Antipsychotic Usage And Kids In State Custody
70 CommentsBy Ed Silverman // May 23rd, 2011 // 10:08 am
In the latest example of who antipsychotics are being prescribed inappropriately, Florida’s state-run jails and residential homes are regularly giving large doses of the meds but not for uses that were approved by the FDA. And in some cases, the drugs are prescribed by contract doctors who have taken speaking fees and other gifts from drugmakers, according to The Palm Beach Post.
As a result, the state’s Department of Juvenile Justice has ordered a review. “The questions recently brought to our attention are serious, and deserve answers based on a careful, thorough and independent review of the facts,” DJJ Secretary Wansley Walters tells the paper, which ran a two-part series about the problem (read here and here).
The series raises familiar questions about the extent to which antipsychotics are prescribed to vulnerable populations. This has been raised in connection with the elderly in nursing homes, in particular. A recent report the US Department of Health & Human Services Office of Inspector General found that the pills were marketed inappropriately (read here). Johnson & Johnson is fighting such allegations in a whistleblower lawsuit charging kickbacks (back story).
And Florida has previously encountered controversy over the use of these meds in children. In 2009, a 7-year-old foster boy committed suicide and a state task force recommended, among other things, that children never be allowed to participate in a clinical trial designed to evaluate new psychotropic meds or whether (see this).
A few findings from the Post: In 2007, DJJ bought more than twice as much Seroquel as ibuprofen. Overall, in 24 months, DJJ bought 326,081 tablets of Seroquel, Abilify, Risperdal and other antipsychotics for use in state-operated jails and homes for children. That works out to 446 pills a day, seven days a week, for two years in a row, to kids in jails and programs that can hold no more than 2,300 boys and girls on a given day, the paper writes.
Most Seroquel tablets, by the way, were high dose, 400mg pills. For those who may not recall, AstraZeneca recently agreed to pay $68.5 million to 36 states and for for marketed the pill for unapproved uses to treat both children and the elderly. Among those unapproved uses: Alzheimer’s Disease, dementia, anxiety, depression, sleep disorders and post traumatic stress disorder (see this).
The Post also writes that one in three of the psychiatrists who have contracted with DJJ in the past five years took speaker fees or gifts from drugmakers. In two years, the four top paid docs combined to accept more than $190,000 while working for DJJ. Three of the four psychiatrists still are seeing patients in state jails and residential programs, the Post writes. Yet, DJJ doesn’t track prescriptions.
One example: AstraZeneca and Pfizer began paying Umesh Mhatre after he started working for DJJ. Last year, he received $65,475 in payments and gifts, including $63,250 in speaker fees. Records show that, between April and June 2010, he wrote 328 children’s scrips for antipsychotics, or 35 percent more than he had billed Medicaid for, on average, in three-month spans over the preceding 2-1/2 years.
This is only part of the story. Private companies run most of the 116 residential programs, but some companies don’t have drug reporting requirements written into their state contracts. And so DJJ provided data only for its 25 jails and for three programs, a fraction of all residential homes statewide, and only for a two-year period ending in mid-2008.
A former DJJ spokesman, Frank Penela, tells the Post that DJJ doctors prescribe Seroquel and other drugs off label to treat sleeplessness, anxiety or post traumatic stress disorder. And the Post found at least 40 cases since 2008 in which DJJ files lacked proof that parents or guardians gave consent before children were put on meds, were told of possible side effects or that docs were adding drugs or adjusting dosages.
One representative of a private program operator, who spoke to the Post on condition of anonymity, says children in DJJ programs often are drugged needlessly. “We were doing a disservice to the public because we were claiming the kids were being treated. In reality, we weren’t treating them. We were medicating them.”
There were 32 instances in which records show inconsistencies or problems with the way workers tracked psychiatric meds. At Gulf Academy in Clearwater in 2009, files for four kids lacked proof that a psychiatrist consulted key notes before making diagnoses. There were 11 cases where workers gave meds “haphazardly,” failed to keep proper dosage records or monitor for side effects. Records show nurses at one facility gave a child the wrong pill for several days and then falsified records.
Dr. No
If taking these drugs keeps them in control, then so be it. It is a lot cheaper, and keeps the fighting and contention to a minimum. Just make sure that the inmates(juveniles) are examined on a regular basis. Overdosing is not good medicine.
Lisa Van Syckel
This is just another form of child abuse, these children don’t need to be medicated they need to be rehabilitated because eventually they will be released back into society.
Dr. J. W. R.
Anyone read “The Girl Who Kicked the Hornet’s Nest?” Sound familiar?
industry insider
In 2009 There were 36,075 emergency room visits nationwide for seroquel overdose, according to the DAWN network. Once we can get SQ classified as a scheduled drug, we can cut down on its distribution and misuse.
Dr. No
Lisa,
Rehabilitation has been proven over and over, that it is not a dependable remedy to many of the so-called patients. The rate of recidivism is over 60% or so.
I have read many of your “comments” and you seem to be a very compassionate person.
Gassa
“The Girl Who Kicked The Hornet’s Nest” , in fact the whole Millennium trilogy, was based on a ridiculous premise. It was almost as if Stieg Larsson didn’t know that his own country, Sweden, was part of the European Union and subject to its laws on guardianship, mental health, hospitalization, etc. etc.
So, Larsson paid no attention to the law in his fiction. But what is the law here? Someone should be checking that appropriate medical care was given in compliance with the law. Neither of those points was addressed in the article.
madness
Clearly, the wrong people are in jail.
Walter
I don’t believe that the level of antipsychotic use here is appropriate, but I think the Palm Beach Post could use a lesson in statistics (as well as spelling, its psychiatrist, not pyschiatrist).
“Over half” of the prescriptions are being written by doctors who have taken payments from the pharmaceutical industry. True, but to get to this “pyschlogically” important benchmark, the author lumps together Dr. Umesh Mhatre, who recieved $68K and wrote 24,771 prescriptions, with Dr. Jose Adan, who accepted $287 and wrote 15,012 prescriptions. That’s 1.9 cents per Rx. Dr. Gomez wrote 11515 prescriptions, for which his “kickback” amounted to 2.6 cents per Rx. And so on. These guys could make better money parking cars. The Palm Beach Post is torturing the data until it yields the conclusion the author reached before the data was ever analyzed.
Gerrymandering the data in a different way, and assuming typical psychiatrist earnings, 77% of these prescriptions were written by doctors who obtained >98% of their earnings from sources other than the pharmaceutical industry.
