On February 1, Allen Frances, MD, published an interesting article on the Huffington Post blog. The article is called Do Antipsychotics Help or Harm Psychotic Symptoms?, and is a response to Robert Whitaker’s post of January 27: “Me, Allen Frances, and Climbing Out of a Pigeonhole. This post, in turn, was a response to Dr. Frances’s Psychiatric Medicines Are Not All Good or All Bad, which was published in the Huffington Post on January 15. Readers may remember that I published a critique of this latter article on February 9.
A detailed analysis of the debate between Dr. Frances and Robert Whitaker is beyond the scope of this article. My primary observation is that in his February 1 response, Dr. Frances does not address the points that Robert made on January 27. Instead, he sets up caricatures of these points, and dispatches these caricatures with the skill and verve of a shadow-boxer who imagines he is engaged in genuine combat.
My present purpose is to take a closer look at Dr. Frances’s February 1 article, and to spell out some of its implications. Here are some quotes, interspersed with my comments.
“Bob’s [Robert Whitaker’s] advocacy is ambitious, global, and future oriented- requiring a radical reconception of the US approach to people with psychosis. I am preoccupied more by the desperate, unmet needs of patients living dreadful lives in the current moment. In furthering his long range agenda, I believe Bob is misjudging what is best for severely ill people in the present. His recommended ideal treatment can only have a chance of success in an ideal treatment system. People who might do well with less medicine in his ideal world often get in terrible trouble if they try to stop medicine in our shamefully neglectful real world.”
Note the truly exquisite spin. Robert is “ambitious, global, and future-oriented”, while Dr. Frances is the humble pragmatist rising tirelessly to the daunting challenge of meeting the “unmet needs” of desperate “patients”.
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“Bob acts as if there is an inherent tension between service users and psychiatric providers. I see the current animosity as an unfortunate and idiosyncratic phenomenon, peculiar to the US, and partly contributed to by Bob’s own passionate and somewhat misleading rhetoric.”
This is a huge issue. The heart of the matter is that there is “tension” between psychiatrists, on the one hand, and some of their former clients, on the other. Dr. Frances’s contention is that this conflict is not inherent, but, rather, is “an unfortunate and idiosyncratic phenomenon”, for which Robert Whitaker is, at least partly, to blame.
The reality, of course, is quite different. There is indeed “tension” between psychiatrists and many of their former clients. This “tension”, which I would call out-and-out conflict, also embraces a very large, and growing, number of other mental health professions and members of the general public. This conflict has arisen because:
- Psychiatry’s definition of a mental disorder/mental illness embraces every significant problem of thinking, feeling, and/or behaving, and psychiatry has been using this definition to medicalize problems that are not medical in nature for more than fifty years.
- Psychiatry routinely presents these labels as the causes of the specific problems, when in fact they are merely labels with no explanatory significance.
- Psychiatry has routinely deceived, and continues to deceive, their clients, the public, the media, and government agencies, that these vaguely defined problems are in fact illnesses with known neural pathology.
- Psychiatry has blatantly promoted drugs as corrective measures for these illnesses, when in fact it is well-known in pharmacological circles that no psychiatric drug corrects any neural pathology. Indeed, the opposite is the case. All psychiatric drugs exert their effect by distorting or suppressing normal functioning.
- Psychiatry has conspired with the pharmaceutical industry in the creation of a large body of questionable, and in some cases fraudulent, research, all designed to “prove” the efficacy and safety of pharma products.
- A great many psychiatrists have shamelessly accepted pharma money for very questionable activities. These activities include the widespread presentation of infomercials in the guise of CEUs; the ghost-writing of books and papers which were actually written by pharma employees; the promotion of new drugs and “diagnoses” by paid psychiatric “thought leaders”; the publication of fraudulent advertising in psychiatric peer-reviewed journals; the acceptance of pharmaceutical money by the APA; targeting of captive and otherwise vulnerable audiences in nursing homes, group homes, and foster-care systems for prescription of psychiatric drugs; etc., etc…
- Psychiatry’s spurious diagnoses are inherently disempowering. To tell a person, who in fact has no biological pathology, that he has an incurable illness for which he must take psychiatric drugs for life is an intrinsically disempowering act which falsely robs people of hope, and encourages them to settle for a life of drug-induced dependency and mediocrity.
