I Get Knocked Down...

photo by ELŻBIETA KRUSZEWSKA
photos

I don't what it takes for anyone else, heck sometimes I don't know what it takes for me...I have had some experiences that a whole lot of people can't relate to, I say this not to garner any particular sentiment; just as a statement of fact.  In all reality, I am grateful; because I would not want anyone to go through what my son has.  What I have experienced as his mom has on a regular basis triggered my own "issues,"  I am told it is understandable that it has; and I believe that.  I don't want to look at my injury though, because I know from experience, that I can become incapacitated; which is simply not an option...

I am no longer a victim.  My son was victimized at the age of three, and now, twenty+ years later, he continues to struggle to feel safe; and have any confidence in himself---or trust and have any confidence in other people.  I am so grateful that he trusts me; and I respect the fact that he has no trust in, or desire to be around other people much.  I hope he can regain some confidence in people and learn that some people can be trusted.  It's all I can do to breathe easily some days, but it's just life.  It's my life.  Most of the time I am so very aware of how truly blessed I've been; but once in a while, something takes all the wind from me, and in those moments I forget: 

I am a MadMother: I am not a victim. I am a witness. 
I am a survivor. I am blessed.

 "No passion so effectually robs the mind of all its power of acting and reasoning as fear."

Edmund Burke

I'm Wide Awake

I'm not sleeping...

via: Crossroads to Change  

"Crossroads to Change Campaign’s 17-Year Legacy to End State Inaction with Protection of Rights

Carole’s final analysis is that there is no enforcement of the law and there is a refusal to enact Revised Code of Washington (RCW) Chapter 71.05.520 that would have DSHS assign appropriate staff with authority to examine records, inspect facilities, attend proceedings necessary to monitor, evaluate, and guarantee dedication of protecting both Washington State and US Constitutional rights of people with mental disabilities."

RCW 71.05.520  - Protection of rights.

The department of social and health services shall have the responsibility to determine whether all rights of individuals recognized and guaranteed by the provisions of this chapter and the Constitutions of the state of Washington and the United States are in fact protected and effectively secured.

To this end, the department shall assign appropriate staff who shall from time to time as may be necessary have authority to examine records, inspect facilities, attend proceedings, and do whatever is necessary to monitor, evaluate, and assure adherence to such rights. Such persons shall also recommend such additional safeguards or procedures as may be appropriate to secure individual rights set forth in this chapter and as guaranteed by the state and federal Constitutions.”   [1973 1st ex.s. c 142 § 57.]

"Due to a letter and request to Washington State Governor Christine Gregoire in early 2008, Carole Willey, a social justice activist & community organizer, Chair of CCC, received a letter from the Governor stating that she would assign David Reed, a staff person to work with Carole on these violations. With the documentation of the WA ST Mental Health Division finally acknowledging the “concerns,” the state agency agreed to forward his concerns to their Licensing staff, which they never did.
On July 10, 2008, Carole, along with witnesses Therese Holiday & Ann Clifton (two healthcare advocates), met with David Reed of the Department of Social and Health Services / Mental Health Division (DSHS / MHD). They met to review her analysis of the two reports and discuss violations of inpatients’ rights at Sacred Heart Medical Center in Spokane, WA."  more at :  Crossroads to Change

I found Carole Willey's website on July 8th, and immediately after reading the above, around 11:30 in the morning, I called Mr. David Reed.   Mr. Reed denied knowing of any instance or any history whatsoever of violations of individual's Constitutional Rights in the State of Washington in Involuntary Commitment proceedings; including my son's case from last summer.  However, I know this is a lie.  Recently, in "Constitutional Rights Violations Committed Under Color of Law in Washington State," I posted some email communications between staff members of Department of Social and Health Services,  Yakima County,  elected representatives and myself. 


One of the emails I posted is dated September 1, 2010 and is from Ronald Moorehead to me;  it is cc'd to two State employees; one of them is the same David Reed, who like Mr. Moorhead, is an Administrator at DSHS/HRSA/DBHR and knows about my complaint.  He obviously knows Carole Willey; he sent her two letters on this subject, as she reports on her website.  In a letter she received from Governor Gregoire,  "stating that she would assign David Reed, a staff person to work with Carole on these violations." (emphasis mine)

I have since been in contact with Carole Willey, who has given me permission to post two letters from Mr. David Reed she received from him as a result of his being assigned to work with her by the Governor.  David Reed told me in our brief phone conversation that if I  had a complaint, he could give me the number of the person to call.  I asked,  "Do you mean Ronald Moorhead?"  To which he responded, "Yes."  I informed Mr. Reed I had Mr. Moorhead's number; but then, I know he knew that!  He also knew I had filed my complaint, since he was one of the people involved in not "resolving the issues."  I knew when I called Mr. Reed, that he knew about my son's case; and I suspected that he would lie when I asked him whether he had any knowledge that the department has a history of ignoring complaints about improperly obtained illegal Court Orders for Involuntary Treatment, and people's Constitutional Rights to Procedural Due Process being violated.  Unfortunately, I was right. He lied and said he had never heard of any such complaints...

