Use Of Psychopharmaceuticals Research Articles

The (Mis)use of Psychotropic Drugs and Addiction to Anxiolytics among Older Adults Living at Home or in Retirement Homes: Implications for Quality of Life.

Nowadays, the growing number of people aged 65+ has become a global phenomenon. At that age, the most common medical problems are multimorbidity and inappropriate polypharmacy, which have a negative impact on the quality of life in older adults. The aim of this cross-sectional study was to examine comorbidity, the use of psychopharmaceuticals, and symptoms of addiction to anxiolytics among older adults living at home or in retirement homes, and to examine the differences in quality of life in relation to the use and misuse of psychotropic drugs. The research included 383 people aged 65+ living in the Republic of Croatia (EU). A standardized questionnaire CAGE was used to collect data about the use of psychotropic drugs. Quality of life was examined using the WHOQOL-BREF scale. The average age of respondents was 83 years. There is a significantly higher prevalence of anxiety disorders (p = 0.001) in respondents who live at home. Psychopharmaceuticals were used by 218 (56.9%) respondents, equally in both groups of respondents. A total of 77 (20.1%) respondents had been using anxiolytics for more than five years, while 26 (6.8%) of them had significant clinical symptoms of addiction to anxiolytics. All domains and the overall quality of life scale were significantly lower (p < 0.001) in respondents who have clinical symptoms of anxiolytic addiction. The results indicate that the use of psychotropic drugs by respondents is inappropriate. Respondents who inappropriately and excessively use psychotropic drugs have a significantly worse quality of life.

SARS-CoV-2 and risk of psychiatric hospital admission and use of psychopharmaceuticals: A nationwide registry study of 4,585,083 adult Danish citizens.

Current evidence on the risk of admission- or medication-requiring psychiatric sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is limited to selected populations, short durations, and loss to follow-up. This study examined if SARS-CoV-2 infection was associated with increased long-term risk of psychiatric admissions and de novo prescription of psychoactive medication in the general population of Denmark. Adults (≥18 years) were assigned to either the control or SARS-CoV-2 group based on polymerase chain reaction (PCR) tests between 1 January 2020 and 27 November 2021. Infected subjects were matched 1:5 to control subjects by propensity score. Incidence rate ratios (IRRs) were calculated. Adjusted Cox regression was applied to the unmatched population with SARS-CoV-2 infection as a time-dependent covariate. Follow-up time was 12 months or until the end of the study. A total of 4,585,083 adults were included in the study. Approximately 342,084 had a PCR-confirmed SARS-CoV-2 infection and were matched 1:5 with 1,697,680 controls. The IRR for psychiatric admission was 0.79 in the matched population (95% confidence interval [CI]: 0.73-0.85, p < 0.001). In the unmatched population, the adjusted hazard ratios (aHR) for psychiatric admission were either below 1.00 or with a 95% CI lower limit of 1.01. SARS-CoV-2 infection was associated with an increased risk of de novo prescription of psychoactive medication in both the matched (IRR 1.06, 95% CI: 1.02-1.11, p < 0.01) and unmatched population (HR 1.31, 95% CI: 1.28-1.34, p < 0.001). We found a signal of increased use of psychoactive medication, specifically benzodiazepines, among SARS-CoV-2-positive persons, but the risk of psychiatric admissions did not increase.

Die andere pandemie: inzichten in en suggesties voor een betere public mental health (care)

That other pandemic: insights and suggestions for a better public mental health (care). Like Covid-19, mental health problems threaten to undermine our society and the personal well-being of many – perhaps more dormantly, but not less destructively. Many people suffer from mental health problems and high suicide rates, skyrocketing psychopharmaceutical use and endless waiting times suggest that the quality of care today – despite the efforts of dedicated professionals –is sub-optimal. These staggering figures make the rollout of a larger plan to prevent, early identify and promptly treat mental health problems an urgent matter. This article focuses on how we can intervene in the mental wellbeing of our population: what bottlenecks underlie the current situation, what societal changes need to be made, and what data can contribute in the matter.

