Informed consent is an essential human right which was guaranteed by the Nuremberg Code and an ethical principle approved by the World Health Organization, the United Nations and even the US government. This is a human right that all human beings have under both international law and under US Constitutional law. Mental health professionals need to honor the ethical and human rights principle of informed consent. The human right to have informed consent is a right that even prisoners of war and convicted felons have and yet mental health patients, who have been charged with no crime, have been routinely denied this basic human right. As a third party decision maker, the legal guardian stands for the human rights of the patient when the patient is incapacitated. The legal guardian needs to stand firm and insist that he/she be fully informed regarding all medical treatment choices including the dangers of all drugs and treatments given.
The right to informed consent is delineated in the federal regulation Protection of Human Subjects, 45 CFR 46 also known as the Common Rule under the authority granted by the U.S. Department of Health and Human Services. The Belmont Report was written concerning the Ethical Principles and Guidelines for the protection of human subjects of research. Since 1945, various codes for the proper and responsible conduct of human experimentation in medical research have been adopted by different organizations. The best known of these codes are the Nuremberg Code of 1947, the Helsinki Declaration of 1964 (revised in 1975), and the 1971 Guidelines (codified into Federal Regulations in 1974) issued by the U.S. Department of Health, Education, and Welfare Codes for the conduct of social and behavioral research have also been adopted, the best known being that of the American Psychological Association, published in 1973.
Respect for persons requires that patients, to the degree that they are capable, be given the opportunity to choose what shall or shall not happen to them. Information about risks should never be withheld for the purpose of eliciting the cooperation of a patient and truthful answers should always be given to direct questions about the treatment and research. But a lack of informed consent is exactly what has happened to many mental health patients. The medical information about these drugs is often conveyed to the legal guardian in a technical, disorganized and rapid fashion and thus there is often not sufficient time to consider the information or to question it. Often there is no substantive discussion with hospital or clinic staffs in which the views of the patient and the legal guardian were honored and listened to; instead patients are often ignored as if they did not have any rights to express their dislike for medications or treatment options. There is often no voluntary agreement to participate in research thus there was no valid consent. Informed consent requires conditions free of coercion and undue influence and it is clear that while incarcerated in a locked psychiatric hospital ward there is the use of coercion. There can also be the use of undue influence by the court appointed attorney through offers of inappropriate or improper reward in order to obtain compliance vulnerable patients. The doctor in his/her position of authority who can exert a commanding influence and who can threaten sanctions can easily force patients to take drugs against their consent.
The first priority for any mental health professional should be the identification of biological causes for the patients’ behavior and to rule out the role of any known pre-existing medical condition such as Post Traumatic Stress Disorder or physical brain trauma.
Neuroleptic Induced Deficit Syndrome (NIDS) can be caused by these medications which change in emotional awareness, sense of aliveness, and in the speed, and clarity of thought. The treatment effects felt by many people who have taken these medications are described as feeling like a zombie. Neuroleptic effect is present when the following features are observed:
1. Psychomotor Retardation – motor slowing, body not moving so well
2. Emotional indifference - not being emotionally responsive / not caring
3. Reduced initiative – not showing interest in initiating activity
4. Slowing of thought
As the dose of the medication increases, and more time elapses, it appears that the effects change – from sedative effects, into anti-psychotic effects, and possibly into other less desirable side effects; akathisia (restless leg syndrome), emotional parkinsonism (emotional blunting) and on into some other unwanted side effects. It is not uncommon when the first symptoms appear like apathy, emotional indifference, motor slowing or slow mentation that these were attributed to the underlying condition of the patient (the patient’s disease) when really they are the effects of the medication itself. A patient on these medications can initially demonstrate an improvement in symptoms only to later over time have that initial improvement go away or to only reach a certain point and then plateau or level off. There is also one more important one effect: neuroleptic dysphoria – which is like depression. When this happens when patients are often given even higher dosages of the drugs, leading to even more severe effects.
Many of the symptoms that are used to justify hospital treatment may actually be caused by the psychiatric medications given. So continuation of these medications only creates a self-filling prophecy that furthers the financial goals of the hospital institution and may cause further permanent brain damage.
A medical review of the complete medical record is necessary. Although dose reductions may or may not improve troublesome symptoms, they are often a good place to start. Dose reductions should be conducted gradually and with careful monitoring, unless an immediate health emergency (such as neuroleptic malignant syndrome) demands abrupt cessation.
