Genius and Psychosis

Thanks to very fine teachers I used my time in training on call studying the long history of psychiatry.  I read the original works of Jung and Freud , Reich, Adler, and later Frankl, Menninger, Erickson.  It was in their personal writings that so many of the most profound insights were recorded. I love R. D. Laing living with Schizophrenics and the original community projects and other experiments that clarified modern ideas of mental illness.

 Today too much emphasis is placed on the ‘evidence based’ scientific study since it’s inherent limitations are the money and selection of the research that such studies so commonly are designed for.  Clearly the Grant Study like the Framingham study, prospective studies with profound insight are a step above so many others.

I liked the original observers who questioned matters like ‘secondary gain’ and considered the ‘advantages of insaneity’ and why it persisted.  What ‘value’ did these states have.  The disease model has been so fixed on eradication without consideration of the benefits.  The studies of distribution and the genetic studies of the turn of the century showing a crazy aunt or uncle in the attic of all the greatest of the New England seaboard were that kind of insight.

I liked the the studies which showed the relationship of genius to Schizoprehnia.  What was the difference between the grandiose idea of the manic depressive and the grandiose idea of the great creator, statesman or artists. 

Today there’s a beurocratic emphasis on the median and mediocrity whereas that was not always the case.  I fear that the end of the world is more likely to follow such stultifying reductionism than it is to any cataclysmic world event.  There’s a wearing tedium to this safe thinking and safe behaviour and emphasis on safety that has been shown associated with the fall of great eampiers and not associated with the greatest breakthroughs. Science is the world of wonder and daring whereas too often the politics of today is based on fear rather than belief. 

In my own work with geniuses and with schizophrenics and manic depressives I’ve I saw  that often the only real distinction was in the outcome of the ideas as opposed to the variation. Both the ideas of a mad man and the ideas of a genius are equally frightening and alien. This explains the common concept of ‘awe’ before encounters with God.  It is difficult to maintain an open mind and more easy to take the safer route of being closed minded.

Yet to the mediocre genius is wholly alien.  

Now having met folk who feel that eating their neighbours would be a great idea there’s limits to one’s open mindedness especially if one is the close most proximal neighbour to this ideology.  Yet that’s less a concern than the tendency to reduce the possible to the limits of the mediocre especially where there is fear and frank cowardice.  

Every day we live with miracles that would have had us shot, locked up or burnt at the stake were it not for risk taking and open mindedness.  I thinkit’s  important to embrace genius and also to have the humility to recognize that genius is commonly so much beyond the scale of one’s own conception. It’s childlike in wonder.  It’s birthplace is curiosity and I would add love.  

I truly am thankful to have had the privilege to have known genius, rare and wonderful and struggling to relate in a world where they are not the masses. To the majority, their genius was not so much as blessing as a curse.  

Schizophrenic man beheads innoscent man on bus

A man on a bus beheaded his fellow passenger.  The witnesesses say they still suffer the trauma of seeing this.  No doubt the headless man, had a problem with his own fate.
Now the court decided in Canada that the man who did the beheading was schizoprhenic. After a few years of being in custody he was allowed to go to a group home where the fellows says he is planning on changing his name.

My concern as a psychiatrist who has treated violent schizophrenics in the United States and Canada is whether or not the man will be required to remain on injectable medication.  The 'non compliance with medical regimen' runs up to 80% with schizophrenics.  I was in charge of a dangerously insane ward in a provincial asylum.  One day my patients would hear a command hallucination, "kill " and it was no different than I might hear myself say, 'go outside'.  The trouble is that a schizophrenic hearing such a command hallucination may well follow the internal or externally perceived 'advice'.

One of the principle problems I have had treating schizophrenic patients is the commonly misperception that "if I stop my medication my disease will go away".  Non adherence to medical regimen occurs roughly 30% of the time for most people with medications at some time. We can forget a pill or taken three in stead of 4 or stop our antibiotics on day 7 instead of 10 or 14 'because we're feeling better" .  The schizophrenic patient on medications 'feels normal' and on medication those around him after a while think he is normal.  However without the medication the psychosis returns usually in weeks or months.