The real crime here is any psychiatrist is writing 10x as many prescriptions as the number of patients they could theoretically see in a year.
Salient point
industry insider-There were 60,429 ER visits for acetaminophen OD in 2009. Should that be a scheduled drug too?
harpy
the whole damn country is held together with spit and baling wire
Gassa
You would think an investigative piece on this subject in the Palm Beach newspaper would mention that Clearwater, Florida (where one of these facilities is located) is the world-wide HQ of Scientology. And that Tom and John and who knows who else have huge homes there.
Hm, maybe that angle will be in part 2 of the story?
Anyway, for me that’s the Big Elephant in the room.
industry insider
Salient point, point well taken. In fact I do believe that acetaminophen should be much more tightly regulated than it is. I’ve seen more than my share of hepatotoxicity from Tylenol, and I believe that thisd drug has a much narrower therapeutic window than many people think.
Obviously we can’t schedule Tylenol. But we can look at the ratio of ER visits to number of scrips written, which I would surmise would be much higher for Seroquel than for Tylenol.
Salient point
industry insider-Well there are no Rx’s for Tylenol, of course, but your larger point is well taken. Seroquel abuse may be inching toward the level where DEA would want to get involved. I imagine, though, that scheduling would entail a battle royale with the medical community, state governments, the House, etc.
Larry Bone
We move closer and closer to a totalitarian gulag nation where children are beaten up with anti-psychotic chemical restraints turning foster care into mental health facilities.
Salient point
It’s problematic that jails & residential homes seem to be lumped together in this analysis. There’s room for debate when it comes to prisons, but systematically using unindicated, abuseable medications on foster children is simply outrageous.
industry insider
Thanks, Salient point. There seems to be an atificial therapeutic divide, i.e, anxiolytic benzodiazepines and sedative hypnotics are scheduled, while antidepressants and antipsychotics are not considered addictive and of low abuse potential and hence not scheduled. The reality is that drugs like Seroquel are used plenty for anxiety and sleep, which would provide a rationale in my mind for scheduling.
Interestingly, in today’s NY Times there was an article on providing in-flight medical treatment when an emergency occured midair. They gave the example of a an passenger having angina attack. When the flight attendant asked over the PA system whether anyone had some nitroglycerin, no hands were raised. However, when asked if anyone had a Valium, a “forest” of hands went up according to the article. Must say something about the world we live in.
Salient point
industry insider-May also be a comment on how scheduling may (or may not) affect Rx’ing habits.
aa
Salient Point, you said,
“It’s problematic that jails & residential homes seem to be lumped together in this analysis. There’s room for debate when it comes to prisons, but systematically using unindicated, abuseable medications on foster children is simply outrageous.”"
Hmm, I don’t understand if why using abuseable medications is ok for one population group but not another.
Also, you’re assuming that everyone in prison is a Charles Manson type kind of person when many juveniles end up in prison for various reasons such as running way from home.
Once we start saying it is ok to abuse a so called less desirable population group, we go down a real slippery slope.
Frankly, as one who definitely is not soft on crime, I am appalled that people think this practice is justifiable. Sometimes, I don’t recognize the country that I thought I lived in which is the US.
D Bunker
Antipsychotics cause brain damage. I don’t care What the kids in custody have or haven’t done.
Somebody show me Where in Any State’s criminal code that the infliction of Brain Damage, on children, is Legal for the violation of Any criminal offense, much less some Quack’s Opinion that it’s in either those kids or society’s best interest.
If they’ve broken the law, then slugging them with antipsychotics is a slam dunk violation of their 8th Amendment Rights.
original industry insider
Sorry, Bunker, antipsychotics do not cause brain damage when properly used. Sure your real name isn’t Edith or Archie?
dbunker
original industry insider;
I hadn’t seen your comment until today, November 21 2011.
I suggest you get on board with the science rather than the Marketing hype on these disgusting toxins
http://psychrights.org/states/alaska/CaseXX/3AN-08-493PS/JacksonOnNLtoxicity.pdf
And there is NO such Thing as a ‘Proper Use’ for these drugs, None.
original industry insider
Thanks for the rapid turnaround time on your response, Bunker. You’d never make it in industry.
dbunker
OO Insider
I guess not, since I considered the Facts Sufficient to settle the issue, Here at least where Ed presents a whole Bunch of facts, without having to rebut Industry Hype & Shill.
http://www.mindfreedom.org/kb/psychiatric-drugs/antipsychotics/neuroleptic-brain-damage
So, let’s see, that’s Two Ad Hominums in a row. You posed a second barb rather than try to prop your initial Incorrect Information/personal denigration/jibe.
And now I’d never make it in industry. Probably not. You see I have an aversion to rubbing shoulders with people who peddle Suicide and Homicide along with Tardive Dyskiniseas and Dystonias as if they were selling candy apples.
Back to point one. No Brain Damage, huh?
http://www.atlantapsychiatry.com/forms/AIMS.pdf
Then why do the Industry’s pushers have all these AIMS (Abnormal Involuntary Movement Scales) to Score all of that neurological damage their products aren’t inflicting?
Why does the APA have a diagnostic code to BILL Insurers for Medication Induced Movement Disorders?
original industry insider
I should have also thanked you for your ability to string together several clearly written, logical, internally consistent paragraphs. Not only would you not make it in my industry but you probably wouldn’t pass the writing sample examination I would require of all new applicants.
dbunker
You launch a flat out lie,
“Sorry, Bunker, antipsychotics do not cause brain damage when properly used. Sure your real name isn’t Edith or Archie?”
and change the subject/dodge the issue when you get called on it.
Since you’re so enamored of cheap shots like the Archie Bunker crack, I’ll answer it, just to amuse you.
“Are you now, or have you ever been, a member of the RWJF Communitarian Party?”
http://www.rwjf.org/reports/grr/027098s.htm
“Eric Schaps, panel presentation at the Communitarian Network’s Fourth Annual Conference on Character Building, June 1997, Washington.”
You still have not Retracted, Addressed, or Explained, Your Lie.
“I should have also thanked you for your ability to string together several clearly written, logical, internally consistent paragraphs. Not only would you not make it in my industry but you probably wouldn’t pass the writing sample examination I would require of all new applicants.”
You Keep making my point For me.
You Should have also thanked me? Well what’s stopping you, aside that is from your overweening arrogance?
