary principle if nothing else, I think these are worth highlighting and using to generate discussion.

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  • I wish I’d had a champion like you when psychiatry got their hands on my child and killed him. It is too late for me but if there is anything I can do from over here to support Justine’s parents please let me know. I feel pretty useless saying that because all I have is a loud mouth and the recklessness that goes with having nothing left to lose but if those can be of any use…

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  • A factor of being a bereaved mother and having gone through 10 government enquiries and the longest inquest in history – no one believes a mad mother so you have to spend your life quoting others so people will listen to you! My research project for my MBA was on ethical boundaries in competitor intelligence gathering and i learned a lot about how to get information people would rather you didn’t have. When Toran died I felt like my study had been a total waste of time I could have spent with him but now I feel like it has its uses πŸ™‚

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  • Hi Vicki. I’m a mother whose child died from suicide 15 days after being prescribed prozac. Both my government and Mylan Pharmaceuticals have conducted causality assessments and determined the causal relationship between my son’s death and the drug he was taking as ‘probable.’

    I established and am CEO of CASPER a charitable organisation run by families bereaved by suicide for families bereaved by suicide. Amongst our many services, we support families to present their cases at coronial inquests with a view to getting recommendations in relation to psychiatric drugs that may prevent more children killing themselves.

    We are assisted in our work by a small number of psychiatrists who, free of charge, review our childrens’ medical files and provide expert evidence to the court in those cases where he believes there is a causal link between the drug and the suicide or where breaches of best practice around diagnosing and prescribing practice need highlighting.

    Is this an area of work you are, or could see yourself involved in?

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  • Great post Ted, thank you. No point me saying much as I would be repeating myself and repeating what you have said. I do want to challenge the notion that without diagnosis there would be no treatment. In my country psychiatrists are salaried employees of the state and do not have to bill based on diagnosis. My son had no diagnosis but was medicated and died. In the past 5 years, 75% of the children under 18 years who have died from suicide under the care of this health board, had no diagnosis but were on meds.

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  • My blog provides information and my opinion about psychology globally, not a country by country analysis. I am very aware that UK clinical psychologists called for an abandonment of psychiatric diagnosis and the β€œdisease model” last year. I am also aware that that this has done little if anything to halt the use of this paradigm by psychologists around the world.

    Contrary to your assertion, I explicitly stated in my blog that the number of prescribing psychologists is small. I provided evidence that psychologists in the US and other countries (including my own) are lobbying strongly for prescribing rights and offered the opinion that they will gain them and that this will change the face of psychology. Whether this will happen in the UK remains to be seen and is something I did not offer an opinion on.

    We may have to agree to disagree about the current and potential links between psychology and big pharma. I believe they are strong and growing and provided evidence to support this position. You may wish to present the evidence that I am incorrect about this rather than merely stating your view that the links are “not significant.”

    In response to your question about my motivation in writing this blog it is the same as it is with all the blogs I write – to encourage informed debate on issues related to supporting those in emotional distress. My vested interest is in creating a world in which my child would have been supported rather than medicated and would not have ended his life by suicide. I am always very explicit about my agenda.

    In reference to your claim I have misrepresented your profession, I note that psychology exists outside of the UK and suggest that its practice in other jurisdictions may have more influence over its practice globally.

    Finally while you claim that “psychologists here in the UK do not work within the psychiatric β€œdisease model and the DSM”, the British Psychological Society statement on the open
    letter to the DSM-5 Taskforce “recognizes that a
    range of views exist amongst psychologists, and other mental health professionals, regarding the validity and
    usefulness of diagnostic frameworks in mental health in general, and the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association in particular.” http://www.bps.org.uk/sites/default/files/documents/pr1923_attachment_-_final_bps_statement_on_dsm-5_12-12-2011.pdf
    This suggests that your views, while of course entirely valid as opinion, do not represent all UK psychologists.

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  • I have reported on public perceptions of psychiatry as per a survey conducted by the WPA, not given my personal opinion of psychiatrists. I do have a very poor view of the competence of psychiatry as a profession, one I might add that surveys show is shared by their colleagues in other medical specialties, patients and the general public. I agree that psychiatrists are ignorant rather than evil but note that my son is just as dead whether his psychiatrist operated from a position of ignorance or ill intent.

    Of course emotional distress is real. In my view and my work this means environments need alteration not that a person’s broken brain needs ‘fixing’ with a drug. How is my approach more stigmatising than the label and drug approach?

    You exhort me to take some action but are perhaps unaware that after my son’s prescription drug induced suicide I sold my home and everything I own to devote my life to changing the way emotional distress is viewed and addressed and to prevent suicide. I currently sleep in the bottom bunk of a friends 6 year old daughter’s room, have everything I own in the world in two suitcases and work 24/7 lobbying government, supporting families with suicidal kids or kids who have died from suicide. That doesn’t make me a hero but it makes me someone who doesn’t need a lecture about taking action to prevent suicide, which in my country has reduced by 20% since my organisation started.