One dangerously insane patient I remember well stopped taking his medications having chopped off someone's arm with a machete and was then seen a while later wandering about with a machete all set to do it again.  Outreach mental health nurses are a good send in the world of psychiatry.  With a nurse I went out and brought this fellow in with the help of the police assistance.  So often police are required in such cases and often as we've seen in the news these are the cases where the police  are attacked by a sad sick tragic schizophrenic man who off his medication will and do kill policemen believing they're aliens from another planet.

Now I've weighed in on this discussion simply because in the articles that I've perused in the papers I've not seen that the man will be mandated to be on injectable antipsychotic medication for life.  Injectable medications are given monthly and are more effective than pills generally. The critical matter is that if a patient doesn't show up for his intramuscular injection we know t hat the patient is at increasing risk for psychosis and can alert the police.  There's no 'mouthing' of medication or 'spitting out' or 'throwing up later' with injectable medications.  It's done.

In all enlightened forensic settings this is the standard.  I agree that schizophrenics who have been violent don't need to be incarcerated.  However, when a person has killed another human being, especially in such a heinous way,   the risk of another psychotic episode is too great to trust to anything but injectable medications.   I have been happy following schizophrenic patients on injectable antipsyhotic medications and felt that individual and community are safe. However, too often I've been faced with non compliant schizophrenic patients who have not been taking their oral medications and many times I've been faced with near catastrophic consequences.  It's difficult enough to "find" schizophrenic patients who "escape' between injections given every 2 to 4 weeks.  I've had to "return' a dangerous Toronto schizophrenic patient from Vancouver where they escaped to.  Fortunately no one was hurt.

And the vast majority of schizophrenic patients are the least likely to be violent.  Further on medications the vast majority of schizophrenics are safe in the community. Very very few need to be in psychiatric asylums. However I now work in the DTES where I see schizophrenics with histories of violence on crystal meth or crack cocaine, or drinking. all of which counteracts medications and increases risk of violence. If they are on injectable antipsychotic medications even abusing drugs is unlikely to cause a recurrence of violence. Off anti psychotics 'street drugs' exponentially increase the risk of further offences.

The Injectable anti psychotics today are highly superior in patient tolerance than the old medications of the 'One Flew Over the Cuckoo Nest " era.  No longer do patients do the "Thorazine Shuffle" or feel like they are in the Haloperidol 'chemical straight jacket.'  While some patients liked Haldol, even, with the introduction of Flupenthixol there was a breakthrough in well tolerated medications. Today my patients tell me how much they like the Paliperidone Intramuscular monthly mediation and the Long Acting Abilify and even the every 2 week Long Acting Rispiridone.  The safety to the individual and the community is central.  I hope for this man's sake and for others as well that he will be on an Injectable Antipsychotic for life.  Otherwise, frankly, knowing what I do about the disease and violence, I won't be taking buses anytime soon.

Marijuana and Youth

Marijuana and Youth

-Dr Shimi Kang

This was a lecture at the Canadian Society of Addiction Medicine Conference in Vancouver Sept. 26, 2013.  Dr. Shimi Kang is on staff at UBC Women’s Hospital and with the Department of Addiction Psychiatry UBC.  She is a truly brilliant speaker, and astute clinician whose presentation was one of the best I ‘ve ever head on a subject I’m very familiar with.  I have copied my rough notes here though would strongly recommend for anyone who ever has the opportunity to hear her, to take advantage of this, as she is one of the very best speakers for combining scientific and academic information with clinical experience.  I apologize for the notes that really don't do justice to this splendid presentation. However I believe that by uploading these notes it will perhaps help someone find the right direction to look.  Dr. Kang has a book coming out as well and it certainly will be worth looking for and reading.  

Learning objectives

• incidence in youth
• risk factors

Are you a tiger, dolphin or jellyfish?

When we look at therapists we see

• distinct results 
• engagement
• success

Average doctor patient 

-70% doctor

Listening more is good

Non judgemental

I give information to adolescents all the time but in the end I always tell them it’s your 

Empathy is the biggest thing for success

Standing in their shoes and walking in their shoes

Saying “i can tell marijuana serves in your life but....”

