DrFocker

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Just kidding, but I got your attention,right? Anyway, read below, all I can say is WOW. :eek: I should have been a lawyer!



Psychiatric News March 4, 2005
Volume 40 Number 5
© 2005 American Psychiatric Association
p. 7

--------------------------------------------------------------------------------

Government News


N.M. Psychologists Seek To Expand Privileges
Regulations permitting qualified psychologists to prescribe psychotropic medications in New Mexico went into effect on January 7. Since then, advocates have introduced bills to expand the list of drugs that psychologists can prescribe, allowing them to prescribe off-label and possibly to prescribe nonpsychotropic drugs as well, said Paula Johnson, deputy director for state affairs in APA's Department of Government Relations.
Language in the original legislation limits psychologists to prescribing drugs only for FDA-approved indications. The new bills would permit psychologists to prescribe drugs "recognized and customarily used...for the treatment of mental, emotional, behavioral, or cognitive disorders...." Drugs listed as used "sometimes" for mental or emotional disorders in Drug Facts and Comparisons or in the American Hospital Formulary Service would be acceptable.

In addition, the new proposal would permit psychologists to prescribe drugs to manage the side effects of psychotropic drugs. These could cover drugs to treat any condition from high blood pressure and seizures to Parkinson's disease and impotence, according to a report prepared by the Psychiatric Medical Association of New Mexico and the New Mexico Medical Society in opposing the proposed legislation.

"Psychiatrists who prescribe these drugs off-label are medical doctors with years of training and experience in recognizing and treating complex body chemistry actions and reactions," said the report.

The physicians also expressed dismay about the timing of the new bill. New Mexico's prescribing law requires a two-year supervised prescribing program for psychologists who want prescription privileges. Their advocates now are pushing for expanded rights even before any psychologist has completed this initial program.
 

NeuroDO

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:eek: This is SCARY for the patients.

However, I think there's an upside to this, namely that it will help to illustrate to other states that this is a dangerous slope for any state to start down. Clozaril today, cogentin tomorrow, then who knows...

Another problem for New Mexico in this is that why would a qualified psychiatrist go to New Mexico to open a private practice if he or she is going to be in competition with a Psy.D. or a Ph.D. who can charge less than half of what he or she does. Perhaps this will only exacerbate their shortage of qualified psychiatirsts in NM.
 
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DrFocker

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NeuroDO said:
:eek: This is SCARY for the patients.

However, I think there's an upside to this, namely that it will help to illustrate to other states that this is a dangerous slope for any state to start down. Clozaril today, cogentin tomorrow, then who knows...

Another problem for New Mexico in this is that why would a qualified psychiatrist go to New Mexico to open a private practice if he or she is going to be in competition with a Psy.D. or a Ph.D. who can charge less than half of what he or she does. Perhaps this will only exacerbate their shortage of qualified psychiatirsts in NM.
Yep, I've said it before as well, how many qualified Psychiatrists will now leave those states with these kind of laws? Unfortunately, I think it will get worse before it gets better. There will have to be cases of patients dying and severe malpractice and suddenly Psychologists will be center stage in the media and there will be a push to change the laws again. Another thing I don't understand is that I assume they have to have malpractice insurance since defacto they are practicing medicine, what insurance company in the world would insure a Psychologist? Can you imagine a Psychologist on the defense stand:

Lawyer: So what formal training do you have to practice medicine sir?
Psychologist: Well, of course we do 300 hours of classroom time and 100 patient practicum.
Lawyer: So you're saying you don't go to medical school for 4 years?
Psychologist: Yes, but..
Lawyer: And you don't do a residency for 4 years?
Psycholigist: Yes, but..
Lawyer: And you don't have to pass the licensing board exams given by the USMLE, specifically steps 1,2, and 3?
Psycholigst: Yes, but..
Lawyer: And you aren't board certified by the American Board of Psychiatry and Neurology?
Psycholigst: No, but..
Lawyer: Your honor, the prosecution rests.