This time you’ve placed Yourself in the Superior position of Me being an Inferior, coming hat in hand to You to ask for Money, as one of your Brain Damage peddling henchmen.
You Still have not retracted or justified in Any way, your initial statement. And I don’t expect you to given your hilarious, holier than thou evasions on this exchange. You, Insider, are a Perfect Exemplar of your Industry: Lie, Evade, and Condescend.
original industry insider
Retracted? The truth requires no redaction or retraction. BTW, here’s a suggestion on how to spend your Xmas money.
http://www.universalclass.com/i/subjects/general-education/w-series.htm
dbunker
http://psychroachesadverseevent.blogspot.com/2009/03/abilify-adverse-reactions.html
“Sorry, Bunker, antipsychotics do not cause brain damage when properly used.”
Tell it to Medwatch.
original industry insider
Man, bunker, you’re really hepped up on this brain damage thing. At least here’s some soothing musing to serenade by:
http://www.youtube.com/watch?v=FiWEfKRot7c
dbunker
“Sorry, Bunker, antipsychotics do not cause brain damage when properly used.”
Tell it to National Science Medal Holder Dr. Nancy Andreasen
http://bonkersinstitute.org/graymatter.html
“The more drugs you’ve been given, the more brain tissue you lose.
What exactly do these drugs do? They block basal ganglia activity.
The prefrontal cortex doesn’t get the input it needs and is being shut down by drugs.
That reduces the psychotic symptoms. It also causes the prefrontal cortex to slowly atrophy.
~ Dr. Nancy C. Andreasen, New York Times, Sept. 16, 2008″
Dr Andreasen spent 15 year taking brain pics of people slapped with a Psychiatric Opinion and in that time she oversaw $38,030,493.00 of NIH monies to fund those pictures. She then admitted that she Sat On her findings for two years.
Contradict her if you like.
original industry insider
Bunker, speaking of brain damage, you seem to suffer from what neurologists call perseveration, as you’ve now introduced your last three posts repeating my quote, “Sorry, Bunker, antipsychotics do not cause brain damage when properly used.”
You should really get yourself checked out, pal. Hope it’s nothing serious.
dbunker
“Sorry, Bunker, antipsychotics do not cause brain damage when properly used.”
http://psychrights.org/research/Digest/NLPs/TDandLowDoseHaldol.pdf
Piet P. Oosthuizien, M.B,; Robin A. Emsley, M.D.; J. Stephanus Maritz, D.Sc.; Jadri A. Turner, M.B.; and N. Keyter, R.N.
“Background: previous studies suggest that the risk of tardive dyskenisia is increased with higher doses of conventional antipsychotics. This study evaluates the 12 month incidence of tardive dyskinesia in subjects with first episode psychosis who were treated with very low doses of haloperidol.
Method: Fifty-seven subjects with first-episode psychosis and a DSM-IV diagnosis of schizophreniform disorder, schizophrenia, or schizoaffective disorder were treated according to a fixed protocol with a mean dose of haloperidol of 1.68 mg/day and prospectively studied for 12 months. Subjects were assessed for extrapyramidal symptoms at 3-month intervals. Data were gathered from 1999-2001.
Results: Twelve month incidence of probable or persistent tardive dyskinesia according to Schooler and Kane criteria was 12.3% (N=7).”
For more “general knowledge” see:
http://psychroaches.blogspot.com/2010/11/atypical-trials-rigged-haldol-tardive.html
Tell it to the study authors. I’m sure they’d welcome your fund of superior knowledge, since you present yourself as knowing more about this subject than a Dr who photographed, for 15 years, what appears to contradict your stance.
original industry insider
bunker, not sure of your educational background, but the phenothiazines have not been used treat schizophrenia since around 1996. They are only used today to control severe agitation in ER settings when patients don’t respond to benzodiazepines or the hospital is prohibited from using physical restraints. Your own paper states that the modern atypicals cause much less TD than Haldol.
Let me guess. You have no medical training whatsoever, but you like to play a doctor on TV and in the blogosphere. You have about 15 years worth of reading to get up to speed on modern pharmacology, pal. Come back and visit us when you’ve caught up.
Justice in MI
Good grief. Phenothiazines have been used to treat schizophrenia since the 1950s, not the 1990s, first via Thorazine and the several otehrs that followed. No question that TD a big problem with them.
Beyond that, I won’t say anything about the guy with supposed medical education stepping in it.
Justice in MI
OK, my bad. I missed the “not.” it is certainly true as far as general practice, although some number of pts are still rx’d them. especially Haldol.
And the dates still seem wrong. A close friend was prescribed clozapine (which kiled him) when it was in the early stages of use, and that was around 2000. (I know the date because we spent our wedding anniversary at his funeral.) He’d been taking Haldol previously.
Anyway, i will go out and find some Clozaril to step in.
Justice in MI
Bad again. Cloz approved in 1989 by FDA. All kinds of warnings, as we know. And slower pick up because this was in the days before “schizophrenia lite,” “Viva Zyprexa,” etc.
Anyway, still good for stepping in.
original industry insider
JiM, dates aside, the point that bunker was trying to make was that antipsychotics cause “brain damage”. I have a few years of pathology training under my belt, including performing autopsies on patients from state mental institutions on long term neuroleptics, who died under suspicious circumstances. In these “coroners cases” a full autopsy is required, including the brain, and in every case there were no discernible neuropathological changes on gross examination histopathlogic examination, and even in a few cases electron microscopic examination
Yes, you will read reports of things such as MRI changes associated with tardive dyskinesia due to antipsychotic experience, but to date there has been no correlation between the imaging studies and what we find to be a complete absence of microscopic changes in such patients.
dbunker
Insider;
Perhaps you’d like to explain why the Atypical Risperdal carries State Police Registration in California if it doesn’t cause Brain Damage.
And as for Haldol not being used anymore, I’ve an acquaintance in NJ who was poisoned with the stuff just a few years back.
It took her 4 months of Physical Therapy to learn to use her arms and legs again.
“Let me guess. You have no medical training whatsoever, but you like to play a doctor on TV and in the blogosphere.”
You are Perfect. Made To Order.
You can lead an industry shill to water, but you can’t make them drink.
john
“Perhaps you’d like to explain why the Atypical Risperdal carries State Police Registration in California if it doesn’t cause Brain Damage.”
