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Learning Where Psychiatric Illness "Lives:" Brain Regions Involved in Mood and Psychotic DisordersDaniel Healy, M.D.

Major CategoriesPsychotic DisordersSchizophreniaSchizoaffective DisorderMood DisordersMajor Depressive Disorder + psychosisBipolar Disorder (Manic-Depression) + psychosisAnxiety DisordersPTSDOCDGADPanic DisorderPersonality DisordersCluster A (Paranoid, Schizoid, SchizotypalCluster B (Borderline, Antisocial, Narcissiistic, Histrionic)Cluster C (Avoidant, Dependent, Obsessive Compulsive)Substance Abuse Disorders

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5NeuroanatomyProblem in certain brain regions that comprise circuitsFrontal lobe- cognition, alertness, control impulses, motivationTemporal lobe (hippocampus plus)-forming memories, auditory hallucinationsThalamus-interprets inputs from the five sensesCingulate gyrus-normal expression of emotionsCaudate-putamen, nucleus accumbens-fine tunes emotions and movements, reward/reinforcementParietal lobe-allows you to be aware of your own actions Amygdala-anxiety, angerHypothalamus-sleeping, eating

6NeurotransmittersProblem with certain neurotransmitters (nerves dont connect, gap is called synapse, neurotransmitters connect nerves)Dopamine-reward/reinforcement, paranoia, substance abuseGlutamate-ubiquitous, excitatory, too much kills neurons, stress increases cortisol increases glutamate (stress kills nerves), cognition, pain/temperature, affects dopamine releaseSerotonin-depression, anxiety, abnormal movementsGABA-ubiquitous, inhibitory, anxiety, cognitionAcetylcholine-memory, cognition, movements, nicotine affects acetylcholine nerves

http://www.brainexplorer.org is a good website; so is www.sharpbrains.com, which puts brain function in the context of investing.7We think of it as a disorder of thinking.But it is more than just that.Neurochemical anatomyWhy it is complicatedBillions of connectionsDifferent brain areas use different neurotransmittersNeurotransmitters have multiple types of receptors, some having opposite effects for same neurotransmitterFew medications affect only one neurotransmitter, so cant control the (side) effects of medications (most selective, least effective)Homeostasis, tendency to maintain status quo, means that it is hard to drive one area onlyGiving a medication to affect one area causes changes in other regionsGenes and environment are both influential8Psychosis

Defined by impaired reality testingPositive symptoms (presence of abnormality):thought content: delusionsperception: hallucinationsthought stream: grossly disorganizedbehavior: grossly disorganizedDopamine imbalance in the frontal lobe and caudate putamen)9Focus today: disorders of thinking and mood

Not to say that other mental illnesses are not importante.g. anxiety disorders (OCD, Panic D/O, PTSD); dementias (Alzheimers disease)

Really two separate lectures

CMH - severe and persistent mental illness

Legal Mental illness:Substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life.Psychosis

Negative symptoms (absence of normality):Affect blunted or flatAvolition/amotivationAlogia: decreased amount or contentAnhedonia: lack of interestsDopamine and glutamate imbalance (too little frontal lobe, too much in caudate putamen, maybe amygdala and hippocampus)10Focus today: disorders of thinking and mood

Not to say that other mental illnesses are not importante.g. anxiety disorders (OCD, Panic D/O, PTSD); dementias (Alzheimers disease)

Really two separate lectures

CMH - severe and persistent mental illness

Legal Mental illness:Substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life.Attention / Arousal Modelof SchizophreniaStimulus floodingLack of an effective filterToo much information from the environmentLeads to withdrawal from social contactStimulus overloadLeads to frustration, poor concentration, nervousnessThalamus uses gaba and glutamate to filter info from all five senses11PLAY TAPE OF AUDITORY HALLUCINATIONSFirst Generation Antipsychotics

ChlorpromazineThorazineFluphenazineProlixinHaloperidolHaldolLoxapineLoxitaneMesoridazineSerentilMolindoneMobanPerphenazineTrilafonPimozideOrapThioridazineMellarilThiothixeneNavaneTrifluoperazineStelazine

