The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Mr. Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
one in 150 people.
Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “It’s used to skirt the rules.”
refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.
The figures showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokeswoman for the agency, which is known as C.M.S.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”
significant drop since 2012 in the share of residents on the drugs.
But when residents with diagnoses like schizophrenia are included, the decline is less than half what the government and industry claim. And when the pandemic hit in 2020, the trend reversed and antipsychotic drug use increased.
A Doubled Risk of Death
For decades, nursing homes have been using drugs to control dementia patients. For nearly as long, there have been calls for reform.
In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
11 percent from less than 7 percent, records show.
The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
A Substitute for Staff
Caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue patients and avoid having to hire extra staff. (Homes with staffing shortages are also the most likely to understate the number of residents on antipsychotics, according to the Times’s analysis of Medicare data.)
more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Even some of the country’s leading experts on elder care have been taken aback by the frequency of false diagnoses and the overuse of antipsychotics.
Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, said she had discovered that her father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
Homes that violate the rules face few consequences.
In 2019 and 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The Times found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
a state inspector cited Hialeah Shores for giving a false schizophrenia diagnosis to a woman. She was so heavily dosed with antipsychotics that the inspector was unable to rouse her on three consecutive days.
There was no evidence that the woman had been experiencing the delusions common in people with schizophrenia, the inspector found. Instead, staff at the nursing home said she had been “resistive and noncooperative with care.”
Dr. Jonathan Evans, a medical director for nursing homes in Virginia who reviewed the inspector’s findings for The Times, described the woman’s fear and resistance as “classic dementia behavior.”
“This wasn’t five-star care,” said Dr. Evans, who previously was president of a group that represents medical staff in nursing homes. He said he was alarmed that the inspector had decided the violation caused only “minimal harm or potential for harm” to the patient, despite her heavy sedation. As a result, he said, “there’s nothing about this that would deter this facility from doing this again.”
Representatives of Hialeah Shores declined to comment.
Seven of the 52 homes on the inspector general’s list were owned by a large Texas company, Daybreak Venture. At four of those homes, the official rate of antipsychotic drug use for long-term residents was zero, while the actual rate was much higher, according to the Times analysis comparing official C.M.S. figures with unpublished data obtained by the California advocacy group.
make people drowsy and increases the risk of falls. Peer-reviewed studies have shown that it does not help with dementia, and the government has not approved it for that use.
But prescriptions of Depakote and similar anti-seizure drugs have accelerated since the government started publicly reporting nursing homes’ use of antipsychotics.
Between 2015 and 2018, the most recent data available, the use of anti-seizure drugs rose 15 percent in nursing home residents with dementia, according to an analysis of Medicare insurance claims that researchers at the University of Michigan prepared for The Times.
in a “sprinkle” form that makes it easy to slip into food undetected.
“It’s a drug that’s tailor-made to chemically restrain residents without anybody knowing,” he said.
In the early 2000s, Depakote’s manufacturer, Abbott Laboratories, began falsely pitching the drug to nursing homes as a way to sidestep the 1987 law prohibiting facilities from using drugs as “chemical restraints,” according to a federal whistle-blower lawsuit filed by a former Abbott saleswoman.
According to the lawsuit, Abbott’s representatives told pharmacists and nurses that Depakote would “fly under the radar screen” of federal regulations.
Abbott settled the lawsuit in 2012, agreeing to pay the government $1.5 billion to resolve allegations that it had improperly marketed the drugs, including to nursing homes.
Nursing homes are required to report to federal regulators how many of their patients take a wide variety of psychotropic drugs — not just antipsychotics but also anti-anxiety medications, antidepressants and sleeping pills. But homes do not have to report Depakote or similar drugs to the federal government.
“It is like an arrow pointing to that class of medications, like ‘Use us, use us!’” Dr. Maust said. “No one is keeping track of this.”
published a brochure titled “Nursing Homes: Times have changed.”
“Nursing homes have replaced restraints and antipsychotic medications with robust activity programs, religious services, social workers and resident councils so that residents can be mentally, physically and socially engaged,” the colorful two-page leaflet boasted.
Last year, though, the industry teamed up with drug companies and others to push Congress and federal regulators to broaden the list of conditions under which antipsychotics don’t need to be publicly disclosed.