I don’t know, does the FDA have a position on the 55 mph speed limit?
original industry insider
I don’t know about State Police registration in California. Any relationship to the number of color tv’s in China?
John, excellent point. FDA should regulate the 55 mph speed limit. After all, doesn’t everyone know that “Speed Kills”.
Becky Murphy
@original industry insider
You stated that Thorazine has not been used to treat a diagnosis of schizophrenia since 1996—that is not what my son’s medical chart in the years 2000-2005 says…
As for the argument about evidence of brain damage and whether it shows up in an autopsy—I think it just may be relevant how the damage manifests while the patient is still sucking air; perhaps even more relevant than whether the damage inflicted can be seen by you, or any other person conducting an autopsy…
Somehow, I believe that the damage that is so apparent in my son while he is still alive is so much more relevant than whether it will be seen upon autopsy…At seven his IQ was 146 and he did triple digit math in his head, and never used his fingers to count–he put together 1,000 piece jigsaw puzzles–by himself. He played music by ear, and had a high school level vocabulary. Last December he needed to use his fingers to count the seven days until Christmas, and he remembers being able to do things that he no longer can do. He says, “they stole my intelligence mom!”
The larger issue for me in all of this is the DISHONESTY with which these drugs have been mass-marketed: the collusion of academia, industry, and government; the lack of ETHICS and the lack of integrity among “Medical Professionals” who belong to the APA, work for the FDA, or the NIMH and/or who are Federally-funded academic researchers— The failure to acknowledge what was in fact known about the safety and efficacy of these teratogenic drugs—until forced by Lawsuits to disclose this RELEVANT safety and efficacy data is morally reprehensible.
This pervasive fraud and corruption resulted in misinforming other medical professionals—who relied on this to treat REAL people—It also resulted in teaching utter bullshit in Institutions of Higher Learning—this crap was put into College textbooks for fuck’s sake! There is no way in hell that Informed Consent can or will reasonably occur in the prescribing of psychotropic drugs when so much subterfuge is still going on. To this day, I have never– NOT ONCE–had a psychiatrist talk about the KNOWN negative effects that my son has and continues to experience, OR the obvious damage being done to his intellect, his heart, his entire body— I don’t know what planet you live on but here, in the real world, Doctors are not supposed to lie to and mislead patients—or their parents!!!
Many medical professionals in fact had no clue they were MISINFORMING patients now did they?? The drug industry and research academia were misinforming them purposely, without regard for their PATIENTS. The Ethical Guidelines for Informed Consent are supposed to be followed—but how would a medical professional be able to provide anyone accurate information given the utter bullshit that FDA approval, professional journal articles and off-label marketing campaigns were based on?? All due respect to your professional expertise, original market insider:—if these drugs are such “good medicine;” why in the hell was so much academic dishonesty, financial fraud and government/medical/industry corruption necessary? To paraphrase Shakespeare: Given the reality of the situation, you seem pretty arrogant original industry insider, and you also doth protest too much, methinks.
original industry insider
I agree that Thorazine was oversold and overpromised, but remember what it replaced. My mother was a nursing student at a large state psychiatric hospital, and before Thorazine came along the only tool at the physician’s disposal to control the agitated schizophrenic was the straightjacket. Patients were also subjected to hypothermic hydrotherapy, insulin coma therapy and other harsh measures. My father was also a surgical resident at the same institution, which is where he learned the technique of prefrontal lobotomy, which was also a standard of treatment prior to introduction of neuroleptic drugs. Thus you must always keep context in mind when talking about this particular drug. Despite Thorazine’s limitations it is hard to argue with an FDA decision to replace a physical straightjacket with a non physical restraint.
Issues with Thorazine have been well known for a long time. The government and the medical community erred when it believed it could depopulate the mental institutions and use Thorazine in a community based setting. They were wrong, but it was not a decision born of corruption or financial fraud. Many patients paid the price and landed on the street.
With all due respect, I don’t see how your suggestion of government/medical/industry corruption plays into the Thorazine story. At the time of its approval it was the best alternative to the long term warehousing of chronic schizophrenic patients in state institutions with no hope of ever being released.
dbunker
“Sorry, Bunker, antipsychotics do not cause brain damage when properly used.”
You typed “antipsychotics”, not typicals, phenothiazines, butyrophenones, or atypicals. Haldol is an antipsychotic, and my Post documents that it was still part of a major city’s MH plan in Dec 2007 at up to 30 mg per day when 1.68 mg causes measurable TD in 1 out of 8 victims.
The point of my Post – which you ignored - is that massive TD from Haldol was, as late as Dec 2007, knowingly inflicted to make the TD Caused by the atypicals appear an acceptable trade off for 31.67 Times more money. So much for Your Industry’s “Ethics”.
“you probably wouldn’t pass the writing sample examination I would require of all new applicants”
And apparently, Neither would You.
“the phenothiazines have not been used treat schizophrenia since around”
That Should read “the phenothiazines have not been used [To] treat schizophrenia since around” ….. pal.
“Let me guess. You have no medical training whatsoever, but you like to play a doctor on TV and in the blogosphere. You have about 15 years worth of reading to get up to speed on modern pharmacology, pal. Come back and visit us when you’ve caught up.”
I make no claims or pretentions to being a pill peddling purchaser of pharmaceutically corrupted University issued educational credits redeemable with a State Government for an Equally Corrupted Work License authorizing one to invent specious excuse after excuse to Defraud consumers into drug addictions, disabilities, Brain Damage and Death to fatten chemical factories and their 100% Incompetent to cure Any of their own Opinions Psychiatric FRAUDS, and their Profit Packing Non Profit Teaching Hospital, Disease Mongering Chop Shops.
“Come back and visit us when you’ve caught up.”
Your jibe is as baseless as an argument that people who’ve never been President have no business selecting one at the polls, since they’re not Experienced, (or yet sufficiently University indoctrinated) to understand the awesome responsibilities shouldered by Socialist/Marxist/Public-Private Partnership Owned, Fascistic Kafka-esque Bureaucracies wherein only the Pharmaceutical University Anointed are welcome, or for that matter even permitted, at YOUR Altar of General Assistance Welfare Trough. Without LBJ’s vote buying Medicare Ponzi Scheme, most of YOUR antipsychotic pushers would be wearing paper hats and asking “Would you like fries with that McGagger?”
“the phenothiazines have not been used treat schizophrenia since around 1996. They are only used today to control severe agitation in ER settings when patients don’t respond to benzodiazepines or the hospital is prohibited from using physical restraints. Your own paper states that the modern atypicals cause much less TD than Haldol.”
