BRITISH JOURNAL OF PSYCH IAT RY ( 1007). 191 ( s upp l. 50 ), 171 -177. d ol: I0 .1191/ b j p . 191.5 0 .s71 REVIEW ARTICLE

Schizophrenia outcome measures in the wider including clinical symptoms and their im­ provement, and social functioning, espe­ cially the ability to relate to people and international community performance at work (including employ­ ment, housework and tasks). Cognitive MOHAN ISAAC , PRABHAT CHAND and PRAT I MA MURT HY function, family burden and quality of life are other outcome measures. Outcome is also influenced by the course of schizo­ phrenia. The possible contribution of fac­ tors to the good prognosis observed in low- and middle-income countries is shown in the Appendix. Background Outcome of Schizophrenia may have a better outcome schizophrenia has been described as in low- and middle-income countries. The initial evidence for this came from the Inter­ Clinical symptoms favourable in low- and middle-income national Pilot Study of Schizophrenia (!PSS; The Present State Examination-9 (PSE-9; countries. Recently. researchers have World Health Organization, 1979) and was Wing et al, 1974) has been used as the mea­ questioned these findings. further strengthened by rwo subsequent sure of clinical symptoms at baseline and studies, the Determinants of Outcome of during follow-up in almost all long-term Aims To examine the outcome studies Severe Mental Disorders (DoSMED; studies from low- and middle-income coun­ carried out in different countries Jablensky et al, 1992) and the recently con­ tries. The PSE-9 assesses 140 symptoms specifically looking at those from low- and cluded International Study on Schizo­ grouped into 36 syndromes and measures phrenia (ISoS; Harrison et al, 2001). A host the presence of symptoms in the previous middle-income countries. of sociocultural factors have been cited as month. In a 20-year longitudinal study Methods Long-term course and contributing to the better outcome in these from India (Thara, 2004), all syndromes countries, including lower expressed emo­ registered decline, although slowness, loss outcome studies in schizophrenia were tion, closely knit family structures and family of interest, concentration and simple de­ reviewed. i.nteractions (Kulhara & Chakrabarti, 2001). pression registered an increase over the However, there is little evidence for the second 10 years whereas positive symptoms Results A wide variety of outcome beneficial influence of these factors. The showed little difference. In this cohort only measures are used. The most frequent are World Health Organization (WHO) follow­ 5 out of 61 patients (8%) were continu­ clinical symptoms, hospitalisation and up studies of the past 25 years have been ously ill. Using a similar methodology, 10- mortalit y (direct indicators), and social/ unable to tease out the specific patterns year clinical outcome was reported as occupational functioning, marriage, social and timing of cultural influences that favourable in three-quarters of the sample determine a better prognosis in these coun­ (Thara & Eaton, 1996). support and burden of care (indirect tries. The strongly held belief in a better Outcome was classified into broad indicators). Areas such as cognitive outcome in these countries has been ques­ categories in the DoSMED cross-cultural function, duration of untreated psychosis, tioned in recent times (Patel et al, 2006). study Oablensky et al, 1992). The outcome quality of life and effect of medication have The !SoS study, coordinated by the criteria used were: good, remitting course WHO, addressed the outcome and related with full remission; poor, continuous/ not been widely studied in low- and issues in a 15- to 25-year follow-up of 14 incomplete remission. A more recent long­ middle-income countries. culturally diverse schizophrenia cohorts. term study from Singapore (Kua et al, Although the outcome results were 2003) described final outcome measures in Conclusions The outcome of consistently more favourable from low- and similar broad domains - good, patient not schizophrenia appears to be better in low­ middle-income countries, there was marked receiving treatment, well and working; fair, and middle-income countries. A host of heterogeneity across the centres (Hopper & patient not receiving treatment and not sociocultural factors have been cited as Wanderling, 2000). Removing Hong Kong working, or receiving out-patient treatment contributing to this but future research left three centres in this category from India and working; poor, patient receiving (one in Madras and two in Chandigarh). It treatment and not working, or receiving should aim to understand this better might be helpful to examine which cultural in-patient treatment. This study included outcome. There is a need for more culture­ aspects of the Indian subcontinent contribute treatment, employment and hospitalisation specific instruments to measure to an improved outcome in people with as indicators of severity of clinical symp­ outcomes. schizophrenia (Patel et al, 2006). toms for patients with schizophrenia. Over rwo-thirds of patients had a good/fair Declaration of interest None. outcome. DIMENSIONS OF OUTCOME Measurement of positive or negative MEASUREMENT symptoms/syndromes has been used by most studies. However, neurocognitive Outcome is a multidimensional construct symptoms were not properly covered in consisting of several independent domains, the outcome measures used. This domain