- Psychiatry’s “treatments”, whatever tranquilizing effects or transient feelings of well-being they may induce, are almost always destructive and damaging in the long-term, and are frequently administered involuntarily.
- Psychiatry’s spurious and self-serving medicalization of every significant problem of thinking, feeling, and/or behaving, effectively undermines human resilience, and fosters a culture of powerlessness, uncertainty, and dependency. Relabeling as illnesses, problems which previous generations accepted as matters to be addressed and worked on, and harnessing billions of pharma dollars to promote this false message is morally repugnant.
- Psychiatry neither recognizes nor accepts any limits on its expansionist agenda. In recent years, they have even stooped to giving neuroleptic drugs to young children for temper tantrums, under the pretense that these children have an illness called disruptive mood dysregulation disorder.
The anti-psychiatry movement has been in existence, and vocal, for decades. But it had been successfully marginalized and ridiculed by pharma-psychiatry until the explosion of Internet access provided a voice that even pharma-psychiatry couldn’t silence. Robert Whitaker has been a powerful, reasoned, and if I may say, restrained voice in these endeavors, and Mad in America is at this time one of the primary outlets for anti-psychiatry views and information. But blaming the world-wide anti-psychiatry sentiment on Robert is a bit like blaming news reporters for wars, plagues, famines, and natural disasters. It’s not only false, but betrays a fundamental disconnect with reality. The anti-psychiatry movement exists because psychiatry is something fundamentally flawed and rotten. And it is fundamentally flawed and rotten because its leaders have made it so.
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“Bob’s misreading fails to take into account the fact that psychotic presentations vary greatly in cause, severity, chronicity, prognosis, and appropriate treatment. Many psychotic episodes are transient. Some are stress related- eg a soldier in combat, a college kid or traveller who becomes delusional when away from home. Some are a transient part of mood disorder and remain quiescent if the mood disorder is successfully treated. Some are related to substance intoxication or withdrawal. Some are caused by head trauma or medical illness. And some normal people have hallucinatory experiences that cause no impairment and have no clinical significance. Transient psychotic symptoms in the above situations may require a short course of antipsychotics, but these should be gradually tapered after the episode has resolved. Generally this can be done without much risk of return of psychosis- assuming the stressor, substance problem, mood disorder, or medical problem has resolved. Bob and I would agree on short term or no antipsychotic treatment for such transient psychoses.”
Once again, note the spin. Robert Whitaker’s article was about people who had been labeled schizophrenic, but Dr. Frances is “refuting” Robert’s contentions by focusing on “psychotic episodes” that clearly do not meet the APA’s criteria for schizophrenia. This discrepancy persists throughout Dr. Frances’s post. In Robert’s article the word “schizophrenia” occurs 12 times, but in Dr. Frances’s response, the word is nowhere to be found. Dr. Frances is obviously aware of these distinctions, and it’s extremely difficult to put a benign interpretation on this kind of obfuscation.
The central point of Robert’s paper is, I believe, contained in the following passage:
“Every important detail from the conventional narrative, which tells of a great medical advance, can basically be filed under the heading of ‘not really true.’ The arrival of the antipsychotics into asylum medicine did not lead to deinstitutionalization; a change in social policy did. The dopamine theory of schizophrenia arose from an understanding of how drugs acted on the brain, and not from an understanding of what was going on in the brains of people so diagnosed, and when researchers looked to see whether people diagnosed with schizophrenia had overactive dopamine systems as a matter of course, they didn’t find that to be so. The drugs were not like insulin for diabetes. Nor was there evidence that the arrival of the antipsychotics kicked off a great advance in outcomes for schizophrenia patients. Indeed, in a 1994 paper, Harvard researchers reported that long-term outcomes were now no better than they had been in the first third of the 20th century, when water therapies were a mainstay treatment.
In contrast, a scientific understanding of antipsychotics supported the patients’ counter-narrative. Thorazine, Haldol, and other first-generation antipsychotics powerfully blocked dopamine pathways in the brain, which reduced one’s capacity to respond emotionally to the world and to move about it. Hence the zombie feeling. Antipsychotics did cause brain damage, as could be seen in the twitchings of people who developed tardive dyskinesia after years on these drugs. Moreover, research had shown that in compensatory response to the drug’s blockade of dopamine receptors, the brain increased the density of its dopamine receptors, and, there was reason to worry that this increased the person’s biological vulnerability to psychosis. Given these facts, there was plenty of reason for people diagnosed with schizophrenia and other psychotic disorders to want to stop taking them.