Letters on Crossroads to Change Website

The department's failure to do any investigation when these violations are reported, or to, "assign appropriate staff who shall from time to time as may be necessary have authority to examine records, inspect facilities, attend proceedings, and do whatever is necessary to monitor, evaluate, and assure adherence to such rights. Such persons shall also recommend such additional safeguards or procedures as may be appropriate to secure individual rights set forth in this chapter and as guaranteed by the state and federal Constitutions."  as the Washington State law requires in RCW 71.05.520  


The Law is clear, DSHS has an obligation that it has failed to meet and actually has employees who take these complaints, DENY any DUTY whatsoever.  Mr. Moorhead advised me to file more complaints with other entities, while first denying the department has any authority to investigate; when in fact the department has a legal:  

DUTY TO INVESTIGATE

Every legally authorized representative of the State of Washington failed to perform their duty lawfully, thus far.  Federal Crimes were committed against my son by two people, because he has a "mental illness."   Once these crimes were reported, there was no investigation, and further crimes were then committed. (in a cover-up?)  The Federal Crimes committed violated my son's individual right's to Procedural Due Process under the United States Constitution, the right to be free of undue restraint, and the right to keep and bear arms.  These crimes were committed by employees of the State of Washington and/or it's duly authorized representatives; these  violations of my son's Civil Rights were committed 

UNDER COLOR OF LAW

It is in vain, sir, to extenuate the matter. Gentlemen may cry, Peace, Peace-- but there is no peace. The War is actually begun! The next gale that sweeps from the north will bring to our ears the clash of resounding arms! Our brethren are already in the field! Why stand we here idle? What is it that gentlemen wish? What would they have? Is life so dear, or peace so sweet, as to be purchased at the price of chains and slavery? Forbid it, Almighty God! I know not what course others may take; but as for me, give me liberty or give me death!

Patrick Henry

feeling old this morning...

My Son's "Great Idea" to Change the World

a text sent to me in the wee hours by my eldest son:
"Hey I just got a great idea.  We should start a pledge for mental health workers to only endorse evidence based practices to help ensure sound scientific progress and the fair humane treatment of individuals."
 Nathan Murphy 

  (that's my boy!) 

In February of this year there was event held in Portland Oregon it was a gathering of peers active in the Psychiatric Civil Rights Movement and professionals.  There were people from several states, including psychiatric survivors who work as peer counselors and  Professionals working in the mental health field.  What all of these people have in common is a desire to be part of the mental health transformation to effectively help those experiencing  emotional difficulties due to being in crisis and/or experiencing extreme states; more commonly know as the symptoms of psychosis.  What is apparent to psychiatric survivors and many professionals, is that the current paradigm of drugging people, adults and children alike for the symptoms of distress and behavioral issues that children have, whatever their psychiatric diagnosis; is causing far too many harm.

Free Falling and Brotherly Love

 James Raymond Murphy 1957-2009 

My brother Jim died in 2009 after fighting brain cancer for a year.  
Today is the anniversary of his birth. 

The Chutist

To fly is to live.

Letting your spirit soar.

Being totally free.

Separating your dreams,

from hard reality.

The descent is...

a suspension in time.

To glory in the feel

of being timeless.

To rely on only 

yourself.  A part 

of the winds.

Written for my brother Jim on 3-21-1993

Jim loved to skydive and I went up as an observer once. I got a little taste, and I can  understand just why he loved it so much. I wrote "The Chutist" while I was waiting for him to take one more jump---he had to do it just one more time. He truly loved it.

I wrote this when he died:

We are all brothers.  I knew this first by faith and then through experience. I am fortunate to have several, and I am grateful for all my brothers.  It is through God's love for us and our brotherly love for each other, that we edify one another. There are moments of time some fleeting, others of longer duration, when I am aware of how the virtue of brotherly love has been demonstrated solely for my benefit.

I have no doubt that the Winter of 1993 was one such time. I had been suicidal since grade school.  I would not admit to another human being that my first attempt was when I was 13 years old, until I was 29.  My brother Jim is the first person I told that I had been trying to kill myself since I was thirteen.  He told me that he didn't want me to die.  He asked me to promise him that I wouldn't try to kill myself for him. I promised that I wouldn't; eventually, I realized that I wanted to live,  no matter what.  I have not been suicidal since.  

It has been 16 years, since that time, I have lived as long as I had tried to kill myself. I believe that my brother Jim was my guardian angel; he listened to my insanity, and shared how he had dealt with his own. My brother Jim demonstrated how to survive temendous losses. He convinced me that I was worth the effort. He had the will for me to live, until I had it for myself. I know what "I am my brother's keeper" means.

I know this: I will remember always when my brother Jim was mine.  

Jim's favorite musician was Tom Petty. The day he went "free falling" for the very first time, he got pulled over for speeding. He was roaring down the highway at 80 miles an hour; singing at the top of his lungs to one of my personal favorites:

parachutist photo: wikimedia

The "Anti-Stigma" Campaign Increased Discrimination

Mental Illness Stigma Entrenched in American Culture new strategies needed, study finds

ScienceDaily (2010-09-16) -- "A new study finds no change in prejudice and discrimination toward people with serious mental illness or substance abuse problems despite a greater embrace by the public of neurobiological explanations for these illnesses. The study raises vexing questions about the effectiveness of campaigns designed to improve health literacy."