3 qualities

genuineness --I don’t say anything I don’t believe in with adolescence -

empathy 

kindness

Tiger therapist - I am the authority, I’ve recommendations

Jellyfish therapist - going with flow, very kind and empathic and rapport but they don’t use this for any goal - we all know these - patients say I saw this counsellor three yeas and she was very nice - but when I ask her did your substance change - and she says no

We don’t want to be tiger or jellyfish

We want to be a dolphin - highly intelligent, collaborative - working with young people, collaborative - playful, going side by side - creative - great communicators - adaptable - not a tiger pushing and not a jellyfish - 

Favourite teacher

Attributes and Affect

nonjudgemental

Challenge patient

Even if they’re forced to come to us - we allign them to move forward - everyone wants to move forward in their life

Marijuana

• life magazine -1950 on cover

• time magazine - 2013 - still on cover

50 years later same questions being asked, big topic

15 -24 -3x risk

average age 15

in BC its lower age of starting 

Michael Phelps - “What a Dope?”  I always use him as comorbidity - 13 times Olympic goald medal winner with cannabis pipe

When I started psychiatry years ago and we asked do you drugs - now I ask specifically - marijuana use - if you ask drugs -they don’t answer - it’s pervasive

THC content and potency

-it’s increased over 30 years

NIDA  Marijuana Abuse (2010)

Saw father of adolescent and he said he didn’t think his son’s smoking marijuana is a problem because he used marijuana every day through law school - however his son was 16 and the potency was greater than a man at 23.  As we’re seeing younger and younger we’re seeing greater problems  - we shouldn’t call it the same drug - we don’t call heroin - poppy - even though marijuana is very different drug we call it the same drug - what you son is using is a very differrent drug than what it was in the 60’s.  

the more potent for THC the less neuroprotective drug in the cannabinoid.

Also I said that the life style was different - different situations from the 60’s - the son wasn’t sleeping and had had head injuries from hockey and 

Brain impact from marijuana

• Marijuana Effects 
• CBR - Cannabinoid receptors - naturally in the brain - high densities are found in areas that influence pleasure, memory, thinking, concentration, movement, coordination and sensory and time
• NIDA Marijuana ABuse 2010

THC stimulates CBR - overstimulation - disruption of natural or endogenous cannabinoids - ‘marijuana - ‘high’

They say I’m not depressed and not anxious - but I tell them they are ‘high’ and that they wouldn’t be anxious or depressed with being drunk but they’d recognise that they were ‘drunk’.

High - heightened perception, altered perception of time and increased appetite

disrupts co ordination 

-psychosis - 

effects on general health - heart rate speeds up

when they say they feel anxious without pot - I ask how long since they were off marijuana for 2 weeks - there is a withdrawal phase - so I explain the withdrawal and cycle and explain that we really don’t know until we have a period of time to see

Medical marijuana - scientists confirmed cannabis plants contain active ingredients with therapeutic potential for relieving pain, controlling nausea, stimulating appetite and decreasing ocular pressure

NIDA 2010

Heath Canada grants accept to marijuana for medical use to those who are suffering from grave and debilitating illnesses

-documentary WEED 

-young people saw this and come with the argument and there was real disconnect in this documentary, what it was saying and who it was saying about

Csnnabis and Schizophrenia

• Longitudinal studes in 5 countries strong evidence of causal link
• researchers established drug abuse lead to double rate in adolescents in hospitalization for sx
• metal analysis McLaren et al 2010 causal link

--temporal link can not be connected

Prodromal patients

• genetic marker - at risk
• Haroun t al 2006
• Kristensen & 2006

Pre-existing vulnerability

• family history of psychosis
• have you had hallucinations using pot - risk - not everyone who experiences psychosis when they use coke or pot - then ask how long after you used did the psychosis - if longer days or weeks - then it sounds like your brain is having trouble recovering from the hit you gave it
• head injury - I use analogy of head injury - mohammed alli - boxer dementia - his condition didn’t come from a single knockout - culmination of multiple hits - everytime we experience psychosis when high - this works
• Stefanis et al 2004 
• Downside of High-CBC Documentary

