I'd like to ask for a researcher with a background in dealing with
mental illness in some form or another, to answer this question if at
all possible, thanks. Maybe a doctor, nurse, experienced carer, or
even someone who has been through the nightmare illness I allude to
below, and recovered.

One of my oldest friends, going way back to schooldays, has been
suffering from what I understand to be a form of schizophrenia.

Before she became ill, this young lady was a beautiful, pleasant &
bubbly, articulate person of sharp mind and wit and immaculate
appearance. She didn't have a care in the world, and was immensely
popular.

There is some suggestion that the condition was maybe caused or
triggered by
amphetamine use when she was 17,18,19; that sort of age. There could
have been a predisposition there before the trigger event? (She's
clear
about the trigger - she said today, '10 years ago to the day I went
loopy, it was after someone gave me some speed') She's around 30 now
and still suffering from a fixation or obsession with her past & a
seeming inability to release the grip on the past (grass was greener
in the past.. she often cites past jobs, boyfriends, training courses
.. repeatedly, almost ad nauseum), inability to make life descisions,
and 'voices' which seem to lead her to beleive that she is a
worthless, evil individual, which she in reality patently is not.

I can sometimes *nearly* get her through a process of logic to the
point
of convincing her what a super gal she really is, but at that point,
invariably she comes out with the line 'I dunno, how am I supposed to
know about anything' - skirting the issue.

She currently takes the medication 'clozapine', prescribed by her
specialist. She tells me she takes it as prescribed. To compound her
other problems however, she is an active alcoholic (2? maybe more
bottles of wine a day plus assorted beers & spirits).

I *suspect* this causes situations to occur whereby she might miss a
dose now and again. She tells me she drinks as a temporary method of
combatting 'all this horrible stuff in my head'. She also tells me
that the morning after, the horrible stuff in her head is only worse..

My questions are:

1. What effect upon the long term efficacy of this medication might
such a level of alcohol consumption have in isolation

2. What effect upon the long term efficacy of this medication might
the regalar, odd missed dose (perhaps caused by a fall down drinking
session) have ?

3. Any general advice regarding how to be of the best possible utility
for good for that person.

She is a member of our local Alcoholics Anonymous meetings
She currently takes no drugs whatsoever except those prescribed by her
specialist.

The questions I ask relate essentially to how a close friend such as
myself, who is not perticularily knowledgeable in the medical field,
can endeavour to help her work through her problems. I've done what I
can over the past few years, but I'm running out of options, perhaps
one of the researchers may have experience in this general area and
might be able to raise some practical ideas. I know that with
conditions of this nature, there is no simple answer, and often no
100% magic cure.

Please, please feel free to ask for clarification where needed -
obviously It wouldn't be possible to post her entire life and medical
history in the question, so I'd expect you might well have a few
questions.

Hi, gan-ga!

I think Denco-ga has probably covered the drug interaction part of
your question well, and I must echo what s/he has said about Google
answers not being a substitute for professional advice. I am writing
from the point of view of a carer and a researcher, not a mental
health professional.

NAMI - the Nation's Focus on Mental Illness - have a page on Clozapine
by Dr. David Pickar, National Institute of Mental Health (1/94) and
Dale R. Grothe, Pharm.D., Mental Health Clinical Pharmacy Specialist,
NIH/NIMH Clinical Center Pharmacy Dept.
 at:

http://www.nami.org/helpline/clozapine.htm

They write:

"Clozapine is a relatively new medication for patients with
treatment-resistant schizophrenia. Approved by the FDA for general use
in the U.S. in 1990, the drug is used for patients with schizophrenia
and other mental disorders who have not responded well to standard
antipsychotic drugs or who have had intolerable side effects to
them....

Clozapine is effective for about 60 percent of those who try it. A
patient should try clozapine for at least four to six weeks. ...