Long Acting First Generation Antipsychotics

Haloperidol Decanoate (Haldol)Fluphenazine Decanoate (Prolixin)Benefits of First Generation Antipsychotics

Effective control of psychotic symptoms in responsive patientsReduced need for institutional careClinical experienceRelatively inexpensive, generics availableLimitations of First Generation AntipsychoticsLack of efficacyNegative symptoms (frontal lobe, glutamate)DepressionSafety and tolerability concernsExtrapyramidal symptoms / tardive dyskinesia (dopamine/acetylcholine in caudate putamen)Sedation (frontal lobe)Cognitive impairments (frontal lobe)Prolactin elevation (dopamine pituitary)Cardiovascular symptoms (arrhythmias)NonadherenceSecond Generation Antipsychotics

clozapine (Clozaril) 1990risperidone (Risperdal) 1994olanzapine (Zyprexa) 1996quetiapine (Seroquel) 1997ziprasidone (Geodon)2001aripiprazole(Abilify)2002paliperidone(Invega)2006ileoperidone(Fanapt)2009asenapine(Saphris)2009lurasidone (Latuda)2011

Dissolvable Second Generation Antipsychotics

clozapine (Fazaclo) risperidone (Risperdal M-tabs) olanzapine (Zyprexa Zydis) aripiprazole (Abilify Discmelt)asenapine (Saphris is sublingual)

Long Acting Second Generation Antipsychotics

risperidone Consta (Risperdal)paliperidone Sustenna (Invega)olanzapine Relprevv (Zyprexa) (Watch out for coma. Seriously.)The Benefits of Second Generation AntipsychoticsAt least as effective as conventional agentsShift the risk / benefit ratioThe EPS advantage (serotonin)Reduced risk of tardive dyskinesia (dopamine serotonin)Broader symptom efficacyMay enhance compliance, reduce hospitalizations, be cost-effectiveChallenge providers to deliver effective rehabilitation servicesThe Limitations of Second Generation AntipsychoticsExpensiveWeight gain, diabetes, cholesterol Sedating (histamine)Sometimes not efficacious against positive symptoms (dopamine)Seroquel can be a drug of abuseIncreased Morbidity and Mortality in SchizophreniaLife expectancy increasing in general population (when controlling for infant mortality)Life expectancy still around 55 for folks diagnosed with schizophreniaLifestyle improvements not adopted by the people we serve (exercise, nutrition, smoking)Access to healthcareWeight gain from medications

Major Depression: Emotional SymptomsSad, irritable or empty moodDiurnal variationDiminished capacity for enjoymentDiminished interestsFrontal lobe, serotonin, norepinephrine, dopamine (anhedonia)

22Major Depression:Thought (Cognitive) SymptomsDifficulty concentratingIndecisivenessMemory problemsDepressed content of thoughtWorthlessnessGuiltHopelessnessDeath and Suicide