I tell young people to look at this documentary on You Tube

Marijuana, Memory, Amotivation

-amotivational syndrome is real - we see it all the time - 28 year old guy playing video games in parents basement

associations with marijuana use and depression, anxiety, suicidal thoughts, among adolescences and personality disturbances

• told parents to be hypocrites- be parent not the friend - don’t get caught in that - don’t tell them you smoked pot - 

Cannabis and MVA

• clear evidence that cannabis like alcohohl impairs psychomotor skills required for safe driving
• moderate doses cannabise impaires automated tasks but leave complex function
• drives at increased risk of crashin
• lower reaction

Should marijuana be legalized? 

WHO _ Biggest public health disaster of all time was the legalization of tobacco - director general

When alcohol prohibition was in the states - all health indicators improved though in a different system - crime went up but from health basis - much improved

Cons to Legalization

• cannabis use is harmful to adolescents especially with early or frequent use

• Implications
• marijuania more prevalent among patients with psychaitric disorders

increase schizophrenia and chronic psychosis

One tool - cycle of drug use - 1 abstience - experimentation - recreation use - habitual use - abuse - dependence 

I show this to adolescents 

When I ask adolescents where they are they are usually not that far off telling me where they are in the cycle - then I ask ‘wouldn’t it be great if you could go back ‘ then show them how especially to the very resistant

In psychiatry we say you shouldn’t self disclose but I find that self disclosure helps and I saw myself doing this when I was a mother that I was self disclosing so I developped a different view .  But if I’m working with a person and I’m not using a ‘recovery’ model I can say that I’m not talking about  but rather I’m talking about coping methods so I don’t only have to speak from experience and be helpful

Asked re harm reduction and marijuana - don’t see any benefit for ‘smoked’ marijuana - 

Discussion of other agents - sativex, cesamet and newer pharmaceuticals that are superior to ‘medical marijuana’ and recommendation that doctors specify that there is no ‘medical’ benefit to ‘smoked’ so indicated only for use as ‘tea’.

