In Memory of Gabriel Myers

By Richard Warner
windwarner@aol.com

On April 16, 2009, a 7-year-old Florida boy locked himself in the bathroom of his foster home after arguing with the 19-year-old son of his foster dad and committed suicide by hanging himself from a detachable shower hose. According to Jack Moss, Broward regional director of the state Department of Children & Families, the boy, Gabriel Myers, had been prescribed four psychiatric drugs: Vyvanse, an amphetamine, Lexapro, an antidepressant, the antipsychotic Zyprexa, and Symbyax, a drug that combines Zyprexa with another antidepressant, Prozac. He was taking two or three of these drugs at the time he hung himself [1]. Moss stated that “there were no suicidal tendencies recognized by the professionals” who had examined Myers [2], suggesting that the drugs may well have influenced the child’s behavior.

Any one of the drugs Myers was prescribed could have pushed him to suicide (see analysis below) and the combined effect of multiple psychotropic drugs is virtually guaranteed to exacerbate the drugs’ negative effects. Only Vyvanse has been approved by the Food and Drug Administration (FDA) for use in children.

How culpable is the psychiatrist who was treating Myers, who was red-flagged by the state’s Agency for Health Care Administration as having ”problematic” prescribing habits? Should he be charged with murder? How about the companies that made the drugs Myers was taking?

For many this question has an easy answer. Of course not. Even if one is emotionally inclined to bring murder charges, it remains that neither the psychiatrist nor the drug makers hung the boy and it would appear that neither deliberately planned to kill him. Yet even within the strict legal definition of murder the liability issues surrounding Myer’s death, and the deaths of many others as a result of psychiatric treatment, are not so clear cut.

According to Black’s Law Dictionary murder is “the killing of a human being with malice aforethought [3]. The key phrase here is “malice aforethought,” defined by Black’s as “extremely reckless indifference to the value of human life.” Malice aforethought is not the same as premeditation – deliberately planning to kill someone. There is a great deal of case law on the concept but it basically boils down to this: the accused was aware that his actions posed a serious risk of death or serious bodily harm to others and yet acted in complete and willful disregard for that risk [4]. Second degree murder charges can be brought when the killing, while not deliberately planned, evinces a callous disregard for human life, as is often the case, for example, with drunk driving.

In fact, just a week before Myer’s death a drunk driver in California killed three people in an accident that received a great deal of media attention. One of those killed in the crash was California Angels pitcher Nick Adenhart. The drunk driver, Andrew Gallo, was not only charged with three counts of vehicular manslaughter, the usual charge in such cases. He was also charged with three counts of murder [5]. Gallo had a prior DUI conviction and, as CBS’s 60 Minutes reported earlier this year, the fact that drunk driving kills more than 13,000 Americans each year has caused some prosecutors to bring more serious charges, like murder [6].

For its story, 60 Minutes interviewed Nassau County, New York District Attorney Kathleen Rice, who brought murder charges against a drunk driver under a statute which allows such charges when the defendant acts “with completely depraved indifference to human life” [7]. According to Rice, the actions of the defendant in this case made the deaths of the two victims, one a 7-year-old girl, “… inevitable. It was as inevitable as taking a gun and firing it at an individual who’s standing five feet away from you” [8]. Rice convinced a jury she was right. The defendant was convicted of second degree murder and sentenced to 18 years to life. A second driver convicted under Nassau’s depraved indifference statute got 25 years to life.

One might well argue that Rice exaggerated the inevitability of the deaths. Estimates are that in 2002, Americans took over 159 million alcohol-impaired driving trips, resulting in 17,419 deaths [9]. That’s about 110 deaths per 100,000 trips. Clearly the vast majority of alcohol-impaired trips don’t result in death. Yet forty-one percent of fatal crashes in 2002 involved alcohol and according to the organization, Mothers Against Drunk Driving, on average someone is killed by a drunk driver every 40 minutes [10]. Drunk driving deaths are a very common occurrence.