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  • Thanks Duane. When I was a child and asked questions about life and the universe my mother would respond “because that’s the way God made it.” When i ask questions of psychiatry now I get a similar response with God replaced by an academic psychiatrist, the DSM or ‘clinical experience.’ At least my mum made it clear she was trying to fob me off while psychiatrists try to make it sound like they know the answers.

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  • Thanks Ted, I feel like we are on the same page too. Before Toran died I believed dead was dead and yet when it happened I could not believe that his energy, his laughter, his love had just ceased to exist. Quantum theory, which I knew nothing about but he had mentioned to me a week before his death, helped me find hope that there is a possibility his consciousness survived death. That possibility allows me to sustain the hope that is necessary to the maintenance of life – without it, I would have ended my life. Quantum theory is one of the many gifts my son gave me and has become a very important part of my life.

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  • I live in an ethnically diverse nation too but I find I’m often thinking in ethnocentic ways that my fellow New Zealanders from ethnic minorities wouldn’t fall into, so I think I do mean ethnocentric.

    I was interested when I did the research for this blog to find that corruption was a key concern of chinese citizens http://www.pewresearch.org/fact-tank/2013/11/08/inflation-corruption-inequality-top-list-of-chinese-publics-concerns/ and that the GSK scandal was first discussed on a chinese social media site http://www.ft.com/intl/cms/s/0/93990558-2156-11e3-a92a-00144feab7de.html#axzz2ox8Itdux
    I have no idea to what extent the chinese public is aware of or concerned about this but suspect levels of both would be higher than in my country.

    I agree that the marketing plans of pharmaceutical companies extend beyond their use of doctors as a distribution channel and recently wrote about the way in which pharmacists are being engaged in drug marketing but the scope of this blog was confined to my thoughts on the reasons behind the changing relationship between pharma and doctors.

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  • I think its slightly ethnocentric to give such weight to the impact of DTC advertising and patient advocacy groups. It ignores the 26% growth in emerging markets against 7% decline in profits in Europe and 2% growth in America. In Asia, India and other emerging markets there is no DTC advertising and there are no patient advocacy groups. Consumers get their information from doctors as, I would argue, the majority in traditional markets do too.

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  • Thanks Wayne. I agree that Motivational Interviewing should be about empowerment and informed choice but in the literature on motivational pharmacotherapy there are so many references to overcoming resistance to medication and ignoring patient reports of adverse reactions which don’t fit with these constructs that it appears to me it is being used for manipulation rather than empowerment.

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  • Thanks Steve. When I first started blogging for MIA I struggled to find a picture which wasn’t taken by the media and showed me in floods of tears. This one was taken on a friends phone and my other friends give me such a hard time about it πŸ™‚ Recently a magazine did a story on Toran and I and took this photo amongst others which finally shows me with my actual hair colour and no tears!

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  • Hi Chaya. No insurance companies involved in New Zealand. Our government buy the drugs and we pay a small fee for our prescription. I paid only $3.00NZD for my son’s 3 month supply of Prozac. Incidentally I wrote to the drug manufacturer after Toran died (and they admitted the drug caused his suicide) asking for a refund citing comsumer legislation around refunds if the product was not fit for purpose. They refused my request.

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  • I’m so sorry Iarmac. The cannabis / suicide link is only too clear in the work I do with CASPER and I can only imagine what it must be like to hear people talk about how smoking it is a ‘victimless crime.’ I hate the stuff because I see it inducing younger and younger children to take their lives.
    Two weeks out from Christmas I’m sending you much love and wishing you the strength you and I know it takes to get through the holiday season without our childrens’ physical presence.

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  • Hey Jonah

    Because I have a very short attention span, I’ve had a lot of career changes and for a period of five years to 2007 was the manager responsible for gambling regulation for the North Island of NZ. Around the world the gambling industry is associated with money laundering, drug dealing and loan sharking, children are left unattended locked in cars while their parents gamble and those who cannot afford it are offered incentives to continue gambling until they lose everything.
    In relation to detention, yes I think sometimes people might need to have their freedom restricted for periods of time but just as with a child who needs to be restrained from running out on the road, the appropriate place for this to occur is within families and communities, not institutions which employ the coercive power of the police.
    A few weeks after my son died, I was handcuffed by five police officers and involuntarily committed to a psychiatric hospital on the grounds I was a risk to myself. I was put in restraints and had my clothes cut off me in front of two male security guards. As a result of the police action, I was x-rayed for a suspected broken wrist and extensive bruising was photographed. When I asked for a patient advocate, the nurse with the scissors in her hand laughed and said “that’s what nurses are – I’m your patient advocate.” I was not forcibly medicated but that experience has left very deep scars. I needed family and friends to be with me. I needed them to let me talk about the trauma of finding my only, deeply loved child hanging from a noose. I needed to be given hope for the future. I was intensely suicidal and a serious risk to myself but I did not need to be locked up in an institution, I needed to be in my own home, cared for by people who knew and loved me.