Are you conflating a butyrophenone (Haldol) with a phenothiazine, ….. Expert? We’ll let that pass for the moment, since the Direct Effects of both are similar enough to treat them as one for the purpose of our discussion.
Not used since 1996? My Haldol poisoned acquaintance suffered through a mere 6 weeks of it in 2008 before suffering through 4 months of rehab for her non functioning arms, legs, bowels, and eyes, because, Government HC programs wouldn’t Pay for the atypicals that time, and without those Govt programs in situ to Begin with, she wouldn’t have been Crippled by Your Industry breaking its own neck and Everybody Else’s necks to glom onto that Vote Buying GA Money, to Begin with.
Tell me Insider, are You an ‘Illuminati’ too?
http://psychroaches.blogspot.com/search/label/Illuminati%20Psychiatric%20Bio-Science
How many more of the Illuminati are out there pitching your Insider Condescension and BRAIN DAMAGE, aside from the Siskel & Ebert Road Show I dug up at Esalen?
Those same Esalen ‘Illuminati’ made 2 entire Hospitals and Psychiatric staffs Disappear, at SF City Hall,
http://psychroaches.blogspot.com/search/label/SFMHB%2006%2F13%2F07
the same way you’ve made all that Brain Damage Disappear here at Ed’s kitchen: strictly on your Own, 100% unsupported by Any corroborating documentation, say so.
“Come back and visit us when you’ve caught up.”
How about I come back and visit you after I’ve Thrown Up?
And I’m not your ‘Pal’ as I’m sure we’re Both well aware, as is Everyone reading here.
You are a Godsend. An absolute Godsend. Please, by All means, just keep being exactly who you are.
dbunker
“I don’t know about State Police registration in California.”
You present yourself as knowing a Whole lot More about antipsychotics than I do.
The State Police Registration, Insider, is because of the Violent Murders YOUR Industry’s antipsychotics, which don’t cause Brain Damage according to You, have been MedWatch reported as being the primary suspect drug, CAUSING.
“My father was also a surgical resident at the same institution, which is where he learned the technique of prefrontal lobotomy”
Hmmm. This affinity for Lobotomies seems to run in your genes, No?
Does this admission from you validate the junk science, null set field of Psychiatric/Behavioral Genetic Research, Insider?
http://psychroaches.blogspot.com/2009/05/psychiatric-genetics-another-empty-box.html
Sigh
At ease, dbunker and Becky Murphy. Regular readers of this blog know that OII is simply a fantasist with limited knowledge of this industry. Having this arrogant fool representing genuine industry folk with his endless boring and anecdotal commentary derived from Google is frustrating for us all. Please, just ignore
original industry insider
Bunker, we both agree that we are not “pals” in the literal sense. I used the term in the same way it was used by Gordon Gekko in “Wall Street”, pal.
original industry insider
Sigh, since you’re playing arbiter of taste, howabout admonishing Becky to avoid the four letter words.
dzieczko
@Becky - “At seven his IQ was 146 and he did triple digit math in his head, and never used his fingers to count–he put together 1,000 piece jigsaw puzzles–by himself. He played music by ear, and had a high school level vocabulary.”
What was considered behavioral evidence to support the diagnosis requiring such strong medication? High intelligence children would present with a different set of disorders. Getting bored in school to the point of completely disappearing in one own’s imagination and refusing to be *normal* again is not something to be treated as a mental disorder, rather a ploy for a change in life style - ie. learning at a more comfortable pace.
Your story is disconcerting and upsetting and deserves a better analysis than what can be provided in these fly-by shootings of politically motivated cherry picked factoids that comment boards tend to provide.
original industry insider
For those folks unfamiliar with the term, the “Illuminati” refer to a secret, group which conspires either to cause or take advantage of world events in order to increase its power and eventually bring about a fascist world government.
Bunker, do you really think that the evil pharmaceutical industry has really conspired with facist elements in world governments to secretly poison its citizens through the use of mind controlling and highly toxic neuropsychopharmacologic agents? If so, I think I have a few bridges I might be able to sell you on the cheap.
stephany
My child is disabled from being placed on antipsychotics from age 11 on for a misdix of childhood bipolar which doctors, YES doctors have said is NOT her dx. She is on the autism spectrum. She lost ability to form words, as in speak and went mute and with years of titration down off of the antipsychotics, (Zyprexa was the one that caused the 100+weight gain as well)Clozaril is the last being removed and time as in YEARS meaning over half of her life growing up was on antipsychotics that we were told were to help her….now she is being rehabilitated to be able to write and read and talk again.
After years of silence, and drugs not needed, she is talking in up to 8 word sentences.
These drugs are potent chemicals and the long term use on kids growing brains has not been proven to be safe or effacious. The long term studies WILL come out though in studies of n=1 as in MY child and millions of others that will end up damaged in body and brain and MIND as a result of using these drugs for chemical restraints and more.
The foster kids have no one, and the jailed ones even less!the cavalier use of these kind of drugs on them for behavior control proves that no one cares about their outcome, their heart disease possibility, dropping dead as a side effect via QT Prolongation, diabetes, weight gain to cause obesity….
Until you’ve witnessed damage as I have first hand inside locked psych wards with hundreds of ppl to view…tremors, loss of sparkle in their eyes, weight gain…inability to speak is one of the worst things I witnessed in my now adult child. Try that some time. It causes lost sleep.
original industry insider
Stephany, I’ve seen such patients as you describe on the psych wards. However, I’ve also seen schizophrenic patients who go off their medications because they can’t be compelled to take them by the courts. In due course the command auditory hallucinations and persecutory delusions return to the paranoid schizophrenic, in some cases reulting in suicide.
Both situations are tragic, and there is no quantitative way to compare them.
MsPiggy
Antipsychotics drugs to not treat schizophrenia or any other so called coined disorders….since no one knows the biological cause, mechanism, or origin of these human psychological conditions. These drugs are merely heavy duty tranquilizers that muffle symptoms…they fix nothing….the side effects are many and very serious….including decreased brain volume/mass…[that is brain damage] “insider”…add TD, weigh gain, sudden cardiac death, metabolic disorders and a whole host of debilitating negative effects caused by directly these drugs and not the so called disease….