Clearly when Andrew Gallo chose to drive his vehicle under the influence of alcohol, what happened – the deaths of three people – was not unexpected. It was what is termed in law a “natural and probable consequence” of his action. Such a consequence happens frequently enough that it might well be expected to happen again, as distinguished from “possible consequences,” which “happen so infrequently that they are not expected as likely to happen again from the commission of the same act” [11]. Considering the amount of publicity given to drunk driving it is difficult to imagine anyone not knowing that driving drunk can put life at risk.

Myers’ death should also have been no surprise. Consider the drugs he was prescribed and, let’s not forget, had little choice but to take. Vyanse is an amphetamine. Three of its most common side effects in children are insomnia (19%), irritability (10%) and affect lability (i.e., mood swings, 3% – from the word “labile,” meaning apt to change, unstable). An agitated state is a contraindication for use of the drug, meaning use of the drug is not advised under that condition. Yet the three other drugs Gabriel was taking cause exactly that state.

Lexapro is in a class of antidepressants known as selective serotonin reuptake inhibitors, or SSRIs. Prozax, Paxil and Zoloft are all SSRIs. Earlier this year the Justice Department charged Forest Laboratories, the maker of Lexapro, with defrauding the government of millions of dollars by illegally marketing that drug, and another SSRI, Celexa, for unapproved uses in children [12]. Lexapro, like other antidepressants, carries a black box warning which states, “Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders.” The SSRIs commonly cause insomnia and a state of extreme agitation known as akathisia, both of which are known precursors of suicide [13].

Akathisia and sleep disorders are also common side effects of Zyprexa, one of the newer, so-called “second-generation,” antipsychotics. A recent review of akathisia induced by second-generation antipsychotics noted that combining them with other psychotropic drugs increases the risk of akathisia, as do symptoms of hostility [14] and affective disorder diagnoses, like depression or bipolar disorder [15]. Myers was almost certainly diagnosed with bipolar disorder. His psychiatrist justified the use of the drugs as a treatment for mood instability and insomnia. Child welfare officials said the boy threw “extreme tantrums” [16], although he showed no such symptoms when he was living with his uncle and the boy’s pediatrician discontinued all psychotropic drugs [17]. Myers was caught in a dwindling spiral of toxicity. The drugs (amphetamines and SSRIs) created effects, like insomnia and mood swings, which were then “treated” with more drugs (Zyprexa) with equally serious effects. Dr. Stephen Hyman, former director of the National Institute of Mental Health, when asked about the use of antipsychotics like Zyprexa in children, said, “We don’t know the first thing about safety and efficacy of these drugs even by themselves in these young ages, let alone when they are mixed together” [18].

According to a story in the Miami Herald, Lexapro and Zyprexa were discontinued in the weeks prior to the suicide and replaced with Symbyax, a drug combination of Zyprexa and Prozac [19].

In short, Gabriel Myers had been placed on multiple drugs known to significantly increase the risk he would try to kill himself and placed on those drugs under circumstances that clearly contraindicated their use and with little or no supervision. If this is not malice aforethought it comes perilously close.

A black box is the most serious warning the FDA can put on a drug. Renown psychopharmacologist David Healy states, “…had a cumulative meta-analysis of published SSRI trials been undertaken since 1988, it would have shown a relative risk of suicidal acts on SSRIs compared with placebo of 2.93” [20] – nearly three times the risk. This is true, he adds, “even though many of the published trials either did not report suicidal acts or reported them as having happened on placebo rather than on active treatment” [21].

In 2002, Dr. Arif Khan presented to the National Institute of Mental Health’s New Clinical Drug Evaluation Unit the results of research he had conducted on over 71,602 people who had participated in clinical trials on antidepressants, antipsychotics, and other psychotropic drugs. As reported by Clinical Psychiatry News,

“One striking finding was the elevated rate of completed suicides for patients during these trials. Compared with the rate of 11/100,000 persons per year for the population at large, the rates of completed suicide were 752/100,000 persons per year for those in antipsychotic trials; 718 in antidepressant trials; 425 in trials of medication for social anxiety disorder; 136 for panic disorder; and 105 for obsessive-compulsive disorder. This was particularly surprising in light of the attempt, in most clinical trials, to exclude patients who are actively suicidal, Dr. Khan said [22].”