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  • I think the problem with your argument is this. First, there are many people in society who pose a risk to themselves and others but we apply different standards and protections around detention for those who are labelled mentally ill than those who are not. Under criminal law, the police do not go into someone’s house, ask them a series of risk assessment questions and then lock them up to prevent them committing a crime in the future. Even where there is evidence they may have already committed a crime, the police must have very strong evidence to detain them pending trial and then prove beyond reasonable doubt that they are criminals before detention orders are considered. For those assessed as mentally ill via an entirely subjective assessment process which has been shown to have little validity or reliability can see them detained indefinitely. No proof of mental illness is required and if the test was beyond reasonable doubt, no one would ever be diagnosed.
    Second, in practice, compulsory detention is almost invariably combined with compulsory pharmacological treatment. Separating the two ignores the real world experience of involuntary commitment.
    Third, Professor Roger Mulder of Otago University has recently published a paper which presents evidence that suicide risk assessment and involuntary commitment are conducted primarily to manage clinician anxiety rather than patient safety.
    Fourth, research is very clear that psychiatric hospitalisation is a key risk factor for suicide and violence rather than being a risk prevention measure.
    If as a society we are prepared to manage the risk of non-mentally ill people perpetrating harm on themselves and others through means other than preventative detention, I wonder why we would not afford the same rights to those experiencing distress.
    In my view, if we provided places of support and safety where those who are sad, scared, worried or angry, those dealing with violent or self destructive feelings as a result of negative life experiences or drug use, places where people were given love and hope and compassion, we wouldn’t need laws detaining them. They would want to go there.
    Yes detention and treatment are separate entities but both are harmful and there are alternatives to both which are more humane and manage risk more effectively.

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  • I get quite a lot of tv, radio and print media exposure through CASPER on the issue of suicide and psychiatric drugs but don’t get to air my views on wider issues around psychiatry anywhere except on MIA and in cafes where my friends and I solve the problems of the world. Perhaps its time for MIA TV where we bloggers can preach to the world. Maybe we could pass legislation mandating MIA TV viewing for everyone over the age of 18. People who refuse to rip up their prescriptions could be detained at the pharmacy maybe and forced to watch us for an hour a week.

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  • And yet the families I work with didn’t have lots of time. Their children died from SSRI induced suicide within days of being prescribed. In my son’s case, 15 days. In light of other comments you have made I feel the need to add that the causal relationship between the drug and his suicide was assessed both by our regulator and the pharmaceutical company as ‘probable’ so I am talking causation not correlation.

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  • As a mother whose child killed himself 15 days after being prescribed a drug that both the manufacturer and my government have admitted is the most likely cause of his suicide, I of course agree with you totally. I am now told that the prozac he was given is close in chemical composition to methamphetamine.

    Had my son taken a street drug he would have known he was taking a risk. Because it was a prescribed ‘medicine’ he did not. The drug didn’t behave differently because it was handed out by someone in a white coat rather than a jacket with a gang patch.

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  • Lol! You should know that Leonie Fennell and I are working towards getting an audience with the Pope. Yes seriously. If it is a sin to usurp God’s role by killing yourself, is it not also a sin to usurp God’s role by playing with the chemicals in God’s greatest creation – the human brain? We want to ask Pope Francis about the churches position on this.

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  • Any system which has a basis in the notion that normal human distress renders someone defective and practices the commercialisation of a cure for being human (often fatally) has, in my opinion, no hope of being fixed and should be scrapped. There are good, evidence based alternatives located within families and communities rather than clinics and research facilities. Psychiatry is to medicine what orphanages are to families.

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  • Oh I’m nowhere near past the anger believe me. I’m absolutely white-hot furious. I guess doing the hunour thing helps me redress the power imbalance dynamic a little. These people take themselves so incredibly seriously and I don’t think my anger touches them at all but my sarcasm may. Humiliation and not being seen as gods are things they are afraid of. Anger they just pathologise. My son was a specialist in sarcasm and I think he would appreciate me fighting back that way.

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  • We have a scheme in NZ known as Accident Compensation, administered by the Accident Compensation Corporation (ACC). It provides for compensation from the government in the event of injury or accident including ‘treatment injury.’ It was designed to make sure we didn’t have to wait years to get to compensation as a result of delays in the Court system. It provides a statuory bar on suing doctors.

    The problem is that while the bar applies to families bereaved by suicide, the compensation does not. The best lawyers in the country have told me that despite Toran having died from a treatment injury (on the balance of probabilities) i cannot take a case against his doctor, nor can I get compensation on his behalf from ACC.

    In relation to compensation for my suffering, the Act only covers physical injury, not mental injury. Which is why I have a letter from ACC adivisng that if I suffered a strain or sprain injury taking Toran down from the noose, I am covered but if it is ‘just’ the mental trauma of finding him dead, the Act does not apply.