Psychosis

Psychosis is the state of being out of touch with reality.  Reality is an aggreement a society shares about the world we live in physically and socially.  For example, gravity is a concept of reality.  It is not uncommon for psychotic individuals to believe that the laws of gravity and other 'scientific realities' do not apply to them.  Hence a person may believe they can fly and jump off a building to their death.  This is an extreme form of psychosis.
At lesser levels of psychosis a person may believe that they are above the laws of society.  Such an individual may say the 'police can not arrest me' for any number of legal infringements such as having sex with children or assaulting women or threatening prime ministers.  These individuals truly believe they are 'immune' to such legislation and act with persistent astonishment throughout the police arrest and even during trials, often only coming to a real sense of reality when they are locked up for sometime in prison.  This individual may however may appear 'normal' in all other aspects of their life, whereas a more severe psychotic individual would have a lesser grasp on aspects of day to day living and be noted as odd often even by strangers.
When I was a member of the organization "Psychiatrists Against Political Abuse of Psychiatry" our principal concern at the time was totalitaran regimes like Russia then and China now which would accuse anyone who disagreed politically with being psychotic. Then they would lock  these indivduals, often world reknown scientists, up in asylums denying them all manner of human rights by claiming they were 'sick' and 'mentally ill'. While these kind of abuses occurred regularly internationally with psychiatrists voluntarily or sometimes involuntarily being part of the abuses I only witnessed such abuse extremely rarely in Canada.
When I was a member of the "Canadian Civil Rights Association" I was more often concerned about abuses against mentally ill patients.  Being psychotic can put an individual at extreme risk for abuse and exploitation by individuals and institutions  In these cases the rights of individuals who were ill were more likely being removed whereas it was rare for individuals to be called psychotic and treated as such by courts or state. The reason for the latter is the independence of psychiatrists generally in Canada and the legal system which requires psychiatrists often two, one for the state and one for the plaintiff when there is such a problem, to independently exam the individual.  Judges in Canada, generally being a rather reasonable and independent sort, usually make very good decisions in this regard based on the sometimes opposing presentations. Having declared probably a hundred or more individuals psychotic over the years I am pleased to say that none of my colleagues or the community at large disagreed with my diagnosis.  Individuals who felt they were superman, Jesus Christ, or had the right to having sex with their neighbours animals did take offense to my diagnosis but rarely did even family, friends or spouses. Indeed more often than not and especially in extreme cases the diagnosis of 'psychosis' is 'merciful' and helps protect an individual from themselves or others.  That said I do appreciated the patient advocacy groups such as the Canadian Mental Health Association which works as a watchdog over this process.
Psychosis can be brief or extended in time.  Brief Psychotic Episode is commonly in the range of hours or days.  Schizophreniform psychosis requires months for a diagnosis.  A typical manic psychosis untreated wiill last months.  Historically the diagnosis of schizophrenia required a year or four seasons of psychosis.  Typically these days in paranoid schizophrenia an individual will believe that their neighbours are spying on them, that car horns are being honked specifically and personally to bother them, that others can read their minds or that they can read the minds of others, that they have a special message from God or aliens to do something that in general that is not supported even by their mosque, temple or church or by the community they want to act out in.
One of the earliest and most unnerving features of psychosis interpersonally is when the other person accuses you of what they are in fact doing. Just last week I said in nearly a whisper to a manic psychotic patient, "please lower your voice, you're shouting' and their response countless decibels of volume above mine was ""I'm not shouting, you're shouting'.
This type of 'psychosis' is common when a person is emotionally challenged and their emotional range is peaked, either in anger or fear . so that they lose touch with where they leave off  and another begins.  At the extreme a schizophrenic patient whose room I entered was in utter terror and asked me to leave as I was 'stepping on his brain'.  Each of us carries a sense of self that is 'limitted' but a psychotic person might experience their sense of 'self' as 'expanded' and filling the room or encompassing others around them. This has been speculated as a regression to the infantile sense where a child doesn't separate their mother from themselves. In such a situation, and this is just one hypothesis for the well recogised phenomena of 'loss of boundaries,'  the individual who  "merges' so to speak can't separate their actions from those of others.  Hence the inability of the individual to recognise they were shouting, not I.
Locus of control refers to this the early aspects of psychosis in which the person feels that they are a 'victim' and deny that they are 'victimizing'.  They will say that they were 'made to do something' , they were 'forced to do something" as if they have no 'agency' in actions.  Later the same patient said "You're making me shout'" when we agreed they were shouting as I persisted in whispering. This locus of control and agency issue is readily apparent to trained observers and one can watch a person claim they have  no 'control' over any number of actions that community would say a person has control of. Hence the psychotic gunman would say he was not the agent of the killing of the children but rather that 'decadent west' made me kill them.
This is psychosis. It's important to note to that psychosis is common in drug abuse. It's extremely common in hallucinogens, routinely seen with cannibis consumption and extremely common with cocaine. The psychosis seen with these brain altering substances can persists months sometimes a year after a person has stopped using the brain altering substance.  It is more common to see the psychosis in such instances which is really close to the surface by watching the person when they are mildly frustrated, when they are unable to get something they feel 'entitled too'.
Just last month in my drug addiction practice I witnessed two relatively normal patients become acutely psychotic when I refused to write letters saying they were healthy and well and that I would approve of them and speak up for them having special priviledges that might put them in a position of risk to others.  In an instant they became threatening and verbally abusive and said that I was a 'devil', 'ruining their life' 'the cause of all the ill in the world' etc. It was certainly over the top, giveing me for more power, than I had and what I was suggesting was that we review their case in a week before I gave them a letter on their behalf. Given their psychotic reaction I was clearly 'right' in feeling they were not nearly as 'stable' as they insisted.  Indeed one person said they would 'hunt me down".  I think that individual wanted a bus pass so the reaction by all means seemed a tad extreme for what most people would consider 'normal' or based in 'reality'.  Not having a bus pass for a week is not reason to call a doctor the 'spawn of satan' yet that's perfectly reasonable in the reality of the psychotic individual where there is little measure outside the emotion and why this particular individual's psychosis would be further explained as 'emotioal reasoning'.  When this person is not 'frustrated' they are relatively reasonable but when they are in 'withdrawal' from cocaine everything in their world needs to have happened yesterday to be fast enough for them.
Much more can be said about psychosis. It's a 'state' that has many causes and can occur in many situations. It is seen in depression, anxiety disorders, substance abuse, thought disorders, personality disorders and post traumatic stress disorders.  There are treatments. The acute and more serious forms respond well to medications but psychological approaches can work in combination with social approaches over a much longer time frame.  Some chronic psychosis do not respond well to treatment but increasingly specialized units are being developed to deal with  these conditions where people are usually as a result of their psychosis a physical risk to themselves or others.

