Reducing Anti-Psychotic Adverse Events

By Marvin Ross

One of the frustrations faced by those with schizophrenia, their families and their doctors is medication side effects. It can result in considerable frustration and in failure to achieve stability. In fact, patients will abandon treatment as a result. However, a group of researchers at McGill University in Montreal have suggested how this can be overcome through pharmacogenetics in a new research article just published in the Journal of Psychiatry and Neuroscience .

Drugs are metabolized in the body via the cytochrome P450 (CYP) super family of enzymes. These are the major enzymes involved in about 75% of drug metabolism. There are a number of CYP enzymes that work on different drugs and often a number that metabolize just one drug. Some drugs increase or decrease the activity of the the CYP and can be a major source of drug side effects. If one drug inhibits the metabolism of another drug, that second drug will accumulate in the body and thus require a lower dose. Or, the opposite can occur and the metabolism is sped up and the drug gets out of the system too rapidly to have much therapeutic impact.

Other substances can also impact the metabolism of drugs and cause problems. Probably the best known that caused a stir a few years ago with Florida citrus farmers is grapefruit juice. It can interferes with the metabolism of the statin drugs used to reduce cholesterol so doctors when prescribing those drugs will tell their patients to avoid grapefruit juice. Another interaction is between St John’s Wort used for depression and birth control pills. There are probably a lot of kids around who should have been named St John’s Wort because they were conceived when that drug nullified the birth control pills their mothers took.

If you have a family member on anti-psychotics, you’ve probably heard that if the ill person increases or decreases smoking to tell the doctor because his/her dose may need to be adjusted. That is because smoking induces CYP1A2 which is involved with the metabolism of clozapine, olanzapine and fluvoxamine.

The journal article discusses the case of a 21 year old with first episode psychosis who was initially placed on 10 mg of aripiprazole for 4 days. He developed disabling extrapyramidal rigidity. Risperidone at 2 mg caused hypersalivation and disabling daytime tiredness. The patient refused clozapine and olanzapine due to concerns about weight gain but agreed to try haldol. That resulted in tremors, stiffness and anhedonia.

Doctors then performed a CYP450 assay and found that the patient was a poor metabolizer for CYP2D6. The three drugs that were tried are likely too slowly degraded in people who are too poorly metabolized by this enzyme leading to the side effects observed. The patient agreed to try paliparidone as it is less metabolized by CYP450 as is also the case with amisulpride. It worked and the patient is now doing well.

Metabolism status is something that is rarely considered by most prescribers although there are now a number of commercial tests available to them. If this were done on a more regular basis, the prevalence of adverse events would be significantly reduced and patients would receive faster and better results.

Schizophrenia Is an Illness

By Dr David Laing Dawson

Schizophrenia is an illness, a disease afflicting a finite number of people in each and every culture, language and country. We have medical treatment that usually works. Relapse and re-hospitalizations are almost always the result of stopping medication or not receiving the right medication in the first place.

Of course family support, housing, meaningful activity and good relationships are important components for achieving and maintaining recovery. But we know the numbers. They have not changed over the years except in response to changes in diagnostic criteria and data collection.

Because of this, devising programs with sufficient numbers of hospital beds for acute illness, and community programs (involving families) for long-term care should not be difficult.

On the other hand drug abuse and addiction are social phenomena albeit with serious medical ramifications. The incidence and prevalence of drug addiction and death by overdose vary dramatically from culture to culture, country to country, and era to era. At this moment in time over six people in British Columbia alone die from drug overdose daily. We do not have a specific medical treatment. Most rehabilitation and abstinence programs have a high failure rate.

Many American soldiers became addicted in Vietnam. Those who were given, (forced into) a long period of abstinence before returning home to their ordinary communities did not relapse. Those brought back to American cities and put in drug treatment programs (i.e. in small communities with other drug addicts) relapsed at a strikingly high rate.

I am quoting this study to underscore the fact that addiction has social origins. Seldom, if ever, does a person alone, apart from peers and group patterns, decide to seek out a drug dealer and try a little fentanyl.

(Notwithstanding the fact I once asked a 13 year old how on earth she managed to get her hands on drugs. “Easy”, she answered, “You just go downtown and find some shady looking guy standing on a street corner and ask him if he’s holding.”)

I am oversimplifying and I don’t have an answer for drug addiction. Tinkering here and there doesn’t make a difference. The solutions proposed by Jinping and Donald Trump are tempting, the “war on drugs” didn’t work and adolescent education can have paradoxical effects, but we do need to closely study Portugal’s program, laws, and results, and seriously consider the social factors that lead to ghettos of drug addiction.

But I am sure that lumping schizophrenia and other serious mental illnesses together in the same planning, policy and resource boat as drug abuse and addiction will result in neither group being well served. Addictions and the consequences of addictions will continue to climb and treatable serious mental illness will go untreated.

Psychiatry, Schizophrenia, and Psychiatric Hospitals Left Out in the Cold

By Dr David Laing Dawson

Some years ago I pitched a screenplay to a producer in Toronto. The story involved a man, a teacher, with bipolar disorder, who becomes manic and delusional in the classroom. I like it, said the producer, and we talked some more. But before the subject of finances came up he said, “But I think at the end we must learn that all his so-called delusions are true.”