“There is specific and compelling evidence that psychotropics are underutilized in treating dementia and it is time for C.M.S. to re-evaluate its regulations,” wrote Jim Scott, the chairman of the Alliance for Aging Research, which is coordinating the campaign.
The lobbying was financed by drug companies including Avanir Pharmaceuticals and Acadia Pharmaceuticals. Both have tried — and so far failed — to get their drugs approved for treating patients with dementia. (In 2019, Avanir agreed to pay $108 million to settle charges that it had inappropriately marketed its drug for use in dementia patients in nursing homes.)
‘Hold His Haldol’
Ms. Blakeney said that only after hiring a lawyer to sue Dundee Manor for her husband’s death did she learn he had been on Haldol and other powerful drugs. (Dundee Manor has denied Ms. Blakeney’s claims in court filings.)
During her visits, though, Ms. Blakeney noticed that many residents were sleeping most of the time. A pair of women, in particular, always caught her attention. “There were two of them, laying in the same room, like they were dead,” she said.
In his first few months at Dundee Manor, Mr. Blakeney was in and out of the hospital, for bedsores, pneumonia and dehydration. During one hospital visit in December, a doctor noted that Mr. Blakeney was unable to communicate and could no longer walk.
“Hold the patient’s Ambien, trazodone and Zyprexa because of his mental status changes,” the doctor wrote. “Hold his Haldol.”
Mr. Blakeney continued to be prescribed the drugs after he returned to Dundee Manor. By April 2017, the bedsore on his right heel — a result, in part, of his rarely getting out of bed or his wheelchair — required the foot to be amputated.
In June, after weeks of fruitless searching for another nursing home, Ms. Blakeney found one and transferred him there. Later that month, he died.
“I tried to get him out — I tried and tried and tried,” his wife said. “But when I did get him out, it was too late.”
WASHINGTON — A detainee at Guantánamo Bay has agreed to a deal intended to lead to his release in the next few years in return for giving up the right to question the C.I.A. in court about its torture program, United States government officials said.
The deal, negotiated by the Pentagon official who oversees the military commissions that serve as a court for some detainees, was reached in recent weeks, and comes as a number of those who have been charged at Guantánamo are seeking to cite their abuse at the hands of the C.I.A. as part of their defense.
Under the deal, the prisoner, Majid Khan, 41, who has pleaded guilty to serving as a courier for Al Qaeda, would complete his prison sentence as early as next year and no later than 2025 and then could be released to another country, assuming one will take him, according to people who have seen the terms or are familiar with its details.
In exchange, Mr. Khan will not use his sentencing proceedings to invoke a landmark war court decision that allowed him to call witnesses from the C.I.A.’s secret prison network to testify about his torture.
2014 Senate investigation. He was also sleep deprived, kept naked and hung by his wrists, and hooded, to the point of hallucinations.
Mr. Khan was transferred to Guantánamo Bay in 2006 and saw a lawyer for the first time in his fourth year of detention. In 2012, he pleaded guilty to terrorism-related charges stemming from his work for Al Qaeda after the Sept. 11 attacks, and agreed to postpone his sentencing while he cooperated with government prosecutors.
On April 16, he and his lawyers reached agreement with the overseer of military commissions for a sentence that would end sometime between early next year and March 1, 2025.
The agreement itself is under seal, at least until a judge questions Mr. Khan on whether he voluntarily entered into it. But several people, speaking on the condition of anonymity to describe details of the deal, said that it has a sentencing range of 11 to 14 years, applied starting with his guilty plea in 2012.
prosecutors failed to disclose certain evidence. Colonel Watkins retires from the Army on Aug. 1 and was replaced on the case Wednesday by an Air Force judge, Col. Mark W. Milam.
The agreement is the first involving a Guantánamo detainee that the Biden administration has reached since taking office. It was made by Jeffrey D. Wood, a National Guard colonel who was appointed by the Trump administration to the civilian role of convening authority for military commissions.
had actually seen Mr. Khan in C.I.A. detention.
The issue had been simmering but had not come to a head because travel restrictions during the coronavirus pandemic brought most military commission hearings to a standstill for the last year.