The most distressing thing is that it will take cases like this where patients are hurt or killed before the laws are changed again. Who knows, maybe they'll never be able to afford malpractice insurance so it will be a moot point in the future. Time will tell.
 

ptolemy

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Don't get me wrong, I agree that this is a stupid idea, period. BUT, has anyone else noticed that the states trying to pass these bills are the states that are typically underserved by physicians?

I'm just making an observation, it will only take one or two patients with poor management (hopefully) to get a public backlash, but the people lobbying for this have good PR campaigns, physicians just don't seem to care about PR campaigns.. except maybe radiologists.
 
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Pterion

ptolemy said:
Don't get me wrong, I agree that this is a stupid idea, period. BUT, has anyone else noticed that the states trying to pass these bills are the states that are typically underserved by physicians?

I'm just making an observation, it will only take one or two patients with poor management (hopefully) to get a public backlash, but the people lobbying for this have good PR campaigns, physicians just don't seem to care about PR campaigns.. except maybe radiologists.
Accepting that these states are underserved by physicians, is the best answer to dilute the requirements for the practice of medicine, or might it be a better idea to find out why there are comparatively fewer physicians and fix that? I know, preaching to the chior. For the record, I am a psychologist (and now a medical student) who opposes this movement.

As for the PR stuff, another thread garnered a response to the effect that physicians aren't as active perhaps because they are actually working, leaving less time for the media blitz than the psychologists seem to have. :D
 

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If PAs are licenced to practice medicine (prescribe, do minor procedures, H+Ps, etc) with physician supervision, maybe psychologists can be licensed to prescribe with the supervision of a psychiatrist. ;)
 
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rpkall said:
If PAs are licenced to practice medicine (prescribe, do minor procedures, H+Ps, etc) with physician supervision, maybe psychologists can be licensed to prescribe with the supervision of a psychiatrist. ;)
Of the PA schools I know about, they typically are 4 years and are completely medically based with the typical Patho, Physio, Anatomy classes but lacking the future residency. A Psychologist who's training is not based on any medical model and who claims that a 300 hours of classroom time and a 100 patient practicum is the same as a PA or NP is kidding themselves. Put this into perspective: PA's and NP's have vastly superior training compared to what is being touted for the future of Psychologist RxP and yet they have to still be supervised by a physician. The "medical" Psychologists are pushing for FULL autonomy and supervision only by a Psychology board and yet have vastly inferior training in comparison to the above mentioned degrees. There just aren't any short cuts in medicine. If you want to practice medicine and learn physical diagnosis, physio, pathology then go to medical school. It's that simple. If Psychologists are so concerned about the undersupply of Psychiatrists, why do they not go to PA/NP school or even medical school to get the training they need to practice safely. Quite simply, you can't practice medicine in a vacuum and expect to see only Psychiatric conditions. Obviously, the Psychologists know this and are pushing for full autonomy without limitation to their formulary as evidenced in the article above.
 

ptolemy

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Pterion said:
Accepting that these states are underserved by physicians, is the best answer to dilute the requirements for the practice of medicine, or might it be a better idea to find out why there are comparatively fewer physicians and fix that? I know, preaching to the chior. For the record, I am a psychologist (and now a medical student) who opposes this movement.
I agree with you completely, I was just pointing out that the driving force is mostly serving the population. Personally, I agree with most of what has been said here, psychologists do not have enough training to handle not only med management, but side effects of med management. I wouldnt want one prescribing me a blood pressure med, etc.

As for the PR stuff, another thread garnered a response to the effect that physicians aren't as active perhaps because they are actually working, leaving less time for the media blitz than the psychologists seem to have. :D
I personally think this is a load of crap. I think physicians arent as active because med school does not select for those types of people. Physicians don't want to worry about the media, public perception, etc. they want to b!tch about it, like many threads in other forums(ie gen residency forum-I think there's two threads right now- link to one at bottom), but when it comes to actually doing something about it, the response in that thread is: tell people you're a nurse so you don't have to deal with it. For the record also, I was not a psychologist, but I did do research with a few, and am a 4th year med student.

http://forums.studentdoctor.net/showthread.php?t=185661
 

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*sigh*

I just want to say, again, that as a psychologist I think this is absolutely horrible. I dumped my membership to our APA because they are so monomaniacal about this stuff. They are ignoring nearly 50% of their membership who oppose RxP and have never put this to a formal vote.