Frontal lobe, serotonin, norepinephrine23Major Depression:Somatic Symptoms (Body Functions)Sleep disturbancesAppetite disturbances, weight changesFatigue, low energyUpset stomach, constipationPhysical painHypothalamus serotonin, norepinephrine, histamine (sleep)24Major Depression: SeverityMild to severeMay include psychosis, poor self care, suicideAbraham Lincoln describing his own depression:I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on earth. Whether I shall ever be better, I cannot tell. I awfully forebode I shall not. To remain as I am is impossible. I must die or be better, it appears to me.25Significant suicide risk.A biological illnessNo ones faultFamous people with mental illnesses - Lincoln, Hemingway, Churchill, Tolstoy, many poetsAntidepressant MedicationsAll antidepressants must be taken for at least 4-6 weeks to have substantial benefitStudies are showing that if you dont respond in the first week or two, youre probably not going to, so augment or change earlier than previously recommended.NeuroanatomyProblem in certain brain regions that comprise circuitsFrontal lobe- mood, cognition, alertness, motivationCingulate gyrus-normal expression of emotionsCaudate-putamen-fine tunes emotions and movementsAmygdala-anxiety, angerHypothalamus-sleeping, eatingHippocampus-memory27NeurotransmittersDopamine-reward/reinforcement, anhedoniaGlutamate-ubiquitous, excitatory, too much kills neurons, stress increases cortisol increases glutamate (stress kills nerves), cognition, affects dopamine releaseSerotonin- all aspects of depressionNorepinephrine- all aspects of depressionGABA-ubiquitous, inhibitory, anxiety, cognitionAcetylcholine-memory, cognition, 28We think of it as a disorder of thinking.But it is more than just that.Antidepressants: Selective SerotoninRe-uptake Inhibitors (SSRIs)Fluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)Citalopram (Celexa)Escitalopram (Lexapro)Fluvoxamine (Luvox)Common Side Effects of SSRIsNauseaDry mouthDiarrhea or stomach upsetLack of appetiteFeeling tired, weak, or dizzyHeadacheAnxiety or nervousnessSexual dysfunctionAtypical AntidepressantsBupropion (Wellbutrin, Zyban)Can cause agitation, anxiety, insomniaVenlafaxine (Effexor, Pristiq)Hypertension, SSRI-like side effectsTrazodone (Desyrel)Sedation, dizzinessNefazodone (Serzone)SSRI-like but more sedation, monitor for liver toxicityMirtazapine (Remeron)May cause sedation, weight gainDuloxetine (Cymbalta)May cause nauseaTricyclic Antidepressants (TCAs)Amitriptyline (Elavil)Clomipramine (Anafranil)Desipramine (Norpramin)Doxepin (Sinequan)Imipramine (Tofranil)Nortriptyline (Pamelor) TCA Side EffectsCan be fatal in overdoseFatigue, sedationLight-headedness, dizzinessDry mouthConstipationWeight gainHeadacheAntidepressants: Monoamine Oxidase Inhibitors (MAOIs)Isocarboxazid (Marplan)Meclobemide (Aurorix)Phenelzine (Nardil)Tranylcypromine (Parnate)Selegiline (Eldepryl)MAOI ChallengesStrict dietary restrictionAvoid aged cheeses and meats, soy sauce, soy beans, fava beans, wine, beer, othersAvoid other anti-depressantsAvoid over-the-counter medicationsSide Effects of MAOIsHypertensive crisisSerotonin syndromeWeight gainFatigueConstipationDizzinessBipolar Disorder: The Course1% of general populationEqual in men and womenAge of onset similar to schizophreniaEpisodes can come on very fast (1-7 days)Later episodes longer, more severe, more frequentSubstance abuse commonHeredity plays a greater role than in depressionFamily members also at higher risk for major depressionHigh suicide risk37Mania: Signs and SymptomsPersistently elevated, expansive or irritable mood for one weekAssociated symptoms (need 3 or more for diagnosis)Inflated self -esteem or grandiosityDecreased need for sleepMore talkativeRacing thoughts or flight of ideasDistractibilityAgitation or increase in activitiesExcessive involvement in pleasurable activities with a high risk for painful consequencesSpending sprees, sexual indiscretions, foolish investments 38HypomaniaDistinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days plus three of the following:

inflated self-esteem or grandiosity

decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

more talkative than usual or pressure to keep talking

flight of ideas or subjective experience that thoughts are racing

distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

39Mixed EpisodeThe criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

40Mania PhysiologyFrontal lobe and amygdala-emotion regulationImpulsivity-dopamine reward/reinforcementLack of need for sleep-histamineIncreased neuronal firing, glutamateMood stabilizers may reduce the chemicals produced after a nerve firesMood Stabilizing MedicationsFDA Approved Agents

lithium (Eskalith, Lithobid) (mania, depression)valproate (Depakote) (mania)carbamazepine XR (Tegretol XR) (mania)aripiprazole (Abilify) (mania)asenapine (Saphris) (mania)chlorpromazine (Thorazine) (mania)olanzapine (Zyprexa) (mania)olanzapine + fluoxetine (depression)lamotrigine (Lamictal) (depression prevention)risperidone (Risperdal) (mania)quetiapine (Seroquel) (depression, mania)ziprasidone (Geodon) (mania)LithiumToxic in overdoseSevere tremor, confusion, disorientation, seizure, comaCan check blood levelsTremorGastrointestinal symptomsIncreased weight