s7 1 ISA AC ET AL

Table I Important outcome studies from low- and middle-income countries'

Source Study/ Design n at Instruments Outcome,% follow-up beginning/end

Thara et al ( 1994), Madras Longitudinal Study, Prospective, three 90/76 PSE. PPHS, IFS Death, 11.84 India I 0-year follow-up follow-up assessments No symptoms, 65 at 2, 5 and I O years Good, 72.3 Psychotic, 22 (7% continuously since inclusion) Complete recovery, 14.5 Complete remission with one or more relapses, 48.7 Incomplete remission, 27.6 Thara (2004), India Madras Longitudinal Study, Prospective, four 90/61 PSE , PPHS, IFS Asymptomatic at syndromal level, 59 20-year follow-up follow-up assessments (first I Oyears), Complete recovery, 8.2 at 2, 5, I O and 20 years GAF Continuously ill, 8.2 Death, 17.7 Tirupati ec al (2004), Uncreated psychosis, Prospective follow-up 49/49 PSE, PPHS Good India I-year follow-up Clinical , 29 Social, 35 Occupational, 51 Global, 31 Kurihara et al (2000, Treatment-naive schizo- Prospective 59/5 I, 5 years PANSS, ESAS Remission, 23.9 2005), Bali' phrenia, 5- and I I-year 59/46, 11 years Partial remission, 19.6 follow-up Self-supportive, 39.1 Kua et al (2003), 20-year follow-up Assessment at 5, 10, 15 402/216 Clinical interview on Good/fair, 66 Singapore and 20 years treatment and work Working, 32 status, no scales Lee et al (1998), IS-year follow-up File review 100/70 PSE- 9, DAS, LCS , Recovered, 53 Hong Kong PIRS- 11 , SFD, BRS GAF score > 60, 71 Working, 74

PSE, Present State Examination ; PPHS, Psychiatry and Personal History Schedule; IFS, Interim Follow-Up Schedule; GAF, Global Assessment of Fu nctioning; PANSS, Positive and Negative Syndrome Scale ; ESAS, Egum a's Social Adjustment Sca le ; DAS, Disability Assessment Schedule; LCS, Life Chart Schedule; PIRS, Psychological Impairment Rating Schedule; SFD, Schedule for the Deceased; BRS, Broad Rating Schedule. I. Excluding World Health Organization multicentre studies. 2. 5-year outcome strongly predicted long-term outcome; minority needed maintenance medications.

