Low Risk, Heavy Drugs – State’s Nursing Homes Might Be Overusing Antipsychotics

Hartford Courant


Connecticut’s nursing homes dole out antipsychotic drugs to residents who do not have psychotic disorders at one of the highest rates in the country, raising questions about whether the medications are being used to subdue agitated patients because of a lack of staffing and attention to alternate treatments.

Federal data from the Centers for Medicare & Medicaid Services show that since 2005, Connecticut has consistently ranked in the top four states in the prevalence of antipsychotic drugs dispensed to nursing home residents who have no psychotic or related conditions. In the most recent quarterly report, through September 2007, only Louisiana had a higher prevalence rate than Connecticut, where more than 26 percent of residents who lacked an appropriate psychiatric diagnosis were prescribed antipsychotics.

Nationally, the prevalence rate is 19.8 percent, with several states, such as Florida, Pennsylvania and New Jersey, well below that average.

“This is not a good indicator” for Connecticut, said Charlene Harrington, an expert on nursing home quality and professor of sociology and nursing at the University of California-San Francisco. “One of the main factors [for a high medication rate] is not having enough staff. If patients are having behavioral problems, it’s easier to give them a pill to keep them quiet” than to hire more staff. “It’s cheaper. They’ll sleep a lot.”

Nursing-home staffing is now a focus of state lawmakers, who are weighing proposals that would update the state’s minimum staffing standards to nationally recommended levels. The existing standards are more than 25 years old and rank among the least stringent in the country. The staffing proposals were prompted by a series in The Courant that detailed the troubled patient-care and financial history of one of the state’s largest chains, Haven Healthcare, which filed for bankruptcy after the stories appeared.

Federal data from the past three years show that Connecticut has ranked highest or second-highest among states in the prevalence of antipsychotic use among “low-risk” nursing home residents, defined as those who do not exhibit cognitive impairment and behavioral problems. In the most recent reporting period, 23.3 percent of low-risk residents were receiving antipsychotics, compared with the national average of 16.5 percent.

Among “high-risk” residents who do exhibit those problems, Connecticut prescribes antipsychotics at the highest rate in the country — 55.2 percent, compared with the national average of 42.5 percent, according to data from the most recent reporting period.

The Nursing Home Reform Act of 1987 mandates that residents be free from “chemical restraints” imposed for the purposes of discipline or convenience. Federal guidelines allow nursing homes to administer antipsychotic drugs to residents with dementia-related behavioral symptoms, but they require that residents meet specific clinical criteria and receive gradual dose reductions and behavioral interventions in an attempt to wean them off the medications.

Although the newer antipsychotics, called atypicals, are approved only for bipolar disorder and schizophrenia, doctors routinely prescribe them “off-label” to quiet behavioral problems associated with dementia or Alzheimer’s disease. The use of such drugs in nursing homes has grown in recent years, despite studies questioning their benefits and highlighting their risks.

The most commonly prescribed antipsychotics carry Food and Drug Administration “black box” warnings that elderly dementia patients using them face an increased risk of death. In addition, studies have shown that the drugs most commonly prescribed off-label for Alzheimer’s patients are no more effective than placebos for most people, and carry side effects that include confusion, sleepiness and rigidity, which can increase the risk of falls.

State public health officials say they are not sure why Connecticut nursing homes have a high rate of dispensing antipsychotics to residents who lack an appropriate diagnosis. They say that their prevalence data might be better reported than other states, and they note that the health department has been aggressive about citing homes for medicating residents unnecessarily.

Some health officials suggest that the prevalence rate is high because Connecticut has a relatively large proportion of residents who are over age 80 and who have dementia-related problems.

“One of the reasons could be we have a large number of seniors in our [nursing home] population. Our population is getting older. Our dementia numbers are probably increasing,” said Barbara Cass, the state health department’s program manager for the Medicare survey program.

But Connecticut nursing homes do not have especially high numbers of residents diagnosed with dementia or other psychiatric conditions in comparison with other states, according to federal data. In 2006, 46 percent of Connecticut’s nursing home residents had a dementia diagnosis — slightly higher than the national average of 45 percent, but lower than 22 other states. About 15 percent of Connecticut’s nursing home residents had other psychiatric diagnoses, lower than the national average of 20.5 percent.

Those figures account for residents with specific diagnoses, but they do not include all residents who exhibit dementia-related behavioral problems.