Therapeutic drug dependence occurs with psychiatric drugs. Although these drugs produce no tolerance and no euphoria, they produce enduring post-discontinuation changes that are as extensive and long lasting as the changes underpinning current disease models of addiction. Patients also get withdrawal or discontinuation syndromes when they stop taking their medication or when their medication is lowered in dose. When anti-depressant or anti-psychotic medications have been in the brain for a while and then the dose is suddenly lowered, or if the medication is taken away too quickly there is a reaction to that change called Neuroleptic Discontinuation Syndrome. So when a patient runs out of medication or is suddenly put on a lower dosage they can demonstrate exacerbations of psychosis, become delusional or even hallucinate. Seizures can also occur from rapid withdrawal from these psychiatric medications. What usually happens to the patient in withdrawal is that they end up back in the hospital again. These crisis admissions lead to being labeled with a new disease diagnosis – schizophrenia, or delusional or manic depressive and then placed on even greater dosages of even more dangerous drugs. The doctors in these instances are quick to blame the patient, for a relapse rather than considering when the patient last took his medication. Discontinuation syndrome can sometimes last for weeks or months - some people have said they can last as long as six months. (see the article by Psychiatrist Dr. Grace E. Jackson MD)
Once falsely labeled with a severe mental illness or psychiatric diagnosis such as schizophrenia, the patient is then court ordered into treatment and subsequently forcibly drugged. Often forced hospitalization prevents contact and even communication with the patient’s family and friends, thus severing ties to those who are closest to him. While hospitalized the patient is especially vulnerable and thus unable to protect himself from adverse influence, coercion and threat to make him/her to take medications. If the mental health patient is a victim of PTSD, this would make the patient especially vulnerable when he/she is threatened due to the long term effects of trauma on him/her. Patients who are also economically disadvantaged may be because of this dependent status much more easily manipulated due to their socioeconomic situation.
Iatrogenic effects are inadvertent adverse effects or complications resulting from medical treatment and can include complex drug interactions. These kinds of effects are commonplace with psychiatric medications. In the USA an estimated 44,000 to 98,000 people die every year because of iatrogensis. Causes of iatrogensis include medical error, negligence, poor research design as well as inattentiveness to clinical symptoms reported by the patient and the patient’s family.
These psychiatric drugs are not of small risk but instead cause massive changes in the way the brain functions. Long term studies have indicated that there are severe debilitating and sometimes fatal effects of these drugs. Possible negative effects were minimized or not even discussed at all. There are risks of long term psychological harm, physical harm, social harm and economic harm. The probability of developing Parkinsons’ like symptoms is also great.
The so-called “atypical” antipsychotics are neither “atypical” nor “antipsychotic.” Not infrequently, these chemicals induce or enhance bizarre statements (disorganized speech or delusions), social withdrawal (depression), and sedation (encephalopathy), regardless of dose. The processes through which these medications exert destabilizing effects include receptor blockade (D2, ACH, histamine), electrophysiological (depolarization) blockade; direct toxicity (cell death); and induction of other disease processes (pneumonia, diabetes, hypothyroidism, Pulmonary Embolism). Unfortunately many prescribing clinicians are largely unaware of these problems and thus do not inform their patients.
Numerous psychiatric medications are dangerous and even life threatening adverse effects including: weight gain and diabetes, tardive dyskinesia (movement disorder), tremor, akathisia (restless leg syndrome), dyskinesia (uncontrollable movements, tics, tremors), dystonia, as well as the side effects of nausea, dizziness (low blood pressure), and insomnia. Dystonia is a neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. It is painful to even watch a video of someone with dyskinesia or dystonia. The doctors when prescribing these medications tell patients and their families just to disregard these potentially life threatening and life altering side effects.
Many of these drugs cause symptoms that can themselves be construed as mental illness. One drug Abilify or Aripiprazole, is known to cause neurological side effects, gastrointestinal signs, movement disorders, disturbances in thinking, anxiety disorders, sleep disorders and even suicidal behavior. These are the actually side effects of the drug – yet when these symptoms occur they are attributed often to what they claim is the medical diagnosis. Doctors reported to the FDA that their patients had hallucinations, psychosis, heart rate, diabetes, cardiac problems, liver dysfunction, coma, and blood coagulation problems while on Abilify. Even a very cursory review of the FDA warnings and listing of adverse side effects would cause any responsible legal guardian to reconsider the use of these drugs on a loved one.