There is no way I would be able to defend myself in a malpractice suit if I prescribed the combos some of my patients are on. I have one on Depakote, Nortriptyline, Xanax PRN and Prozac. I have another on Lamictal and at least two other meds with a heart condition.

No. Way.
 

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Indeed. The American Psychological Assoc seems to be a largely propagandist organization that pushes their agendas quite heavily. I'm not surprised to hear that you say they've never put the prescribing issue to a vote. They simply make blanket statements that "our membership wants this."

What's even more scary is the fact that these psychologists can prescribe to children and geriatrics, WITHOUT a fellowship. That's just insane. Even psychiatrists, 1000 times more versed in special population medical complications, are reluctant to do this with additional training beyond their four years of psychiatric residency.

American healthcare is in a downward spiral. It appears that governmental political correctness (no one should feel bad, left out, or inferior) is allowing anyone and everything to practice whatever they want. Between optometrists performing surgery, chiropractors doing school medical physicals and becoming "primary care physicians", NPs becoming "doctors," naturopaths in general, psychologists prescribing medicine, etc., it seems that medical school is quickly becoming an outdated thing of the past. The aforementioned professions are all important and valuable in their traditional roles to the healthcare team, but the constant demand for more rights seems more like a civil rights movements than proper healthcare policy for patients.

Why go through a minimum of 7-8 years of hellish generalized and specialty medical training when you can practice the same basic medicine with half the time, with no pimping, no call, dozens of less tests, no need to take three levles of medical boards or skills exam, no medical internship or any of the countless struggles or grooming process required to become a competent physician?
 

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Anasazi23 said:
Why go through a minimum of 7-8 years of hellish generalized and specialty medical training when you can practice the same basic medicine with half the time, with no pimping, no call, dozens of less tests, no need to take three levles of medical boards or skills exam, no medical internship or any of the countless struggles or grooming process required to become a competent physician?
I think that it's a societal problem in general. I could say the same thing about my field. The doctorate is no longer particularly valued. The way it was -- a six year process including structured postdoc -- provided us with some good supervisors, researchers, and therapists. Now you have non-degreed or even degreed fruitcakes making up therapies like Attachment Therapy (a la Candace Newmaker) and people being unwilling to pursue anything higher than an MA "because it's too much work." Some of my students are being ridiculed by their peers that I make them learn good diagnostic interviewing on therapy practicum...they're asked, "What's she making you do that for? You're on THERAPY practicum!!?" Like you can do any kind of therapy without a good dx interview or knowledge of dx criteria.

The writing is terrible and the thinking skills are blunted. It's upsetting. I have recently decided to become a consultant and go into business for myself because I'm just so sick at what we've become.

Hijack, sorry...but I do believe our APA has become a refuge of scoundrels, and those that aren't scoundrels belong just because "you should." We have it beaten into us that we need to belong to the APA. As long as I abide by the ethical code (which I do), I'll give my money and time elsewhere.
 