Dr. Harry Morgan, a geriatric psychiatrist in Glastonbury, said he was disturbed to learn that Connecticut ranks high in its rate of dispensing antipsychotics to residents without diagnoses. He said that the protocol he advocates as a consultant to nursing homes calls for clinicians to try behavioral interventions and examine possible physical causes for agitation before considering antipsychotics.

“There are times in which patients with dementing illnesses are in such distress, to do nothing would be inhumane,” Morgan said. “But in some nursing homes, what you see is a knee-jerk reaction — they’ll put someone on a neuroleptic [or antipsychotic] … in hopes of a quick fix tonight.”

“The use of these medicines can be appropriate, but it is not appropriate to use them as an alternative to adequate staffing,” Morgan said. “People shouldn’t approach them as a first-line treatment. …We have to work to drive down the usage of antipsychotic drugs.”

Toby Edelman, an attorney with the Center for Medicare Advocacy Inc. in Washington said that in the 20 years since the nursing-home reform law was passed, the industry has focused more on reducing the prevalence of physical restraints than on limiting chemical restraints.

Medication “is not as visible as physical restraints, so it’s used as a substitute,” Edelman said. “That’s hardly what the [reform act] was intended to do.”

Edelman and Harrington said that a high prevalence of antipsychotic use in a nursing home can be an indicator of inadequate staffing. Non-pharmacological interventions for residents with dementia, such as recreational activities, exercise and one-on-one attention, require extra staff.

“You have to have the time to spend with people,” Harrington said.

On average, nursing homes in Connecticut provide about 3.7 hours of care per resident a day — 1.4 hours by licensed or registered nurses, and 2.3 hours by certified nursing assistants.

Other states have taken steps to boost staffing to levels recommended in a study commissioned by the federal government: 4.1 hours of care per resident a day.

Connecticut homes have had little incentive to boost staffing, in part because state law requires only 1.9 hours of nursing care a day. The state health department has rarely ordered individual homes to increase their staffing levels.

But federal data do suggest that Connecticut is more aggressive than other states in citing nursing homes for administering unnecessary antipsychotic drugs and other medications.

In the latest surveys, state health inspectors cited 21.7 percent of Connecticut’s 244 licensed homes for administering “unnecessary drugs” to residents, a rate higher than the regional average of 14.7 percent and the national average of 18 percent. Although unnecessary drugs can include all kinds of medication, the citation frequently is issued for improper use of psychoactive drugs.

Cass, the health department program manager, said that Connecticut has been “very astute” in identifying unnecessary drug violations, in part because the state uses a more in-depth inspection process than many other states. In each nursing home, inspectors closely review the medication records of a sampling of residents to ensure that there are appropriate diagnoses, she said. In addition, the health department flags homes with high rates of prescribing antipsychotics and conducts “more focused reviews” of those facilities.

Inspection data show that the state has issued more than 110 citations to nursing homes since October 2005 for administering unnecessary drugs. Eleven homes have been cited twice for that violation, with the second citation coming within a year of the first. Among the homes cited twice was Wethersfield Health Care Center, which was included on a recent federal list of 54 of the most poorly performing nursing homes nationwide.

Eight homes owned by Haven Healthcare have been cited for unnecessary drugs in the past two years, federal records show. Haven’s chain of 15 Connecticut homes filed for bankruptcy in November after The Courant’s stories detailed the chain’s repeated patient-care deficiencies, lower-than-average staffing and serious financial problems.

The improper use of psychotropic drugs at one Haven home in Torrington led the health department to issue a consent order against the home in December 2006 that mandated closer monitoring of residents receiving antipsychotics. State health inspectors had cited the home for seven cases in which it failed to justify the use of antipsychotic, antidepressant or sedative medications, or to monitor residents for side effects.

In one of those cases, a resident receiving five such medications, without an appropriate diagnosis, was found to be in such declining health that hospice was called — until a physician was alerted and ordered a reduction in the drugs. The resident’s mental state then rebounded: “The agitation and anxiety are gone, the resident is much more alert [and] vital signs are stable,” the state health inspection report says.

More recently, in November 2007, state health inspectors imposed a consent order and two years’ probation on Haven’s home in New Haven for myriad violations, among them failing to justify and monitor the use of antipsychotic medications prescribed to two residents. The New Haven home also was cited for low staffing levels.