has been receiving increased attention completely might have been included, con­ Duration of untreated psychosis because of its association with functional tributing to good outcomes. Non-affective recovery. Although there continues to be acute remitting psychoses are far more Studies from the West have shown that the wide heterogeneity in cognitive functioning common in low- and middle-income duration of untreated psychosis (DUP) is in individuals with schizophrenia, a number countries (Susser & Wanderling, 1994 ). associated with poorer outcome, with the of recent studies from the West have sug­ However, reanalysis of the data excluding relationship being strongest in the initial gested that cognitive deficits once estab­ patients with these psychoses cl.id not months of psychosis (Drake et al, 2000). lished are relatively stable over time. change the results to any appreciable extent This is particularly relevant in low- and (Hopper & Wanderling, 2000). Indeed, middle-income countries where a significant such patients had slightly better outcomes number of patients come late ro treatment. Acute psychosis debate in the high-i ncome countries and excluding Reasons for this include lack of awareness, Several researchers have argued that many them increased the differences between h.igh­ a strong belief in magical or religious causes, patients with acute psychosis might have income countries and India. Furthermore, poor accessibility of healthcare systems and been included in samples of people with other studies (Ku lh ara & Chandi ramani, lack of communi ty care (Isaac et al, 1981; sch.izophrenia from low- and middle­ 1988) using more than one diagnostic Padma vath.i et al, 199 8) A cross-cultural income countries (Kulhara & Chakrabarti, definition and criteria for sch.izophrenia, study on pathways to psychiatric care (Garer 2001). They argue that by including also supported better outcome in low- and et al, 1991) replicated these findings. Most diagnostic criteria of 1 month's duration m.iddle-income countries irrespective of patients are brought for treatment after a sig­ people with acute psychosis which rem.its diagnostic criteria. nificaar delay from the onset of symptoms.