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DrFocker

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Anasazi23 said:
Why go through a minimum of 7-8 years of hellish generalized and specialty medical training when you can practice the same basic medicine with half the time, with no pimping, no call, dozens of less tests, no need to take three levles of medical boards or skills exam, no medical internship or any of the countless struggles or grooming process required to become a competent physician?
I ask myself this all the time when I see so many of the NP's that our program hires for cheap labor. They take no call, don't do the residency, don't take steps 1-3, don't suffer the fun of Surgery, OB/GYN, etc, etc as a 3rd year student. I recently admitted a patient that was seen by an NP at our Psych ER that was given 80mg Geodon, 10 mg Haldol, 3mg Risperdal, and 50mg of Benadryl. It was just shocking :eek: that she had akithisia by the time I saw her. Another patient I admitted, the NP gave 80 Geodon, 1500 Depakote, 25 Abilify, and 50 of Haldol, yes FIFTY of Haldol. Another patient when I was on Neuro we got consulted on because this small, petite Asian patient the NP had written for aproximately 300 mg of Haldol-D over 1 month!! The consult was to r/o Parkinsonism!! Well, gee, I wonder why? :idea: The stories go on and on. Yes some of the attending MD's make mistakes, but I've never seen them do things as egregious and dangerous as the NP's at my program. I notice also that the NP's in the program also don't get trained by any MD's, but fellow NP's! I guess it's most depressing to think I'm training for at least 4 years of school + 4 years of residency with all the call, sleepless nights, and pimping so that an NP can take my job and provide low-cost, low-quality care? HUH? Very sad for us and our patients.
 
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Paendrag said:
Dr. Focker,

There seems to be a predicted shortage of doctors in the future, I don't think you have much to worry about with regards to not having a job. What may be a problem is pay level. As midlevel practitioners permeate the market, pay may be affected. In neuropsychology we see this with the current influx of Psy.D. and professional school graduates willing to take lower pay. Also, all of your evidence on NP is anecdotal. IF there is truly a problem, real research needs to be done to demonstrate it. I'm sure anyone with some experience in healthcare can opine all day on the various inadequacies or practitioners they encounter from all specialities.
Yes, I agree about the job situation. I also think that many factors such as the cost of malpractice insurance and liabilities will make it cost prohibitive for most Psychologist RxPing. Yes, my experience is anecdotal, however it makes common sense that with less training/experience one is going to give less competent care. I mean, it would be the same as saying that if I wanted to be a Dentist, all I would need is some remedial weekend courses and follow a few patients and then I could provide the same care as someone who went to Dental school. We don't need a study to demonstrate that, it just makes common sense I wouldn't be as competent as a real Dentist. And, yes, somebody could do a study demonstrating the differences or similarities in care of NP's and MD's, but we all know that anyone can design a study that can sway the results to what one wants the results to be. I guess my point is, we don't need a study to show that inferior training often results in inferior care.
 

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Paendrag said:
For instance, with little in the way of formal coursework, should psychiatrists be allowed to assess/diagnose mental illness or conduct non-pharmaceutical based therapy of any sort?
This analogy is invalid because psychiatrists have been conducting therapy for the better part of 100 years. Not allowing psychiatrists to perform therapy would be TAKING AWAY something they already do. Psychiatrists arguing psychologists prescribing is arguing against something they WANT.

I think psychologists that are in support of prescription privledges for psychology might argue that this superior training in all things behavior puts them in a better position than most M.D.s to address patient needs with regards to medication and other therapeutic interventions.
Behavior doesn't even come close to equalling physiology and clinical medicine. So again, this doesn't make much sense. (I realize you said you don't agree with this position.)

I also think that psychiatry far oversteps their expertise in assessment and treatment of mental illness. Ideally, psychiatrists should be supervised by or required to consult with clinical psychologists before prescribing meds (beyond ER issues) to treat mental illness, and should not be conducting therapy. To clarify, I don't mean consult on which meds to prescribe, I mean consult on the diagnosis before prescribing inappropriate medications.
Again, psychiatrists were clinically evaluating patients before psychologists ever were. Are you serious about psychiatrists being "supervised" by psychologists? It'll be a cold day in hell. This is a completely unrealistic scenario in modern medicine. No other specialty is required to consult with another non-MD/DO in choosing their treatment regimin. Besides, the psychiatrist is also looking at concomitant medical information in their choices, something psychologists are not trained to do. Just doesn't make sense.