Nationally, the rate of prescribing psychoactive drugs in nursing homes has been rising in recent years, with a 2005 study showing that antipsychotic use in 2000-01 had reached the highest level in more than a decade. That study, headed by a University of Massachusetts Medical School researcher, found that about one-third of nursing home residents receiving antipsychotics had “inappropriate indications” for the drugs.

In 2005, the taxpayer-funded Medicaid program — the main payer for drugs prescribed in nursing homes — spent more than $5 billion on antipsychotics such as Risperdal and Seroquel, which retail for several dollars per pill.

Since the FDA warnings, some doctors increasingly have turned to antidepressants to treat the agitation and psychotic symptoms associated with dementia. Morgan said that depression can be an underlying cause of agitation, and he noted that antidepressants don’t carry the adverse side effects — or expense — of antipsychotics.

Morgan said that although most Connecticut nursing homes have a large proportion of residents with dementia-related symptoms — 50 percent to 70 percent, in his estimation — many homes “don’t think of themselves as dementia-care facilities, in terms of having special expertise” or extensive training for staff. That needs to change, he said.

“We have to begin to shift the model of dementia care away from skilled-nursing facilities, so that we also focus on behavioral interventions [and] recreational and interpersonal activities,” Morgan said. “Staffing certainly has to be looked at, but so does the training of that staff.”

Contact Lisa Chedekel at lchedekel@courant.com.



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2 responses to “Low Risk, Heavy Drugs – State’s Nursing Homes Might Be Overusing Antipsychotics

  1. Gary Knutson

    Has The Anti-Depressant Myth Bubble Burst?
    By: Ann Blake Tracy, PhD Source: http://www.rense.com February 28, 2008

    The British newspaper, The Guardian, in the article below states that the news broke yesterday in the UK that antidepressants have been all hype with no beneficial results for two decades. Along with that release the British government announced that $335 Million would be allotted to train 3600 new talk therapists to help those suffering depression.
    In the meantime the world rocked with the realization that they had been duped. The question that remains is just how great has been the cost of that deception?
    The study, published in the journal PLoS (Public Library of Science) Medicine, looked at Prozac, Seroxat, Effexor and Serzone and found the drugs were only better than a placebo for some people with severe depression. “Given these results, there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients unless alternative treatments have failed to provide a benefit.”

    Looking for medications to take over where Valium left off we were left with a void in treating anxiety and we were introduced to a new disorder – depression and a new batch of miracle cures in pill form – the SSRI antidepressants, beginning with Prozac. Since the end of 1989 Dr. Ann Blake Tracy has worked non-stop to educate the public to the fact that these drugs were NOT doing what we were being told they were doing to help us. She has sounded warnings of the dangers of the drugs, the anaesthetizing effects of these drugs and questioned how anaesthetizing someone could be “therapeutic” especially when the action of SSRIs was so similar to a slow fuse PCP or LSD effect. Then in August the head of the National Institutes of Mental Health, Dr. Thomas Insel, publicly stated that antidepressants do produce the same effect as Ketamine, sister drug to PCP (Angel Dust).

    Meanwhile worldwide people stood back asking how Bipolar Disorder could increase by 4000% from 1994 – 2003? And where was all the violence and insanity coming from that now seems to engulf our world?
    I would encourage you to please read below the beginning of a shocking article out of the United Kingdom this morning on this issue. Then below that don’t miss Dr. Tracy’s two latest brief presentations to the FDA on the SSRI antidepressants and their impact upon society as we adjust to the concept of such great deception in medicine along with the danger of millions coming off these drugs, when few professionals know safe methods of withdrawing from antidepressants.

    We hear the word “conspiracy” a lot, but how many know what the word means? I have always understood it to mean “concealing truth in order to get gain.” Knowing that the antidepressant market was bringing in $200 Million per day makes it quite clear that there was much gain on the part of the pharmaceutical giants to keep these studies concealed from the public. What everyone must feel like today is what J. Edgar Hoover stated long ago: “The individual is handicapped by coming face to face with a conspiracy so monstrous he cannot believe it exists.”
    THE WITHDRAWAL AFTERMATH: As Dr. Tracy explains below in bold print it is very critical to make sure patients are weaned EXTREMELY slowly so as to avoid ANY chance of going into a withdrawal state. The FDA warned with the black box warning on these drugs that abrupt changes in dose can produce suicide, hostility or psychosis. All we need are millions of people going into suicide, hostility, or psychosis because they, or their doctors, are not familiar with safe withdrawal methods for antidepressants.