    With admissions from the government and Mylan that the drug was the probable cause of Toran’s suicide, I suspect I would be a wealthy woman in the States – particularly as there are no black box warnings here nor patient information leaflets. But in NZ I am left without income or compensation and thrown on the scrapheap, particularly as I don’t have any other children.

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  • I know. How creepy is it that Brendel lists all the information that might be gathered on patients and THEN says ‘and clinically significant information such as suicide plans.’ A total admission that the bulk of information being gathered has no clinical significance and is pure invasion of privacy. I hate the attempt to legitimise it by giving it a name and acronym.

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  • Yep was sectioned twice after Toran died. Found to have no mental disorder both times but that didn’t stop them from locking me up and trying to ‘treat’ my grief. Toran’s suicide was all over the papers and on TV and I was saying in interviews the drug killed him and being sectioned may have been an attempt to undermine my credibility. Would be nicer to think they were genuinely concerned that I may kill myself but sending me home to an empty house with enough drugs to do the job doesn’t seem like very good suicide prevention.

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  • Thanks Richard. In my life, if you don’t laugh you’re going to do a whole lot of crying and using sarcasm helps me laugh at things I’m sick of crying over. As for being thought provoking, I’m still trying to make sense of the world following my son’s suicide and I’m not at the point of having the right answers just hoping to ask some of the right (or at least interesting)questions.

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  • He did Ted, he was pretty mean to me but in retrospect I think it was a good thing that he and I didn’t trust each other. If he’d been kind and respectful to me I probably would have done anything he wanted including taking the mix of TCAs,Benzos and Hypnotics he recommended and a lot of unhelpful stuff around severing attachment to my son. I’m glad that because I didn’t like him or trust him my default position was to be wary of his recommendations and look for flaws in his proposals.

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  • It feels very counter-intuitive to me to be suggesting that warm, respectful, collaborative relationships can be harmful but I guess what I’m trying to say is that when we keep our distance and wait to see whether the therapist is competent not just nice, we keep ourselves a little safer than if we trust too much, too quickly and run the risk of trying to please and being less able to critically assess treatment plans, approaches etc. Sometimes I think the emphasis on therapeutic relationships can be a bit like falling in love with someone totally unsuitable but being blind to their faults or incompatibility.

    Really just saying I found this hard to write to and am not sure I’m convinced but thought it was a useful discussion to have.

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  • As a CEO Maria, I know the buck stops with me. I am of course aware that as Mylan’s counsel, you provided Mr Price with advice that guided his treatment of me but as with any legal advice, he could have chosen to reject rather than accept it. That was his choice. Just as it is his choice to lead a company that acts unethically. CEOs do far more than conform with company standards and policy – they shape those standards and policies and they collect large salaries for implementing them. They are therefore accountable for their actions which can and should be challenged. As a CEO, when my behaviour and ethics are questioned, I am not at all threatened by being challenged and happy to engage in discussion around the issues. I think it would be hugely helpful if Mr Price would do the same.

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  • Thank you so much Duane. I don’t think you are over-simplifying things at all. On the contrary, I think the medicalisation of suicide has rested on convincing people that it is a hugely complex issue that can only be understood by ‘experts’ with white coats and prescription pads. Its as simple in my view as making people feel they matter. Kindness, love, respect and acceptance – cheap and effective suicide prevention.

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  • Love it and have just subscribed to your blog. I suspect that in proposing Prodromal Anosognosia you exhibited symptoms of Psychiatric Disrespect Disorder. It may be that your recommendation is on hold pending treatment and remission. Exciting to think our disorders could be DSM neighbours and are likely to become common comorbidities.

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  • My son killed himself 15 days after being prescribed an SSRI by a psychiatric registrar who despite conducting what he considered a thorough assessment, found no mental disorder. At inquest, he told the Coroner that when he was advised that my 17 year old had hanged himself he “couldn’t remember his name or face.” That says much about psychiatry. The fact he would say it in front of the mother of his dead ‘patient’ says just as much.

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  • Morias, I endorse two things

    1. universal awareness of the risks of SSRIs
    2. fully informed consent to their use

    I am far more interested in these things than I am in whether Sundance’s test works or not.

    I will take any opportunity to raise awareness of risk and promote fully informed consent to as broad an audience as possible. Those who dismiss Toran’s story as anecdotal or as an idiosyncratic response and CASPER as an anti-psychiatry lobby group may be less quick to dismiss the science discussed in this discussion.

    To sit back and wait for anything, including the success of Sundance, condemns more children like Toran to a horrible, lonely, painful death so waiting is not an option for me.

    I am not endorsing Sundance, I am endorsing science and business recognising the harms of these drugs and working to reduce those harms. It makes a nice change from science and business promoting their use and denying they cause harm.