Long-Term Gender-Affirming Hormone Therapy and Cognitive Functioning in Older Transgender Women Compared With Cisgender Women and Men

Long-term gender-affirming hormone therapy (GHT) in older transgender individuals could have beneficial effects on cognitive functioning. Cardiovascular risk factors and psychological factors are known determinants of cognition. Despite the rising number of older transgender individuals, only few studies have examined cognitive functioning in this population. We aimed to assess differences in cognitive functioning between transgender women, and non-transgender (cisgender) women and men, and investigated the contribution of cardiovascular risk factors and psychological factors on these differences. In this study, 37 transgender women (age range 55 to 69) receiving GHT for at least ten years (range 10.2 to 41.6) were examined, and their cognitive functioning was compared to an age and education level matched cohort consisting of 222 cisgender women and men from the Longitudinal Aging Study Amsterdam. Linear regression analyses were performed. Cognitive functioning was assessed by neuropsychological tests including Mini-Mental State Examination (MMSE), Category Fluency animals, Letter Fluency D, 15-Word test (15WT) immediate and delayed recall. Additionally, cardiovascular risk factors and psychological factors such as cardiovascular disease, hypertension, antihypertensive use, statin use, diabetes mellitus, overweight, smoking, alcohol consumption, psychopharmaceutical use, anxiety and depression symptoms were collected. Transgender women had higher MMSE scores compared with cisgender women (+0.9, 95% CI 0.4 to 1.5), and cisgender men (+1.1, 95% CI 0.4 to 1.8). On all other tests transgender women performed similar to cisgender men. Transgender women performed at a lower level than cisgender women on 15WT immediate recall, -5.5, 95% CI -7.6 to -3.4, and 15WT delayed recall, -2.7, 95% CI -3.7 to -1.7, and equal to cisgender women on Fluency animals and Fluency D. Cardiovascular and psychological factors (i.e., cardiovascular disease and depression symptoms) partly explained differences on MMSE score between transgender women and cisgender-control groups. The results of this study do not indicate a need for tailored hormone treatment strategies for older transgender women, based on cognitive aspects after long-term GHT. As one of the first studies, this study compared older transgender women to a large cohort of cisgender men and women regarding cognitive functioning and took into account numerous potential influencing factors. Limitations include difference in test procedures and the cross-sectional design of the study. Cognitive differences between transgender women and cisgender women and men were small, albeit significant. This may suggest that long-term GHT effects on cognitive functioning in older transgender women are minimal.

The handling of psychotropic drugs in outpatient long-term care of older people : Part2: the perspective of outpatient care providers

Studies show risks in the psychopharmacological care of older people with long-term care needs. In developing recommendations on the handling of psychotropic drugs in outpatient long-term care, the perspective of care professionals has so far received only sporadic attention. The study aims to explore perspectives in outpatient care on the use of psychopharmaceuticals in the care of older people in need of long-term care. The importance of the topic, problems in dealing with it, priorities of measures as well as knowledge and distribution of instruments are examined. An online survey was used to interview personnel in leading positions in arandom sample of 20% (n = 2957) of the 15,138 outpatient long-term care facilities licensed with acare contract in 2019. Statistical data analysis and content analysis of answers to open questions was conducted. A total of 212 questionnaires was completed (7.2% response rate), 87.2% of the respondents evaluated the importance of dealing with psychotropic drugs as high and 46.2% were confronted with problems related to psychotropic drugs in their own work. Participants located problems predominantly with physicians (53.1%), but also with patients (19.6%), nursing staff (11.2%) and caring relatives (6.1%). The use of measures varied. Cooperation with physicians and-with less priority, but still important-the qualification of nursing staff and the involvement of caring relatives were named as central fields of action. The heterogeneity of experiences and initial conditions regarding the handling of psychotropic drugs in outpatient long-term care should be taken into account when developing corresponding recommendations for action and implementation concepts.