DepakoteMonitor blood levelsStomach upsetWeight gainSedationLiver failureYellowing of skin or eyes, dark urine, nausea/vomitingPancreatitisAbdominal pain, nausea/vomiting, decreased appetitePolycystic Ovary riskHair loss

Other Mood Stabilizing MedicationsOther anticonvulsantsOxcarbazepine (Trileptal)Topiramate (Topamax)Tiagabine (Gabitril)Gabapentin (Neurontin)Other second generation antipsychoticsiloperidone (Fanapt)Conventional neurolepticsBenzodiazapines

Anxiety DisordersPosttraumatic Stress Disorder

Obsessive Compulsive Disorder

Generalized Anxiety Disorder

Panic Disorder with or without agoraphobia46The new four As of schizophrenia.

Anxiety DisordersSSRIs, SNRIs, TCAs effective in concert with psychotherapyAmygdala mediates fear and anxiety, GABA+glutamate balance, norepinephrine, dopamine, serotoninFrontal lobe mediates increased attention/vigilance, norepinephrineHypothalamus-blood pressure, increased heart rate47Antidepressants: Selective SerotoninRe-uptake Inhibitors (SSRIs)Fluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)Citalopram (Celexa)Escitalopram (Lexapro)Fluvoxamine (Luvox)Atypical AntidepressantsBupropion (Wellbutrin, Zyban)Can cause agitation, anxiety, insomniaVenlafaxine (Effexor, Pristiq)Hypertension, SSRI-like side effectsTrazodone (Desyrel)Sedation, dizzinessNefazodone (Serzone)SSRI-like but more sedation, monitor for liver toxicityMirtazapine (Remeron)May cause sedation, weight gainDuloxetine (Cymbalta)May cause nauseaAnxiolytics / HypnoticsAlprazolam (Xanax)Chlordiazepoxide (Librium)Clonazepam (Klonopin)Diazepam (Valium)Lorazepam (Ativan)Oxazepam (Serax)Temazepam (Restoril)Triazolam (Halcion)Zolpidem (Ambien)Zaleplon (Sonata)

50Note: all have addiction potential, last four mostly for sleep, GABA in amygdala a major target Sedative/Hypnotics (Benzodiazepines)SedationAddiction potentialCan be fatal in overdose, especially if combined with alcoholStudies show most likely outcome for adding a benzo is to create benzo dependence; either no benefit or trigger for abusing other substances51Sedative/Hypnotics (Benzodiazepines)Severe craving lengthens tapering off periodTaking benzos decreases craving for benzos, alcohol, or other substance of abuse, but does not improve illnessFolks with bipolar disorder and depression have a very high risk of developing benzo abuse/dependence, with no evidence that benzos beneficial for mood52Sedative/Hypnotics (Benzodiazepines)Many states are restricting or eliminating benzos from formularyTime-limited, supervised use for detox/withdrawal and akasthisia now only acceptable use for benzos53Substance Abuse DisordersIntending to use the substanceHoping not to get in troubleMake bad choicesDo get in troubleOutcome goal- abstinence or non-harmful useDopamine in nucleus accumbens, amygdala frontal lobe, temporal lobe (withdrawal balance of GABA and glutamate)54Principles in the Olden DaysAchieve abstinence before treating mood, anxiety or psychotic disorder

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Principles in the Olden DaysPsychotropic medications reduced the likelihood of sobriety

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Principles in the Olden DaysNo medications available to facilitate sobriety (Antabuse-no data on sobriety)

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Principles now and for the futureTreat all illnesses simultaneously, and combine medications designed to enhance sobriety with psychosocial interventions

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58Principles now and for the futureHarm reduction is a useful treatment goal as part of the treatment plan.