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  • Thanks Kim and Sam. The last couple of days, and yesterday in particular have been difficult to say the least. My heart is broken. I yearn for my son with an intensity I can’t describe. I spent most of the day in bed yesterday, unable to face the world which without Toran feels so lonely and empty. Today I was out doing a suicide prevention education session in his memory. So…I have missed this exchange and having read it quickly now, need to read it again before I can make any sensible response. But not tonight. Tonight I am going to do absolutely nothing πŸ™‚

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  • Thanks Rachel, wise advice and I appreciate it. I understand sundance have been in contact with David Healy and are hoping to engage him in reviewing the data. I am hoping they can make this happen. Those of us who are cautiously optimistic about this research have also talked to David who I believe supports the idea of testing for adverse reactions (rather than testing for therapeutic response)as does Dr Dee Mangin who we at CASPER also work with. Their professional opinions are ones we respect completely and whose views will influence our own.

    I have discussed with Sundance providing my son’s post mortem blood sample for this project and would not do so without fully exploring all the issues you raise and obtaining clear written agreements around data transparency and independent review. I would be devastated if Toran’s DNA was used to perpetrate any fraud or harm.

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  • I hope the comment from Sundance diagnostics, posted elsewhere and copied here, explains the initial focus on SSRIs

    “The reason to start the project with SSRI’s is a scientific one. It is imperative that the first whole genome sequencing study for heightened drug risk is successful. If the science is questionable, studies for genetic prediction of drug risk with other drugs will be hampered. The critical need in this type of study is to find exceptionally well diagnosed patients with extensive and complete medical records. With such, we can defend the results of our research. Well diagnosed patients with complete medical records are much easier to obtain for suicidal ideation than for any other drug side effect at the moment. That is why we are starting with the risk of suicidal ideation. We have the DNA prepared and ready to sequence for the first SSRI we will study. The cost of the study and the confirmatory trial will be anywhere from $12 to 20 Million. With success we will move to the next drug. Predictive genetic markers may be consistent througout all drugs in the SSRI class. If we find that to be true, our research with SSRI’s may go much more quickly and we can move on then to other drugs.

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  • I run a suicide prevention organisation Belinda and am certainly not under the illusion that everyone who kills themselves is taking an SSRI.

    Sundance has been very clear to say that regardless of the risk rating returned by their test, these drugs carry a risk of suicide for everyone who uses them. Here’s a link to an interview with the test developer if you want to see what they are saying publicly http://fiddaman.blogspot.co.nz/2013/03/antidepressant-suicide-gene-solution.html.

    I think you will find that your statement that “This company is doing this, because they believe totally that these drugs save lives and that we need to actively promote and encourage their use” is completely incorrect. If that were the case, they would be developing a test showing genetic markers for therapeutic response, not suicide risk.

    Currently available DNA testing would not show that “99% of people will not be adversely affected” so I’m not sure why you would think that this test would lower, rather than raise the percentage of people shown to have elevated risk.

    You have every right to be skeptical about this and to challenge and question it. As I said in my blog, I had many reservations initially too. I’ve been fortunate to have months of being able to ask them questions directly and one of the reasons for blogging about this was to give other people the opportunity to do the same. As you’ve seen, Sundance CEO Kim is happy to respond.

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  • My personal strategy for educating the public about the risks (and lack of benefit) of these drugs is to share my son’s story, run free public education sessions, get in front of key opinion leaders and politicians in my country and conduct research. I believe I make a difference but I don’t believe for a minute that the average person is going to take as much notice of me as they are of their doctor. I believe that while for some people Toran’s story is compelling, the majority believe it couldn’t happen to them.

    While I do my little bit, I support everyone else who is doing their little bit too. Sundance and their test are not the key to abolishing SSRI harm. They are one part of the multi-pronged approach to this issue.

    Doctors will never tell their patients my son’s story but they will give them test results that include information that clearly states the drugs carry a risk of suicide. And people who think that what happened to all the suicide victims couldn’t happen to them will see their own personalised results and realise that it could.

    Yes there are risks associated with this process but there are risks in not implementing new strategies too. Antidepressant prescriptions are increasing by 10% per annum in my country. We have the highest rate of youth suicide in the english speaking world. I think we have to be pragmatic as well as principled and for me, saving lives will always have priority over winning against pharma.

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  • One of the things I like about Sundance’s approach is that they don’t pussyfoot around suicide and violence with medical terminology. They name these drug reactions for what they are rather than talking about suicidal ideation or agitated depression they just say these drugs cause suicide and violence.

    Personally I’m glad a corporation is fronting up with some money to confront the reality of what these drugs do to people. Its criminal that individual activists, many of whom have been financially devastated by their experience of psych drugs, sell their homes and assets and work for nothing to mount this challenge.

    Why spend more money on something no better than a sugar pill? That’s a question for Regulators who in my country fund 16 different antidepressants, none of which work, all of which cause harm.

    Why spend money raising awareness of the dangers of these drugs? Because people will continue to use them until they understand there are safe, effective alternatives and continue to be harmed.