In terms of the ‘evidence base’ cited by psychiatry for its use of the drugs, which is held up by psychiatry as its trump card in this battle of narratives, it is easy to see that the evidence for long-term use is flawed. Researchers had conducted any number of studies in which a group of stabilized patients were either maintained on an antipsychotic or abruptly withdrawn from the drug, and with great regularity, the drug-withdrawal group relapsed at a higher rate. This was seen as proving that continual drug use lowered the risk of relapse, and thus provided evidence for maintaining patients indefinitely on the medication. But, of course, another conclusion to be drawn is that the high relapse rate is a drug-withdrawal effect, and not evidence of the long-term risk of relapse in unmedicated patients. The relapse studies also didn’t provide any evidence about how well schizophrenia patients functioned on the drugs, or their quality of life, particularly over the long term.”
Note that the word “schizophrenia” occurs five times in this passage alone, and it is clear that Robert is referring to individuals who have been labeled schizophrenic and who have been “treated” from that perspective. Dr. Frances’s discussions concerning transient “psychotic episodes” are not pertinent, particularly in the light of psychiatry’s long-held insistence that “schizophrenia” is a life-long degenerative illness.
So it’s not a case of Robert Whitaker misreading the matter, but rather one of Dr. Frances miswriting the matter.
Nor is the miswriting inconsequential. By juxtaposing the terms “schizophrenia” and “transient psychotic symptoms”, Dr. Frances has managed to convey the impression that he personally favors a more selective and tapered approach to neuroleptic drugs than that which has been typically adopted by psychiatrists since the drugs first came on the market. This approach has been: keep taking the “medications” even after a first episode has been successfully “treated”.
Dr. Frances is also conveying the impression that he has favored a less-is-more approached since the ’60s:
“I began my career in psychiatry in the mid 1960s, just when antipsychotics were first being used widely. The new meds dramatically improved psychotic symptoms, but equally dramatically produced dreadful side effects, especially in the ridiculously high doses then being tried.”
“Troubled by this, I was one of the principal investigators on a multisite NIMH funded study testing the feasibility of two new approaches to reducing medication burden. The first was very low dose treatment; the second was expectant treatment, with meds used intermittently only when patients needed them. Patients were randomly assigned to 3 conditions: 1) standard dose injectible med; 2) one-fifth standard dose injectible med; 3) placebo injection with oral meds added as needed. All three groups also received intense individual and family therapy and social support, often done in the home. Many patients in the low dose and expectant groups did well, but the catastrophes were sometimes catastrophic and irreversible. I became convinced that the risks of going off meds for people with chronic psychosis usually overwhelm the benefits. It is the patients’ decision to make, but my advice has been not to rock the boat when chronic psychotic symptoms are responding to meds. Stay on the lowest possible dose, but stay on it over time. When psychosis has been chronic, the risks of discontinuing medication usually far outweigh the benefits.”
As I mentioned in my earlier article, I have been unable to find this particular study, and Dr. Frances provides no reference, so I have no way of ascertaining the methodology or the formal outcome/conclusions. It does seem odd that Dr. Frances would refer to a piece of research in two successive articles without providing a citation to enable his readers to access the study.
Dr. Frances’s subjective assessment that the “catastrophes were sometimes catastrophic and irreversible” and his equally subjective conviction that “the risks of discontinuing medication usually far outweigh the benefits” are interesting, but obviously are subject to the kind of selection bias that formal studies are designed to overcome. Dr. Frances saw individuals come off the “meds”, and subsequently crash and burn, but by the same token, those individuals who came off the “meds” and did well, wouldn’t necessarily have come to his attention. Indeed, it is entirely credible that many of these latter individuals would have actively avoided the ministrations of psychiatry.
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“Antipsychotics have many grave disadvantages that make them a last resort. They suppress symptoms, rather than curing them. They can cause unpleasant side effects and dangerous medical complications. They contribute to shortened life expectancy. And they are subject to wide overuse even when there is no indication. We should be extremely cautious and selective in their use quite independent of Bob’s tenuous claim that they worsen psychosis.”