I read this article and thought well, what else would the outcome be?

It is not possible to change negative attitudes derived from ignorance by misinforming the people who have them. How could being dishonest about a group of marginalized people "help" them? I was taught as a child that it is impossible to 'do good' by being dishonest. The people cannot be asked to believe "mental illness" is a "disease or disorder of the brain, like any other illness," but also be expected to believe the people who have them need to be forced to take harmful drugs. Supposedly, they need to be forced because, "they don't know what's good for them," and people are expected to believe having a "mental illness" is like having a disease like cancer or diabetes! It defies logic. Why would "mental health professionals" believe that telling people lies about the people who have been diagnosed with "mental illnesses" would be a good thing to do? Or that it would be helpful to them?! Stating that "mental illnesses" are "brain diseases" implies that the so-called, "diseases" develop in a biological vacuum. Going further and claiming one can never 'be cured,' but can only be "effectively treated," with neuroleptics, helps the pharmaceutical industry. It does not help those with a psychiatric diagnosis, to be dishonest about what people with a diagnosis experiences. A genuine effort to change entrenched ignorant societal beliefs would require accurate information, not lies. Ignorance can only be corrected by education. Any genuine effort to eliminate the stigma of a psychiatric diagnosis, needs to be based on reality, not science fiction. An honest effort requires the truth.

How is it that a deception of the masses was believed to be the best way to "bust the stigma?" In kindergarten we learned (or not) that one is supposed to follow the rules because it is the right thing to do. Now deception of the masses is supposed to inspire society at large to do the right thing for "the seriously mentally ill" because it is the right thing to do; but the reason offered to compel understanding and altruistic action is a deception? How could college educated professionals not see the glaring inconsistencies inherent in this dishonest strategy?

The anti-stigma effort in theory, was supposed to encourage the general public to stop excluding and to start including "the seriously mentally ill." Teaching the general public that "mental illnesses" are caused by "diseased brains" and that those with "seriously diseased brains" are just like everybody else. The Human Rights of those who the public is told have "brain diseases" instead of emotional, cognitive and behavioral difficulties resulting from abuse, and neglect, trauma and other types of environmental, sociological and interpersonal subjective experiences are further violated when the public believes this obfuscation.

The people and entities who benefit from this unscientific classification of emotional distress are many; and not always readily recognized. There are the obvious financial beneficiaries of academia, medicine, and pharmaceutical companies, that most can readily agree are all branches of the same twisted tree feeding off what the bible called the root of all evil, the love of money. The relative few benefit financially, earning their wage in an pale imitation of the noble characteristics required of those who practice the Medical Arts. Wages are earned by deceiving the masses; while depriving those labeled "seriously mentally ill" of their dignity and hope. Coercing patients and trusting family members alike, to gain "treatment compliance." This process did not happen overnight, and it is not a recent phenomenon.

The article in Science Daily is not the original report of the study, the original report appeared in the online version of the American Journal of Psychiatry on September 15, 2010. Here is a link to the abstract: American Journal of Psychiatry

I noticed right away in the first paragraph, the abstract did not say that mental illnesses are diseases! In fact it truthfully stated that they had been presented, "as medical diseases in efforts to overcome low service use, poor adherence rates, and stigma." So, now we have an answer to why this subterfuge was perpetrated. Primarily, it was to "to overcome low service use, poor adherence rates," i.e. to encourage treatment compliance. The lie that "mental illness," or more accurately, states of crises, are caused by biological  "diseases" or "chemical imbalances" was told to get more people to take psychiatric drugs and "reduce stigma" of doing so.  This is no justification for mental health professionals to lie about the very people they are supposed to be helping! In reality this plan was developed by college educated mental health professionals who seemingly perceived no moral dilemma in abandoning their ethical integrity; or in lying to patients and their families, and the American public. Incredibly, many in medicine, academia, government and industry are clinging to this lie which continues to cause the people it was intended to help further harm. On the face of it, this deception may appear to be harmless, as it is instigated to supposedly achieve better "medical treatment" for those unfortunates with "diseased brains."

Looking closer, it appears to be an attempt to misinform the general public and thereby gain support for bio-psychiatry practitioner's methods of "practicing medicine." These methods include coercing the "seriously mentally ill" and "teaching" by manipulating their family members and the general public into supporting social control strategies, that are being called, "medical treatment." Human Rights violations that happen as a matter of course for those with the label of "serious mental illness" we are told by bio-psychiatry's devotees are justified; because, "seriously mentally ill" people lack insight! Llaws have been passed mandating this "medical treatment," which does not help the vast majority "treated" with neuroleptic drugs; but in fact hurts them. A particularly cruel twist to the "anti-stigma" lie, when one considers the fact that neuroleptic drugs induce iatrogenic neurological and metabolic abnormalities, leading to disability and early death; sometimes sudden death, regardless of the age of the patient.

