Lowest effective dose is often much lower than the minimum dose

Common sense seems to be returning now that pharma is coming more and more under scrutiny. Keep in mind that lowest effective dose applies to psych drugs, too, and it may be more than half the minimum dose.

Here is an excerpt from The Globe and Mail.
Canadians overmedicated because MDs unaware of drug risks, experts say

ADRIANA BARTON The Globe and Mail
Published Thursday, Apr. 25 2013, 6:03 PM EDT
Last updated Thursday, Apr. 25 2013, 6:23 PM EDT

But more often than not, McCormack said, the dosage is too high. A phenomenon he calls the “unintentional medication overdosing” of Canadians is due to a systemic flaw in the drug regulatory process, he said. To prove that a medication works in clinical trials, drug companies select a dose high enough to generate a response in the majority of patients. The studied dose becomes the marketed dose – and the dose that most health professionals choose, he explained.

Studies to determine the lowest effective dose are rarely conducted. Nevertheless, many drugs work in much smaller doses, with fewer side effects, he said. For example, when the antidepressant Sinequan was introduced as a sleeping aid, the studied dose was 25 to 50 milligrams. Years later, however, a follow-up study found that 1 milligram of Sinequan “was effective for sleep,” McCormack said.

Unless a condition is severe or life-threatening, he said, patients should ask their doctor about starting with one-quarter to one-half of the marketed dose, and then increasing the dose as needed.


Driving to a doctor’s appointment today, I rounded a corner and thought I saw one of the mothers from Chris’s old recovery program about to cross the street. It’s been eight years since Chris and her son were in the program, and I wondered how she and he were doing. Did she manage to overcome the sadness that every parent in the program seemed to share about the hopes of their child’s recovery? Does she no longer believe in the medical model of psychosis that the program reinforced? I wonder.

Community Treatment Orders – superficially appealing

It’s really quite amazing that the British psychiatrist who was a champion of Community Treatment Orders, tested his own theory (published in The Lancet) and acknowledges that he was wrong. The evidence suggests CTOs don’t work. The re-hospitalization percentage was the same for both groups (those force treated for a short time) and those on CTOs. In my opinion, the damage inflicted on the CTO patient in the form of stigma and loss of civil liberties is a big contributor to worse mental health outcomes over time.

From The Independent

In the study, researchers compared two separate groups of mentally ill patients to test if they experienced fewer hospital admissions. The first set of 166 patients were under CTOs, which can initially last for up to six months and can be renewed at the end of this period. Meanwhile, the other 167 participants tested had been placed on Section 17 leave, which is intended to be only a very short-term solution and can last a matter of days.

Their findings, published in The Lancet this month, revealed that 36 per cent of patients in both groups were readmitted to hospital within one year. There were no significant differences between the two groups in terms of the frequency and duration of admissions, the study found.

Both sets of patients were also remarkably similar in their social and medical outcomes.

Professor Burns added: “We were all a bit stunned by the result, but it was very clear data and we got a crystal clear result. So I’ve had to change my mind. I think sadly – because I’ve supported them for 20-odd years – the evidence is staring us in the face that CTOs don’t work.”

The Lancet study

The Lancet, Early Online Publication, 26 March 2013
This article can be found in the following collections: Psychiatry (Schizophrenia)

Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial

Prof Tom Burns DSc, Jorun RugåsPhD, Andrew Molodynski MBChB , John Dawson LLD, Ksenija Yeeles BSc , Maria Vazquez-Montes PhD, Merryn Voysey MBiostat, Julia Sinclair DPhil, Prof Stefan Priebe FRCPsych 


In well coordinated mental health services the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty.