s72 OU TCOM E M E A S UR ES I N D IFFER E N T COUN T R I ES

Out of 75 pati ents in India who were alternative systems of 'residential care' periods of 1-4 years (Kebede et al, 2005). treatment naive and living with their that exist in high-income countries limits Suicide accounted for nearly half of the family, 60% had a DUP of over 5 years the use-of hospitalisation as a reliable out­ deaths of those under 35 yea rs. and 36% over 12 years. Following treat­ come measure. According to the World ment for 1 year, patients with a DUP of Health Organization 2005 figures (http:// 5 years or less had shown good clinical globalatlas.who.int), the median number Social functioning outcome (Tirupati et al, 2004). All were of hospital beds per 10 000 population in In low- and middle-income countries treated with antipsychotics on an out­ low- and middle-income countries 1s schizophrenia has been shown to have patient basis and none needed hospital around 0.2 (India, 0.25) whereas it is 7 in better outcome in terms of social and occu­ admission. An encouraging observation high-income Western countries (UK, 6; pational functioning; social functioning was the notable treatment response despite Switzerland, 13.20). more than clinical status influences the many years of untreated illness. Short-term Social factors such as unemployment in functional competence of people with studies using score on the Positive and males, family awareness of the nature of schizophrenia (Verghese et al, 1990; Harrison Negative Syndrome Scale (PANSS) as an illness and family type are strongly related et al, 2001). outcome measure corroborated these find­ to treatment-seeking in low- and middle­ The development of measures for the ings (Philip et al, 2003). income countries (Srinivasan et al, 2001). assessment of impaired social functioning The PSE- 9, which is used in most stu­ Gender, level of literacy and economic lags behind clinical rating. This relative dies, measures the presence of symptoms status appear to be unrelated. Surprisingly, neglect of a standardised assessment of only for the past month, which is probably more florid posi tive symptoms (such as social adaptation may reflect an assump­ too brief for outcome assessment in a delusions, hallucinations or aggressive be­ tion that symptomatology is closely tied to chronic illness such as schizophrenia. haviour) were not associated with seeking impairment in social functioning. This Moreover unanchored global judgements treatment or hospitalisation. However, pattern is repeated in research in low- and such as good, fair or poor are crude self-neglect seems to lead to treatment; an middle-income countries. Most social out­ parameters. One method for maximising unhygienic, unkempt person was more come measures are derived from scales specificity and generalisabiliry is the use of noticeable in public or to visitors to the measuring psychopathology (i.e. the PSE} structured instruments for interviews, de­ house, and family embarrassment stimulated or from the course of the ill ness (e.g. the fining core symptom variables with clearly treatment-seeking for the patient. Psychiatric and Personal History Schedule, outlined operational criteria and incor­ The use of complementary medicines PPHS; Verghese et al, 1985) (Srinivasan et porating relevant existing scales with estab­ and consultations with traditional healers al, 2001; Thara, 2004). Social functioning lished psychometric credentials (McGlashan is widely acknowledged in low-income outcomes that were measured from PSE et al, 1988). countries such as India (Raguram et al, items could not distinguish social impair­ This has been reflected in studies such 2002), but their impact, apart from a likely ment from prevailing neurotic or psychotic as ISoS (Harrison et al, 2001), in which placebo effect, has not been adequately conditions. The PPHS rates the availabiliry the PSE-9 has been supplemented in most studied. and frequency of a patient's social contact cases by the Schedule for the Assessment during 1 month preceding evaluation. of Negative Symptoms (SANS; Andreasen, These items refer to living in a household, 1983), the Schedule for Clinical Assessment Mortality close friends, casual friends and the pres­ in Neuropsychiacry (SCAN; World Health The mortality rate is often neglected in out­ ence or absence of social activity groups. Organization, 1998), and the Scale for come studies, but recently high mortaliry Few studies have used locally derived scales Assessment of Positive Symptoms (SAPS; rates have been reported from low- and (e.g. Egunia's Social Adjustment Scale; Andreasen, 1984) for outcome measure­ middle-income countries (Patel et al, Kurihara el al, 2000, 2005) to assess social ment with respect to clinical symptoms 2006). In schizophrenia outcome studies and vocational outcome. (Petersen et al, 2005). spanning 15-25 years, the proportion of Several measures have been developed patients who died or were lost to follow­ and validated for use in these populations. up ranged from 23 % in Chennai to over Scales from low- and middle-income Hospitalisation/treatment-seeking 50% in Chandigarh and Agra (Harrison countries include the Schedule for the Hospitalisation has been used as an out­ et al, 2001). Thara's (2004) study found a Assessment of Psychiatric Disability (SAPD; come measure in several studies, generally mortality rate of 10% at 10 years, which Thara et al, 1988) and the SCARF Social as a proxy for acuteness of symptoms and increased to 17% at 20 years. The mean Functioning Index (Padmavathi et al, functional disabiliry (Burns, 2007, this age at death was 34.2 years, which is well 1995); and from high-i ncome countries supplement). In low- and middle-income below the national average life span of the Groningen Social Disabiliry Schedule countries, hospitalisation is more a reflec­ 60.5 years. A much higher mortality of (GSDS; Wiersma et al, 1988), the Life Skill tion of policy and resource availability than 47% was reported in a 15-year follow-up Profile (LSP; Rosen et al, 1989), the Social an indication of need (Harrison et al, study of patients from North India with Function Scale (SFS; Birchwood et al, 2001 ). Many people with schizophrenia early poor outcome. Out of 15 patients 1990), the Social Adaptive Functioning have never been treated or hospitalised, with a poor course of schizophrenia during Evaluation (SAFE; Harvey et al, 1997), and and assuming that they are asymptomatic the first 2 years, 7 had died before comple­ the Independent Living Scale Survey (JLSS; or symptoms are not severe is unjustified tion of follow-up (Mojtabai et al, 2001). A Wallace et al, 2000). For most cross-cultural (Isaac et al, 1981; Padmavathi et al, high mortality rate of over 10% has been studies the Disability Assessment Schedule 1998). The lack of hospital beds and reported from Ethiopia during follow-up (World Health Organization, 2000) and