If these are the rates in trials where individuals who are actively suicidal are excluded, the rates in actual practice are most likely worse. Polypharmacy, the prescription of several drugs to one person, is known to exacerbate side effects and when applied to a child the consequences must be predicted to be potentially life-threatening.

Indeed the consequences would appear to be far more life-threatening than driving drunk. As we noted earlier, drunk driving deaths happen at a rate of about 110 per 100,000. That compares to 752 per 100,000 persons per year for those in antipsychotic trials; 718 per 100,000 for patients in antidepressant trials. These figures represent an increase in the risk of suicide over the population at large (11 per 100,000) of 68 and 65 times respectively.

In their book, Encyclopedia of Forensic Science, the authors cite a study which found that, “Someone with a blood alcohol level of 0.100 percent is more than 10 times more likely to cause an accident and one at 0.150 some 40 times more likely” [23].

These facts raise a compelling question. If a drunk driver can be found guilty of murder for disregarding the statistically small likelihood that he would kill someone, why shouldn’t murder charges be brought against Myer’s psychiatrist and the companies who manufactured the drugs that precipitated his suicide?

Drug companies and the psychiatrists have long been aware of the deadly effects of their drugs. Case in point: Eli Lilly’s antidepressant, Prozac (fluoxetine). Anyone familiar with the history of psychiatric drugs knows that drug companies must be forced via lawsuits to reveal the actual drug effects that they discover in clinical trials. One internal Lilly document dated March 29, 1985, was uncovered in a wrongful death suit brought by the widow of Joseph Wesbecker, a man who was taking Prozac when he shot 20 people, killing eight, before killing himself. The document stated, “The incidence rate [of suicide] under fluoxetine therefore purely mathematically is 5.6 times higher than under the other active medication imipramine” [24]. In another civil action against Pfizer, the manufacturer of the SSRI Zoloft, David Healy uncovered an unpublished study of healthy female volunteers that had to be cancelled after they began complaining of agitation and apprehension [25]. Healy’s own Zoloft study of 20 healthy volunteers, half given Zoloft and half a non-SSRI antidepressant, resulted in two of them becoming dangerously agitated and suicidal on Zoloft [26].

Drunk drivers are now being convicted of murder. Gallo has been charged with three counts of murder. Their indifference to the fatal consequences of their actions is no worse than the indifference of psychiatrists who give multiple drugs, all capable of inducing suicidal ideation, to children. Indeed, drunk drivers, unlike psychiatrists, are not experts in the possible results of their actions. A better analogy would be to a highway patrolman who drives drunk. Surely such actions on the part of a law enforcement officer would demonstrate a “reckless indifference to the value of human life,” or malice aforethought. And just as surely it does for psychiatrists.

Premature death

Suicide is, of course, not the only means by which psychiatric treatment can end in an early death and it is not only children who die. This fact was brought home in 2006 when the National Association of State Mental Health Program Directors released a report which revealed that “people with serious mental illness served by our public mental health systems die, on average, 25 years earlier than the general population” [27]. The researchers examined mortality data submitted by public mental health agencies in eight states. Seven of the states (Arizona, Missouri, Oklahoma, Rhode Island, Texas, Utah and Vermont) submitted data on persons served in both inpatient and outpatient services during the period 1997 through 2000. (The eighth state was Virginia.) The 25 year figure is actually a minimum for those 7 states. Averaging the “Years of Potential Life Lost” (YPLL) statistics for the seven states yields a figure of 25.9 years, with three of the states averaging over 28 years of life lost.

In addition to the eight states, the report mentioned an Ohio study in which persons discharged from Ohio public psychiatric hospitals were matched against Ohio Department of Health death records over a five year period (1998-2002). The study found, “The mean age at death for all decedents was 47.7, corresponding to an average of 32 years of potential life lost per patient” [28].

The study also noted that “previous research suggested that people with schizophrenia died 10 years earlier than age-matched contemporaries” [29], a fact which prompted the lead author of the study, Joseph Parks, the director of psychiatric services for the Missouri Department of Mental Health, to say, “We’re going in the wrong direction” [30].

The majority of these patients are not killing themselves. They are being killed – and the NASMHPD report shows this – by the psychiatric drugs they are being prescribed, as well as a number of other factors associated with psychiatric treatment. Again the question arises: at what point does it become legitimate to ask whether such deaths could happen without a considerable indifference to the lives of these victims.