"Something that actually works": Cannabis use among young people in the context of street entrenchment.

BackgroundCannabis is one of the most widely used substances among vulnerable young people (<26 years of age) experiencing street entrenchment. Although previous research has documented the role cannabis can play in harm reduction, substance use and mental health treatment and pain management, this research has predominantly been quantitative and focused on adult drug-using populations. Little qualitative work has examined how young people who use drugs understand, experience, and engage with cannabis in the context of street entrenchment and drug use trajectories that include the use of other substances such as alcohol, opioids and crystal methamphetamine (meth).MethodsSemi-structured, in-depth qualitative interviews were conducted between 2017 and 2019 with 56 young people recruited from a cohort of street-involved youth in Vancouver, Canada. We also conducted 13 interviews with 12 youth-focused care providers across the same time period. Interview data were triangulated by drawing on the findings of a program of anthropological research conducted by the senior author since 2008. Interviews were transcribed verbatim and thematic analysis was conducted.ResultsThe vast majority of study participants engaged in daily, intensive cannabis use at the same time as they cycled on and off other substances that were perceived as much more harmful (primarily alcohol, fentanyl, heroin and meth). While most participants derived significant pleasure from the use of cannabis, no participants in our study described using cannabis for purely recreational purposes. A number of participants explicitly framed cannabis as a form of mental health and substance use treatment that was more effective and “healthier” than the long-term use of psychopharmaceuticals and medication-assisted substance use treatment (e.g., opioid agonist therapies). Cannabis use was also understood to ameliorate some of the harms of, or even facilitate transitions out of, periods of street-based homelessness. While the majority of our participants highlighted the positive effects of regular cannabis consumption, some described how intensive cannabis use could generate significant harms.ConclusionIn the context of the recent legalization of non-medical cannabis use in Canada and amid ongoing overdose and housing crises, it is imperative that future policy and programming interventions and provider education and training be responsive to the ways in which vulnerable youth in our setting are actively using cannabis to navigate their everyday lives and healthcare needs.

Medication by Proxy: The Devolution of Psychiatric Power and Shared Accountability to Psychopharmaceutical Use Among Soldiers in America\u2019s Post-9/11 Wars

With the United States military stretched thin in the “global war on terror,” military officials have embraced psychopharmaceuticals in the effort to enable more troops to remain “mission-capable.” Within the intimate conditions in which deployed military personnel work and live, soldiers learn to read for signs of psychopharmaceutical use by others, and consequently, may become accountable to those on medication in new ways. On convoys and in the barracks, up in the observation post and out in the motor pool, the presence and perceived volatility of psychopharmaceuticals can enlist non-medical military personnel into the surveillance and monitoring of medicated peers, in sites far beyond the clinic. Drawing on fieldwork with Army personnel and veterans, this article explores collective and relational aspects of psychopharmaceutical use among soldiers deployed post-9/11 in Iraq and Afghanistan. I theorize this social landscape as a form of “medication by proxy,” both to play on the fluidity of the locus of medication administration and effects within the military corporate body, and to emphasize the material and spatial ways that proximity to psychopharmaceuticals pulls soldiers into relationships of care, concern and risk management. Cases presented here reveal a devolution and dispersal of biomedical psychiatric power that complicates mainstream narratives of mental health stigma in the US military.

Pharmaceutical Creep: U.S. Military Power and the Global and Transnational Mobility of Psychopharmaceuticals.

In 2006, the United States Department of Defense developed for the first time official criteria for the use of psychopharmaceuticals "in theater"-in the physical and tactical spaces of military operations including active combat. Based on fieldwork with Army soldiers and veterans, this article explores the transnational and global dimensions of military psychopharmaceutical use in the post-9/11 wars. I consider the spatial, material, and symbolic dimensions of what I call "pharmaceutical creep"-the slow drift of psychopharmaceuticals from the civilian world into theater and into the military corporate body. While pharmaceutical creep is managed by the U.S. military as a problem of gatekeeping and of supply and provisioning, medications can appear as the solution to recruitment and performance problems once in theater. Drawing on soldiers' accounts of medication use, I illuminate the possibilities, but also the frictions, that arise when routine psychopharmaceuticals are remade into technologies of global counterinsurgency.