Reading just the abstract for the American Journal of Psychiatry article, and the article written about this study for Science Direct, I could not help but notice that it seemed that the message was somehow different in Science Direct. In the final paragraph of the AJP abstract, which acknowledges the two effects of the strategy to increase awareness of the need for those labeled to be treated with medication The campaign to promote the belief that "mental illnesses" are diseases like any other diseases; resulted in an increase in support for "treatment;" but ironically, it also led to an increase in rejection experienced in the community by those with a psychiatric diagnosis!

This means that once the general public believes the deception offered by the "anti stigma" campaign, the people who have a psychiatric diagnosis experience more rejection. Rejection of a person due to a psychiatric diagnosis is inhumane and leads to isolation and loneliness. This study supports the belief of many survivors: Stigma originates with and is attached to the psychiatric diagnosis itself. The strategy to garner community acceptance and inclusion for "the seriously mentally ill" actually led those diagnosed with a psychiatric "mental illness" becoming more isolated, and experiencing more rejection. Perhaps it is time for the professionals who develop these grand ideas to help others, to tell the truth. Perhaps these professionals need to ask those they wish to help, "What can we do to help you?"

Australian Mental Health, Human Rights and Law Reform Coalition

FUNDRAISER & LAUNCH

 

Please come and support this significant Mental Health, Human Rights and Law Reform Coalition 

Sunday, July 24 · 3:00pm - 6:00pm 

 The Evelyn Hotel  351 Brunswick St.  Fitzroy, Australia

Please invite all your friends, families and comrades to work together, 

as true and equal partners for an improved 

Australian Mental Health System 

*Outstanding Speakers and Advocates* 

Victorian Human Rights 

      Indigenous People's Rights                                                  Mental Health Rights 

Featuring Activists:

Robbie Thorpe, Kelvin Onus King, David Webb,

 Heidi Everett, Greg Oke, Amanda Thorburn, Barry Dickins 

*Entertainment*  

Heidi Everett and Hotel Echo Jake Hapeta and Band 

Kelli Mac Guinness and Friends  

 other amazing artists to be announced.

The winners of the Inaugural 

"2011 Bruce MacGuinness Victorian Human Rights Awards for Mental Health" 

will be announced 

Awards will be presented to Individuals and Organizations who have fearlessly identified and remedied Human Rights Violations 

committed against vulnerable, marginalized individuals and groups across Australia 

Full Bar is available:  Entry: $5 Concession and $10 Non Concession

**Under 18 yrs old ARE permitted accompanied by an Adult.** 

No alcoholic drinks will be served to people under 18. 

**We look forward to seeing you all**

Family, Friends, Carers, Support Workers and Colleagues

 Australian Mental Health, Human Rights and Law Reform Coalition

and our many supporters.

**Date of the protest to be on the steps of Parliament House**

 will be announced at this Fundraiser and Launch Party

 The members of the Australian Mental Health, Human Rights and Law Reform Coalition

advocate for 

HUMAN RIGHTS, FREEDOM, RESPECT, EQUALITY, DIGNITY and JUSTICE

for

ALL AUSTRALIANS

Working together, Coalition members support people who experience difficulties 

WE believe that all Australians who struggle can succeed!  

WE Believe that working together, all Australians can achieve

Mental, Emotional and Spiritual Wellbeing!!

Organizers: Gregory Oke, Heidi Everett, Heidi Song and Nax Green

Contact: 0431 704 975 anytime for more information

Choosing antipsychotics for children with schizophrenia: Evidence plus experience

NOTE: The article below initially states there were 119 children enrolled in the TEOSS drug trials; and subsequently states there were 116.

Standard Practices used in clinical psychiatric practice are not Evidence Based.

The article below is from the "The Journal of Family Practice" in which two psychiatrists are discussing prescribing neuroleptic drugs, called, "antipsychotics," to children and the Evidence Base; specifically, the TEOSS Drug Trial data.  Jean Frazier, was one of the primary investigators for the TEOSS multi-site drug trial.  14 of the 116 participants actually remained enrolled the entire trial period.  The majority dropped out due to the inefficacy  and the adverse effects of the drugs; one committed suicide.  Jean Frazier is making treatment recommendations in this article based upon the TEOSS "Evidence" and her "professional experience," both as a TEOSS investigator, and as a clinician.

Given the real world outcomes for the TEOSS trial participants, this psychiatrist's treatment recommendations beg the question, "Is this psychiatrist even capable of basing treatment recommendations on Scientific Evidence?  Because it is obvious  that the recommendations below are based on the Practice Parameters for Treating Early Onset Schizophrenia which were written prior to the TEOSS drug trials.  They were developed by consensus of the subjective observations and opinions of psychiatrists which were determined by a vote taken by  members of the American Academy of Child and Adolescent Psychiatry.  Obviously, because  the Practice Parameters were developed using a political process, the parameters are not "Evidence Based" and cannot ethically be considered,  "Science- Based Medicine." 