s73 ISAAC ET AL

Global Assessment of Functioning (GAF; rates (up to 75%) have been found in India Eaton, 1996). Good marital outcome in American Psychiatric Association, 1987) (Thara, 2004). A similar trend is described terms of marryi ng and maintaining the have been used. among Chinese patients; nearly half were marriage was associated with good overall Some measures of social functioning in­ able to work after 5, 10 and '15 years of outcome in people with schizophrenia. clude items reflecting clinical symptoms follow-up (Tsoi & Wong, 1991). These Similarly, good marital outcome is related which need to be distinguished from those rates of employment are markedly higher co a decrease in symptoms and a lower of functioning. ln the West, many patients than those in similar populations in high­ relapse rate . reside in assisted living facilities whereas income countries (Mueser et al, 2001 ). There are conflicting reports on marital in low- and middle-income countries the The employment rate in the UK over the status and outcome as few follow-up studies majority live in the community and are past 20 years among people with schizo­ have studied this in derail. A few studies cared for by family members. This import­ phrenia ranges from 4 to 31 %, with most found that being married favours a good out­ ant component has not been adequately Western studies reporting a rate of between come and others found no such relationship represented in instruments for assessment 10 and 20% (Marwaha & Johnson, 2004). (Thara et al, 2003a). Outcome when schizo­ of social functioning (Sarswac et al, 2006). Workplace colleagues are found co be phrenia develops after marriage, or in those Recently the Social Occupational Func­ generally supportive in low- and middle­ who marry without disclosing their illness tioning Scale (SOFS) has been developed income countries (Srinivasan & Tirupati, (which is common in low- and middle­ and validaced ·in India, and has been found 2005). They rarely make an issue of the income countries), needs further study. suitable for use in multiple settings such as unusual behaviour of the person with Patients whose marriages have broken out-patient clinics, facilities and rehabilita­ schizophrenia, in contrast to the West down, in addition to the stress of their tion centres (Saraswac et al, 2006). A where a 'hostile social climate' may con­ mental illness, face hostility from family younger age at onset but not gender was as­ front persons with schizophrenia, whose members ·and rejection by society. This sociated with greater impairment in social diagnosis denies them access to employ­ can be a significant contributing factor to functioning. Although none of the items ment (Marwaha & Johnson, 2004). After outcome in traditional societies (Thara et was related co overall psychopathology, treatment for an episode of illness their re­ al, 2003a). In a qualitative study of 75 the item scores were correlated with posi­ rum to work is often accompanied by criti­ divorced/separated women with mental ill ­ tive and negative symptoms (Saraswac et cism and a denial of their skills. ness (57% of whom had developed their al, 2006). This discrepancy derives in part from illness after marriage), Thara et al (2003a) A neurocognitive study from India the easy availability of work in informal found that many did not get any mainte­ showed a lack of association of cognitive def­ sectors, differences in socio-economic status nance from their husbands and were fully icits with social functioning, employment and and economic pressure owing ro a lack of dependent on their parents for both social work performance (Srinivasan & Ti.rupaci, disability benefits in low- and middle­ and financial security. They initially felt 2005). At the same time there is an associa­ income countries. Employment is a critical helpless and lost, but most ultimately re­ tion of negative symptoms with these para­ factor for perceived recovery from illness conciled themselves to their face and were meters. Measures of social functioning in countries where families are reli ant on pess imistic about the future. However, (i.e. communication and interest) are the members for support. Future outcome few had contemplated suicide. Concerns strongly associated with work functioning. studies need to incorporate in-depth analysis of being a burden to their aged parents, Currently there are few studies using of these factors (i.e. type of job, sectors, and hostile criti cism from parents and social functional outcome measures from performance, financial gain, absenteeism, siblings further reinforced their plight. In low- and middle-income countries. Social etc.) to understand such significant variations. the current era of rapid globalisation, the functioning is an important domain and, effects of diminishing social support and although sometimes cumbersome to mea­ the increasing prevalence of the nuclear sure, urgently needs to be incorporated as Marriage family warrant close examination of the a regular outcome measure. Marriage requires certain social abilities to be effects of these social changes on outcome. successful. In countries such as India, mar­ riage is a once-in-a-lifetime event and is Employment associated with a high degree of socia l ap­ Social/family support People with schizophrenia in low- and proval. The sociocultural factors determining Social support as a predictor of outcome in middle-i ncome countries are more likely marriage and its maintenance are vastly low- and middle-income countries has to be employed than their Western counter­ different from those in Western societies. attracted considerable attention. Recent parts. Srinivasan & Thara (1997) found an Marital state can be considered an out­ studies propose that supportive and fa vour­ annual rate of employment of 63-73% in come measure, as its maintenance depends abl e attitudes among family members and the first 10 years of follow-up in a cohort on stability and functioning of both part­ the community contribute to the improved of 90 people with first-episode schizo­ ners. Schizophrenia manifests maximally outcomes (Kurihara et al, 2000, 2005). phrenia. Moreover, among untreated at a marriageable age (i.e. around the The mean time spent in hospital by people Indian people with schizophrenia almost 20s). Most studies from the West have with schizophrenia is approximately a fifth one-third were employed (Padrnavathi et reported low rates of marriage for people in Bali compared with Tokyo (Kurihara et al, 1998). Moreover, almost half obtained with schizophrenia (Nanko & Moridaria, al, 2000). Studies from Asian countries employment within a yea r of starting 1993; Hutchinson et al, 1999). In contrast, showed chat less than 10% were hospital­ treatment with antipsychocics (Srinivasan a 10-year follow-up study from lndia found ised during follow-up, suggesting high et al, 2001). Generall y, high employment a high marital rate of 70% (Thara & levels of family involvement in patient care