Literature and film are replete with stories of disabilities, people living with disabilities, surviving disabilities, overcoming disabilities, accomplishing much despite the disability, living with illnesses, surviving illnesses, succumbing to illnesses. For the most part they have helped reduce stigma, raise awareness, shape public attitudes, and inform policy. With the exception of the horror genre the devil is not involved, evil is not present and miracles do not happen.

Down’s Syndrome is generally presented quite realistically and sensitively. More recently autism has been well represented, though usually with that rare gift of a particular and enhanced mental skill: code breaking, card counting, eidetic memory.

Poor schizophrenia, and, to a slightly lesser extent, poor bipolar illness. One well-known film implies the young musician’s madness was caused by an oppressive father and his own passionate response to Rachmaninoff’s Piano Concerto Number 3, and then he is unfortunately housed in a mental hospital for years, only to retrieve his life when he is discharged and stumbles across a piano. Another man tells the psychiatrist, off and on through 90 minutes of film that he is from a different planet, which, of course, turns out to be probably true.

All too often multiple personality (invented as a fictional device, remains fiction) becomes the explanation for why the psychotic person, the killer, the psychiatrist, and the detective are so well acquainted.

And then there’s the mental hospital – active and run by an evil psychiatrist, or abandoned on the fog-shrouded hillside – what better location for a story of intrigue, illusion, madness and horror. When, in fact, the mental hospitals were for the most part just buildings in which doctors go about doctoring, nurses nurse, social workers social work, counsellors counsel, and occupational therapists organize as many health promoting activities as they can.

I am writing about this because I am trying to understand why psychiatry, schizophrenia, and psychiatric hospitals have been left behind during the last 40 years when enlightened attitudes, knowledge, policies, and practices benefiting people who have autism, Down’s syndrome, suffer from Cancer, Aids, Alzheimer’s, and even addictions, have emerged.

And, I suspect, much of the blame falls on popular culture, the books, films, television, movies, and Netflix series we all devour for an average of, say, 3 hours per day.

Cancer, in fiction and fact, is a treatable disease, sometimes with success, sometimes partial success, sometimes failure. Schizophrenia is also, in fact, a treatable disease, sometimes with success, sometimes partial success, sometimes failure.

But in fiction, schizophrenia and madness are, can be, usually, delicious metaphors for humankind’s struggle for peace, harmony, truth and meaning. And certainly when the occupants of a Greek Mental hospital escape into the war torn village they are definitely more likable, sensible, kind and humane than the men and women trying to kill one another. And what could be more intriguing than Robin Williams looking for the Holy Grail in New York city?

But John Nash didn’t will himself to wellness with his superior intellect; he was treated with one of the (at the time) newer anti-psychotic medications, and then he regained stability and sanity. His son, John Charles Nash, also suffering from schizophrenia, lives at home, his illness controlled with medication and regular visits by a mental health team.

Both Vince Li and Scott Starson are living at home following and continuing with medical treatment for their schizophrenia. But, where is the story in that?

Woke, the Cultural Revolution and Bill Maher

By Marvin Ross

One of the comments I received from my last blog A Pox on the Woke Folk was that I was not explicit enough with what Woke represents. Let me try again with an example from California. This is from the LA Times of January 26:

A coalition of disability and civil rights advocates filed a lawsuit Thursday asking the California Supreme Court to block the rollout of Gov. Gavin Newsom’s far-reaching new plan to address severe mental illness by compelling treatment for thousands of people.

I don’t know about you but this confuses me. There are thousands of people suffering needlessly from some form or other of severe mental illness who could be helped with treatment. The governor wants to help them get back some normality of life so that they do not have to live on the streets pushing all their worldly belongings around in a shopping cart.

Why is that a bad thing?

Ok The answer is that:

Disability Rights California, Western Center on Law and Poverty and the Public Interest Law Project — asked the state’s high court to strike down as unconstitutional the program known as CARE Court (for Community Assistance, Recovery and Empowerment). The groups argue that the sweeping new court system will violate due process and equal protection rights under the state constitution, while “needlessly burdening fundamental rights to privacy, autonomy and liberty.”

This is an absurdity since people have a right to be well and to not suffer. If part of their illness means that they do not realize that they are even ill (as is the case with many with mental illnesses), we have even more of an obligation to help them. The philosophical basis for this belief that we have no right to impose treatment on anyone comes from the philosopher John Stuart Mill and his treatise On Liberty.

“the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant.”

Mill wrote that book in 1859 at a time when there were very few medical treatments for anything let alone mental illnesses. But Mill was not stupid or arrogant and he also added this:

“Those who are still in a state to require being taken care of by others must be protected against their own actions as well as against personal injury.”

By not taking care of these people, we are denying humanity. Besides, medical science has progressed considerably since 1859 and we now understand to a much greater extent the causes of these illnesses and we can now treat to a certain degree of success. Why should these individuals be denied the relief we have?

The reason seems to be that the woke folk do not believe in the scientific advances that have taken place in psychiatry. What gives them the right to ignore those advances? Have they studied these disciplines? What if they decide that they do not agree to allow people with cancer to be treated? We’ve already seen what those who do not believe in vaccine science have caused.

In Bill Maher’s rant on the topic, he says that “good intentions can turn into the insane arrogance of thinking your revolution is so awesome and your generation is mind bendingly improved that you have bequeathed the world with a new kind of human”

That was the Cultural Revolution and that is the arrogance of these so called civil libertarians who welcome seeing people suffer because they think they know better than others. Well, they don’t know better.

Enjoy Bill Maher’s rant.