The very last statements made by these two psychiatrists are extremely disturbing given the results of the TEOSS drug trials; and indeed, the entire scientific record for neuroleptic drugs: "I don’t think anybody wants to treat children with antipsychotics or mood stabilizers, but it’s what keeps these children well."  Robert Kowatch states; "I agree"Jean Frazier responds. (emphasis mine)

In what alternate reality?   Neuroleptics have a poor record of treatment response; and an even worse safety record both in clinical trials, and in real world clinical practice.  The treatment protocols, and standard practices are derived from Practice Parameters which are formulated using the quasi-democratic process of consensus.  They are based on a consensus of subjective opinions; opinions are not empirical evidence of anything other than agreement.     Given the reality that both the diagnoses themselves, and the treatments are based on consensus not science, and the fact that the drugs used to treat these diagnostic labels are neither safe or efficacious: isn't it misleading, false advertising to claim that teratogenic, neuroleptic drugs called "anti-psychotics," treat any psychiatric condition safely or effectively? The Evidence Base does not support the conclusions made by Kowatch and Frazier in this article in the slightest.  Is it possible that their opinions are due to anosognosia, Conflicts of Interest, errors of attribution, willful blindness, or pathological dishonesty?   

"Dr. Kowatch receives grant/research support from the Stanley Foundation, National Institute of Mental Health, National Institute of Child Health and Human Development, and the National Alliance for Research on Schizophrenia and Depression. He is a consultant to AstraZeneca and Forest Pharmaceuticals and a speaker for AstraZeneca.

Dr. Frazier receives grant/research support from Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline, Johnson & Johnson, Neuropharm, Otsuka America Pharmaceuticals, and Pfizer Inc."

Vol. 8, No. 7 / July 2009

Choosing antipsychotics for children with schizophrenia: Evidence plus experience

• Managing side effects • Choosing antipsychotics • Less than 50% chance of efficacy? • Are antipsychotics overused?

Seeking efficacy while managing adverse effects in early-onset psychosis

Jean A. Frazier, MD 

is the Robert M. and Shirley S. Siff Chair and professor of psychiatry and pediatrics, and vice chair and director, division of child and adolescent psychiatry, University of Massachusetts Medical School, Worcester, MA. 

Robert A. Kowatch, MD, PhD 

a Section Editor for Current Psychiatry, is professor of psychiatry and pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. 

Comment on this article

“A patient I’ve seen for a number of years had been diagnosed in the pervasive developmental disorder spectrum, but she was quite atypical. Her perseverative thinking focused on a fantasy world, and she was so preoccupied that it was very difficult to pull her out of it. Now at age 12, she has a full-blown psychotic disorder, and the fantasy world is enveloping her. She hears people talking to her all day long.”

Clinical Point

The 3 antipsychotics in TEOSS showed no difference in efficacy, but the meaningful finding to me was the side effect profile of these agents

Dr. Frazier discusses the unexpected findings of the TEOSS trial with Current Psychiatry Section Editor Robert A. Kowatch, MD, PhD. Based on the trial findings and her experience, she tells how she makes decisions when prescribing antipsychotics for children and adolescents with schizophrenia and related disorders.Jean A. Frazier, MD, who treats this patient and other children with psychotic disorders, was 1 of 4 principal investigators in the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) study, a randomized, double-blind, multisite trial funded by the National Institute of Mental Health. The study, published in November 2008,¹ compared the efficacy and tolerability of 3 antipsychotics—olanzapine, risperidone, and molindone—in pediatric patients with schizophrenia or schizoaffective disorder (Box 1).

DR. KOWATCH: The TEOSS trial found no significant differences in efficacy between molindone and the atypical antipsychotics (olanzapine and risperidone) included in the study. You’ve prescribed both typical and atypical antipsychotics in research and in your clinical practice. Do you believe there’s any difference between the 2 classes?

DR. FRAZIER: There are some differences. For example, treatment-refractory patients, especially young children, sometimes need more D2 blockade than some atypical antipsychotics provide. I’ve seen more extra pyramidal side effects with the typical antipsychotics than the atypicals, although it’s not uncommon to see some akathisia with aripiprazole or some dystonia and dyskinesia with risperidone.

DR. KOWATCH: What are the benefits and risks of using antipsychotics in young children?

Clinical Point

If a child has not responded to 2 trials with atypicals, I might start thinking about a typical agent or clozapine

DR. KOWATCH: Have you changed the way you prescribe antipsychotics as a result of the TEOSS study? DR. FRAZIER: The benefit is that antipsychotics can decrease children’s suffering and get them more centered in reality so they can enjoy their friends and progress in school. And when that happens, it’s wonderful. What are the risks? With the atypicals my greatest concern is weight gain, and with the typical agents it’s tardive dyskinesia. (emphasis mine)

DR. FRAZIER: Actually, I have. Clinicians have to be very careful about selecting psychotropic agents that can worsen pediatric-onset obesity. Olanzapine is an effective agent for targeting psychosis and mood symptoms, but the weight gain associated with it is a concern. I do not prescribe olanzapine as much as I have in the past, although I keep it in my armamentarium and tend to reserve it for third- or fourth-line therapy.

I have found molindone to be quite effective in children with schizophrenia or schizoaffective disorder, especially in those who have gained a lot of weight on atypical antipsychotics. They usually lose weight on molindone.

DR. KOWATCH: Do you think the TEOSS study had adequate power to demonstrate differences among molindone, olanzapine, and risperidone?

DR. FRAZIER: We enrolled 119 patients—which is large for a study such as this—but we did not reach our target of 168 patients, which might have increased our power to detect differences. Among the children we did enroll, the 3 antipsychotics showed no difference in efficacy, but the meaningful finding of this study to me was the side effect profile of these agents.