Something that would help psychologists understand the psychiatry process. Diagnosis is only one piece of the pie. While psychologists feel and state that they will be the white horse that gallops in to protect patients from bad diagnoses from psychiatrists, psychologists should realize: We don't prescribe solely on diagnosis...but on symptom and physiological pictures. There's a big difference. You don't always throw an antidepressant an depression, or an antipsychotic at psychosis in every scenario. There are a lot more subtelties and physiological extenuating factors than most others realize.
 

Anasazi23

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Your point about the DSM is well taken. Both psychiatrists and psychologists should use it as it's intended purpose...as a tool. It's a lot easier to describe someone as "schizoaffective" than to go into a 1000 word essay on all their psychotic an mood symptoms from a descriptive psychopathology standpoint.
MD's assign categories as an ease of communication in a hectic world. We don't generally generate long reports like psychologists do, and have no time to do so if we wanted. It eases communication and is the diagnosis that hospital personell use in treating the patient.

Doing therapy for a long time may not make it right, but it does make it "a right." Again, the point of the analogy was that psychiatrists are not attempting to take away common practice routine of psychologists...to make the opposite proposal isn't fair. I can point out lots of things that psychologists do that are generally poor. That wouldn't be the point of the discussion from either side.

Psychiatrists have diagnosis and treatment training in residency for four years. You state that this isn't enough. What do you propose? A 6 year residency on top of medical school? Lots of psych patients are getting better with the current training system and through psychiatrists doing therapy. It's fine.

Behavior and physiology are interrelated - to a point. A very limited point. Simple descriptive behavior does not assume competence in physiology and clinical medicine by a long shot.

The business twerps at insurance companies do have doctors working for them. I talk to them all the time (unfortunately). At the end of the day, the physician administers the treatment (most often) that THEY want. This is no way should qualify psychologists to "supervise" psychiatrists. I'm sure that's not what you literally meant, anyhow.

EVERY psychologist you know is competent in considering the concomitant medical factors in the patients they see? They know how to assess liver function and type II renal tubular acidosis in their integration of the psychiatric patient? Hmm....

Health psychologists have knowledge of the existence of a small fraction of medical disorders. That doesn't make them adept and integrating the two - just like a psychiatrist isn't adept at the intricacies of psychological testing. The door appears to want to swing one-way as far as the psychologists are concerned. They can/do know all the medical information they need, yet psychiatrists know nothing of their expertise and are incapable of incorporating any of "their" skills, such as therapy or personality assessment. Doesn't seem fair.
 
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Paendrag said:
An excellent point. I assume you would argue against D.O. degrees, prescribing rights for NPs and PAs, and the like. QUOTE]

I'd never argue against D.O. degrees as they have basically the same training as an MD, do similar tests, do the same residency, etc. The training is very similar if not the same. My beef with NP's and PA's is limited to my program as I think they can safely prescribe SOME medications, but with oversight. At my residency program, they're basically given autonomy and have very limited supervision. Yeah, the supervision is there on paper, but in reality they basically do what they want. When I was a medical student the PA's/NP's I worked with on Internal Medicine were basically treated as residents in training. i.e. They go see the patient, write a note, go to the attending with a plan, present the patient and the attending either signs off on the plan or modifies it. At my Psych program the NP's are defacto attendings and I've seen some horrible patient care because of it. Like I said, the most frustrating thing is that these patients are suffering because they want to save a few bucks and here I am in training for another 4 years to be a good physician. It makes me question the entire purpose of medical training at this point. I do think Psychologists have their place and it's not with a script pad as you seem to agree. Consulting Psychologists on all diagnosis would be (pardon the pun) crazy! We do get a lot of training in dx in residency when were on overnight call 5-6 times a month seeing at least 5-10 admits, inpatient wards, VA, Geriatrics, Psych ER, etc., for 4 years. I think the length of residency is more than adequate given that in IM resident only does 3 years. We do consult our Psychologists when a diagnosis is still unclear and for some underlying Axis2 stuff and they can be helpful in their input and are involved with group therapies.
 