There is, of course, one group that has been legally defined by their malice aforethought: murderers. According to the U.S. Department of Justice, Bureau of Justice Statistics, the average age of a murder victim in the United States in 2005 was 32.3 years old. In 1990 the figure was 32.0 and it really didn’t vary much in the 15 year period from 1990 to 2005 [31]. Life expectancy in the U.S. reached 78.1 years in 2006 [32]. In 1990 it was 75.4 years [33].

So, using an average age of death for murder victims of 32 and a life expectancy of 78, the years of potential life lost for murder victims is about 46 years. By this measure, state mental health systems are already 60 to 70 percent as “effective” as murderers in shortening the lives of those with whom they come into contact. Moreover, their statistics are rising, and have been for decades.

The previous 10-year figure mentioned in the NASMHPD report comes from a 1980 study of mortality in schizophrenics which found “the male schizophrenics had their survival time shortened by ten years while survival time for female schizophrenics was shortened by nine years” [34]. In 2000, a study in the British Medical Journal reported finding a linear increasing trend of mortality during 5-year periods from 1976 to 1995 among people with schizophrenia [35]. A 2001 study of the life expectancy for individuals with psychiatric diagnoses found the life expectancies reduced by 8 – 15 years for schizophrenia and functional or affective psychoses [36]. Finally, a 2007 analysis of studies that investigated mortality in schizophrenia published between 1980 and 2006 found, “With respect to mortality, a substantial gap exists between the health of people with schizophrenia and the general community. This differential mortality gap has worsened in recent decades” (emphasis added) [37].

For a number of reasons, the YPLL stat for mental patients will most likely increase in the next decade. The two most significant reasons are 1) the fact that the principal factor resulting in increased mortality for the seriously mentally ill is, as the NSDMHPD report shows, the treatment they are given and, 2) that treatment is beginning at increasingly younger ages.

The NASMHPD report stated that, “While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary, and infectious diseases.”

And what is causing these medical conditions? Psychotropic drugs! Antipsychotics, for example, significantly increase the risk of heart disease and factors related to heart disease, such as hypertension, obesity, problems related to cholesterol, and diabetes. Studies report that antipsychotic drugs can increase the risk of diabetes by 2, 3 or, in the case of one very popular antipsychotic, 7 times [38], and that people taking antipsychotics are “much more likely to have high blood pressure, a high waist-to-hip ratio, high cholesterol and poor control of their blood sugar, all of which can be risk factors for heart disease” [39].

The American Diabetes Association warns that, “People who take antipsychotic drugs for the treatment of a variety of mental illnesses may be at increased risk for obesity, diabetes and high cholesterol – all of which can lead to heart disease.” According to the association, diabetes is “the nation’s fifth leading cause of death by disease. Diabetes also is a leading cause of heart disease and stroke, as well as the leading cause of adult blindness, kidney failure and non-traumatic amputations” [40]. The NASMHPD report notes that “second generation antipsychotic medications have become more highly associated with weight gain, diabetes, dyslipidemia, insulin resistance and the metabolic syndrome” [41].

Other studies have linked antipsychotics to sudden death, stroke, and fatal blood diseases. The NASPHPD report cited a number of other factors which contribute to the early death of mental patients, including misdiagnosis due to the interpretation of all symptoms as psychiatric rather than symptoms of physical illness [42]. This, and the resultant non-treatment of the physical condition, has been a consistent problem for psychiatry [43]. Real world causes (e.g., lack of sleep, low thyroid, family disturbances, poor schools) are commonly ignored in psychiatry, where everything boils down to unsubstantiated and untestable “chemical imbalances” in the brain.

Making matters worse, both antidepressants and antipsychotics are largely ineffective. A 15-year follow-up study published in the Journal of Nervous and Mental Disease in 2007 found that schizophrenics treated without antipsychotic drugs were functioning significantly better than those given drug treatment at 4.5, 7, 10 and 15 years [44].