s74 OUT C OM E M E A S U R ES IN DI FFE R E NT COUNTRIES

(Ganev et al, 1998). It is suggested that Substance misuse muJticentre research, money, manpower social support is increased for both patients Comorbid substance rrususe in schizo­ and technical expertise are essential, and and caregivers from the extended family. phrenia has heen described as a high-risk these have always been scarce in low- and This minimises the damaging effects of the factor for poor outcomes, including treat­ middle-income countries, especiall y for illness and improves outcome. ment non-adherence, relapse, rehospitalis­ mental health. This is one of the reasons Migration, urbanisation, changes in ation, violence, victimisation, criminal justice for the few studies on outcome in these family structure and social support networks, involvement, HIV and hepatitis C (Swartz countries. In the majority of these studies, plus the increase in economic insecurity and et al, 2006). Estimates of the prevalence the various outcomes were not studied widening social inequalities which are evi­ of substance use disorders are up to 70% , using standardised and cuJturally appro­ dent in low- and middle-income countries depending on diagnostic assessment meth­ priate instruments. Longitudinal studies will change the social support available for ods. Comorbid substance misuse (nicotine using parameters such as neurocognitive people with schizophrenia and influence their excluded) has been reported in about half function and quality of life are almost outcome (Patel et al, 2006). of people with schizophrenia in the USA non-existent. Most studies are hospital (Regier et al, 1990). based and there is a need for well-designed There are few epidemiological studies community-based outcome studies in these Illness beliefs from low- and middle-income countries countries. India, like many other low- and middle-income countries, represents a Research from low- and middle-income on the prevalence of substance misuse in society in transition. Whether the current countries consistently shows that there is a the general population, and even fewer on sociocultural patterns associated with good significant delay in seeking treatment for prevalence among people with schizo­ outcome will themselves change and in turn people with schizophrenia. Misconceptions phrenia. A study in a psychiatric hospital alter the outcome of schizophrenia needs to of illness, superstition and ignorance have showed that the prevalence of alcohol dis­ be examined through prospective studies. been proposed as reasons. However, recent orders among patients with severe mental studies have shown that very few people disorders was much lower than in the still named supernatural factors alone as a general population (Carey et al, 2003). An APPENDIX out-patient study in Chennai showed that cause of schizophrenia (Srinivasan & Factors apparently contributing only 38% of males with schizophrenia were Thara, 2001). In a study of Indian patients to good prognosis of schizophrenia current smokers, which was nor signifi­ (Srinivasan & Thara, 2001 ), supernatural in low- and middle-income cantly different from the general population cause was named by only 12 % of families countries with a member with schizophrenia. (Srinivasan & Thara, 2002). Srinivasan & Thara (2002) have argued that comorbidicy Established with nicotine use is not entirely biological; Less expressed emotion Burden of care 'culture' plays a major determinant role. Good social support Substance misuse may thus be an Tolerance of odd behaviour by society and Although the overall burden of care might important cultural factor among a host of family be comparable across cultures, there are others that may mediate the course and Marriage different patterns reflecting different socio­ outcome of schizophrenia in low- and cultural factors. The issue is particularly re­ middle-income countries. Doubtful levant in low- and middle-income countries where the majority of patients stay with Less industrialisation and urbanisation their caregivers. Pai & Kapur (1982) devel­ CONCLUSIONS Early death of those with bad outcome oped a semi-structured instrument covering Increased prevalence of acute psychosis six broad areas of burden (financial, family Low- and middle-income counties are routine, leisure, interaction, effect on physi­ characterised hy a poorly organised health­ Needs to be studied cal health and effect on mental health). care sector, limited access to psychi atrists Comorbid substance use They found that caregiver burden decreases and longer duration of untreated psychosis. Duration of untreated psychosis with a reduction in the patient's symptoms Yet the outcome of schizophrenia appears Pharmacological interventions and improving drug adherence. Reduction to be better. What has contributed to the of fami ly burden is associated with better better outcome in these countries is difficult REFERENCES outcome and social functioning (Pai & to say. Prevailing cuJtural factors and the