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59Co-occurring Mental Illness and Substance Use DisordersComorbidity is the expectation, not the exceptionPersons diagnosed with schizophrenia47% use substances55% of those in psychiatric treatmentBipolar disorder62% have substance use disorderBipolar consumers more likely to abuse alcohol and cannabis than MDDMajor Depressive disorderMore likely to have alcohol dependence than abuseConsumers with mood disorders, in general, are likely to abuse benzodiazepines.60Psychosocial TreatmentsProvision for basic needsAssertive community treatment (ACT)Patient and family psychoeducationVocational rehabilitationClubhousesSocial skills trainingSupport groups61Psychosocial TreatmentsMotivational enhancement therapyCognitive behavioral (relapse prevention)12 step programsContingency managementFamily interventionsSelf-help manuals/workbooksCase management62Co-occurring Mental Illness and Substance Use DisordersThere is little evidence that there is a gene that increases likelihood that you will have a co-occurring disorderThere is also little evidence that any one factor causes you to develop co-occurring disorder (e.g. personality disorder, addictive personality).63Co-occurring Mental Illness and Substance Use DisordersThere is little agreement whether mood disorder symptoms precede or follow substance abuse64

Should one stop taking psychiatric medication if start using substances?NO (most of the time)Treat both conditions simultaneouslyYearly schizophrenia relapse rateWith medication - 15-20%Without medication - 70%Without medication and with precipitant such as substance abuse greater than 70%65Why do people with serious mental illnesses use substances?With deinstitutionalization, more choices including self-determinationNot just to self-medicate symptomsRelieves feelings of isolation, loneliness, boredom and despairFacilitates peer interaction and social engagementPromotes a sense of well-being, escape from life perceived as bleak or hopeless, mitigates withdrawalHarder to modify behavior if have cognitive impairmentsIncreases metabolism, effectively reducing doses of medications66Medications That Support Recovery (alcohol)disulfiram (Antabuse)

Works by interfering with alcohol metabolism-cousin of formaldehyde accumulates in blood, causing illnessDoesnt affect craving directly, limited data on relapse reductionMore of an aversive treatmentAvoid alcohol in any form (aftershave, etc)67Medications That Support Recovery (alcohol)naltrexone (Revia)

Works by affecting endogenous opioid systemReduces cravingWill induce withdrawal if consumer using or abusing opiatesCant use opiates for pain management68Medications That Support Recovery (alcohol)injectible naltrexone (Vivitrol)

Works by affecting endogenous opioid systemReduces cravingWill induce withdrawal if consumer using or abusing opiatesCant use opiates for pain management69Medications That Support Recovery (alcohol)acamprosate (Campral)

Works by affecting glutamate and/or GABA receptorsMay reduce craving by mitigating early withdrawal, and reduces relapse ratesAvoid if consumer has kidney problems70Medications That Support Recovery (opiates)methadone (Dolophine)

Works by occupying opiate receptors in same way morphine and its cousins doWill reduce withdrawal symptoms but some abuse potentialNeeds to be prescribed in a subspecialty clinic71Medications That Support Recovery (opiates)buprenorphine (Suboxone)

Works by occupying opiate receptors without fully stimulating themWill reduce withdrawal symptoms and may have less abuse potential than methadonePrescribers must go through special training in order to prescribe72Medications That Support Recovery (opiates)imipramine (Tofranil)

Used to treat depression in consumer with opiate abuse/dependenceTreatment for depression with imipramine was associated with reduced craving for, and self-reported use of, opiates, cocaine, and cannabis73Medications That Support Recovery (nicotine)Nicotine replacement

Works same way smoking and dipping doesMay reduce craving by occupying and stimulating receptorsAvailable in multiple delivery systems74Medications That Support Recovery (nicotine)buproprion (Zyban, Wellbutrin)

Works through the dopamine and norepinephrine system (presumably)May reduce craving indirectlyEffect independent of antidepressant effect75Medications That Support Recovery (nicotine)Varenicline (Chantix)

Works by occupying nicotinic receptors, blocking nicotine effectsMay reduce craving by mildly stimulating receptorsNicotinic receptors are odd: initially stimulated, then shut downInsomnia, agitation, psychosis possible76Medications That Support Recovery (caffeine)No medication approved for caffeine use/abuseCaffeine blocks adenosineAdenosine receptors in brain affect wakefulnessAdenosine receptors in the heart regulate rhythmAdenosine receptors in stomach affect acid secretion77Medications That Support Recovery (general)Consumers on clozapine seem to have lower rates of substance abuse Lithium for adolescents seems to reduce alcohol abuse78Detoxification/WithdrawalWithdrawal from alcohol and benzos can be fatalWithdrawal from opiates is very uncomfortable, with significant physical symptoms, but rarely fatalWithdrawal from cocaine rarely requires close supervision79The Perfect Treatment SystemAccessible