The most important study of antipsychotics in recent times, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), published in 2005 in The New England Journal of Medicine, concluded, “The majority of patients in each group discontinued their assigned treatment owing to inefficacy or intolerable side effects or for other reasons” [45]. The vast majority of patients discontinued treatment within 3 – 5 months. The “Duration of successful treatment” was 3 months for one drug and 1 month for all the others [46].

A 2002 review of 47 studies on antidepressant drugs, the actual studies that the FDA used for approving six newer antidepressants, found the drugs to be only slightly more effective than placebo, a difference that may simply reflect the enhanced placebo effect of the drugs [47]. Healy puts it very directly: “… we have little solid evidence that antidepressants actually work” [48].

The bottom line is easily stated: psychiatric drugs are extremely toxic and very ineffective. One might think that this would call for caution in prescribing them to children; but just the opposite is occurring.

According to a 2006 study in the journal Ambulatory Pediatrics, “The overall frequency of antipsychotic prescribing increased from 8.6 per 1,000 U.S. children in 1995-1996 to 39.4 per 1,000 US children in 2001-2002” [49]. A similar report in the Archives of General Psychiatry founded that, “In the United States, the estimated number of office-based visits by youth that included antipsychotic treatment increased from approximately 201,000 in 1993 to 1,224,000 in 2002” [50].

A 2008 British study on the increasing use of antipsychotics, published in the Journal of Child and Adolescent Psychopharmacology, noted that “There have been numerous reports of adverse drug reactions associated with atypical antipsychotic use in children and adolescents, including neuroleptic malignant syndrome, weight gain, metabolic abnormalities, diabetic ketoacidosis, hepatotoxicity, and hyperprolactinemia” [51].

A recent study published in the Archives of Pediatrics and Adolescent Medicine found that children and adolescents treated with antipsychotics were twice as likely as those treated without antipsychotics to be obese, over three times as likely to have type 2 diabetes, and nearly three times as likely to suffer from cardiovascular conditions. The study concluded, “Antipsychotics are associated with several metabolic and cardiovascular-related adverse events in pediatric populations, especially when multiple antipsychotics or classes of psychotropic medications are co-prescribed, controlling for individual risk factors” [52].

USA Today review of FDA data from 2002 – 2004 uncovered 45 deaths in which antipsychotics were listed as the primary suspect. Six deaths were related to diabetes. An 8-year-old boy died of cardiac arrest [53].

With antipsychotics being prescribed at increasingly younger ages and for an increasingly broad spectrum of behaviors, with no regard to their poisonous profile, it would not be surprising to find those labeled seriously mentally ill dying even earlier in the future. This would, of course, raise the number of years of life lost figure. How much is anyone’s guess. Another 15-year increase like the one we’ve just seen would take it to a minimum of 40 years of potential life lost and, in several states, bring it in line with murder statistics.

Conclusion

As the studies above reveal, suicides like Gabriel Myers and the deaths of mental patients as a result of the toxic effects of the drugs they are given – often by force – are not uncommon. The psychiatric treatment of both adults and children, resulting in their early deaths, demonstrates a callous indifference to their lives and to life itself. For the mortality statistics of mental patients to even approach those of murder victims, and for those responsible for their treatment to watch this happen for thirty years and do nothing, is inexcusable; for this to happen while drug companies and psychiatrists do everything they can to hide the deadly effects of their treatments, is unconscionable. For those in charge of mental health care to continue, in the face of both of these facts, to push for the psychiatric screening and drugging of children at ever younger ages, is the very definition of malice aforethought.

It is time that we begin calling the deaths of young and old alike, at the hands of psychiatrists and their accomplices, what it is: murder.

References

1. Miller, Carol, “Broward child’s suicide raises questions about medication,” Miami Herald, April 21, 2009.

2. Id.

3. Black’s Law Dictionary, Eighth Edition, 2004, p. 1043.

4. See Words and Phrases, Vol. 26, pp. 315-327, West Group, publisher, 2003. Words and Phrases is a compilation of thousands of judicial definitions or words and phrases, with citations of the cases involved.

5. Dillon, Nancy, “Andrew Gallo charged with 3 counts of murder in crash that killed Angels pitcher Nick Adenhart,” New York Daily News, April 10, 2009.