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s76 OUTCOME MEASURES IN DIFFERENT COUNTR I ES

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s77 Enclosure

REFERENCE LIST

Authors

Robert Whitaker (Medical and science investigative journalist)

"Mad in America, Bad Science, Bad Medicine, And The Enduring Mistreatment of The Mentally JI/", 2002, second edition 2010.

Anatomy of an Epidemic, Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, 2010, Second edition 2014.

Peter R. Breggin M.D. (Psychiatrist, USA)

" Your Drug May Be Your Problem, How and Why to Stop Taking Psychiatric Medications", Peter R. Breggin, M .D. and David Cohen, Ph .D., 1999, second edition 2007 .

"Brain Disabling Treatments in Psychiatry, Drugs, Electroshock, and the Psychopharmaceutical Complex", 1997, second edition 2008.

"Psychiatric Drug Withdrawal, A Guide far Prescribers, Therapists, Patients, and Their Families", 2013.

Refer to Breggin.com for a complete list of books written by Peter R. Breggin M.D. since the 1970s.

Dr. Joanna Moncrieff (Psychiatrist, UK)

"The Myth of the Chemical Cure", 2008

"The Bitterest Pills: the troubling story of anti-psychotic drugs", 2013.

Refer to joannamoncrieff.com .

Kelly Brogan M.D. (Psychiatrist, New York, USA)

"A Mind of Your Own: The Truth About Depression and How Women Can Heal Their Bodies to Reclaim Their Lives", 2016.

Irving Kirsch, Ph. D. (Professor of Psychology at the University of Hull, United Kingdom, as well as professor emeritus at the University of Connecticut, USA) .

"The Emperor's New Drugs, Exploding the Antidepressant Myth", 2010.

The Author reviews all the data and studies on anti-depressants that purportedly establish the effectiveness of these drugs and shows that "what the published studies really indicate is that most of the improvement shown by depressed people when they take ant-depressants is due to the placebo effect", at p. 3.

1 Websites:

Madinamerica.com

Psychiatrists, psychologists, doctors, survivors publish research and lived patient experiences and commentary not otherwise available. The website/movement arose out of the publication of Robert Whitaker's first book Mad in America .

Breggin.com

CEPUK.ORG

Rxisk.org

(Publishes risks and effects of many different drugs).

Joannamoncrieff.com

Davidhealy.org

SurvivingAntiDepressants.org

BeyondMeds.com

SSRlstories.org

YOUTUBE

Search :

"The Simple Truths About Psychiatry", a video series by Peter R. Breggin M .D.

Search:

"Open Paradigm Project Joanna Moncrieff"

See the interview with Dr Joanna Moncrieff. Published on you tube on 6 October 2013. The video is about 10 mins. But just see from 8 minutes on.

She points out there is no evidence establishing that anti-depressants cure a disease nor an underlying chemical imbalance and she refers to an interview with the Chief Scientist with the pharmaceutical company that invented Prozac where he admits the same thing.

Search:

"Laura Delano" (and see her videos. She is a survivor from the use of psychiatric drugs).

2