In responsive patients, clozapine adds another alternative to the
traditional antipsychotics in treating the positive symptoms of
schizophrenia such as hallucinations, delusions, bizarre behavior and
hostility. It also effectively treats the negative symptoms—
withdrawal, blunted emotions, lack of motivation, and inability to
experience pleasure or enjoyment. It is the negative symptoms which
seem to respond better to clozapine than to the traditional
antipsychotics."

It is relatively free from side effects, but "One to two percent of
patients who take clozapine will develop a condition called
agranulocytosis, in which the white blood cell count drops
dramatically. " A weekly blood test is advised.

By "relatively new" they mean it was discovered in 1958 and it's been
in use since 1989 in the UK, so there may well be something newer on
the market that is as effective.

The main concern with combining it with alcohol, from what I can find
out, is that Clozapine can occasionally upset liver function :

( http://www.cix.co.uk/~cyberville/medizine/clozapin.htm )

and of course alcohol also adversely affects the liver. But if your
friend is having the regular blood tests as recommended then
presumably liver function is being monitored. It should not be used in
patients with liver problems.


A professional site for nurses gives more detail at:

http://www.nursespdr.com/members/database/ndrhtml/clozapine.html

You will notice that alcohol is not listed in the Drug Interactions
section at the bottom, so presumably it's not of major concern in
combination with Clozapine. You will also see that the maintenance
dose can be anywhere from 300 to 900 mg per day.


As far as missed doses go, Clozapine's own website says:

"If you take clozapine several times a day, take the missed dose as
soon as you remember it and take any remaining doses for that day at
evenly spaced intervals. However, if you remember a missed dose when
it is almost time for your next scheduled dose, skip the missed dose.

If you take clozapine once a day at bedtime and do not remember it
until the next morning, skip the missed dose. Do not take a double
dose to make up for a missed one."

This bears out what Denco-ga found, and is probably what is in the
guideline sheet in the package. Obviously, the occasional missed dose
is not crucial.



Moving on, I'm posting below some information I found when researching
schizophrenia - and particularly hearing voices - for my 19 year old
son, who has been hearing voices for a little over a year.

He too can pin-point the exact moment when the voices started, and it
had nothing whatsoever to do with either drugs or alcohol. Whether
your friend's amphetamine use triggered the illness or not is possibly
of historical interest, but it's unimportant in the overall picture,
though perhaps she should avoid them in the future. The late
adolescent onset is very common for this problem, drug related or not.

My son says that coping with these loud, insulting, degrading voices
is extremely tiring, and takes a great deal of concentration. He tends
to speak more loudly than necessary (he's trying to be heard above the
voices, which of course the person he's speaking to can't hear) and
this sometimes makes him seem aggressive in attitude. Playing loud
music when the voices are particularly bad sometimes drowns them out
or sends them away for a while (as well as keeping the rest of the
household awake....).

He will also, when carrying on a conversation, watch the face of the
other person very closely, and pause for a moment before replying;
this is to make sure he's hearing you correctly and to gauge when you
stop speaking - a little like lip-reading. If your friend doesn't do
this, maybe you can suggest she try it - otherwise she may be
"hearing" you say:

"You're a great girl, no, you're not, you're awful, " when you've
actually said "You're a great girl" and the voices have added the
rest.

Remember keeping focussed takes a lot of effort for her; don't expect
her to sustain a long session. Try the supportive technique of
praising her for something small and immediate ("Your hair looks great
today" - only if it does !) rather than something distant ("Of course
you're clever enough to study law" - even if you think she is).