Medication by Proxy: The Devolution of Psychiatric Power and Shared Accountability to Psychopharmaceutical Use Among Soldiers in America’s Post-9/11 Wars

Medication by Proxy: The Devolution of Psychiatric Power and Shared Accountability to Psychopharmaceutical Use Among Soldiers in America’s Post-9/11 Wars

Psychotropic drugs in Nepal: perceptions on use and supply chain management

BackgroundPsychotropic drugs play an important role in the treatment of mental, neurological and substance use disorders. Despite the advancement of the use of psycho-pharmaceuticals in the developed countries, the psychotropic drug production and supply chain management in low- and middle- income countries are still poorly developed. This study aims to explore the perceptions of stakeholders involved in all stages of the psychotropic drug supply chain about the need, quality, availability and effectiveness of psychotropic drugs, as well as barriers to their supply chain management.The study was conducted among 65 respondents from the Kathmandu, Chitwan and Pyuthan districts, grouped into four categories: producers, promoters and distributors (N = 22), policy makers and government actors (N = 8), service providers (N = 21) and service users/family members (N = 14).ResultsThe respondents reported that psychotropic drugs, despite having side effects, are 1) needed, 2) available in major regional centers and 3) are effective for treating mental health problems. The stigma associated with mental illness, however, forces patients and family members to hide their use of psychotropic drugs. The study found that the process of psychotropic drug supply chain management is similar to other general drugs, with the exceptions of strict pre-approval process, quantity restriction (for production and import), and mandatory record keeping. Despite these regulatory provisions, respondents believed that the misuse of psychotropic drugs is widespread and companies are providing incentives to prescribers and retailers to retain their brand in the market.ConclusionsThe production and supply chain management of psychotropic drugs is influenced by the vested interests of pharmaceutical companies, prescribers and pharmacists. In the context of the government of Nepal’s policy of integrating mental health into primary health care and increased consumption of psychotropic drugs in Nepal, there is a need for massive education and awareness as well as strict monitoring and supervision to avoid the misuse of psychotropic drugs.

Sindrom 'slomljenog srca' - takotsubo kardiomiopatija

INTRODUCTION: Psychosomatic diseases indicate a causal relationship between mental and somatic illnesses in clinical practice. A broken heart syndrome or Takotsubo cardiomyopathy is of a recent date and was first described in 1991 by Japanese doctors. The syndrome is 9 times more common in women, and it is characteristic that over 60% of patients experience severe emotional stress before the onset of symptoms. Tis condition mimics the symptoms of a heart attack, and often in such a state, the wrong diagnosis is made to the patient. CASE REPORT: The patient was not previously treated as a cardiac and psychiatric patient. Seven days before the onset of acute cardiac problems, the stressful situation was preceded by the death of the patient's wife. He was received as an emergency case in the coronary unit of the Internal Department of the General Hospital Sabac, and the following day, due to a clinical finding, was sent to the General Hospital in Valjevo for emergency coronarography. Conclusion of the findings of coronarography: on coronary arteries, angiographically, no significant stenosis are observed. Further internist and psychiatric medication therapy was proposed at the competent hospital. CONCLUSION: Our goal was to point out the necessity of a holistic approach to each patient by each physician, because the only adequate treatment in psychosomatic patients is the simultaneous treatment of somatic illness and the use of psychopharmaceuticals. Acute stress due to emotional loss, with further present anxiety, has caused acute cardiac problems, which will further be prevented by regular psychiatric treatment.

Determinants of physical, affective, and cognitive fatigue during breast cancer therapy and 12 months follow-up.