The Food and Drug Administration or FDA is the agency charged with protecting the safety of consumers. Hundreds of cases have been brought in the last several years against pharmaceutical companies arising from deaths and injuries attributed to drugs used to treat psychiatric disorders. The most urgent warnings are those known as “black box” warnings, in which drug companies are required to (or voluntarily) post warnings in bold black print in a bold black box. These warnings appear in the Physician’s Desk Reference and in the package inserts for the drugs, which doctors are presumed to read.
The black box warnings of Luvox included the possibility of violent behavior including homicidal thoughts. The drug industry makes it confusing that many psychotropic drugs have different names and different warning labels in different countries and thus what is known about dangerous side effects in one country may not be common knowledge for patients or even prescribing doctors in another country. There is suppression of the research findings of negative outcomes and also suppression of reports of clinical adverse events. There is little adherence to the guidance of the Food and Drug Administration guidelines in these matters, with hospitals and mental health professionals routinely ignoring FDA warning labels and withholding the truth from patients and their families.
Even a cursory view of the serious effects of these drugs would make any person be concerned. One clear possible outcome of the use of the antipsychotic drug Abilify is tardive dyskinesia. Tardive dyskinesia is a difficult-to-treat and causes the patient to have in involuntary, repetitive body movements that started some time after starting the medication. The only way to prevent tardive dyskinesia is to not give these medications to the patient. It frequently appears after long-term or high-dose use of antipsychotic drugs. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements, such as grimacing, tongue protrusion, lip smacking, puckering and pursing of the lips, rapid eye blinking and rapid finger movements. To knowingly force someone unnecessarily on medications that cause this outcome could surely be considered cruel and unusual punishment or even torture – because life with tardive dyskinesia is daily torture. Tardive dyskinesia is often misdiagnosed as a mental illness rather than a neurological disorder, and as a result patients are prescribed more drugs which increase the probability that the patient will develop this disabling disability. In such cases, it is critical to properly identify the signs of the disorder and stop drugs as soon as possible. These drugs have a tendency to mask the very symptoms they are causing, thus making it more difficult to determine what the problem is.
Physicians should educate patients and families about the dangers of tardive dyskinesia. The majority of patients who are on the drugs long enough will develop the disorder of tardive dyskinesia, with some getting this problem after only 4 months of treatment with the medication. The published rate for tardive dyskinesia among people who stay on the older drugs is approximately 3-5% per year - if you stay on these medications, for ten years, the risk of developing TD is 50%. (Dr. Grace E. Jackson MD ‘What Doctors May Not Tell You About Psychiatric Drugs’ Public Lecture, UCE Birmingham June 2004)
Many patients who take these drugs also develop Parkinsonian side effects about 40-50% (or more) experience Parkinsonian symptoms. Julia Child, a very famous cook over in the US and the actor Michael J Fox are both famous victims of severe Parkinson’s disease. In Parkinson’s disease people lose these dopamine cells in the substantia nigra area of the brain. With antipsychotic medication, there is not actually death of brain cells but the drug does affect how the brain cells function. So Parkinson’s symptoms do occur in a fairly high rate of patients.
There are also long term affects of these drugs called tardive dysmentia and tardive psychosis which are debilitating conditions caused by these medications. But doctors often blame the patient for these problems and attributing symptoms to the underlying condition and not to the medications own effects. Tardive dementia is caused by long-term use of the neuroleptics resulting in a depressive condition similar to NIDS that involves the frontal lobe of the brain. In some individuals, it seemed that long term treatment with neuroleptics was more likely to affect emotional centers in the human brain, and patients were seen to develop dramatic or euphoric mood swings and this was called tardive dysmentia.
The other antipsychotic Clozapine can cause fatal blood problems as well as other side effects of serious concern. Clozaril (clozapine) is a drug which was known to be associated with fatal cases of aplastic anemia which causes low white blood cell counts and predisposes patients to infections. Clozapine has also been linked to high blood sugar and diabetes. Doctors are supposed to watch for unexplained fever, fatigue and low energy levels in patients taking Clozaril. Clozaril has been strongly associated with possible fatal heart problems. [Presto v. Sandoz, 226 Ga. App. 547 (1997)]. Clozapine is also associated with neuroleptic malignant syndrome (NMS) which is a rare, but life-threatening, idiosyncratic reaction to a neuroleptic medication which can be fatal.