We then have a well documented & evidenced situation where the risk of the supposed treatments far outweigh their supposed benefits….we know that outside of the industrialized world where pharmacological methods of treatment are not used long term and as the emergency intervention of last resort…the long term outcomes are much better, and in many cases include complete remission….
You better believe this is about money and power (this isn’t some contrived mythological conspiracy theory on display) the actual evidence speaks volumes and places the blame directly at the feet of the pharmaceutical industry and medicine…it’s not as if there has been a massive pandemic of psychosis happening in America and the industrialized world out of thin air over the past few decades…this is and continues to be a well oiled marketing machine created for massive profit and institutional top down control…has government rubber stamped & been an active conspirator to this ongoing tragedy…absolutely…you would have to completely ignore the mountains of evidence posted on Pharmalot & from countless other reliable sources to reach any other rational conclusion.
The only ones now defending this horrific assault upon our population are the fools, the ignorant, and those like “original industry insider” that have a vested interest/stake in this shameful organized scam…
original industry insider
Ms Piggy, I can’t let your statement about “complete remission” go unchallenged. Spontaneous remission from schizophrenia is an extremely rare event, and in such cases it suggests the possibility of a misdiagnosis.
People should not be given misinformation on remission. When you say that the risks of these drugs outweighs the benefits, please explain to your readers the supposed benefit from a paranoid schizophrenic who goes off his or her antipsychotic mecication, the delusions and command hallucinations return, and suicide is the outcome. I fail to see such “benefit”, and, in contrast to the extremely rare occurences of complete remission, suicide is NOT a rare outcome of people going off their meds.
You should provide your story about the benefits of non-treatment of schizophrenia to the family of Kendra Webdale, who was pushed off a NYC subway platform to her death by Andrew Goldstein, a paranoid schizophrenic who went off his meds. I’m sure we would all like to hear what words of consolation you would have for the Webdale family for a tragedy from which they will likely never recover.
original industry insider
In case you anti drug people don’t “get it”, here’s what a homicidal unmedicated paranoid schizophrenic actually sounds like. It is the writings of David Berkowitz, aka “Son of Sam”, who killed six people in the summer of 1977 because he was commanded to do so by his neighbor’s dog:
“I am deeply hurt by your calling me a women hater. I am not. But I am a monster. I am the “Son of Sam.” I am a little “brat”. When father Sam gets drunk he gets mean. He beats his family. Sometimes he ties me up to the back of the house. Other times he locks me in the garage. Sam loves to drink blood. “Go out and kill” commands father Sam. Behind our house some rest. Mostly young — raped and slaughtered — their blood drained — just bones now. Papa Sam keeps me locked in the attic, too. I can’t get out but I look out the attic window and watch the world go by. I feel like an outsider. I am on a different wave length then everybody else — programmed too kill. However, to stop me you must kill me. Attention all police: Shoot me first — shoot to kill or else. Keep out of my way or you will die! Papa Sam is old now. He needs some blood to preserve his youth. He has had too many heart attacks. Too many heart attacks. “Ugh, me hoot it urts sonny boy.” I miss my pretty princess most of all. She’s resting in our ladies house but I’ll see her soon. I am the “Monster” — “Beelzebub” — the “Chubby Behemouth.” I love to hunt. Prowling the streets looking for fair game — tasty meat. The wemon of Queens are z prettyist of all. I must be the water they drink. I live for the hunt — my life. Blood for papa. Mr. Borrelli, sir, I dont want to kill anymore no sir, no more but I must, “honour thy father.” I want to make love to the world. I love people. I don’t belong on Earth. Return me to yahoos. To the people of Queens, I love you. And I wa want to wish all of you a happy Easter. May God bless you in this life and in the next and for now I say goodbye and goodnight. Police — Let me haunt you with these words; I’ll be back! I’ll be back! To be interrpreted as — bang, bang, bang, bank, bang — ugh!! Yours in murder Mr. Monster”
dbunker
“Sigh, since you’re playing arbiter of taste, howabout admonishing Becky to avoid the four letter words.”
You Started it. And Becky owns very real and legitimate injuries, thanks to ‘Your Industry’ of FRAUD. Unlike You, Becky owns the Moral High Ground in this discussion, and has presented more Facts in this discussion, than You, whose Sole Defense of Your argument is a resort to full on, in your face, Sophomoric Trolling.
My desktop Dictionary defines a Troll as:
3 [ trans. ] informal Computing send (an e-mail message or posting on the Internet) intended to provoke a response from the reader by containing errors.
“If so, I think I have a few bridges I might be able to sell you on the cheap.”
You haven’t sold me on Anything yet, Nor have you addressed a Single Document I’ve presented you with. The Only thing your Industry Has to Sell, is Bridges, and they are anything But on the cheap. You people and your behaviorist Crap are breaking My country’s back selling NO CURES for Any of your Excuses to BILL Insurers: ZERO, NOTHING.
And true to form, you’ve condescended to Ed’s readers yet Again, by explaining who the ‘Illuminati’ are for those readers: Assuming that the readers aren’t Bright enough to have ever run across the ‘Illuminati’, and need Your most capable Tutoring.
The Point, Insider, is that as Laughable as the ‘Illuminati’ Should be, This batch of them take themselves Very Seriously: So seriously that the former Chief Psychiatrist/Illuminati/Film Fan at UCSF actually Tried to make 2 entire Psychiatric Hospitals and their entire Psychiatric Staffs just disappear at an SF City Hall MHB meeting in a room full of people who knew full well better that both of those Hospitals and Staffs Did indeed exist, …… and Not One Single person in that room corrected it. Not One, unless it was subsequently edited out of the Meeting Minutes: the SAME WAY that none of that nasty BRAIN DAMAGE exists, according to you, in an internet forum Full of people who know Full Well Better that it Does Indeed Exist.
And those people at SF City Hall with their moral relativist, Bureaucratic Ladder climbings, their ingrained needs to “Feel Better” about themselves through dispensing the sacred Psychiatric Condescension/BRAIN DAMAGE, are exercising the SAME “Genius At Work, Do Not Disturb” caregiving discretion which You’ve been so generous in trying to Troll Me off with.
http://psychroaches.blogspot.com/2011/06/in-san-francisco-theyre-after-every.html
Every kid in the City should be screened, as a Ruse, to drag them into Your Industry’s Privateering pile of Pharmaceutical Lobotomy Peddlings.