Mood Stabilizers

The first mood stabilizer was Lithium Carbonate. This was the treatment of choice for mood swings and remains the treatment of choice for Bipolar I, manic depressive disorder. The principle concern in use of Lithium is that it can cause kidney disease. To this end one checks Creatine and Glomerular Filtration rate before starting the medication and then again at 3 months and thereafter every 6 to 12 months.  Lithium can also cause thyroid disorder and this also needs to be assess before starting treatment and thereafter at 3 months and then every 6 to 12 months.  Lithium levels are established with safety and efficacy being in the .5 to 1.5 range depending on laboratory normals.  I give these figures here to say that if one is using the lithium predominantly for prevention then the dosage should be established where the lithium level is around .5 however if a person is acutely manic and a risk to self and others the lithium level will be established at around 1.5.  This said Lithium can also be used in the low dose range 300 to 600 mg to augment other mood disorder treatments.
Tegretol or Carbamezapine was the next medication found to be a mood stabilizer. This was used as the second line of choice in Bipolar I, manic depressive disorder.  It's also an antiseizure medication and specific therapy for temporal lobe epilepsy. Clinically I have seen it's benefit with anger management as well.  Bipolar II is a tenuated form of Bipolar I and was previously called 'cyclothymic' or 'dysthymic' disorders.  It can benefit from the use of carbamezapine especially if the 'irritability' component is outright anger.  That said it's use in Asian populations has to be considered in terms of cost/benefit because of the risk for a subset with HLA-B-1502 Allele developing fatal dematitis.  If use is considered in asian population then test for HLA-B-1502 is indicated first.  Aplastic anemia and agranulocytosis blood disorders are a risk so cbc with special attention to wbc is indicated.  The CBC should be taken before starting mediation. There are alot of serious reactions possible including hepatitis, pancreatitis, suicidality, water intoxication and arrythmias.  Therefore CBC, wbc, liver enzymes and EKG are to be considered before starting and when the patient is on the medication especially with increasing dosage.
Valproic Acid was the mood stabilizer most promoted for Bipolar II and so called 'rapid cycling' disorders.  The difficulty with these variants of bipolar is there is a lack of specificity and interrater reliability. Clinically it is also common for mood swings and complaints of them to occur in patients with addiction. When the clinician commonly fails to take an intensive alcohol and drug history or the patient is not forthcoming, the patient is at risk for having liver disease missed. There are been cases of sudden death with valproic in patients with liver disease.  Liver screening is indicated. Adverse reactions noted in Eppocrates include coma, encephalopathy, aplastic anemia in addition to the concerns that can occur with Carbamezapine.  My tendency is to not use valproic acid in the drug and alcohol populations which I treat where liver disease must be considered as most likely. That said I have seen other patients whose lives have been much benefitted from the use of valproic acid.
It should further be considered that the dosages used in psychiatric treatment are often far less than these medications have been used at for seizure disorders for which carbamezapine and valproic acid were first used for.
Gabapentin and Topamax (topiramate) are other mood stabilizers which have benefit in psychiatric disorders.  Topamax must be considered carefully as it can be associated with kidney disease and it can cause reversible with stopping the med unusual localized anaesthesias.  Topamax is often appreciated as it is also associated with weight loss.
Lamotrigine is the latest of the mood stabilizer medications and has been shown to be very beneficial in some cases.  It tends not to be a first choice but has been very robust in its efficacy further it has benefit in augmenting other therapies. It has a side effect profile similiar to valproic acid with sudden death and aseptic meningitis.  I can't say I've heard of any of these complications and my patients have benefitted as greatly from this medication as from the apparently safer carbamezapine, gabapentin and topiramate.
Oddly Dilantin, another anti seizure medication doesn't appear to have any benefit in treating mood disorders.
Clonazepam, the long acting diazepam (valium)  and lorazepam the short acting anxiety medication are interestingly 'anti seizure medications.  Given this it's not surprising that other anti seizure medications have benefit in anxiety disorder, irritability disorders and the bipolar disorders.
Increasingly atypical antipsychotic medications such as olanzepine, rispiridol, seroquel (quitiapine) and the newer abilify and zeldox have become mainstays of use for 'mood stabilization.'
There is always ongoing conflict with pharmaceutical companies and the regulating bodies around this issue of 'off label' and 'on label' usage. These latter drugs were developed at 'anti schizophrenia' drugs but as schizophrenia commonly has a major anxiety component with some schizophrenias overlapping with mood disorders clinicians naturally use these medications with complex cases and find them beneficial.  Medicine is art and science and psychiatry is very much so. The pharmaceutical companies develop medications that are profoundly beneficial for patients and the government regulatory bodies do their best to regulate their usage to reduce the risk to the population.  The politics of this are often difficult for patients who don't understand that very often a safe and very helpful medication for them specifically is politically and legally suddenly in question because of the means whereby it came to market.  Ironically if a pharmaceutical medication of proven benefit says that its good for anxiety and depression where it's only got 'on label' promotion for depression the company can be sued for millions.  I say ironically because the so called 'health food" "alternative medicines" can make no end of unproven and mostly false claims without any legal consequences.  Further much of the information that is being given to patients by pharmacists is not relevant to them as the doctor chooses a medication and dosage which is specific and considered in the light of their clinical experience.  Because of problems of the courts and the FDA more often than not the side effects given for medications are 'medical disclaimers'.  One case is a million risk is shown beside a one in 100 risk side effect without any explanation given to patients.