    As criticism of the industry’s withholding of such results mounted, drug companies were forced to make unflattering results public.

    It is only very recently that this has become a legal obligation. In the heyday of antidepressant PR, only about 10% of results about how the drugs affected quality of life were published. More than two-thirds of studies today are industry funded, and such research is four times as likely to find in favour of the drugs than independent inquiry. It is hardly surprising, then, that research has tended to give a positive spin to antidepressants.

    The Creation Of The Prozac Myth

    The Guardian – UK

    In the 20 years since its launch, 40m people worldwide have taken the so-called wonder drug – but research revealed this week shows that Prozac, and similar antidepressants, are no more effective than a sugar pill. So how was the myth created? Psychoanalyst Darian Leader traces the irrepressible rise of the multibillion dollar depression industry, while others explore the clinical and cultural impact of Prozac, its perceived personal benefits – and sometimes terrible costs

    Has the depression bubble finally burst? Yesterday’s headlines about the inefficacy of Prozac and other bestselling antidepressants must have been an unpleasant shock, not only to the drug manufacturers, but also to the millions of people in the UK taking these drugs. The new research, published in the Public Library of Science Journal, found that a placebo was just as effective as the drugs – excepting in some cases of severe depression, where it was not the drugs that did well, but the placebos that did worse.

    What will the impact of this new research be? Is it a case of recognising that the Prozac emperor never had any clothes? Or, on the contrary, of acknowledging the power of placebo and finding new ways of working with it?

    For many researchers, the PLoS findings actually reveal nothing new. Several earlier studies comparing placebo with antidepressant drugs had found that there was not much difference, yet these results had little media uptake. The new paper owes its coverage partly to the fact that it includes data from clinical trials that the manufacturers chose not to broadcast. As criticism of the industry’s withholding of such results mounted, drug companies were forced to make unflattering results public.

    It is only very recently that this has become a legal obligation. In the heyday of antidepressant PR, only about 10% of results about how the drugs affected quality of life were published. More than two-thirds of studies today are industry funded, and such research is four times as likely to find in favour of the drugs than independent inquiry. It is hardly surprising, then, that research has tended to give a positive spin to antidepressants.

    The new negative results might seem to promise a change of direction. But they may just be the other side of the industry coin. What remains unchallenged is the diagnosis of depression itself. GPs diagnose it every minute of the day, celebrities reveal they suffer from it and soap opera characters wrestle with it. Yet 40 years ago depression was hardly anywhere. A tiny percentage of the population were deemed to suffer from it. So what happened?

    These developments actually followed a surprising course. The story of depression cannot be dissociated from the story of its supposed remedies. And these, like nearly all psychotropic drugs, were not the result of targeted research, but of chance association. The first drugs had in fact been used as antihistamines, yet they seemed to have effects on mood, energy and anxiety.

    Although epidemiological studies had found high levels of nervous conditions in the community before these drugs were marketed, this had not been diagnosed as depression. With the marketing of the drugs, this nervous substrata was now labelled as a depression which had gone unrecognized and untreated. Yet this knowledge was not seized on and marketed until the drugs market made this happen in the late 70s.

    Where depression had been rated at 50 per million in the early 60s, by the 90s this had jumped to 100,000. These remarkable changes coincided with the crisis in the market for minor tranquilizers such as Librium and Valium, prescribed for anxiety. As these widely used drugs were found to be highly addictive, it looked as if a substantial market was about to collapse. Hundreds of thousands of people took these drugs and the economic gains were enormous. Anxiety had to be remarketed and new agents found to respond to it. And this is where depression started to really take off as a diagnosis. First of all, however, it had to be constructed as a discrete, well-defined clinical entity.

    Why couldn’t the drugs companies have simply offered their products as tonics or general mood enhancers? After the thalidomide scandal in the early 60s, tough new standards were set in place and drugs had to specify their active ingredients, the outcomes sought and the delivery period for attaining them. This meant a new kind of surface precision. Drugs would have to pass expensive trials proving they were more effective than placebo and do better than other drugs used for this same group of target patients. These new standards brought with them a new technology to evaluate. Randomized controlled trials became the norm, together with a silver bullet model of illness according to which each specific disorder would have a specific cause and a specific treatment.