Take us both off the “mommy track” – please

I haven’t been posting much in the past few months, because, well, I feel increasingly awkward writing about my 29 year old son like he’s in kindergarten. “Chris’s first day at school, Chris tied his shoelaces today, etc. ” For crying out loud, he’s 29 and “mommy” should take a back seat, even if Chris isn’t the driver of the car. It just isn’t seemly on my part, at my age, to be so involved in being a mother to someone Chris’s age. Chris still doesn’t drive a car, BTW, as his problems came on just as he was taking young driver lessons. Hopefully, he will eventually decide to learn to drive and I can actually climb into that backseat.

However, I’m determined to show to parents and interested parties what the journey has been like, from the mother’s point of view, and the journey continues, as it does for all of us.  We still need to be find support for our situation when most of us aren’t in close physical contact with relatives of those with lived experience. So, here goes.

The goods news is that Chris had been meditating for over a year, is involved in his amateur theatre work, continues to take voice lessons, and has a girlfriend.  That takes a lot of the heat off me. My job has been to increasingly encourage Chris to take the lead in his own health and to speak up for himself. Maybe I’m way off base here, but I wonder how many 29 year old males are really motivated to get curious about their own health and research what to do about it? “I’m tired of doing all the legwork, Chris,” I whined last night (for the umpteenth time). There are self-help groups all over the net and YOU should be involved in them. I shouldn’t always have to draw them to your attention.” This last statement was uttered because Chris still occasionally struggles with hallucinations when he is alone during the day. And, being alone during the day with most of your activities skewed to nights and week-ends is a breeding ground for paranoia.

Another interesting development is that Chris and Dr. Stern are working on switching his medication to one (Risperdal) that affects fewer neurotransmitters than his current medication, Abilify. Abilify affects seven neurotransmitters, while Risperdal affects “only” four. Perhaps one reason Chris was recently not successful getting off the Abilify than he might have otherwise been if he were on a different medication, was that more neurotransmitters were implicated in the withdrawal. But, handling the meds are between Chris and Dr. Stern, and the switch is something they have apparently been discussing for a while. He’s been on Risperdal before. It was the medication that he was given when he was hospitalized for the first time. Chris said, and I agreed, that not one of the drugs he has used was particularly effective, but there you are.

Ian and I are still waiting for the day when Chris will work towards getting a university degree or announce he’s taking some course of action/training that will lead to employment. He tells me he is quite afraid of sitting in a classroom, which is odd, since he seems to have no trouble being on stage or singing solos in church. This is the big frustation point for us as his parents. We, of course, want him to move on to independence and self-sufficiency.

“Schizophrenic” teens and transgendered teens: Some observations

About a Boy, by Margaret Talbot, features in the March 15 edition of the New Yorker Magazine. The author writes about the growing numbers of teenagers–increasingly female ones– who are being surgically transgendered. The New Yorker only posts a small part of the article on the link I’ve provided. Do your own sleuthing to obtain this article, or, better yet, buy it in the name of sociological research. If you don’t already know anyone through your network of friends and relatives who has opted to become transgendered, trust me, you will. It is likely that a friend’s daughter is about to become your friend’s son. Through my own network of friends and relatives, I have personally met four cases, all of them female, who have started or have completed, the transition to male.

Why am I talking about transgender themes on my schizophrenia* blog? Because, as  someone who believes in the value of psychotherapy, who is skeptical of brain and body transforming medications and surgical interventions (electroshock), there is something very alarming indeed about the acceptance by the very young (and perhaps more reluctantly by their parents), of costly and dangerous cosmetic surgical interventions that have lifelong implications. A lifetime of drugs, a body that in other contexts is considered mutilated (think of the outcry surrounding female genital circumcision) and no going back. Homosexuality doesn’t call for medications or surgery, but transgender interventions do.  It is ironic that on the one hand, mental health activists are condemning the widespread medicating and over medicating of children and adults, electroshock for depression, and the dearth of access to psychotherapy, and on the other hand, under eighteens and young adults are clamoring for surgery, medications, and declaring that childhood trauma is not the issue here. I’ll bet that a sound argument can be made that these teens and young adults have trauma issues and that these issues should be explored in great depth before rushing into no going back decisions. But, that argument isn’t being raised.