DR. KOWATCH: You mean weight gain with olanzapine and extrapyramidal symptoms with molindone?

DR. FRAZIER: Yes.

Managing side effects

DR. KOWATCH: How do you manage antipsychotic side effects?

DR. FRAZIER: For any of the antipsychotics’ side effects, you have to decide whether to continue the agent or switch to another anti psychotic. For example, I’ve had a number of children—many with significant weight problems—whose psychotic symptoms have responded only to risperidone. So we put them back on risperidone, and the decision then becomes what can we do to help with the weight gain while continuing that agent.

For weight gain, I think the best intervention is diet, exercise, and drinking a lot of water, but that can be effective only if you engage the patient’s entire family in the intervention as well. Short of that, a number of pharmacologic interventions have been studied, although not specifically in children.

In an open-label trial our group conducted with 11 children age 10 to 18 years who had gained weight while taking atypical antipsychotics, metformin decreased lipid levels and body mass index but not significantly. I’ve followed these children in my practice, however, and all those who continued taking metformin over a period of months lost weight.

Choosing antipsychotics

Antipsychotics in children with schizophrenia:
TEOSS study adds to debate about efficacy and tolerability

The 5-year National Institute of Mental Health-funded Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) trial began with an ambitious goal: to compare the efficacy and safety of 1 typical and 2 atypical antipsychotics in children age 8 to 19 with schizophrenia. The primary hypothesis was that atypical agents would show greater efficacy and tolerability when given for 8 weeks. Instead, the atypical agents showed no greater efficacy, and adverse effects occurred with all 3 antipsychotics. Because the trial was designed for 168 subjects but enrolled 119, it may not have been adequately powered to detect differences among the 3 agents.

Medications: Most of the 116 children who received medications were severely ill with psychotic symptoms when randomly assigned to 1 of the 3 antipsychotics for 8 weeks of double-blind treatment. Administration began at the lowest dose in a set range and usually was increased to midrange within 10 to 14 days. Dosing remained flexible within these ranges:

• molindone, 10 to 140 mg/d (mean endpoint dose 59.9 mg/d)
• olanzapine, 2.5 to 20 mg/d (mean endpoint dose 11.4 mg/d)
• risperidone, 0.5 to 6 mg/d (mean endpoint dose 2.8 mg/d).

Benztropine, ≥1 mg/d, was given to all patients treated with molindone, 14% of those treated with olanzapine, and 34% of those treated with risperidone to prevent or manage akathisia.

Efficacy: Two criteria defined treatment response: a Clinical Global Impression improvement score of 1 or 2 and a ≥20% reduction in baseline Positive and Negative Syndrome Scale (PANSS) score. Tolerability outcomes included neurologic side effects, weight changes, laboratory analyses, vital signs, ECG, serious adverse events, and treatment discontinuation. Extrapyramidal symptoms were monitored with involuntary movement and akathisia scales.

Observed PANSS total score by week of treatment

Mean Positive and Negative Symptom Scale (PANSS) total scores of observed cases during each week of the TEOSS trial. Minimum possible PANSS score is 30; scores >60 typically are viewed as problematic.

Among the 70 patients who completed treatment (25 of 40 with molindone, 17 of 35 olanzapine, and 28 of 41 with risperidone), more than one-half failed to achieve an adequate response. Response rates were 50% with molindone, 34% with olanzapine, and 46% with risperidone. The atypical antipsychotics did not show greater efficacy than molindone, and mean reductions in psychotic symptoms were modest (20% to 34% on the PANSS). Mean medication doses were midrange and considered moderate.

Tolerability: Sedation, irritability, and anxiety were frequent adverse events. Patients receiving molindone reported significantly higher rates of akathisia (P < .0008). Those receiving olanzapine reported significantly higher rates of weight gain (P < .0001) and were the only group with increased lipid and insulin serum levels and liver function tests. Patients in the risperidone group reported significantly higher rates of constipation (P < .021) and were the only group that experienced elevated serum prolactin.

Source: Sikich L, Frazier JA, McClellan J, et al. Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizoaffective disorder: findings from the Treatment of Early-Onset Schizophrenia Spectrum disorders (TEOSS) study. Am J Psychiatry. 2008;165:1420-1431

DR. KOWATCH: Let’s say you’re seeing psychosis in a 12-year-old whom you think is schizophrenic, and he or she has not yet received an antipsychotic. What are your top 3 treatment choices?

DR. FRAZIER: The first agent I usually select is risperidone. We have the most data on the use of this atypical antipsychotic in children and adolescents, and most psychotic children I see do better with a bit more D2 blockade than some of the other atypicals provide. That said, I remain concerned about risperidone’s side effects—such as weight gain and increased serum prolactin—so my usual second-line agent is aripiprazole.

Prodromal symptoms of early-onset psychotic disorder

I became interested in the complicated overlap between pervasive developmental disorders spectrum and psychotic disorders early in my training. More is known about prodromal symptoms in adolescents and adults than in children.