One of the drug companies has some pages on Understanding
Schizophrenia. They list the basic symptoms at:

http://www.seroquel.com/cons_asp/underschiz/underschiz.asp

"Positive Symptoms — distortion of normal function. These symptoms
include the following:
Hallucinations — changes in the senses, such as hearing voices or
seeing unusual things that are not there
Delusions — bizarre fixed beliefs that are not based in reality
Paranoia — feeling fearful that others are plotting against you
Disorganization – changes in thought processes, such as having trouble
thinking clearly or becoming easily confused

Negative Symptoms — deficit symptoms. These symptoms include the 
following:
Loss of the abilities and motivation a person once had
Social withdrawal
Difficulty concentrating
Poverty of speech/Thought "


In my son's case loss of motivation, "social withdrawal" and
occasional "difficulty concentrating" are the only other symptoms that
might fit, and followed the onset of hearing voices. It's not
surprising really. Have you ever been to a cocktail party where
everyone is talking at once against loud music ? It gets a bit
difficult to concentrate, doesn't it ? That's the kind of noise level
he is contending against a lot of the time. (He's a martial artist and
used to meditation, so his ability to concentrate is better than most
people's and he's able to draw on those techniques when he needs to.)

The Seroquel site also has some online brochures on coping both for
the patient and for family and friends. (Menus, top right.)


Hearing voices is much more common than is generally believed. For 
first rate background information along with much practical advice,
read:

"Hearing Voices; a Common Human Experience" by John Watkins, Hill of
Content Publishing, Melbourne, Australia, 1988.

Watkins started from a conventional psychiatric background, but ended
feeling there are more experiences of voices than those that are
purely the result of illness, and that medication is only one approach
to coping with unwanted or distressing voices.


You might also like to read "Understanding Voices a guide for
relatives and friends. "Scotland NSF, May 2000. Booklet produced with
the co-operation of Scotland National Schizophrenia Fellowship run
Fife Hearing Voices Group. Downloadable from their website:

http://www.nsfscot.org.uk/text/main.htm 


"Coping With Psychosis: Some Thoughts From a Psychologist With
Schizophrenia " by Frederick J. Frese III, Ph.D. can be found at:

http://www.psyched.com/schizophrenia/copepsy.html

This is a really good article by someone who is not only a
professional expert but also suffers from the disease. He discusses
the disorganised thinking that can be part of the disease, and into
which your friend's repetitious behaviour ("...she often cites past
jobs, boyfriends, training courses .. repeatedly, almost ad nauseam")
might fit. Equally, if she drinks as much as you say, then the
rambling and maudlin thoughts are just as likely to be the result of
the drinking.


A good article on the recent changes in thinking about hearing voices
is at the UK Mental Health site at:

http://www.mentalhealth.org.uk/page.cfm?pagecode=PMALHV

It says, among other things:

"This view may sound radical, but is based on sound research involving
questionnaires and interviews conducted with many voice hearers, both
within and outside of psychiatry. What was found, was most surprising,
voice hearers cope with their voices (or conversely don't), not
because of the content of the voice experience (which can be either
abusive and devaluing or guiding and inspiring - or both) but because
of the nature of the relationship with the voices. Bottom line, this
means that if you believe the voices to be in control you can't cope -
if you believe you are stronger then the voices are, you can.

As a result of these findings it is no longer a sustainable position
to think of voices as part of a disease syndrome, such as
schizophrenia. Instead hearing voices can be regarded as a meaningful,
real (although sometimes painful, fearful and overwhelming) event,
that speak to the person in a metaphorical way about their lives,
emotions and environment. For instance, people experiencing distress
as a consequence of abusive or commanding voices can often recognise
their voices as those of their actual abusers and the voices have the
effect of attacking their sense of self esteem and worth.

Having discovered these kinds of relationships psychiatrists and
psychologists in the UK and the Netherlands are developing techniques
to assist voice hearers focus on their experience and get to know
their voices better. The new approach requires the voice hearer to
make space for the voices, to listen but not to necessarily follow, to
engage, but in their own time and space - essentially to learn how to
control them in their own terms, according to their own beliefs and
explanatory framework. This acceptance of the voices is crucial to
growth and resolution, voice hearers who have learnt these techniques
can now say "I hear voices, they are part of me and I am glad they
are"

Research at Macquarie University in Sydney Australia. is also
focussing on  helping sufferers find a way of coping, rather than
using medications. (Local news item).