6. CBS, 60 Minutes, “Is it murder?”, January 4, 2009.

7. Id.

8. Id.

9. The first statistic comes from Mothers Against Drunk Driving (http://www.madd.org/Drunk-Driving/Drunk-Driving/Statistics.aspx). The second can be found at: http://www.alcoholalert.com/drunk-driving-statistics-2002.html.

10. Mothers Against Drug Driving, 2009. Statistic available at: http://www.madd.org/Drunk-Driving/Drunk-Driving/Statistics.aspx.

11. Words and Phrases, Vol. 28, p. 53.

12. Meier, Barry and Carey Benedict, “Drug Maker Is Accused of Fraud,” New York Times, February 25, 2009.

13. See the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), p. 745: “Akathisia may be associated with dysphoria, irritability, aggression, or suicide attempts…. Akathisia can develop very rapidly after initiating or increasing neuroleptic [antipsychotic] medication.” See also, Healy, D., Herxheimer, A., Menkes, D.B., “Antidepressants and Violence: Problems at the Interface of Medicine and Law,” Public Library of Science Medicine 3 (9): e372, Sept. 12, 2006. Available at: http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030372. The authors state that there is “consensus that it [akathisia] can be linked to both suicide and violence.” Also, Peters, Brandon, M.D., About.com Guide to Sleep Disorders, “Insomnia Doubles the Risk of Suicide,” April 9, 2009. Dr. Peters writes, “Research linking insomnia to an increased suicide risk has been extended to those without psychiatric illness. Previous studies have shown the association among the mentally ill and teenagers, but a new study suggests they are not the only populations at risk.”

14. Kumar, R. and Sachdev, P.S., “Akathisia and second-generation antipsychotic drugs,” Current Opinion in Psychiatry, 22:293–299, May, 2009 (printed online in advance of publishing).

15. Bratti, I.M., Kane, J.M., Marder, S. R., “Chronic Restlessness with Antipsychotics,” American Journal of Psychiatry, 164:11, pp. 1648 – 1654.

16. Burstein, Jon, “Preliminary investigation indicates 7-year-old died by hanging,” South Florida Sun Sentinel, April 17, 2009.

17. Miller, Carol, “Broward child’s suicide raises questions about medication,” Miami Herald, April 21, 2009.

18. Allen, Scott, “Backlash on bipolar diagnoses in children,” The Boston Globe, June 17, 2007.

19. Miller, Carol, op. cit.

20. Healy, David, 2006. “An antidepressant tale: figures signifying nothing?” Advances in Psychiatric Treatment, Vol. 12, 320-328. Quote on page 323. (Healy demonstrates that studies purportedly showing no effect of SSRIs on suicidality actually show clear effects in the direction of increasing suicidality.)

21. Id.

22. Sherman, Carl, 2002. “Antisuicidal Effect Of Psychotropics Remains Uncertain: ‘We have to ask if medication is the only way’ to approach the prevention of suicide,” Clinical Psychiatry News, Vol. 30, Issue 8, p. 1. See also, Perina, Kaja, “Meds are no defense against suicide,” Psychology Today, September/October 2002, p. 20

23. Tilstone, W. J., Savage, K. A., Clark, L. A., Encyclopedia of Forensic Science, Published by ABC-CLIO, 2006, p. 74.

24. Degrandpre, Richard, 2002. “The Lilly Suicides,” available online at http://www.namiscc.org/News/2002/Fall/TheLillySuicides.htm

25. Id.

26. Healy, David, “Antidepressant Induced Suicidality,” Primary Care Psychiatry, 6, 2000.

27. National Association of State Mental Health Program Directors (NASMHPD), “Morbidity and Mortality in People with Serious Mental Illness,” October, 2006, p. 11.

28. Ibid., p. 14.

29. Ibid., p. 11.

30. Elias, Marilyn, May 3, 2007. Mentally ill die 25 years early, on average. USA Today. Available at: http://www.usatoday.com/news/health/2007-05-03-mental-illness_N.htm.