Fatigue is common in cancer survivors but often insufficiently treated. Due to its complexity a one-size-fits-all treatment seems not appropriate. To gain more information on influencing factors and sub-dimensions of fatigue we investigated potential determinants and correlates of physical, affective, and cognitive fatigue in breast cancer survivors during and after adjuvant therapy. Within the follow-up of two randomized controlled trials physical, affective, and cognitive fatigue were repeatedly assessed during and up to 12 months after cancer therapy with the 20-item Fatigue Assessment Questionnaire in 255 breast cancer survivors. Determinants of the different fatigue dimensions over time were explored with linear mixed models. Chemotherapy appeared as significant precipitating factor for physical fatigue. However, type of cancer therapy had no impact on fatigue one year post-treatment. Obesity was significantly associated with increased physical fatigue throughout all time points (Δ=15.5 at 12 months) whereas exercise appeared to be beneficial (Δ = -6.3). In contrast, affective fatigue was significantly associated with poor social support and worries about the future. In addition, poor sleep quality and previous use of psychopharmaceuticals were significantly associated with physical, affective, as well as cognitive fatigue. Further, hot flashes were associated with increased physical and cognitive fatigue. In conclusion, the broad diagnosis 'fatigue' in cancer survivors needs to be recognized as a diversity of symptoms determined by specific characteristics and likely different etiologies. Taking potential influencing factors such as obesity, physical inactivity, sleep problems, hot flashes, lack of social support, or psychological disorders into consideration might enable a better, individually-tailored fatigue treatment.

Ageing and memory medication: social rationales and consumption practices.

This article focuses on the social rationales underlying the consumption or rejection of medication for memory by the elderly. Our analysis is set within the wider frame of the current use of psychopharmaceuticals for the enhancement of everyday performance, discussing its relationship to new cultures of ageing. Our results, from a recently concluded study, point to different patterns of investment in memory in old age. On the one hand, we found a willingness to consume medication for memory - a heterogeneous disposition split between the imaginary of disease and that of performance enhancement. On the other hand, we found a cultural resistance and scepticism towards the use of psychopharmaceuticals for performance purposes. This suggests that a new frame of psychopharmaceuticalization of old age - represented by memory medication - is prompting different rationales, ranging from consumption to resistance.

Characteristics associated with initiation of hormone replacement therapy among Finnish women: A register-linkage study

ObjectiveTo investigate which patient characteristics are associated with the initiation of hormone replacement therapy (HRT) in a cohort of Finnish women. Study designResponses to postal questionnaires distributed to a nationwide, randomly selected cohort of women in 1998, 2000, 2003, 2005 and 2010 were analyzed. The cohort members were aged 40–44 years at the beginning of the study. Information on hormone replacement therapy was received from the national prescription register. Women who started taking HRT between January 1, 1999 and December 31, 2011 were included and previous users were excluded from the analysis. Main outcome measuresInitiation of HRT was the main outcome measure. The following explanatory factors for predicting the use of HRT were examined: sociodemographic factors, personality, health behavior, physiological and mental symptoms, chronic diseases and use of psychopharmaceuticals. The associations between starting HRT and the explanatory factors were analyzed with single-predictor and multi-predictor logistic regression models. ResultsFactors predicting that a woman would start taking HRT were: living with a partner, weak sense of coherence, BMI less than 30kg/m2, heavy or moderate alcohol use, symptoms of hyperactivity of the sympathetic nervous system, climacteric symptoms and use of psychopharmaceuticals. ConclusionsWomen with a good sense of coherence can cope with climacteric symptoms without resorting to HRT. Clinicians need to bear in mind the burden of menopausal symptoms on a woman’s personal and working life when HRT is being considered.