A group in the Netherlands⁵ compared 32 adolescents with severe early deficits in affect regulation, anxiety, disturbed social relationships, and thought disorder (characterized as “multiple complex developmental disorder” [MCDD]) with 80 adolescents with prodromal psychotic symptoms who met criteria for “at-risk mental state” (ARMS). Three-quarters of the children with MCDD (78%) were found to meet criteria for ARMS, and the 2 groups showed similar schizotypal traits, disorganization, and prodromal symptoms.

Signs of progression to psychosis and schizophrenia in children typically include:

• change in personality
• decrease in functioning or decline in ability to perform at school
• unusual thoughts or behaviors
• crippling anxiety
• supersensitivity to stress.

With experience, the clinician can more clearly differentiate the prodromal signs of psychosis from normal childhood behaviors. Children who are psychotic often don’t make good eye contact. When you try to engage them in discussion about hearing voices, they’re inattentive and internally preoccupied.

Normal vs psychotic children. You want a child in the latency age to have a rich fantasy life. If they do not, that raises concerns. Both normal and psychotic children sometimes say an imaginary friend told them something. Normal children eventually will admit this friend is imaginary. When children are psychotic, especially at an early age, you can’t pull them out of thinking about the imaginary friend, and they can’t distinguish fantasy from reality. Psychotic children also hear imaginary friends talking to them much more often.

Normal children usually are not afraid of their imaginary friends, whereas psychotic children—particularly adolescents—often are afraid of the voices they hear. However, if a psychotic child has heard voices from a young age, the voices aren’t always ego-dystonic. The girl I mentioned at the beginning of this article likes having the voices around. In fact, she gets uncomfortable when the voices are quiet.—Jean A. Frazier, MD

DR. KOWATCH: Why do you like aripiprazole for this patient population?

DR. FRAZIER: Aripiprazole doesn’t tend to be associated with as much weight gain as olanzapine or risperidone, although I’ve had children—especially in the autism spectrum—who have gained quite a bit of weight on aripiprazole. Clinically, I’ve noticed that aripiprazole seems to brighten up children’s affect. It also seems to help many children in my practice with attentional symptoms, although that’s anecdotal.

Clinical Point

When you try to engage psychotic children to discuss hearing voices, they are inattentive and internally preoccupied

Although we don’t have a lot of data to inform this discussion about aripiprazole, a placebo-controlled study of 302 adolescents diagnosed with schizophrenia showed that aripiprazole, 10 mg/d, targeted negative symptoms fairly well, based on changes from baseline in PANSS (Positive and Negative Syndrome Scale) total scores. This was a 6-week multicenter, double-blind, randomized, trial.²

Ultimately, cognition in patients with schizophrenia is the strongest predictor of success in the workplace and in school. We need data on what happens to neurocognitive functioning with aripiprazole—and all the other atypical agents.

DR. KOWATCH: What would be your third-line agent?

DR. FRAZIER: Well, that varies for me. I’m trying to match the medication I use with the individual patient, and at this point I prescribe based on the side-effect profile more than anything else. I also consider if the child has a family member who has suffered from a similar condition and what agents the family member responded to.

Let’s say I have a child who has tried 1 or 2 atypical antipsychotics and has not had a good response. Many times I decide to try yet another atypical, and often I will try quetiapine. But after a patient has not responded to 2 atypicals, I might start thinking about a typical agent or clozapine. I use clozapine quite a bit. I find it is the most efficacious agent available, and the data speak to this as well.^3,4 It has been truly remarkable for some children in my practice.

Less than 50% chance of efficacy?

DR. KOWATCH: The TEOSS study found 50% or lower response rates across 8 weeks of antipsychotic treatment. Clinically, what kind of response rates do you see with antipsychotics in children and adolescents?

DR. FRAZIER: I probably see about a 50% response rate in my practice as well. It’s variable, and the earlier the onset of the illness, the harder it is to treat.

DR. KOWATCH: Do you ever combine a typical antipsychotic with an atypical?

DR. FRAZIER: I try not to, but a number of children in the schizophrenia spectrum have enduring positive symptoms after 2 or 3 trials of atypical antipsychotics. Sometimes adding a touch of a typical agent can improve the situation. The typicals I usually try are perphenazine (around 8 to 16 mg/d) or molin done (around 20 to 60 mg/d). Sometimes I use a very low dose of haloperidol (such as 0.5 to 2 mg/d) with an atypical agent, and it can be quite effective.

DR. KOWATCH: That has been our experience as well; sometimes combining typical and atypical agents improves response. Besides medications, what do you consider an optimal treatment plan for a child or adolescent with psychosis?

Clinical Point

Sometimes I use a very low dose of haloperidol (0.5 to 2 mg/d) with an atypical agent, and the combination can be quite effective

DR. FRAZIER: These children need a multi-modal approach. Pharmacotherapy is the cornerstone because you want to decrease positive symptoms of psychosis, but often these children require therapeutic school placements or residential programs. If they’re old enough, cognitive-behavioral therapy can help by teaching them skills to manage ongoing psychotic symptoms. Older teens often have comorbid substance abuse and may require substance abuse intervention.

Are antipsychotics overused?

DR. KOWATCH: Do you think antipsychotics are overused in pediatric patients with psychosis?