    These changes in the landscape of prescription medicines framed the market for the antidepressants. Since the new diagnosis needed to be publicized, drug companies paid for adverts in medical journals, glossy pullout supplements, conferences and clinical studies to show the prevalence of depression. When Frank Ayd wrote his book Recognizing the Depressed Patient, the pharmaceuticals giant Merck bought 50,000 copies and distributed them to GPs. The book argued that depression was going undetected and untreated in the community. This dissemination of knowledge coincided nicely with their marketing of a new treatment for depression in the form of amitriptyline.

    The later generation of SSRI drugs had an even more exponential success: by the late 90s Prozac was a household word, with millions of prescriptions and a whole cult of novels, films and memoirs based around it. In 2005, traces of Prozac were even found to be present in British tap water.

    This process of marketing depression helped create the clinical category itself. If the new drugs affected mood, appetite and sleep patterns, then depression consisted of a problem with mood, appetite and sleep patterns. A subtle shift in the defining symptoms of depression took place over the years, so that the category itself became taken for granted. Lost here was the simple idea that there is a difference between surface symptoms (insomnia, loss of appetite, feeling low) and underlying causes, which may be different from case to case. The creation of the antidepressant market effectively disallowed this once crucial distinction.

    What would happen, after all, if surface symptoms were separated from underlying causes? How would the clinician make a prescription? What would be targeted? Pretty soon, the absurdity of the idea of a drug curing underlying causes would become clear. How could a drug cure the experience of having lost a loved one, for example? It might numb the pain, but it couldn’t really do much more than that.



    Dr. Ann Blake Tracy’s September 13, 2004 to the FDA

    I am Ann Blake Tracy, PhD, head of the International Coalition for Drug Awareness. I am the author of Prozac: Panacea or Pandora? – Our Serotonin Nightmare and have testified in court cases involving antidepressants for 12 1/2 years. The last 15 years of my life have been devoted full time to researching and writing about SSRI antidepressants.

    Research on serotonin has been clear from the very beginning that the most damaging thing that could be done to the serotonin system would be to impair one’s ability to metabolize serotonin. Yet that is exactly how SSRI antidepressants exert their effects.

    For decades research has shown that impairing serotonin metabolism will produce migraines, hot flashes, pains around the heart, difficulty breathing, a worsening of bronchial complaints, tension and anxiety which appear from out of nowhere, depression, suicide – especially very violent suicide, hostility, violent crime, arson, substance abuse, psychosis, mania, organic brain disease, autism, anorexia, reckless driving, Alzheimer?s, impulsive behavior with no concern for punishment, and argumentative behavior.

    How anyone ever thought it would be “therapeutic” to chemically induce these reactions is beyond me. Yet, these reactions are exactly what we have witnessed in our society over the past decade and a half as a result of the widespread use of these drugs.

    In fact we even have a whole new vocabulary as a result with terms such as “road rage,” “suicide by cop,” “murder/suicide,” “going postal,” “false memory syndrome,” “school shooting,” “bi-polar” – every third person you meet anymore – along with the skyrocketing rates of antidepressant-induced diabetes and hypoglycemia.

    Can you remember two decades ago when depressed people used to slip away quietly to kill themselves rather than killing everyone around them and then themselves as they do while taking SSRI antidepressants?

    A study out of the University of Southern California in 1996 looked at a group of mutant mice in an experiment that had gone terribly wrong. These genetically engineered mice were the most violent creatures they had ever witnessed. They were born lacking the MAO-A enzyme which metabolizes serotonin. As a result their brains were awash in serotonin. This excess serotonin is what the researchers determined was the cause for this extreme violence. Antidepressants produce the same end result as they inhibit the metabolism of serotonin.

    These are extremely dangerous drugs that should be banned as similar drugs have been banned in the past.

    As a society we once thought LSD and PCP to be miracle medications with large margins of safety in humans. We have never seen drugs so similar to LSD and PCP as these SSRI antidepressants. All of these drugs produce dreaming during periods of wakefulness. It is believed that the high serotonin levels over stimulate the brain stem leading to a lack of muscle paralysis during sleep thus allowing the patient to act out the dreams or nightmares they are having. The world witnessed that clearly in the Zoloft-induced murder-suicide of comedian Phil Hartman and his wife, Brynn.