Capable

Comprehensive

Continuous

IntegratedFlexible

Individualized

Willing and Tolerant

Culturally competentKeys to SuccessSafe housing

Meaningful daytime activity

Sober support network

Positive alliance with at least one treatment provider

Social work interventions reduce stress, preserving brain function, and leading to better outcomesNine reasons not to take your medicationsCant remember

Difficult medication schedule

Fear of medications

Bad side effects

No social support

Dont have an illness, so dont need medications

Stigma of taking a psychiatric medication

Dont like/trust the prescriber

The meds arent working

Conditions that may be related to problems with brain regions that mediate facial recognition

Capgras-delusion that family and friends are imposters

Fregoli-delusion that one person is wearing many disguises, so multiple people are actually just one person

Cotard-delusion that all of organs are gone or they are dead

Autism and Aspergers-interpersonal difficulties may be related to inability to recognize facial expressions

Depersonalization-delusion that the face in the mirror is not you

83Studies of people with antisocial personality disorder (sociopaths) show that they are physically unable to detect fear and discomfort in other peoples facial expressions. Lack of empathy may have a biologic basis.

Domestic violence perpetrators overestimate threats, based on facial expressions of partners, which can be measured with brain scans

The insular cortex in the brain may not be active in folks with borderline personality disorder, leading to trust issues and an inability to cooperate in groups

The Rupture and Repair of Cooperation in Borderline Personality Disorder; Brooks King-Casas, et al. Science 321, 806 (2008);

Lack of Insight vs DenialDenial-you understand, on some level, your actions and consequences, but this understanding does not influence behavior

Anosognosia or lack of insight is the physical inability to understand your actions while sick

Anosognosia is more similar to amnesia than to denialCoercion vs RecoveryCoercion assumes that the role of the treatment team is to be right and to minimize risk liabilitiesTherefore, take the steps necessary to optimize a narrowly defined outcome (e.g. suicide prevention)Hospitalization and symptom improvement most likely interventions when suicide risk acutely increasedBoth are independent risk factors for completed suicide, sowhat are we doing?Recovery is a civil rights movement similar to the advances made by the physically disabled to (re-)integrate into the communitySociety created accommodations for physically disabled (ramps, automatic doors, etc) so they could participate in societyAccommodations for the mentally ill were not included in this movement, necessitating a separate movementCoercion vs RecoveryBasic tenets of the recovery movement include hope, engagement, supporting self-efficacy, and the dignity of risk

Treatment providers should take a consultative, rather than directive, role in the treatment of psychiatric illnesses; fewer appointments, and more walk-in availability

Note that recovery is not a synonym for symptom remission; consumers can be symptomatic and still participate in society

The role of any health care intervention is to shift the odds in your favor; ownership of outcomes cannot rest solely on health care providers

Psychiatric illness associated with increased mortality (life expectancy in your 50s), even when suicide excluded; sowhat are we doing?Coercion vs RecoverySome have argued that coercive treatment is an accommodation for asognosia (lack of insight into need for treatment)Others have argued that coercive treatment is a legitimate engagement tool, but should not be relied upon for prolonged periods of timeStill others argue that ATOs and recovery can never be reconciled, and they are even against involuntary hospitalizationIntensive outreach and engagement are the keys to recovery; court orders merely obligate staff to do the job they should be doing anyway (and without resorting to restrictions of liberty)Do ATOs reduce or increase autonomy?Treatment Advocacy Center: Severe mental illness, not its treatment, restricts civil liberties. By assuring timely and effective intervention for the disabling medical condition of severe mental illness, assisted outpatient treatment restores the capacity to exercise civil liberties and reduces the likelihood of the loss of liberty or life as a result of arrest, incarceration, hospitalization, victimization, suicide and other common outcomes of non-treatment.

Thanks for your timeThanks for your time!

Shout out to Dr Tom Coles, for finishing the Detroit Free Press/Talmer Bank Marathon and raising awareness for the Brain & Behavior Research Foundation (formerly NARSAD)