Lorazepam does not improve the quality of recovery in day-case surgery patients

In day-case surgery, the effects of the anxiolytic lorazepam as premedication on the quality of postoperative recovery are unknown. To evaluate whether lorazepam as a premedication beneficially affects quality of recovery (primary outcome) and psychological manifestations (secondary outcome) after day-case surgery. A randomised, double-blind, placebo-controlled clinical trial. Single tertiary centre. day-case surgery; age at least 18 years. insufficient knowledge of the Dutch language; intellectual disability; ophthalmology surgery; extracorporeal shock wave lithotripsy; endoscopy; botulinum toxin A treatment; abortion; chronic pain treatment; preceding use of psychopharmaceuticals; contraindication to lorazepam. Lorazepam (1 to 1.5 mg) intravenously vs. NaCl 0.9% as a premedication prior to surgery. Quality of Recovery-40 (QoR-40) score. State-Trait Anxiety Inventory (STAI-State/Trait); State-Trait Anger Scale (STAS-State/Trait); Multidimensional Fatigue Inventory (MFI); Hospital Anxiety and Depression Scale (HADS). Timing of evaluation: T0: preoperatively (all scales); T1: before discharge (STAI-State/Trait); T2: first postoperative working day (QoR-40); T3: 7th day after surgery (all scales). Robust regression analysis was applied. Statistical analyses were adjusted for the corresponding baseline value and sex. Four hundred patients were randomised; 398 patients were analysed. Postoperative mean QoR-40 scores were similar in both groups at T2 (174.5 vs. 176.4, P = 0.34) and T3 (172.8 vs.176.3, P = 0.38). Postoperative mean STAI-State/Trait scores decreased less in the group with lorazepam at T1 (32.3 vs. 29.3, P < 0.0001; 32.7 vs. 30.8, P = 0.0002). STAI-Trait and HADS-Anxiety decreased less in the group with lorazepam at T3 (31.1 vs. 30.0; P = 0.03, 3.3 vs. 2.5, P = 0.003). STAS-State increased in the group with lorazepam at T3 (10.8 vs. 10.3, P = 0.04). In day-case surgery, lorazepam as a premedication did not improve quality of recovery. Furthermore, this premedication may delay the decrease in postoperative anxiety and aggression. ClinicalTrials.gov identifier: NCT01441843.

Religious Perspectives on the Use of Psychopharmaceuticals as an Enhancement Technology

The use of psychopharmaceuticals as an enhancement technology has been the focus of attention in the bioethics literature. However, there has been little examination of the challenges that this practice creates for religious traditions that place importance on questions of being, authenticity, and identity. We asked expert commentators from six major world religions to consider the issues raised by psychopharmaceuticals as an enhancement technology. These commentaries reveal that in assessing the appropriate place of medical therapies, religious traditions, like secular perspectives, rely upon ideas about health and disease and about normal human behavior. But unlike secular perspectives, faith traditions explicitly concern themselves with ways in which medicine should or should not be used to live a "good life".

Psychopharmacology Decision-Making Among Pregnant and Postpartum Women and Health Providers: Informing Compassionate and Collaborative Care Women's Health

Psychopharmaceutical use by pregnant and postpartum women is complicated by the complexity of prescribing as well as the sociocultural context in which medication-related decisions are made. This study sought to advance understanding of decision-making processes and communication experiences regarding use of psychopharmaceuticals during pregnancy by considering both provider and consumer perspectives. An electronic survey was conducted with health care providers (N = 88) and women consumers (N = 83) from July 2010 through October 2011 regarding the perceived costs and benefits of taking mental health medication during and around the time of pregnancy. Descriptive analysis compared and contrasted experiences between the two groups regarding consumer-provider communication, critical incidents and triggers in decision-making, and response to case scenarios crafted around hypothetical client experiences. Both similarities and differences were evident among health care provider and women consumer responses regarding costs, benefits, communication experiences, and case scenario responses. Both quantitative and qualitative survey results indicated the need for more accurate, unbiased, and complete information exchange around mental health and medication. Study results suggested the centrality of the client-provider milieu to guide decision-making and emphasized the expressed need within both groups to create a shared decision-making practice environment characterized by authenticity, non-judgmental decision-making, compassion, humaneness, and reciprocity.