Serotonin is a neurotransmitter that affects the brain and plays a role in aggression, memory, learning, pain, sleep, appetite, anxiety, depression, migraine, and vomiting. Selective Serotonin Reuptake Inhibitors or SSRI's inhibit the uptake of serotonin or 5-hydroxytryptamine (5-HT) which is a neurotransmitter. Several different classes of psychiatric drugs like anti-depressants, anti-psychotics, anti-anxiety drugs, anti- migraine drugs and psychedelic drugs affect the level of this neurotransmitter inside the neuro-synapses of the brain.
Some drugs such as tricyclic antidepressants (TCA’s) and selective serotonin reuptake inhibitors (SSRIs) inhibit the reuptake of serotonin, making it stay in the synapse longer. Serotonin syndrome which can also be called serotonin toxicity is really a poisoning and is the predictable consequence of excess serotonin activity in the brain and elsewhere in the body which can be caused by therapeutic use of these medications.
The Neuroleptic Malignant Syndrome is characterized by fever, muscle cramps, unstable blood pressure and muscular tremors. Neuroleptic malignant syndrome (NMS) causes changes in mental status, difficulty thinking, agitation, delirium and even coma. It can be life threatening and often fatal and requires immediate cessation of the offending medication and emergency treatment.
Serotonin syndrome may be mistaken for a viral illness, anxiety, neurological disorder, various kinds of poisonings, or a worsening psychiatric condition. Serotonin Syndrome which is less severe than Neuroleptic Malignant Syndrome. What many people might not have been told by their doctors is that this problem can develop with SSRI medications. Serotonin Syndrome does not appear to cause death as often does Neuroleptic Malignant Syndrome. Serotonin Syndrome can cause headache, agitation, hypomania, mental confusion, hallucinations, coma, shivering, sweating, hyperthermia (temperature as high as 104 degrees F and even go as high as 106 degrees F, hypertension (high blood pressure), tachycardia (fast heart rate), nausea, and diarrhea. In addition there can also be muscle twitching and tremor. No laboratory tests can currently confirm the diagnosis of Serotonin Syndrome and it is usually diagnosed base on the patient’s symptoms and clinical history.
Libby Zion died when she was admitted to the hospital for "flu-like" symptoms and the resident interns who treated her did not recognize that she was suffering serotonin syndrome, her temperature rose to 107 degrees Fahrenheit, and she had tremors and the interns gave inappropriate medication which caused her death. But in reality, Libby Zion died because physicians in general are not trained to identify the effects of psychiatric medications and to know their side effects and withdrawal symptoms. Therefore many psychiatric patients suffering serious side effects are given combinations of drugs that are often dangerous and sometimes life threatening due to physician error. Prior to her hospital visit, Libby Zion had been prescribed the antidepressant, phenelzine, and was given merpedine by the resident/interns in the ER - this combination lead to her death. The New York Libby Zion law, which is a regulation that limits the amount of time resident physicians' work in New York State hospitals to roughly 80 hours per week because it was assumed that the overworked intern and resident physicians who treated her made a mistake due to exhaustion and overwork.
Mental health professionals have an ethical duty to inform parents about the potential lethality of drug combinations as well as adverse effects of individual drugs. Yet some psychiatric drugs actually are combinations of drugs. As a medication for ADHD, Adderall was approved for unrestricted use for treatment of attention deficit hyperactivity disorder or ADHD by the FDA in March 1996. Adderall is a combination of stimulants (a combination of dextroamphetamine and amphetamine). In 2005 Adderall XR was pulled off the market in Canada after regulators linked the drug to 20 sudden deaths and 12 strokes. Fourteen of the deaths and two of the 12 strokes were in children. According to Canadian researchers the adverse reactions were not associated with overdose, misuse or abuse of Adderall XR. The effects of amphetamines and methamphetamine are similar to cocaine, but their onset is slower and their duration is longer. (U.S. Drug Enforcement Administration (DEA) fact sheet).