This paragraph is interesting, particularly when compared with The Expert Consensus Guidelines for the Treatment of Schizophrenia published by Dr. Frances and his two colleagues, John Docherty, MD, and David Kahn, MD in 1996 (Journal of Clinical Psychiatry, Volume 57, Supplement 12B). The final chapter in this supplement (p 51-58) is “A Guide for Patients and Families”. Here are some quotes:
“Schizophrenia is a disorder of the brain like epilepsy or multiple sclerosis. This brain disorder interferes with the ability to think clearly, know what is real, manage emotions, make decisions, and relate to others” (p 51)
“Ongoing antipsychotic medication is necessary in both the acute and preventive phases. During the acute phase, medications help relieve the positive symptoms that are often out of control. After the acute phase ends, ongoing antipsychotic medication greatly reduces the chances that acute symptoms will recur (a relapse).” (p 52) [Boldface in original text]
“The drugs used to treat schizophrenia are called antipsychotics. They help relieve the delusions, hallucinations, and thinking problems associated with the disease. These drugs appear to work by correcting an imbalance in the chemicals that help brain cells communicate with each other.” (p 53)
There is no evidence that the individuals whom psychiatry labels as schizophrenic have an imbalance in their brain chemicals. Nor is there any evidence that neuroleptic drugs correct any neurological problem. In fact, they are neurotoxic.
“The newer drugs are called atypical antipsychotics because they are less likely to cause some of the annoying and distressing side effects associated with the conventional antipsychotics.” (p 53)
So, the side effects which today Dr. Frances calls “dreadful”, and which he concedes cause “dangerous medical complications” and “shortened life expectancy”, he characterized in 1996 as “annoying and distressing”. And this is not because any new information has been uncovered. The devastating adverse effects of these products had been known for at least 30 years when Drs. Frances, Docherty, and Kahn (incorporated ironically as Expert Knowledge Systems, LLC) produced the document. And given that the chapter in question is “A Guide for Patients and Families”, it is difficult to interpret this understatement as anything other than a deliberate attempt to deceive the target audience, and to counter any resistance individuals might have to ingesting these products.
“Usually patients respond well to treatment of a first episode of schizophrenia, but if there are repeated episodes or schizophrenia, symptoms sometimes persist despite treatment with the standard antipsychotic medications. Fortunately, the newer drugs can often help patients whose symptoms no longer respond to the standard antipsychotic medications. For such patients, the experts recommended that risperidone be tried first.” (p 53)
Incidentally, the Treatment Guidelines were funded by a grant from Janssen Pharmaceutica, the manufacturer of risperidone. The promotion of risperidone, which is clearly evident throughout the guidelines, is not a coincidence. It has been reported (here) that on July 3, 1996, Drs. Frances, Docherty, and Kahn (as Expert Knowledge Systems) wrote to Janssen:
“We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.” (p 16)
This matter is in the public record (Texas v. Janssen LP, D-1GV-04-001288, District Court, Travis County, Texas), and has been reported by several writers, including Paula Caplan, PhD, but has never, to the best of my knowledge been addressed by Dr. Frances or either of his colleagues, although the venality of the statement is extreme even by psychiatric standards. Drs. Frances, Docherty, and Kahn were reportedly paid $515,000 by Johnson and Johnson (owners of Janssen) for their work on the guidelines.
Back to the Treatment Guidelines document:
“The good news is that schizophrenia is very treatable. A cure for schizophrenia, like diabetes, has not yet been found, but the symptoms can be controlled with medication in most people. Prospects for the future are constantly brighter through the pioneering explorations in brain research and the development of many new drugs. To achieve good results, however, you must stick to your treatment and avoid substance abuse. Be sure to take your medicine as directed. Even if you have felt better for a long time, you can still have a relapse if you stop taking your medication.” (p 54) [Boldface in original text]
“Because people with schizophrenia have to take their medications for a very long time, often for their whole life, it is very important to recognize and try to treat any side effects they may have from these medications.” (p 54)
“For patients who don’t take their medication regularly, more active interventions are likely to be needed to be sure the patient takes medications. There are community treatment programs in which staff frequently go see patients and may give them their medications. For such patients, the experts also recommended day hospitals where patients go 3-5 days a week and participate in several hours of programming that help insure that medication is taken.” (p 56) [Italics in original text]
“The most important factor in keeping patients with schizophrenia out of the hospital is having them take their medications regularly. The best compliance with treatment is obtained when the family works with the patient to help him or her remember the medicine. Sometimes long-acting injectable forms of medication are used when patients find it hard to take a pill every day.” (p 57)
The above quotes call into question Dr. Frances’s present assertion that coming off the “meds” is “the patient’s decision to make”. This is even clearer in the guidelines proper where under the heading “Intervention During Continuation and Maintenance Treatment”, it states unambiguously:
Medication responsive patient – frequently not compliant ■ Assertive community treatment (ACT); Day hospital with medication management. (p 11)
There are a great many other passages in the schizophrenia treatment guidelines that indicate that Drs. Frances, Docherty, and Kahn promoted the use of neuroleptic drugs on a more or less indefinite basis. The Schizophrenia Treatment Algorithm on pages 13 and 14, for instance, sets out in schematic form the treatments and adjustments that should be made in a variety of emerging situations. In none of these situations is it suggested that the “medications” be stopped or that such a move even be considered.