    Connecticut witnessed the Prozac-induced case of Kelly Silk several years ago. This young mother attacked her family with a knife, then set the house on fire killing all but her 8 year old daughter who ran to the neighbors. As she stood bleeding and screaming for help she explained, “Help! My mommy is having a nightmare!”

    Out of the mouths of babes we will understand these nightmares for what they are. She understood that this was something her mother would do ONLY in a nightmare, never in reality.

    This is known as a REM Sleep Behavior Disorder. In the past it was known mainly as a drug withdrawal state, but the largest sleep facility in the country has reported that 86% of the cases they are diagnosing are patients on antidepressants.

    Because this was known in the past as a condition manifesting mainly in drug withdrawal you should see how dangerous the withdrawal state from these drugs will prove to be. That is why it is so critical to make sure patients are weaned EXTREMELY slowly so as to avoid ANY chance of going into a withdrawal state.


    Due to time constraints I refer you to my September, 2004 testimony on the damaging effects of inhibiting serotonin metabolism – the very mode of action of antidepressants. Impairing serotonin metabolism results in a multitude of symptoms including suicide, violent crime, mania and psychosis. Suicidal ideation is, without question, associated with these drugs.
    Rosie Meysenburg, Sara Bostock and I have collected and posted 1200 news articles documenting many exaggerated acts of violence against self or others at http://www.drugawareness.org with a direct link to http://www.ssristories.com
    Beyond suicidal ideation we have mania/bipolar increasing dramatically. Antidepressants have always been known to trigger both.
    According to the Pharmaceutical Business Review in the last 11 years alone, the number of people in the U.S. with “bipolar” disorder has increased by 4.8 million.
    Dr. Malcolm Bowers of Yale, found in the late 90’s over 200,000 people yearly are hospitalized with antidepressant-induced manic psychosis. They also point out that most go unrecognized as medication-induced, remain un hospitalized, and a threat to themselves and others.
    What types of threats from manias?
    Pyromania: A compulsion to start fires
    Kleptomania: A compulsion to embezzle, shoplift, commit robberies

    Dipsomania: An uncontrollable urge to drink alcohol

    Nymphomania and erotomania: Sexual compulsions – a pathologic preoccupation with sexual fantasies or activities
    Child sex abuse has increased dramatically with even female teachers going manic on these drugs and seducing students. The head of the sex abuse treatment program for Utah estimated 80% of sex crime perpetrators were on antidepressants at the time of the crime. While Karl Von Kleist, an ex-LAPD officer and leading polygraph expert estimated 90% – strong evidence of manic sexual compulsions that demand attention.
    Diabetes has skyrocketed, has been linked to antidepressants, and blood sugar imbalances have long been suspected as the cause of mania or bipolar. Anyone who has witnessed someone in insulin shock would see the striking similarity to a violent reaction to an antidepressant.

    If there has been any increase in suicide since the black box warning it is due to doctors not knowing how to get patients off these drugs safely.
    Clearly, far too many lives are being destroyed in various ways by these drugs.


    For additional information contact:
    Ann Blake Tracy, Ph.D., Executive Director,
    International Coalition For Drug Awareness
    Website: http://www.drugawareness.org & http://www.ssristories.org
    Author: Prozac: Panacea or Pandora? – Our Serotonin Nightmare
    CD or audio tape on safe withdrawal: “Help! I Can’t Get
    Off My Antidepressant, etc.!”
    Order Number: 800-280-0730
    E-mail: atracyphd1@aol.com
    Phone: 1-801-209-1800

  2. We had a similar experience with my elderly father at a nursing home in Florida. He had a form of dementia due to many small strokes over a long period of time. As a result, he had very little short term memory and was occasionally difficult to manage. As a solution, the owner of the nursing home gave him Paxil. Within in a very short period of time, his behavior changed dramatically for the worse, bizarre to put it mildly. My brother remarked on this and so I took both my father to a local family physician and asked the owner of the nursing home to come with me. The doctor told her that this medication was likely creating the very effects that she (the owner) was complaining about (to me). She had given Paxil to so many of her other residents as a ‘solution’ that she did not want to believe him. Nevertheless, we slowly took him off the Paxil and eventually, he ceased the bizarre behavior.

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