    Personally I hope Sundance spend a fortune on this and more importantly make a fortune on it. Because then they will develop tests around antidepressant withdrawal and drug use in pregnancy and in specific ethnic groups being targeted by pharma and a heap of other areas that need exposing.

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  • I agree John. In New Zealand, Heroin was a very widely prescribed treatment for a range of illnesses in the 1950s and a recent report from our Law Commission recounted the fact that despite a growing body of evidence the drug was harmful and addictive, the medical profession refused to accept that its risks outweighed its benefits.

    Clearly that situation changed and Heroin became an illegal drug whose harm is now not disputed.

    What will it take for the same to happen with SSRIs, antipsychotics and other drugs that cause serious harm? What would we need to do to make regulators and prescribers stop endorsing these drugs and patients stop requesting them?

    Would an advertisment for a suicidality test that played alongside advertisements telling people to ask their doctor if Effexor is right for them, make a difference?

    Would people who say “I would never be stupid enough to kill myself” pause if they saw DNA results showing they have a genetic profile that makes them susecptible to suicidality on the drugs?

    If science is the new religion – the thing everyone now has faith in – how could the science of genetics contribute to a new set of beliefs around the wisdom of messing with the brain?

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  • Thanks Neil. I agree this is a discussion / debate we need to be having and cannot think of anyone who is better qualified to comment than you. In my view, lived experience of the drug-induced suicide of a child and the committal of all ones waking hours researching its etiology, combine to produce people who bring the perfect combination of pragmatism, vision and knowledge to suicide prevention.

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  • Thanks for your comments everyone. In my view, the market for antidepressants is, as with all economic transactions, a matter of supply and demand.

    Many of the people I work with who want, like me, to see antidepressants off the market, focus on restricting supply. They do this by advocating for greater regulation and attempting to undermine supply by challenging pharmaceutical companies through the legal system or other avenues. This is important work and I’m involved in it too.

    My key focus however has always been firmly on the demand side of the equation. Like any other product, if demand reduces or stops then there is no profit in the product and suppliers will stop producing it.

    In my view, the value of this test is primarily in the impact it could have on demand. Its easy for those of us who work in this field to forget that the vast majority of people prescribed these drugs have no idea they can cause suicide, homicide, mania, psychosis etc. Particularly in my country where there are no Black Box Warnings, no patient information leaflets – and informed consent is a joke.

    Taking an antidepressant in NZ is seen as no more risky than drinking cola. Not necessarily good for you, but not life threatening and certainly less harmful than the scaremongers like Maria Bradshaw would have people believe. Everyone knows someone on Prozac and they are just fine.

    Imagine if there was a major advertising campaign that told people Cola can kill you. If there was a warning on every bottle. If you had to show evidence you were over 18 and to be tested for diabetes before buying it. Might you reach for a bottle of water instead? Might you hesitate before giving it to your children? Might Coca Cola take enough of a hit that they could not justify continuing to produce the product to their shareholders?

    I think this test has the ability to ensure that people are informed of the risks. I think it will encourage more people to select Play Therapy rather than drugs for their child. I think at the very least, it will make mothers like me more vigilant in watching for the signs of suicidality in their kids.

    If we all stopped demanding these drugs — doctors and patients – there would be no money in supplying them. If liability ensurers required that doctors run the test before prescribing in case stroppy mothers like Maria Bradshaw dragged them through the courts, they may be forced to disclose the risks to their patients.

    Sundance have been very clear that this is a discovery project. It may not, as has been suggested, produce useful results. Equally however, the results may be not in the ability of the test to identify risk but in the impact such a test has on demand for these drugs.

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  • I agree with everything you say Belinda, which is why I think this test is a good thing. Doctors cannot be trusted to care about patient safety before profit but they sure as hell care about managing legal and business risks because these go to the heart of profitability.

    One of the key’s to this test is to ensure the public are aware it is available and demand their doctor provides access to it. This serves two purposes. The first is that patients become far more aware that these drugs are clinically proven to cause suicide, the second is that doctors risk legal action and/or decreases in business if they prescribe without conducting the test first.

    Just as no one would accept a blood transfusion without some proof it was necessary and that the blood type being matched, and no doctor would fail to provide this information without being asked, I think if the public are aware of this test it will become the standard of care and we won’t be relying on doctors to do the right thing.

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  • Thanks for your thoughts John. My focus will always be on giving people information on the dangers and falsehoods behind the practices of labelling and medicating people in distress. Some people however will always think this information doesn’t relate to them. My son for example would have (and did) say he would never kill himself even when he heard me discuss the clinical trial information with his doctor.

    Perhaps though if they had a test result showing their personal level of risk and information on how these drugs can induce suicide in people, they may realise they could be affected and make decisions either not to take the prescription or to ensure they are closely monitored by friends and family.

    In the end, I was devastated to learn of my son’s genetic risk of drug-induced suicide AFTER he died rather than before. I am angry that the people who knew these tests existed didn’t tell me and let me make a fully informed decision.