31. United States Department of Justice, Bureau of Justice Statistics, 2007. Available at: http://www.ojp.usdoj.gov/bjs/homicide/tables/meanagetab.htm

32. National Center for Health Statistics (June 11, 2008). U.S. Mortality Drops Sharply in 2006, Latest Data Show. Available at: http://www.cdc.gov/nchs/PRESSROOM/08newsreleases/mortality2006.htm

33. National Center for Health Statistics (2007). Health, United States, 2007, p. 175.

34. Tsuang, M.T., Woolson, R.F., Fleming, J.A., “Premature deaths in schizophrenia and affective disorders,” Archives of General Psychiatry, 37 (9): 979-983, September 1980.

35. Osby U, Correia N, Brandt L, Ekbom A, Sparen P. (2000). Time trends in schizophrenia
mortality in Stockholm County, Sweden: cohort study. British Medical Journal, 321(7259): 483-484.

36. Hannerz, H., Borga P., and Borritz, M. (2001). Life expectancies for individuals with psychiatric diagnoses. Public Health, 115, 328–337.

37. Sukanta Saha, MSc, MCN; David Chant, PhD; John McGrath (2007). A Systematic Review of Mortality in Schizophrenia. Arch Gen Psychiatry,64(10):1123-1131.

38. Gianfrancesco, Frank D., Grogg, Amy L., Mamoud, Ramy A., Wang, Ruey-Hua, Nasrallah, Henry A., 2002. Cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: Results of the CLAMORS Study, J. Clinical Psychiatry 63, 920-930.

39. Mackin, Paul, et al., 2007. Metabolic disease and cardiovascular risk in people treated with antipsychotics in the community, British Journal of Psychiatry, 191, 23-29.

40. American Diabetes Association, “Diabetes, Heart Associations Align Fight Against Heart Disease,” December 27, 2006. Available at: http://www.diabetes.org/uedocuments/ADA-AHAFINAL.pdf.

41. NASMHPD, op. cit., p. 6.

42. Ibid., p. 17.

43. Koran, L., Sox, H., Marton, K, et al. (1989). Medical evaluation of psychiatric patients. I. Results in a state mental health system. Archives of General Psychiatry, 46, 733-740. Koran, L., Sheline, E., Imai, K., Kelsey, T.G., et al. (2002). Medical Disorders Among Patients Admitted to a Public Sector Psychiatric Inpatient Unit. Psychiatric Services 53, 1623-1625.

44. Harrow, M, Jobe, T.H., “Factors Involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medications: A 15-year Multifollow-up Study,” Journal of Nervous and Mental Disease, 195(5), May 2007.

45. Lieberman, J, et al. “Effectiveness of antipsychotic drugs in patients with schizophrenia.” New England Journal of Medicine 353 (2005):1209-1233.

46. Id.

47. Irving Kirsh et al., “The Emperor’s New Drugs: An Analysis of Antidepressant Medication Data Submitted to the U.S. Food and Drug Administration,” Prevention and Treatment, Vol. 5, Article 23, July 15, 2002.

48. Healy, David, “An antidepressant tale: figures signifying nothing?” Advances in Psychiatric Treatment, Vol. 12, 320-328, 2006. Quote on page 323.

49. Cooper, William O., Arbogast, Patrick G., Ding, Hua, et al., 2006. Trends in Prescribing of Antipsychotic Medications for US Children, Ambulatory Pediatrics 6, 79-83. Quote on p. 79.

50. Olfson, M.; Blanco, C.; Moreno, C.; Laje, G., “National trends in the outpatient treatment of children and adolescents with antipsychotic drugs,” Archives of General Psychiatry, 63(6): 679-85, June, 2006.

51. Rani, L., Murray, M.L., Byrne, P.J., Wong, I.C.K., (2008). Epidemiological Features of Antipsychotic Prescribing to Children and Adolescents in Primary Care in the United Kingdom. Pediatrics, 121, 1002-1009.

52. McIntyre, R.S. and Jerrell, J.M., 2008. Metabolic and Cardiovascular Adverse Events Associated with Antipsychotic Treatment in Children and Adolescents. Archives of Pediatrics and Adolescent Medicine, 162 (10), 929-935.

53. Elias, Marilyn, May 2, 2006. New antipsychotic drugs carry risks for children. USA Today. Available at: http://www.usatoday.com/news/health/2006-05-01-atypical-drugs_x.htm.