Ziprasidone

There has been a lot of concern recently about the 'metabolic' side effects of newer antipsychotic medications. These 'atypical' antipsychotics include the following medications, olanzepine (zyprexia), quietiapine (seroquel) , rispiridone (risperdal). They were called 'atypical's' because they worked on different receptors than the previous antipsychotics such as Chlorpromazine and Haldol.

These first line or original break through antipsychotics lead to the ability of many people to leave asylums and live independently in the community. Haldol specifically was amazing for stopping people from having auditory hallucinations. The problem with the original antipsychotics or major tranquillizers as they were also called was that they caused extra pyrimidal side effects which gave a person a 'parkinson's like' syndrome, examples being the 'thorazine shuffle', glazed eyes, muscle stiffness and tremor . Further they could lead eventually to a very unpleasant and potentially untreatable movement disorder called "tardive dyskenesia". This was most notably a restless movement of the tongue which aethetically was most unappealling There was also a sense of being controlled or somewhat restless creepy feelings for some.

It needs to be noted that the very vast majority of people had the most positive benefits from the medications. As with reporting of medication side effects in general it is only a small percentage of those who have a problem with the medication but it may be severe enough or frequent enough to warrant serious consideration. Many medications are used despite serious side effects because the disease warrants the cure. All the anti cancer drugs for instance do have serious side effects as do most of the cardiac and lung drugs. The whole idea is to balance the risk benefit and make adjustments and ameliorate the negatives while maximizing the positive benefit of the medications.

As one of many people said to me "when I didn't take my medication I was haunted by demons and so terrified I couldn't leave my room." "I couldn't talk to anyone because the voices were always interfering." "Thanks to the medication I can lead a normal life." This is what these medications achieve routinely. Peoples lives are restored and the medications that are used for mental illness have been as beneficial as the antibiotics or medications used for other diseases such as those of heart, kidneys or joints.