But, in fairness to Dr. Frances and his colleagues, I have to acknowledge that there is a section headed “Psychosocial interventions” on page 11 of the guidelines. Here’s the entire passage:
- Ensure continuity from inpatient to outpatient care (e.g., schedule first outpatient appointment within 1 week of discharge, give enough medication to last until that appointment, telephone follow-up if patient misses appointment)
- Psychoeducation for family to support and encourage medication compliance”
Incidentally, in the treatment algorithm mentioned earlier, under the neuroleptic complication “Agitation or insomnia”, only one intervention is given: “Add benzodiazepine”.
In this context it needs to be stressed that the Schizophrenia Treatment Guidelines were widely distributed and influential. Indeed, this was the intention from the start. Here’s another quote from David Rothman’s expert testimony:
“The guideline team [Drs. Frances, Docherty, and Kahn] promised wide distribution of its product, including publication in a journal supplement. The team was prepared to have J&J participate in its work, not keeping the company even at arms length. With a disregard for conflict of interest and scientific integrity, the group shared its drafts with J&J. On June 21, 1996, Frances wrote Lloyd [John Lloyd, J&J’s Director of Reimbursement Services]: ‘We are moving into the back stretch and thought you would be interested in seeing the latest draft of the guidelines project….Please make comments and suggestions.’ (Italics added). So too, the group was eager to cooperate with J&J in marketing activities. Frances wrote without embarrassment or equivocation: ‘We also need to get more specific on the size and composition of the target audience and how to integrate the publication and conferences with other marketing efforts’ (Italics added)” (p 15)
Back to Dr. Frances’s current article:
“This debate does have serious real world consequences. There is no more momentous decision in the life of someone who has had psychotic symptoms than whether or not to stop meds- and it always comes up in the treatment, often repeatedly. If the person’s symptoms have been brief and not life threatening, I fully encourage a decision to gradually taper and then stop. It is, under these circumstances, definitely worth the fairly minor risk of relapse to avoid the major risk of medication side effects and complications. Many of Bob’s most enthusiastic followers are in this category- harmed by prolonged overtreatment for transient problems.”
But there’s a catch 22. For a “diagnosis of schizophrenia”, the DSM requires the presence of two or more of five “characteristic symptoms” for a significant portion of time during a one-month period “or less if successfully treated” [emphasis added]. And when this “diagnostic” determinant is coupled with psychiatry’s long-standing preference to use the drugs as the “treatment” of first resort, it is clear that the concept of transience in this context becomes meaningless. There is no way of knowing if a person’s “symptoms” have been brief, if they are routinely suppressed with neuroleptic drugs as soon as they become evident. The individual is still eligible for a “diagnosis of schizophrenia”, (a “life-long disease”) and will be pressured relentlessly by psychiatrists and the mental health system to continue to take the “meds” indefinitely. And this is a situation to whose making Dr. Frances has been a major contributor.
Of course, we can all make mistakes, and we can all learn from our mistakes. And if Dr. Frances is saying that his earlier enthusiasm for neuroleptic drugs and his downplaying of the entailed risks were mistakes, that would be one thing. But to suggest that he has always been a proponent of moderation and restraint in this area is, I suggest, a distortion of the readily checkable historical facts.