The question of whether Mr. Khan could receive a reduction in his sentence because of his torture was also a potential model for the defense in the capital conspiracy case against Khalid Shaikh Mohammed and four other men accused of plotting the Sept. 11 attacks. Defense lawyers for all five defendants say there is evidence that each was systematically tortured in the black sites, and they want a judge or jury to hear graphic details about it to avert a death sentence when the long-delayed case eventually proceeds.
Two contract psychologists who devised the C.I.A.’s interrogation program, James Mitchell and John Bruce Jessen, have been publicly identified. But the identities of the people who interrogated Mr. Khan, and in which countries where they did it, are still classified at the court, which operates under rules that the government says are intended to balance state secrets and fair trial rights.
Prosecutors argued that anonymous, in-person testimony about Mr. Khan’s treatment, whether in a classified session or in public, risked exposing covert U.S. government employees, and said it was not possible to take them to Guantánamo Bay. That left the possibility of the judge ordering their appearances, prosecutors refusing to bring them and as a remedy, the judge reducing Mr. Khan’s sentence.
filing on April 22, Mr. Khan’s lawyers will also ask the judge after sentencing to void the June 2020 ruling that found credit for pretrial punishment is an available remedy at a military commission — undercutting its potential use in the Sept. 11 case.
Mr. Khan has been kept apart from the other former C.I.A. prisoners at Guantánamo since he pleaded guilty. At that time, he became a government informant, and has been debriefed on demand although prosecutors have yet to hold a trial where his testimony would be needed.
In pleading guilty he admitted to delivering $50,000 from Mr. Mohammed to militants in Indonesia that was used to finance the bombing of a Marriott hotel in Jakarta, Indonesia, in 2003, killing 11 people. Three men at Guantánamo have been charged in that plot, but have yet to be arraigned and have no trial date.
During the Trump administration, Mr. Khan was also listed as a government witness in a planned federal prosecution of another Pakistani man, Uzair Paracha. Mr. Paracha was convicted in 2005 in New York of federal terrorism-related offenses, but the conviction was overturned. Rather than retry him last year, federal prosecutors dropped the case in exchange for Mr. Paracha voluntarily giving up his U.S. residency and returning to Pakistan, after 17 years of incarceration.
For Mr. Khan, the path out of Guantánamo may be more complex. Successive U.S. administrations have argued that a convicted war criminal who completes his sentence may still be held at Guantánamo in the quasi-prisoner of war status of a detainee, as long as the United States considers itself to be at war with Al Qaeda and other terrorist groups.
Also, it is unclear where Mr. Khan would go. He was born in Saudi Arabia, lived as a child in Pakistan but went to high school in suburban Baltimore and had asylum in the United States before he returned to Pakistan after the Sept. 11 attacks. By law, he cannot be sent to the United States.
Inside a state-of-the-art lab, tucked in an industrial neighborhood on Vancouver Island in British Columbia, employees wearing protective suits move around two clear boxes, careful not to disrupt the tubes and sensors that keep temperature and humidity constant. Inside the boxes are mushrooms.
But not just any mushrooms. They are psychedelic — “magic” — mushrooms that the start-up Numinus Wellness believes one day may be used to treat mental health conditions as varied as depression, substance abuse and anxiety.
Welcome to the ’Shroom Boom. While Numinus is using mushrooms to make mind-altering therapies, other mushroom growers are promising other benefits, like strengthening immune systems or reducing inflammation. Mushrooms are showing up in all sorts of wellness products, pushing them into the mainstream and making mushrooms a major force in the flourishing, multibillion-dollar wellness market.
legalize psilocybin, the main active ingredient in “magic” mushrooms, for the treatment of certain mental health conditions in supervised settings. In March, the New York City mayoral candidate Andrew Yang said New York State should legalize psychedelic mushrooms, a stance he raised in 2019 when he was a Democratic presidential candidate.
Regulators in the United States and Canada are taking baby steps toward allowing limited use of psychedelic mushrooms, which produce visual and auditory hallucinations over a few hours after ingestion, for the treatment of certain mental health conditions. Popular as part of the counterculture in the 1960s, magic mushrooms were deemed illegal in the United States in the 1970s.
public offering. Another psychedelic company, MindMed, has financial backing from Kevin O’Leary of “Shark Tank.”