People too often forget the amazing progress that medications have brought for literally millions of sufferers of mental illness. Schizophrenia, schizoaffective disorders, manic depressive disorders, psychotic depressions, and borderline personality disorders all were conditions that only 50 years ago could mean a life in an asylum for those sufferers who would not be able to work or have normal relationships. These conditions were not a phenomena of the 'western world' but had been seen throughout history and had lead to horrible difficulties for so many in all the countries of the world. Roughly 1% were afflicted with these difficulties. Certainly some of those with hallucinations or delusions were having a religious experience or spiritual awakening or some situational psychologically complicated event but that was only at most a small percentage of the majority of cases who were more likely having the consequences of encephalitis, meningitis or traumatic brain injury. Increasing evidence from MRI studies shows that the most severe of these conditions have actual brain damage that may well have occurred intra uterine or as a result of a head injury or infection in childhood. It's not something that would just 'go' away on its own. It's a mental illness and not just a bad attitude or lack of will power.

Thanks to medications the asylums literally emptied. The problem today is that we need hospital beds for the mentally ill not because of the old mental illnesses but rather because of new mentall illness mostly associated with drug and alcohol abuse and traumatic brain injury and post traumatic stress disorders. Those with schizophrenia and the other severe mental illnesses are mostly able to live in the community thanks to medication but they do need respite care in hospital at times. The lack of resources often makes this otherwise treatable illness a nightmare. These individuals who once needed to be a lifetime in hospital now will have months or at most a year of their life in hospital however they still need those hospital beds for these periods of illness severity no different than people with heart disease who experience periods of angina and have mild heart attacks. The very success of the antipsychotic medications cost the mentally ill patients the government funding and hospital beds that were once always necessary.

As to the atypical medications, these were a god send to the patients collectively because they didn't have the extra parimidal side effects and didn't have the danger of tardive dyskenesia. They were pleasant to take compared to the original medications for so many. Unfortunately they came with their own side effects which is simply the way of life, there is no 'free lunch'. All treatments come with costs. For most these new side effects are not a problem. The risk is small compared to the overall benefits of the drugs and there are indeed ways of treating the side effects.

The greatest concern is weight gain with associated diabetes. Zyprexia (olanzepine) was an amazingly appreciated medication but had a seriously concerning tendency with increasing dosage to cause weight gain. Alot of the metabolic side effects for all these medications were indeed dose related. A medication that caused no problem at low dose caused problems at higher dosage. Aspirin is like this. One or two pills cause little effect on platelets but more will increasing the tendency for a persons platelet system to not be able to stop bleeding if one has a cut.

One of the problems of patients looking up side effects of medications on the internet is that the side effects listed commonly come from the pharmaceutical companies necessary list of "medical disclaimer side effects". This means that the side effect is listed if it ever occurred even if it is rare and even if it was taken improperly or with other medications by the elderly or dying and in large dosage. It's like saying that planes wings fall off without listing the speed at which the plane was going of that the plane had had it's wings shot up by an enemy plane before the wings fell off later. In contrast the medical and psychiatric community utilized actual clinical resources and clinicians have experience of the medications and use them in a way which will be individualized and result in the least possible side effects. The 'studies' in the individual research papers which doctors read tell the ages and weights and races and other medical conditions which might have been present when a medication was used and then if it worked. Further these studies list whether the research information was randomized or controlled or subject to bias. Too much of the information listed on the internet is for legal purposes, to protect someone from legal assault, or simply a personal account. Too often critical information is missing.

That said, Ziprasidone or Zeldox (Pfizor Pharmaceuticals) is a new class of medication which has all the benefits of the original antipsychotics and the atypicals but in addition is energizing and doesn't lead to weight gain or cause metabolic side effects. It's been a relative breakthrough in the psychiatric medication armamentarium. No doubt it will eventually be seen to have it's limitations. Even the God send Penicillin caused allergies in many while it saved the lives of millions. Ziprasidone for now is working very well for those who need a major antianxiety medication but won't cause the other serious side effects. It's proving highly beneficial in the treatment of schizophrenia but is also very helpful in the treatment of anxiety disorders and mood disorders.

I'm thankful to the pharmaceutical companies for the work they have put into providing yet another medication that will help patients live independent lives to their greatest satisfaction without the nightmares of mental illness destroying their hopes and dreams.