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Interesting as all these matters are, there is a much more fundamental issue that seldom gets aired: the nature and effects of neuroleptic drugs. In recent years, psychiatrists and pharma have been promoting the term “antipsychotics” for these products, denoting that they eliminate, or correct, psychotic thoughts in the same way, for instance, that antibiotics eliminate germs. In fact, the term antipsychotic is much more a marketing device than an accurate descriptor, and it is to psychiatry’s shame that they have adopted and promoted the term so enthusiastically. What these drugs are, and what they were originally called, is major tranquilizers. Back in the 60’s and 70’s, their action was routinely likened to piling damp grass on a fire. The fire wouldn’t go out, but its action and intensity were greatly reduced. Nor are the actions of these products specific to psychotic thoughts and speech. They suppress all activity. In fact, they don’t normally eliminate delusions or hallucinations; rather they render the individual indifferent to them. In the 50’s, the action of chlorpromazine, the first major tranquilizer, was likened to a chemical lobotomy.
A second factor that needs to be recognized is that people very seldom enter psychiatry’s orbit on the grounds of craziness alone. One can be as crazy as one likes in the privacy of one’s home. And indeed, I suggest that most of us adhere to some notions that would meet psychiatry’s definition of delusions: “A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.” (DSM-5, p 819). I, for instance, believe that there are no mental illnesses: that the medicalization of all significant problems of thinking, feeling, and/or behaving is a hoax, designed to enhance psychiatry’s prestige, and to sell pharma products. I occasionally receive emails and comments suggesting that I must be crazy to entertain such ideas, and I suppose, from psychiatry’s point of view, my beliefs could be considered delusional. But, oddly enough, I’ve never been picked up on a 72-hour hold, or court-ordered to have a psychiatric evaluation. Even if I were to stand peacefully on the sidewalk in front of a mental health center distributing anti-psychiatry pamphlets, it is unlikely that I would be molested, though I might be asked to keep a certain distance back from the door and not to impede pedestrian traffic, etc…
But, if I go inside the building and start noisily and agitatedly berating the psychiatrists, and tearing down the pharma-distributed infomercial posters, I will likely be arrested within five minutes. And if I continue to express my views in a loud and agitated manner at the police station, and if my general presentation seems odd or eccentric, it is possible that I will be remanded to a psychiatric facility for a 72-hour evaluation, and will be assigned “a diagnosis of schizophrenia”.
This is the critical point. It is the expression of unusual or non-conformist views, coupled with expressions of anger, agitation, and aggression, that precipitates many of these “diagnoses of schizophrenia” and subsequent “medical” incarcerations. It is certainly possible for an individual to find himself in this situation without any display of anger or agitation. But in many cases, it is presentations of this kind that draw official attention and result in civil commitment, incarceration, and forced drugging, even though the person may not have committed any crime. And yet, amazingly, it is almost unheard of for these interventions to entail any inquiry into the source(s) of the agitation or any attempt to ameliorate the anger in any way other than with tranquilizing drugs.
The central issue is not whether “antipsychotics” are effective in the treatment of “schizophrenia”, but rather, whether major tranquilizers are effective in the suppression of anger, agitation, and aggression. And of course, they are, provided we discount the fairly common adverse effect of akathisia, the manifestation of which, incidentally, according to Dr. Frances’s own Guidelines, may be confused with – and the irony of this is beyond words – “psychotic symptoms”. (p 55). (In other words, one of the long-established adverse effects of the drugs is to make a person seem crazy – and, presumably, eligible for more “treatment”!) But, for the most part, the drugs are strong tranquilizers which reduce general activity and speech, and dampen feelings and emotions.
Neuroleptic drugs have often been called chemical straightjackets. And the question as to whether or not these products should be used to control agitation, anger, and aggression, is not a medical matter. It is a human rights/legislative issue. The use of physical restraints by law enforcement officers is subject to ongoing legislative and judicial oversight, but the use of chemical restraints by psychiatrists is effectively unregulated. The fundamental question is not: are antipsychotic medications effective in the treatment of schizophrenia, but rather: is it morally acceptable to use major tranquilizers, that have devastating adverse effects, as chemical restraints, frequently for years and even decades? It is time to start calling a spade a spade; and it is beyond time for legislative and judicial bodies to recognize the abuse and deception in this area and to take appropriate action. There is a pressing need to recognize that these products are not medications in any ordinary sense of the term. They are chemical restraints.