Stimulants are sometimes used in combination with anti-psychotics. The use of stimulant plus atypical antipsychotic places the patient at risk of sudden death due to stroke or dysrhythmia (heart arrhythmia); neuroleptic malignant syndrome; tardive phenomena (irreversible movement abnormalities of face, tongue, neck, limbs, trunk); and diabetes. Stimulants are designed to enhance dopamine transmission. Atypical antipsychotics are intended to block it. In one sense, the pharmacodynamic effects of stimulants plus antipsychotics would be expected to oppose each other. In another sense, the brain’s adaptations to each class of medication might be synergistic. This enhances the risk of movement abnormalities, dysphoria (an emotional condition in which a person experiences intense feelings of depression and discontent) , and psychosis. There are neurotoxic effects of use of stimulants and antipsychotics together; the dangers include the inhibition of neurogenesis (creation of new neuron cells) and the induction of neurodegenerative changes. In other words, they prevent the healing process and can cause permanent brain damage and dysfunction. Thus the drugs currently given for psychiatric treatment are also likely to increase the likelihood of psychosis and other disabling effects.
A new drug recently put on the market is Saphris or asenapine by Merck. Saphris like other atypical antipsychotic drugs is known to increase mortality. This drug causes very serious side effects including the permanent and totally disabling disorder called Neuroleptic Malignant Syndrome, and also Tardive Dyskinesia, Hyperglycemia and Diabetes Mellitus, Weight Gain, Hypersensitivity Reactions, Orthostatic Hypotension and Syncope (fainting), Leukopenia, Neutropenia, and Agranulocytosis (white blood cell problems), QT Prolongation: (heart rhythm problems), Seizures: Potential for Cognitive and Motor Impairment and Suicide (a mother’s worst nightmare). Adverse reactions to the drug Saphris include causing akathisia (restless leg syndrome, unpleasant sensations of inner restlessness that manifests itself with an inability to sit still or remain motionless) oral hypoesthesia (loss of sensation in the mouth causes difficulty in eating and talking), somnolence (sleepiness) and dizziness.
Effective humane alternatives to these drug treatments for Post Traumatic Stress Disorder or PTSD do exist now and should be promoted and offered to patients. Don’t mental health patients deserve an unbiased independent second medical and legal opinion before being condemned to lifelong mind altering drug treatment that could cause his death from one of the many side effects and with drugs which are known to shorten life expectancy?
The patient’s faith belief should be honored with what would be considered to be culturally appropriate alternatives to the medical and biochemical approaches to treatment. There should also be an effort to provide appropriate peer support or other alternatives to the traditional mental health system.
Psychotherapy is preferable to psychopharmacological treatment, and in many studies it has shown to be more effective than drugs (especially for PTSD) without the potentially troublesome and dangerous side effects. There are proven psychosocial techniques for modifying inappropriate behavior or speech. Mind/body connecting/focusing activities can be helpful. It is valuable to “make contact” with individuals who are unresponsive to usual forms of communication. Also, the mere act of “being with” a person who is experiencing profound emotional distress can provide great solace. [See Dan Dorman’s book, Dante’s Cure, for a real-life story of a woman who made a complete recovery from psychosis, and how that journey occurred.]
People labeled with psychiatric disabilities should be able to select from a menu of independently available services and programs, including mental health services, housing, vocational training, and job placement, and should be free to reject any service or program. Mental health treatment should be about healing, not punishment. Accordingly, the use of aversive treatments, including physical and chemical restraints, seclusion, and similar techniques that restrict freedom of movement, should be banned. Moreover, in part in response to the Supreme Court's decision in Olmstead v. L C., state and federal governments should work with people labeled with psychiatric disabilities and others receiving publicly-funded care in institutions to expand culturally appropriate home- and community-based supports so that people are able to leave institutional care and, if they choose, access an effective, flexible, consumer/survivor-driven system of supports and services in the community.
Reference on effects of psychiatric medications:
Dr. Grace E. Jackson MD ‘What Doctors May Not Tell You About Psychiatric Drugs’ Public Lecture, UCE Birmingham June 2004
Reference on Iatrogensis:
Weingart SN, Ship AN, Aronson MD (2000). "Confidential clinician-reported surveillance of adverse events among medical inpatients". J Gen Intern Med 15 (7): 470–7. doi:10.1046/j.1525-1497.2000.06269.x. PMC 1495482. PMID 10940133.)