The ‘Illuminati’? What I’ve done is point out Who they think they are, and What they think they are, ….. and They think They’re a semi-divine Cadre with a right to condemn, disable, and lobotomize Everyone but themselves, while sending Everyone Else the Bill for their movie reviewings.
“Sigh, since you’re playing arbiter of taste, howabout admonishing Becky to avoid the four letter words.”
Because Becky isn’t Trolling me, That’s Why.
“Despite Thorazine’s limitations it is hard to argue with an FDA decision to replace a physical straightjacket with a non physical restraint.”
Your position is that Defrauding another human being, and their Parents, into a Lobotomy rather than a canvas jacket with buckles on it for 3 days is a position that is “hard to argue with”?
That’s why I’m not admonishing Becky.
I’m admonishing You.
Address the Documents I’ve provided.
MsPiggy
Now the true colors are coming out “original industry insider” is a Fuller Torrey TAC fear mongering clown. I’ve got where your coming from now; “Those crazy people are dangerous and must be force medicated….”
You do know that factually the vast majority of violent crime being perpetrated upon society has little to do with supposed schizophrenia or related conditions…In fact, those labeled with such conditions are much more likely to be the victim of a violent crime and than to commit one.
Talk about taking an extremest unsubstantiated position. Your position is so ignorant and unfounded, that no further discussion is really needed. Your fear mongering does not reflect reality or is it based/grounded in accurate data or evidenced science.
The vast majority of people that go through periods of delusional behaviors or so called breaks from reality are not inherently dangerous and actually do achieve remission if given the proper environment, understanding, encouragement, and support…One of the over-riding factors for suicidal behavior among those labeled with schizophrenia is long term drug intervention and the side effects caused by these intrusive interventions. In fact, the highest suicide rates in this population are among those suffering the never ending torture of TD and related involuntary movement disorders.
“original industry insider” wants to throw out the baby and keep the bath water for themselves as bounty…just as there are heinous criminals that must be removed from society, there are also those rare few cases of delusional conditions that may require a more controlled invasive approach. Those few cases are definitely the rare exception, not the rule of thumb “insider” is touting here..
Once you get where someone is coming from, and which camp they are aligned with; the argument is no longer much of a debate. Just the same old propaganda psychiatric brutality campaign that brought us the eugenics movement, the frontal lobotomy, insulin shock, and now the modern day drug assault; which is nothing more than another recycled money & power grab based upon greed, fear, and ignornace.
original industry insider
dz, I believe that any competent psychiatrist would have to charge you double for the extra time it would take to uncover the roots of your delusional thinking, as if you think the Illuminati actually exist. Pretty soon you and your cohort will be calling all of us in the pharmaceutical industry the modern day Anticbrist.
Now that the prosencephalics have had more than their say, I wonder if anyone is capable of taking a more nuanced position. That is objectively stating a position on the benefits and risks of the drugs my industry makes without being colored by their hatred of the industry as a whole.
Dz, to finally address your point, I don’t intend to address documentation provided by you or anyone else wedded to paranoid conspiracy theories, Illuminati, New World Order Groupies, and Trilateral Komisars.
Please clarify, by Troll, did you mean those who post inflammatory comments on websites, ugly little creatures who hide in caves and are rarely friendly to humans, or both?
Inquiring minds want to know.
john
OII, Webster’s defines “troll” as “a person having a different point of view differing from one’s own, especially when such point of view is expressed in the format of an internet chat board”.
I looked it up two years ago after a gentle fellow reader objected to my statement that marketing a drug which prevented 5 deaths for each one it caused was not “murder”.
stephany
If we use body damage and internal organ damage for the data as a base for comparison then all people injured by the drug become the same result whether or not they used the drug for the intended use; which brings up the off-label use of antipsychotics for behavior control and insomnia, anxiety and more.
Example, take Seroquel off-label use for insomnia and the 28K or so lawsuits buy claimants for using it and becoming diabetic as a result. Those payouts are STILL being adjusted by the law firms.
The bottom line is, whether or not it is ethical to use these drugs designed for use for psychosis as chemical restraints in kids in the JV foster care system.
It’s not ethical. (in my opinion)
john
Stephany, I don’t know the details of the situation, but I agree that based on what is in this article the situation in Florida sounds pretty bad.
I don’t really know about the other stuff. It seems to me that anyone who starts taking a drug and gains 10 pounds over the next 8 weeks really ought to talk to their doctor about trying something else before they have gained 50 and become diabetic. I know that’s an oversimplified description of reality, but I dont’ think its quite the same situation as when you are taking an analgesic for two years and then have a heart attack without warning.
It never would have occurred to me to take an antipsychotic for insomnia, but looking at the many drug review sites on the web, it sounds like some people with truly intractable insomnia find Seroquel useful. It may depend on how desperate you are to get some sleep.
dbunker
Dear MsPiggy;
Thank You! I just Knew that if I kept Feeding this Insider Troll long enough, it would Pop, just like the Plague Boil it is. Now, Insider’s dragged in the ‘Son of Sam’ as an example of, Oh, ….. God only knows What.
But it IS fascinating to have Insider admit to a streak of Gordon Gekko, and, ….. AND, that he believes Psychiatry’s role also encompasses being an Amalgam of J. Edgar Hoover and Elliot Ness.
Simply Fascinating. How many people have mistakenly believed that they were consulting with a Physician who had Their best interests at heart, only to discover that they were dealing with the Psychic Untouchables, out to Get the Son of Sam?
If I’m reading Insider correctly (and how could one miss) Insider’s conception of the APA calls for a rebranding to read ASPA: American Secret Police Association.
But, MsPiggy, that’s why they refer to Themselves as ’Investigators’.
@ OI Insider:
“dz, I believe that any competent psychiatrist would have to charge you double for the extra time it would take to uncover the roots of your delusional thinking, as if you think the Illuminati actually exist. Pretty soon you and your cohort will be calling all of us in the pharmaceutical industry the modern day Anticbrist.”
‘I’ don’t ‘Think’ the ‘Illuminati’ exist. A Lying, “Culturally” competent (as in Racially Biased) Psychiatrist proudly Advertises that he and his Movie Reviewing Psy-Commandoes believe that they Are the ‘Illuminati’.