    For that reason, I don’t think it would be right for me not to let others know – while always continuing give them information on the fallacy of diagnostic labelling, the dangers of psychotropic drugs and the alternatives available to assist with emotional distress and behavioural issues.

    Again, thanks for your views which in general I agree with.

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  • Thanks so much Jonah. We don’t think for a minute we have all the answers, just that we are asking some of the right questions.

    I find nothing more frustrating that seeing the media and policy makers unquestioningly accepting the claims of biological psychiatry. Having to read constantly that “90% of those who kill themselves have a mental disorder” from opinion leaders who have not even looked at the ridiculous research behind that claim, drives me mad.

    Its interesting that in NZ,a very small percentage of those who kill themselves have been diagnosed with a mental disorder and the government’s own research shows a direct causal link between increased prescribing of antidepressants and increases in hospitalisation for serious suicide attempts but that government insists mental health ‘treatment’ is the answer to suicide prevention.

    Thanks again for your kind words.

    Maria

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  • Thanks Steve. I so agree with everything you say and only wish that what seems so obvious to us – work on those things amenable to the most change – was obvious to those who have set themselves up as the experts in suicide prevention. Changing brain chemistry might be lucrative but it is also lunacy!

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  • Thanks Steve. We find our diagrams give families and communities a place to start when they are identifying things they can do to keep their members safe. Rather than being told to look out for depression and focusing on ‘fixing’ a person, they look at the environment and work on altering things that are giving rise to emotional distress. This gives people a set of concrete actions and a sense of control.

    Definitely not popular with our Ministry of Health or mental health professionals although we are working with some sympathetic psychiatrists at the moment and have the support of some mental health professionals who see the lack of results with the current approach.

    In the end, Toran didn’t leave me with the job of being popular so I don’t let it bother me too much.

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  • So sorry this happened to you and your son Alix. Hope your son is doing ok now. You can always contact us through our website or on [email protected] if you need any support or information of just someone to listen. We have families in countries other than NZ who can provide support too.

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  • I know! Discussions of ‘proximal’ and ‘distal’ factors, Axis 1 diagnoses and all the rest only serve to disempower families and communities and make them feel out of their depth. Interesting that a few decades ago when children being sad or scared or worried was seen as something to be addressed by families, our youth suicide rates were pretty low.

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  • Thank you. Many of the families we work with have said they do not believe their child would be alive today if it wasn’t for the support and information we provided. I just wish Toran was one of the ones who had survived.

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  • Thank you. Toran is my only child and along with grieving for him, I grieve the loss of day to day motherhood. The reality is that you don’t stop loving your child when they die, or wanting the best for them and giving him a legacy in suicide prevention is how I continue to be his mum. I’d much rather be giving him an ipad this Christmas, but a causality assessment that might effect change and save other children from suicide is something. Believe me, if you think your relatives are hard to buy for, dead children are nearly impossible πŸ™‚

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  • Thank you for your support and kindness. I am unable to file a complaint against the psychiatric registrar because in New Zealand all complaints are referred to the Health & Disability Commissioner who is the only person who can forward them to the Medical Council. The H&D Commissioner has refused to even investigate my complaint about Toran’s doctor let alone refer it to the Medical Council. I cannot think of another profession where clients cannot file complaints directly with a professional body.

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  • Thank you Alice. I agree that people do not wake up in the morning intending to do harm to their customers but that the responsibility they have to achieve maximum revenues for their shareholders often blinds them to ethical issues. I’m a business major and as I pointed out above, ethical practice is currently highly profitable. Any drug company that positioned itself as the ethical pharmaceutical provider would be alone in that market niche and would do well financially. Its a shame that neither Mylan nor any of the others are prepared to deviate from traditional positioning and pitch for the segment of the market that demands ethical products. If they looked at the fair trade / sustainable / socially responsible positioning of corporates in other sectors and the increased revenues they have achieved since branding themselves as ethical, they would see that there does not need to be a trade off between social responsibility and profit. As an MBA and the mother of a child killed by psychiatric drugs, I would have liked to have worked with Mylan on making that part of Toran’s legacy.

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  • I agree totally that responsibility for managing the safety of citizens where commercial enterprises are selling potentially harmful products, rests with governments. The failure of regulators has been my key focus rather than the behaviour of pharmaceutical companies over the years. I do think however that all commercial enterprises have a responsiblity as corporate citizens to make their money in ways that are socially responsible. Many businesses have shown in recent years how profitable ethical business practices can be. I hoped Mylan might work with me to brand themselves as an ethical company and develop a real competitive advantage doing so. Given Mylan is one of the biggest suppliers of drugs to the NZ government and most New Zealand families have Mylan products in their homes, their refusal to do so is something I believe New Zealanders need to know about.