I recently met with a MTFT transgendered person, who got her surgery done in Thailand by a Thai doctor who has done hundreds of these operations in his lengthy career. Because of this person’s age (60) and the fact that she had many years to consider her choice, the surgeon waived the ten year time frame that the decision process is supposed to take.

Medical misgivings aside, it is interesting that all the parents of the teens in the article are divorced, and the small sample of people I know who have transgendered, have parents who are divorced or never married. Coincidental or not coincidental? Transgendering is like saying I am now almost physically equal to a male or female and I will become more like the absent parent.

Years ago, when the baby boomer generation started getting divorced in droves, we were fed then latest societal myth about the effect of divorce on the child. Children are enormously resilient, we were told.  And it was in our interests to believe that myth. It was, after all, tailored to us and our needs, and the last thing anyone wants to feel about divorcing when children are involved, is guilty. The resiliency myth soothed our guilt. Well, now we are beginning to see one change that can happen in this day and age when children grow up with a remote male or female presence, secure in the knowledge that genders are equal, nourished by an increasingly daring Internet pop culture, and a slavish rejection by key opinion leaders of agreed cultural norms that that were built up over centuries norms.

Back to The New Yorker article: “But Danielle, a lawyer who had studied literary theory in graduate school, told me that she found herself puzzling over Aidan’s desire to transition. ‘I feel like of lot of these kids, including my daughter, might be going through identity struggles, a lot of them are trying on roles.’ We were having coffee at a pie shop in the Mission, at a long communal table. (At one point, the college student who’d been studying across from us politely interrupted to say that she, too, was about to transition to male.) Talking about Aidan, Danielle slipped back and forth between ‘she’ and ‘he,’ saying, ‘I’m still not convinced that it’s a good idea to give hormones and assume that, in most cases, it will solve all their problems. I know the clinics giving them out think they’re doing something wonderful and saving lives. But a lot of these kids are sad for a variety of reasons. Maybe the gender feelings are the underlying causes, maybe not……………….Danielle said that she had met many teenagers who seemed to regard their bodies as endlessly modifiable, through piercings, or tattoos, or even workout regimens. She wondered if sexual orientation was beginning to seem boring as a form of identity; gay people were getting married and perhaps seemed too settled……….’The kids who are edgy and funky and drawn to artsy things—these are conversations that are taking place in dorm rooms,’ Danielle said. ‘There are tides of history that wash in, and when they wash out they leave some people stranded. The drug culture of the sixties was like that and the sexual culture of the eighties, with AIDS. I think this could be the next wave like that, and I don’t want my daughter to become a casualty.’

Danielle thinks that “Aidan” is going through an identity struggle. Just as many people believe that a young person presenting as “schizophrenic” is also going through an identity struggle. The acquiescence to patients groups for the two conditions by psychiatry is telling. The DSM-5 continues to cling to the stigmatizing schizophrenia diagnosis, despite the opposition of those so labelled, but it has done away with the Gender Identity Disorder diagnosis, and replaced it with the more obfuscating term “Gender Dysphoria.” One group is listened to by psychiatry, the other is not.

He is risen

From Refusing Psychiatry Without Pissing Off the Neighbors

Saturday, March 30, 2013

Psychiatry and the Easter faith

Why do you look for the living among the dead?

Mourners visiting a tomb were asked this question one morning, long ago.

I ask it today of anyone who might study the mind or presume to heal mentally caused ills within a framework alienated from religion or in non-religious fields.

Lately we favor the proposition that bad behavior and unpleasant feelings are sicknesses or diseases of the brain. We believe doctors who specialize in behavior (but tellingly, not doctors who actually specialize in the brain) can solve social problems by medical means. We even tend to believe that scientific medicine is the best and most vital route to happiness in general.

We are apparently so far gone as to accept on faith that an individual read the rest here