DR. FRAZIER: In pediatric patients with psychosis? No.

DR. KOWATCH: What about in pediatric patients with behavioral disorders?

DR. FRAZIER: We need more studies to inform our practice and to be mindful of the evidence. Most children with schizophrenia have substantial developmental challenges (Box 2).⁵ In the autism spectrum, often an atypical antipsychotic is the only agent that can help a patient who is aggressive, self-injurious, or agitated.

In terms of bipolar disorder in children and adolescents, it would be ideal if we had more head-to-head comparator studies to inform our prescriptive practice. For example, we need more studies comparing traditional mood stabilizers such as lithium with the atypical agents.

Of course it would be ideal if we could use monotherapy in children who suffer from bipolar disorder and schizophrenia. But early-onset bipolar disorder—like early-onset schizophrenia—can be very difficult to treat and often requires more than 1 agent.

Clinical Point

Early-onset bipolar disorder and schizophrenia can be very difficult to treat and often requires more than one agent

In terms of attention-deficit/hyperactivity disorder (ADHD), it depends on what’s going on with the child. Certain children with an ADHD diagnosis have complicated behavioral issues. First I would wonder if they have a different diagnosis, particularly if it gets to the point that an atypical agent is being considered. But sometimes it becomes a question of treating pronounced aggression. We need more studies to inform what we do. Some studies indicate that stimulants can be quite helpful for the aggressive child with ADHD.⁷In a recent study of a pharmacotherapy algorithm for treating pediatric bipolar disorder,³ the children who did the best were on a combination of a mood stabilizer and an atypical antipsychotic. That has been my experience, too. I do my best to manage children on a mood stabilizer alone, but I rarely have been able to do that.

DR. KOWATCH: I don’t see any child and adolescent psychiatrist in the United States using antipsychotics to treat uncomplicated ADHD. The kids we see [at specialty clinics] have comorbid problems such as conduct disorder, oppositional-defiant disorder, mood instability—whatever you want to call it. And we’re seeing these patients because they haven’t done well on other medications, such as stimulants. Usually the parents are desperate because these children are moody and aggressive. I don’t think anybody wants to treat children with antipsychotics or mood stabilizers, but it’s what keeps these children well.

DR. FRAZIER: Yes, I agree.

Related resources

• Longitudinal assessment and monitoring of clinical status and brain function in adolescents and adults. Boston Center for Intervention Development and Applied Research (CIDAR) study.www.bostoncidar.org.
• Frazier JA, Hodge S, Breeze JL, et al. Diagnostic and sex effects on limbic volumes in early-onset bipolar disorder and schizophrenia. Schizophr Bull. 2008;34(1):37-46.
• Frazier JA, McClellan J, Findling RL, et al. Treatment of Early-Onset Schizophrenia Spectrum disorders (TEOSS): demographic and clinical characteristics. J Am Acad Child Adolesc Psychiatry. 2007;46:979-988.

Drug brand names

Aripiprazole • Abilify
Benztropine • Cogentin
Clozapine • Clozaril
Haloperidol • Haldol
Metformin • Glucophage
Molindone • Moban
Olanzapine • Zyprexa
Perphenazine • Trilafon
Quetiapine • Seroquel
Risperidone • Risperdal

Disclosures

Dr. Kowatch receives grant/research support from the Stanley Foundation, National Institute of Mental Health, National Institute of Child Health and Human Development, and the National Alliance for Research on Schizophrenia and Depression. He is a consultant to AstraZeneca and Forest Pharmaceuticals and a speaker for AstraZeneca.

Dr. Frazier receives grant/research support from Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline, Johnson & Johnson, Neuropharm, Otsuka America Pharmaceuticals, and Pfizer Inc.

References

1. Sikich L, Frazier JA, McClellan J, et al. Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizoaffective disorder: findings from the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) study. Am J Psychiatry. 2008;165:1420–1431.
2. Findling RL, Robb A, Nyilas M, et al. A multiple-center, randomized, double-blind, placebo-controlled study of oral aripiprazole for treatment of adolescents with schizophrenia. Am J Psychiatry. 2008;165(11):1432–1441.
3. Findling RL, Frazier JA, Gerbino-Rosen G, et al. Is there a role for clozapine in the treatment of children and adolescents? J Am Acad Child Adolesc Psychiatry. 2007;46(3):423–428.
4. Kim Y, Kim BN, Cho SC, et al. Long-term sustained benefits of clozapine treatment in refractory early onset schizophrenia: a retrospective study in Korean children and adolescents. Hum Psychopharmacol. 2008;23(8):715–722.
5. Sprong M, Becker HE, Schothorst PF, et al. Pathways to psychosis: a comparison of the pervasive developmental disorder subtype multiple complex developmental disorder and the “at risk mental state.” Schizophr Res. 2008;99:38–47.
6. Pavuluri MN, Henry DB, Devineni B, et al. A pharmacotherapy algorithm for stabilization and maintenance of pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2004;43(7):859–867.
7. Sinzig J, Döpfner M, Lehmkuhl G, et al. Long-acting methylphenidate has an effect on aggressive behavior in children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2007;17(4):421–432.

Current Psychiatry ©2009 Quadrant HealthCom Inc.

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