The Leicester Hearing Voices group has a newsletter at:

http://216.239.53.100/search?q=cache:ivt_06stVYEC:www.lampdirect.org.uk/news/hearingvoices1.pdf+physical+causes+OR+explanation+hearing+voices+-schizophrenia+-psychosis&hl=en&ie=UTF-8

which gives a very clear first hand picture of what it is like to hear
voices, as well as some suggestions for coping. These groups started
up to assist Voice Hearers whether or not they accepted a conventional
diagnosis.


For other alternate approaches The Schizophrenia Drug-free Crisis
Centre and Help-line have a site at:

http://www.jungcircle.com/Schizophrenia.html


Some personal stories are told at Schizophrenia.com:

http://www.schizophrenia.com/family/perstory5.html

Note that the emphasis is on other symptoms of the disease, such as
"flat affect" and psychotic episodes, not on hearing voices, though
"hearing voices" is considered a primary symptom of schizophrenia.


And  a radically anti-psychiatry approach  is taken by the Successful
Schizophrenia group. Their website is at:

http://www.webcom.com/thrive/schizo/

The stance here is perhaps extreme, but some of the articles may be of
interest.


Denco-ga has some good advice on how to help. Here's a few more
thoughts.


Your friend's alcohol intake is obviously excessive (I'm a drinker
myself, but - wow - that's a lot) and it is going to cause problems in
the long run if it hasn't already. The simplest way to help is to make
sure she takes Vitamin B supplements. The brain damage that follows
excess alcohol consumption is primarily due to Vitamin B deficiency,
so is largely preventable. Eating properly is a must; if you can
prevent her getting to the stage where she uses alcohol as her main
food, good. Take her out for a meal once a week, maybe? Drop in with
food and cook for you both ?

I do wonder if expecting her to cope with de-toxing and learning to
stay sober before she's found a way to cope with the voices either
through medication or otherwise, isn't asking too much of her. That's
trying to do two very hard things at once. If it's felt essential that
she withdraw from alcohol right now, has she considered
hospitalisation ?


As a friend, are you able to talk to her specialist yourself? In this
country (Australia) doctor-patient confidentiality would prevent a
doctor from talking about her to you, but does not stop you talking
about her to them. It might help her specialist fill in details and
build up a better picture of the problems. Is/he fully aware of the
extent of your friend's drinking, for example?


Once someone has a diagnosis of schizophrenia it becomes very easy to
fit everything they say into the pattern of symptoms - busy
professionals are particularly guilty of this. eg

She wants to talk about God? It's a symptom ! 
She thinks George W. Bush is out to kill people ? It's a symptom ! 

(A friend of ours was considered to be delusional when he said he was
a baritone soloist, - until we turned up at the hospital to see if he
could come to rehearsal...he was mildly delusional, but not about
that.)

You've known her for years. Really listen to what she is saying, even
if she seems to be rambling  ( I'm talking about when reasonably
sober, here) !!! You will know best whether opinions she is now
expressing have a grounding in her view of reality and her genuine
opinions, and whether they are coming out of left field. Her
specialist doesn't have time for long discussions - you may do.
Fro example, maybe her Auntie Jean had the second sight or saw auras;
that makes those things part of her personal belief system derived
from her family, not something she now believes because she's
delusional. The specialist needs to know that.


Meditation and related mind techniques can help some people, with
focus and concentration if nothing else. Is there a local course you
might both go to? You might get her to go along if you said you wanted
to and asked her along "for company ".


Get her out  whenever you can - do some of the fun things you did as
kids - go to the Zoo, go skating. Don't put her in the position where
she has to talk unless she wants to, and try to persuade her to get
some fun exercise. Try "I'm going to the wherever, want to come?"
approach - and if she says no, you go anyway, then tell her all about
it, and try again next time.


Has she other family and friends who are trying to help in this
situation ? If she's living with her parents, one way of helping might
be to do something for her mother, rather than for her - spread the
load a bit. But it sounds as if you are already doing that with your
concern and friendship.