Anasazi23

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Much of the knowledge garnered in psychiatry residency is indeed practica-based. There is also mandated coursework...4 years worth on certain days that covers all the basic areas of psychiatry. Here's a concise typical psychiatry residency curriculum I just chose at random. As in most residencies, a good portion of the third year is dedicated to therapies, since in many or most residencies, this is where the outpatient therapy rotation (often year long) occurs.
http://psychiatry.ucsd.edu/residency/residencyCurriculum.html

As an aside, the neuropsychiatrists I know are crazy smart and have an unreal amount of information, knowledge, and clinical skills. They don't typically specialize in therapies. Just like not every cardiologist specializes in interventional cardiac caths. It's a subspecialty within a specialty, which is common and fine in medicine.

You stated that psychologists have "superior training in all things behavior." And that's why, psychologists may assert, they are better equipped to prescribe medication. I was simply making the point that knowledge of behavior doesn't assume knowledge of clinical medicine...that's all. Prescribing should come with good knowledge of medicine, which I think you agree with.

I'm not sure what hospital you work in, or what the psychiatrists there do, but I'm going to go out on a limb and say that a large portion of what they do you don't see. No psychiatrist worth their license (and it's their's to lose) doesn't check liver functions, kidney functions, and myriad other medical issues when prescribing certain medications. It's not an option, it's standard practice. You HAVE to do it - at the bare minimum.

I guess I just take exception to the notion perpetuated by psychologists that they are going to somehow make better junior physicians than.....physicians. I know you don't feel this way, Paen, just making a generalization.

Have a good evening.... :)
 

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Keep in mind fellow forum moderator in training, the assumption you dislike that psychology makes is not held by many if any licensed, experienced psychologists. This forum is full of inexperienced students, and that is where you are getting the rhetoric. However, that is the purpose of this site (SDN), so don't assume this level of naivete is present in trained psychologists.

:cool:
 

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psisci said:
Keep in mind fellow forum moderator in training, the assumption you dislike that psychology makes is not held by many if any licensed, experienced psychologists. This forum is full of inexperienced students, and that is where you are getting the rhetoric. However, that is the purpose of this site (SDN), so don't assume this level of naivete is present in trained psychologists.

:cool:
Point taken....and I sincerely hope you're right.
 

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Paendrag said:
The point I was making is that a psychiatrist does not routinely check liver function if someone comes in with a behavioral disturbance, cognitive problem, or whatever. In other words, it is not a routine diagnostic approach for psychatrists.
True. Generally it's not routine except in the context of inpatient psychiatry as a screening device. In my hospital, we're always being told how much certain tests cost. LFT panel costs 0.12 cents to add-on. So there's generally no harm in ordering it - and it can provide some good information, yet often opens up huge cans of worms.
 

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Paendrag said:
We are arguing two different points. For the purpose of medication prescription, I agree psychiatrists do check multiple physiological indicators to ensure safety of drug use. This is one of the reasons I don't think psychologists should prescribe. Even with a much more heavy physio/bio background than most psychology grads, I have little knowledge of what a bad liver level would look like without an M.D. to interpret it. The point I was making is that a psychiatrist does not routinely check liver function if someone comes in with a behavioral disturbance, cognitive problem, or whatever. In other words, it is not a routine diagnostic approach for psychatrists.
I really don't want to get dragged into this conversation, but I wanted to point out that some meds have side effects, such as liver toxicity, etc. that need to be routinely checked. For example, Clozaril causes agranulocytosis and needs cbc's checked routinely, Depakote should probably have LFT's checked also for liver toxicity. I know the psychiatrists at my institution do most of these tests because it is a drug rxn from the drug they're prescribing.
 

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Paendrag said:
Right, we already established that liver toxicity is checked within the context of medication side effects. The issue was diagnosis. Liver problems can cause/modulate behavioral disturbance/cognition.
sorry about that, I really didn't pay too much attention to this thread b/c I think this debate has played out too many times and is a waste of energy to argue about here (after all the previous threads)