I’ve already Given you the Proof.
http://psychroaches.blogspot.com/search/label/Illuminati%20Psychiatric%20Bio-Science
Click on their Own Link.
http://ourilluminati.com/
And if you liked (or even Bothered to Look at) the previous 2, you’ll Love This one.
http://psychroaches.blogspot.com/2010/08/thumb-screwed-english-drag-queen-movies.html
“Please clarify, by Troll, did you mean those who post inflammatory comments on websites, ugly little creatures who hide in caves and are rarely friendly to humans, or both?”
You Could refer to the definition I Already Posted to you, but that’s not the object of your interrogatory, is it? Please refer to the End of my last linked post. Are you chipping away at your own stash of Brain Damaging psychotropic drugs?
All 23 of the Psychiatric Poisons in our FDA Adverse Reaction section feature Psychotic Disorder as an FDA reported Adverse Reaction with each Drug Individually identified as ‘The Primary Suspect Drug’ responsible for that Adverse Reaction
Abilify: Psychotic Disorder
Adderall: Psychotic Disorder
Celexa: Psychotic Disorder
Clozapine: Psychotic Disorder
Cymbalta: Psychotic Disorder
Depakote: Psychotic Disorder
Effexor: Psychotic Disorder
Geodon: Psychotic Disorder
Klonopin: Psychotic Disorder
Lamactil: Psychotic Disorder
Lexapro: Psychotic Disorder
Neurontin: Psychotic Disorder
Paxil/Seroxat: Psychotic Disorder
Prozac: Psychotic Disorder
Risperdal: Psychotic Disorder
Ritalin/Concerta: Psychotic Disorder
Seroquel: Psychotic Disorder
Strattera: Psychotic Disorder
Tegretol: Psychotic Disorder
Wellbutrin: Psychotic Disorder
Xanax: Psychotic Disorder
Zoloft: Psychotic Disorder
Zyprexa: Psychotic Disorder
“Someone Else’s TV Room”, ….. is how “The” top Psychiatrist in “The” most thickly polluted Psychiatric, ….. ahhhm, ….. City in America, defines:
“Medical Research Laboratory”
And You’re telling Me the ‘Illuminati’ are a joke? That doesn’t Begin to describe them.
Address the Documents RE: BRAIN DAMAGE I’ve already Provided You, ……. Insider.
evidenced based
I agree with John that patients need to take some responsibility for their own medical management. Severe weight gain with antispychotics is highlighted in every patient package insert for these drugs that I have read. It is up to the the patient to read them. The PPI’s are not written in technical language.
If you’ve gained 10 lbs on an antipsychotic it is your responsibility to bring this to your doctor’s attention, and not wait until a 50 lb weight gain has triggered Type II diabetes.
stephany
In 1999 when the doctor noted the over 100lb weight gain in my daughter from Zyprexa he new nothing of the side effects that had been buried by Lilly; by 2004 the diabetes warning comes out and that was too damn late.
Also, try telling the patient who is on a psych court order to take antipsychotics to go off of the med because of the weight gain and therefore being a responsible patient! Well, try going off meds at all and not end up being sent back to the psych ward or then having forced injectables, that will STILL cause the weight gain and diabetes!
Imagine having NO CHOICE IN THE SAY OF WHAT HAPPENS TO YOUR BODY.
Now you are in the same shoes as those kids in JV foster care system.
Tell them why they are gaining weight from a metabolic syndrome side effect of an antipsychotic, or have diabetes….
john
Stephany, I’m sorry for your trouble.
I’m really not familiar with the history of this area. I’m aware that Lilly has been accused of hiding the side effects of Zyprexa and has paid out a lot of damages. But the FDA approval documents state that Lilly’s clinical trial data shows it causes dramatic weight gain, and although the original label is not available on the site, the review docs state that this information was being included in the label.
http://www.accessdata.fda.gov/drugsatfda_docs/nda/96/020592_Original_Approval_Pkg%20.pdf
I’d be interested in more info on the history of this issue and the basis of the rulings establishing liability, if someone can offer a concise summary.
evidenced based
John, I believe that Stephany may some validity to her comment re attempts of Lilly to hide the significant weight gain effects of Zyprexa. The “shop talk” promoted by Lilly at the time Stephany speaks, about Year 2000, was that Zyprexa caused no more then the “usual” 10-20 lb weigt gain caused by older antipsychotics. However, the word around the grapevine at that time was that Lilly was interested in developing a product that would combine Zyprexa with a marketed weight loss drug.
Logic dictates that Lilly would not undertake such a multimillion dollar drug development program unless it had data showing that the weight gain effects of Zyprexa we significantly greater than the “usual” 10-20 lbs.
susan
It’s almost Serendipitous for this piece that last night Diane Sawyer reported on this on the ABC nightly news.
I posted the link from You Tube on my blog.
Ed, thank you and the other journalists in the trenches for helping bring this to the main stream media.
http://ifyouregoingthoughhellkeepgoing.blogspot.com/2011/12/psych-drugs-and-foster-kids-abc-news.html
john
Thanks EB.
stephany
Here’s the voice of a 12 year old boy in foster care testifying to Senate and Congress on psych meds and how they were used on him: (forced)
http://fiddaman.blogspot.com/2011/12/12-year-old-kid-speaks-before-senate.html
“The Senate sat in stunned silence as they listened to a statement from 12 year-old Ke’ Onte Cook. Ke’ Onte had been place in care from the age of 6 and a half. He told the panel that he was told that if he didn’t take his drugs he would be punished by not being allowed to watch TV. He did not know why he was on drugs or how many he was taking, he could not remember. Ke’ Onte also informed the panel that later on he had been diagnosed with Post Traumatic Stress Disorder [PTSD] Insomnia, Depression and Attention Deficit Hyperactivity Disorder [ADHD] during which he could not process thoughts, felt glazed and tired, had stomach aches and a “lights out” mood. He added that he was first prescribed the medications [3 different drugs a day] because he was throwing tantrums and was upset after being taken into State care.”
The voice of a 12 year old!!
stephany
Yes, regarding the Zyprexa: 5 at 5 viva zyprexa sales pitch to doctors, and more is all documented in the internal documents. This drug was a heavily marketed drug off-label, remember Lilly was fined by the DoJ for doing that…. whatever that’s worth!
stephany
HERE are the internal Zyprexa documents:
http://www.furiousseasons.com/zyprexadocs.html
Hosted at Furious Seasons blog, these are the real deal documents folks, read them one by one and see how this drug was marketed….
MsPiggy
Would anyone like to justify this…2 minutes & 10 seconds that should be forever etched in your mind…
http://youtu.be/7OeZlw2NCmM