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  • Thanks everyone. Just want to point out that in New Zealand, there is no black box warning on SSRIs nor is there a patient information leaflet in the box which advises of risks and possible adverse reactions. The only thing my son and I were given was a pamphlet written by a psychiatrist which advised that SSRIs reduce suicide risk. This pamphlet was withdrawn by our Ministry of Health on the basis it was ‘outdated, inaccurate and misleading after I filed a complaint about it after my son died. When I raised concerns about the drug with my son’s doctor, I was correctly advised that under NZ Law I had no say in his medical treatment as he was over the age of 16. His colleague who was present during the discussion testified under oath at the inquest that the doctor did not advise me of any side effects and that when I tried to discuss them, and asked for an alternative treatment plan, the doctor was “authoritarian and aggressive” towards both me and my son.

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  • Thanks for sharing your opinion Anonymous. The University contracted by my government to conduct causality assessments, determined that the most likely cause of my son’s suicide was the SSRI he was prescribed 15 days before he killed himself. The assessment was based on the fact that a psychiatric assessment on the day he was prescribed showed he had no mental disorder and there was no other plausible reason for his suicide. On this basis, and despite your not agreeing with it, I will continue to describe my son’s suicide as SSRI induced.

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  • Thanks Glenn. That psychiatry would attempt to make a patient of me as a result of the harm they caused my child and I feels like another form of abuse. They do not get to determine what ‘normal’ is for me or any other family who have suffered the trauma of a child’s suicide. Or at least they don’t get to do it unchallenged while I’m around. Our families could paper our walls with the pamphlets we get from agencies telling us its ok to grieve however we need to, when the reality is that if we don’t grieve in the prescribed manner, we are labelled mad and sometimes detained for compulsory treatment. Psychiatry has taken enough from me – it can keep its hands off my grief.

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  • Actually, what parents tell me about infant mental health is a graphic illustration of the gap between theory and practice. While the theory sounds fine, the reality is that parents experience being assessed as over-involved, uninvolved, hostile, abusive etc as deficit not strengths based and their involvement with your profession leaves them feeling wrong and incompetent.If you doubt that psychiatrists feel comfortable with prescribing to young children I suggest that you google Professor John Werry. Apparently Prof Werry is NZ’s leading child and adolescent psychiatrist. He regularly prescribes to children under two on the basis that it makes life easier for their parents. He is on record as saying he has no problem with prescribing antidepressants to babies as “there is no evidence they cause harm in babies.” I doubt any clinical trials have been conducted which show the harmful effects on babies of ingesting gasoline. That doesn’t mean its not harmful. Perhaps you should also take a look at the evaluations parent-child relationship building programmes promoted by IMH in New Zealand. You may be surprised to find that 100% of the children involved were on Ritalin. You ask if I would be angry at the mental health field had my son not died. Let me tell you, that I am less angry with the field than disgusted by it. Lack of integrity is something for which I have a huge distaste and something which characterises psychiatry. I have yet to meet a psychiatrist who does not accept that subjective diagnostic labelling can be harmful and that psychiatric drugs pose a risk of suicide and yet who continues to justify their practice. The gap between rhetoric and practice in psychiatry is vast. Emotional well-being in infants is important and psychiatry does nothing to enhance it. Mothers who are sad, scared, angry or traumatised are not mentally ill. They do not need your endless checklists, harmful labels and potentially fatal drugs. They do not need to be told by you how inadequate they are. They need support, practical assistance and a sense of self-efficacy. Psychiatry provides none of these – in fact it provides the opposite. Support for the emotional health and high-level functioning of parents and infants has traditionally been the province of families and communities and that is where it needs to be returned. Psychiatry is now, as it has been throughout its history, a collection of unscientific, experimental and harmful interventions which serve no one but those who deliver them. I have no hope that psychiatrists and their partners in the mental health system will stay away from our babies and children but hope that in time, parents will recognise that one of the best things they can do to support their children’s well-being is to stay away from psychiatry.

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  • Recent research undertaken by the Mental Health Foundation in New Zealand found that the practice of diagnostic labelling is association with first onset suicidal thinking and behaviour. Research subjects explained that before being given a label, they saw themselves as people struggling to function as a result of a variety of circumstances. Once given a label however they felt sub-human, isolated and defective. This led to thoughts of suicide.

    However you dress it up, labelling people is harmful and as a doctor, doing harm should be something that is avoided at all costs. Perhaps those of you who use the DSM should conduct an experiment and advise your child’s school, friends and sports coaches that they are schizophrenic, bi-polar or psychotic…then watch the impact on your child. Perhaps that would give you some insight into the real consequences of what you conceptualise as an academic debate.

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  • Its hard to understand why someone who asserts that “Cannabis, alcohol, and other drugs can be destructive to a person’s well being” and encourages abstinence from those drugs, would prescribe others just as harmful. Given the history of the medical profession in prescribing Heroin, Cocaine and other now illegal drugs, I am genuinely interested in the thinking behind the distinctions you draw.

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