Finally, I don't know how much time you are giving your friend, but
don't make it so much you are risking your own health. You won't be
any help to her if you're exhausted or sick yourself.


The best of luck to both you and your friend.




Search Strategy:

Clozapine
"Hearing voices"
schizophrenia symptoms
schizophrenia

Reading and other research bookmarked at various times.

Thanks Angy, Some time after your answering I'm still following trails
from your paragraphs. I hope somewhere along the line, I can use some
of your content positively & constructively. Thanks for your time &
experience.

Howdy gan,

First, keep in mind the "Important Disclaimer: Answers and
comments provided on Google Answers are general information,
and are not intended to substitute for informed professional
medical, psychiatric, psychological, tax, legal, investment,
accounting, or other professional advice."

I am making a comment on this question from personal experience
with a situation similar to what you are experiencing.

So, to your first two questions.

Health-Center.com web site:
http://www2.health-center.com/pharmacy/antipsychotics/atypical_medic/clozaril.htm

"Alcohol and other nervous-system depressants, including
benzodiazepines and other antianxiety drugs, may enhance
Clozapine's sedative actions."

Whole Health MD web site:
http://www.wholehealthmd.com/refshelf/drugs_view/1,1524,153,00.html

"Missed Dose
Take it as soon as you remember, unless the time for the
next scheduled dose is within the next 2 hours. If so,
skip the missed dose and resume your regular dosage
schedule with the next dose. Do not double the next dose. 

Stopping the Drug
Do not stop taking the drug abruptly or without your
doctor's approval. Dose must be reduced gradually to
prevent withdrawal symptoms from occurring. 

Prolonged Use
The risk of side effects may increase with long-term
use of clozapine."

The best way to help your friend?  Be as supportive as you
can be, no matter how trying that will be to you.  While
not being patronizing, take everything she says with a
grain of salt.  Become as knowledgeable about schizophrenia
as you can, but be aware that there is much still to be
learned about schizophrenia.  Encourage her to stop drinking. 
Her continued treatment might be all that can be done at this
time.  Be accepting of her.  Stay positive.


Search strategy

clozapine alcohol
://www.google.com/search?q=clozapine+alcohol

Looking Forward, denco-ga

She might benefit from Byron Katie:
http://www.thework.org/

Hello -

I am very well acquainted, quite personally, with the agonies of what
is commonly termed "mental illness."   I suffered with depression,
anhedonia, and schizophernic-type neuroses on various levels for quite
sometime.  I had lost all emotional capability, drive, desire, and
much of my sentient reasoning.  But I can most definitively report
that I no longer have any such problems.

If you are of an atheistic or related belief system, you may not agree
with what I have to say.  But I personally discovered, empirically,
that psychological problems are many times only secondarily rooted in
the chemical make-up of the brain; that human beings are not just
composed of chemicals, but of spirit and chemicals -- a hybrid of
sorts.  I found that chemical imbalance can be directly related to the
condition of one's spirit; that spirits and the spirit realm are very
real, and have a very real capability to influence and control the
mind/soul.

Because people's personal beliefs vary, I won't elaborate much more
unless you're interested.  Feel free to post a reply to this message.

P1212,

I hear what you say.

My friend, although practising only sporadically, has had a Catholic
upbringing & retains that system of beleif along with a firm faith in
Jesus. Maybe this would form an important part of recovery?

Angy, denco, jas - Still reading through & digesting.

Hi -

That's good news.  Tell your friend that Jesus can deliver her of her
ailments.  He did so in the new testament, and does so today.  The
Catholic church touches on exorcism, but it's not a very prominent
thing in that church.  To be blunt, I would venture to guess your
friend needs a deliverance from demonic spirits that are tampering
with her sense of well-being and mind.   I would recommend she pray
very fervently to God to direct her to where she needs to go to get
cleaned.  I would locate a charismatic church that does deliverance. 
The stuff is real... very real.