References on Tardive dyskinesia:
Breggin, Peter R., M.D. (2001), Tardive Dyskinesia Legal Settlement, Breggin.com
Brašić, James Robert, MD; Bronson, Brian, MD (21 January 2010), Tardive Dyskinesia: Treatment & Medication
Crane, George E. (Sep 1973a), "Is tardive dyskinesia a drug effect?", AJP (American Psychiatric Association: American Journal of Psychiatry) vol.130 (no.9): 1043–4, ISSN 0002-953X, OCLC 104768868, PMID 4727768
Crane, George E. (Oct 1973b), "Rapid reversal of tardive dyskinesia", AJP (American Psychiatric Association: American Journal of Psychiatry) vol.130 (no.10): 1159, ISSN 0002-953X, OCLC 104790755, PMID 4728916
Fernandez, Hubert H., MD; Friedman, Joseph H., MD (Jan 2003), "Classification and Treatment of Tardive Syndromes", Neurologist (Baltimore US-MD: Williams & Wilkins: The Neurologist) vol.9 (no.1): 16–27, doi:10.1097/01.nrl.0000038585.58012.97, ISSN 1074-7931, OCLC 111183504, PMID 12801428
Glazer, William M.; Morgenstern, Hal; Doucette, John T. (Apr 1993), "Predicting the Long-Term Risk of Tardive Dyskinesia in Outpatients Maintained on Neuroleptic Medications" JCP (Memphis US-TN: Physicians Postgraduate Press: Journal of Clinical Psychiatry) vol.54 (no.4): 133–9, ISSN 0160-6689, OCLC 119262955, PMID 8098030
Glenmullen, Joseph (2000), "Ch.1.", Prozac Backlash, New York: Joseph Glenmullen. Simon & Schuster, p. 38 .pdf
Gualtieri, C. Thomas; Barnhill, L.J. (1988), Wolf, Marion E.; Mosnaim, A.D., eds., "Tardive Dyskinesia, Biological Mechanisms & Clinical Aspects", Tardive Dyskinesia in Special Populations (Washington, D.C.: American Psychiatric Press): pp. 137–154, ISBN 0-88048-176-5
Hoerger, Michael (2007), "The primacy of neuroleptic-induced D2 receptor hypersensitivity in tardive dyskinesia", Psychiatry Online (Psychiatry Online) vol.13 (no.12): 18–26
Jeste, Dilip V.; Caligiuri, Michael P. (Feb 1993), "Tardive Dyskinesia", Schizophr Bull (Schizophrenia Bulletin) vol.19 (no.2): 303–315, doi:10.1093/schbul/19.2.303, PMID 8100643
Saltz, Bruce L., MD; Woerner, Margaret G., PhD; Kane, John M., MD; Lieberman, JA; Alvir, JM; Bergmann, KJ; Blank, K; Koblenzer, J et al. (6 November 1991), "Prospective Study of Tardive Dyskinesia Incidence in the Elderly", JAMA (Chicago US-IL: American Medical Association: Journal of the American Medical Association) vol.266 (no.17): 2402–6, doi:10.1001/jama.266.17.2402, ISSN 0098-7484, OCLC
116673469, PMID 1681122
References Libby Zion:
"Libby Zion". New York Times. March 6, 1984.
Philibert I.; Friedmann P.; Williams W. T.; for the members of the ACGME Work Group on Resident Duty Hours (2002). "New Requirements for Resident Duty Hours". Journal of the American Medical Association 288 (9): 1112–1114. doi:10.1001/jama.288.9.1112. PMID 12204081.
Zion, Sidney (December 18, 1997). "Hospitals Flout My Daughter's Law". New York Daily News. "After it became clear to everybody, including a New York County grand jury, that Libby's death was caused by overworked and unsupervised interns and residents, the Libby Zion law was passed: No more 36-hour shifts for interns and residents; from now on, attending physicians would be at the ready to supervise the young, inexperienced student-doctors."
Fox, Margalit (March 5, 2005). "Elsa Zion, 70. Helped Cut Doctor Workloads.". New York Times.
Jane Ellen Brody (February 27, 2007). "A Mix of Medicines That Can Be Lethal". New York Times.
Spritz, N. (August 1991). "Oversight of physicians' conduct by state licensing agencies. Lessons from New York's Libby Zion case". Annals of Internal Medicine 115 (3): 219–22. PMID 2058876.
Mental Health Visions - Using Human Rights Language in a Mental Health Context #14 Tina Minkowitz , Lawyer