Cribado para el trastorno por déficit de atención/hiperactividad en pacientes adultos de atención primaria

AIMS. To estimate the proportion of adult patients in primary care with a positive screening test for attention deficit hyper-activity disorder (ADHD) and to analyse their characteristics. PATIENTS AND METHODS. A cross-sectional descriptive study was performed in nine primary care clinics in the province of Tarragona. The sample consisted of 432 consecutive patients in primary care who visited for any reason, with ages ranging from 18 to 55 years. Screening for ADHD was carried out by means of the Adult ADHD Self-Report Scale (ASRS). Data about functional impact (Sheehan Disability Inventory) were obtained and a review of the patient records provided data concerning psychiatric comorbidity and the consumption of psychopharmaceuticals. RESULTS. The percentage of positive results in the screening tests was 19.9% (95% CI = 16.4-23.9%). Taking into account the sensitivity and specificity of the ASRS, the 'real' prevalence was estimated to be 12.5% (95% CI = 8.2-16.8%). None of these patients were diagnosed or treated for ADHD. Positive screening tests are associated with occupational, social and familial dysfunction, and greater perceived stress. There is also a higher level of comorbidity with affective disorders and substance abuse, as well as greater use of psychopharmaceuticals. CONCLUSIONS. Screening for ADHD in adult patients in primary care gives rise to a notably high proportion of positive screening test results, which suggests that there could be a significant prevalence of patients with ADHD. These data contrast with the absence of this diagnosis in the patient records. Further research is needed to determine the usefulness of the diagnosis of ADHD and the possible role that must be played by primary care.

The Zone of Social Abandonment in Cultural Geography: On the Street in the United States, Inside the Family in India

This essay examines the spaces across societies in which persons with severe mental illness lose meaningful social roles and are reduced to "bare life." Comparing ethnographic and interview data from the United States and India, we suggest that these processes of exclusion take place differently: on the street in the United States, and in the family household in India. We argue that cultural, historical, and economic factors determine which spaces become zones of social abandonment across societies. We compare strategies for managing and treating persons with psychosis across the United States and India, and demonstrate that the relative efficiency of state surveillance of populations and availability of public social and psychiatric services, the relative importance of family honor, the extent to which a culture of psychopharmaceutical use has penetrated social life, and other historical features, contribute to circumstances in which disordered Indian persons are more likely to be forcefully "hidden" in domestic space, whereas mentally ill persons in the United States are more likely to be expelled to the street. However, in all locations, social marginalization takes place by stripping away the subject's efficacy in social communication. That is, the socially "dead" lose communicative efficacy, a predicament, following Agamben, we describe as "bare voice."

The Psychotropic Self/Imaginary: Subjectivity and Psychopharmaceutical Use Among Heroin Users with Co-Occurring Mental Illness

Many people diagnosed with mental illnesses struggle with illicit drug addiction. These individuals are often treated with psychiatric medications, yet little is known about how they experience this treatment. Research on the subjective experience of psychiatric medication use highlights the complex, contradictory, and ambiguous feelings often associated with this treatment. However, for those with mental illness and addiction, this experience is complicated by the need to manage both psychiatric medication and illicit drug use. Using ethnographic data from a study of heroin use in Northeast Ohio, we explore this experience by expanding the pharmaceutical self/imaginary (Jenkins, Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology, School for Advanced Research Press, Santa Fe, NM, 2010b) to include psychopharmaceuticals and illicit drugs, what we call the psychotropic self/imaginary. Through this lens we explore the ways participants interpret and manage their psychotropic drug use in relation to sociocultural, institutional, and political-economic contexts. This analysis reveals how participants seek desired effects of legally prescribed and illicit drugs to treat mental illness, manage heroin addiction, and maintain a perceived "normal" self. Participants manage their drug use using active strategies, such as selective use of psychiatric medications, in the context of structural constraints, such as restricted access to mental health care, and cultural contexts that blur distinctions between "good" medicines and "bad" drugs.