New York in March. But some analysts and many of the companies themselves caution that the path for psychedelics will most likely be very different.
study by researchers at Johns Hopkins Medicine that found use of psilocybin relieved anxiety and depression in people with a life-threatening cancer diagnosis. A second, small study involving 24 participants conducted by Johns Hopkins researchers that was published in JAMA Psychiatry found that those who received psilocybin-assisted therapy showed improvement as well.
“The magnitude of the effect we saw was about four times larger than what clinical trials have shown for traditional antidepressants on the market,” Alan Davis, adjunct assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine, said in an announcement about the study’s results.
The Food and Drug Administration has put at least two psychedelic mushroom compounds on the fast track for approval to treat depression.
Last year, Canada began allowing a limited number of people with terminal illness to use psychedelic mushrooms. Currently, Numinus is working toward a psilocybin-assisted therapy trial for patients with substance abuse disorders.
And while regulators in the United States are taking a new look at psychedelic mushrooms, psilocybin is still a Schedule 1 drug and would need to be reclassified by regulators.
Despite those hurdles, though, Mr. Nyquvest sees the potential for a broader use of psychedelic mushrooms around wellness, beyond what he called “treating really heavy indicators” of substance abuse and depression.
“The same way you go to the dentist to take care of the teeth, we need to think about taking care of the brain and mental well being.”
Reports about the mysterious Covid-related inflammatory syndrome that afflicts some children and teenagers have mostly focused on physical symptoms: rash, abdominal pain, red eyes and, most seriously, heart problems like low blood pressure, shock and difficulty pumping.
Now, a new report shows that a significant number of young people with the syndrome also develop neurological symptoms, including hallucinations, confusion, speech impairments and problems with balance and coordination. The study of 46 children treated at one hospital in London found that just over half — 24 — experienced such neurological symptoms, which they had never had before.
Those patients were about twice as likely as those without neurological symptoms to need ventilators because they were “very unwell with systemic shock as part of their hyperinflammatory state,” said an author of the study, Dr. Omar Abdel-Mannan, a clinical research fellow at University College London’s Institute of Neurology. Patients with neurological symptoms were also about twice as likely to require medication to improve the heart’s ability to squeeze, he said.
The condition, called Multisystem Inflammatory Syndrome in Children (MIS-C), typically emerges two to six weeks after a Covid infection, often one that produces only mild symptoms or none at all. The syndrome is rare, but can be very serious. The latest data from the Centers for Disease Control and Prevention reports 3,165 cases in 48 states, Puerto Rico and the District of Columbia, including 36 deaths.
study published last month in JAMA Neurology, 126 of 616 young people with the syndrome admitted to 61 U.S. hospitals last year had neurological issues, including 20 with what the researchers described as “life-threatening” problems like strokes or “severe encephalopathy.”
The new report, presented as preliminary research on Tuesday as part of an annual conference of the American Academy of Neurology, evaluated children under 18 who were admitted to Great Ormond Street Hospital (GOSH) between April and September of last year with the syndrome (it has a different name and acronym, PIMS-TS, in Britain). The data is also included in a preprint of a larger study that has not yet been peer-reviewed.
As was the case with other studies of the syndrome, including in the United States, the researchers said a majority of those afflicted were “nonwhite,” a pattern that public health experts believe reflects the disproportionate way the pandemic has affected communities of color. Nearly two-thirds of the patients were male, and the median age was 10.
All 24 of the patients with neurological symptoms had headaches and 14 had encephalopathy, a general term that can involve confusion, problems with memory or attention and other types of altered mental function. Six of the children were experiencing hallucinations, including “describing people in the room that were not there or seeing cartoons or animals moving on the walls,” Dr. Abdel-Mannan said. He said some experienced auditory hallucinations involving “hearing voices of people not present.”
Six of the children had weakness or difficulty controlling muscles used in speech. Four had balance or coordination problems. One child had seizures and three children had peripheral nerve abnormalities including weakness in facial or shoulder muscles. One patient’s peripheral nerve damage led to a foot-drop problem that required the use of crutches and a recommendation for a nerve transplant, said Dr. Abdel-Mannan, who is also a senior resident in pediatric neurology at GOSH.
Some of the patients underwent brain scans, nerve conduction tests or electroencephalograms (EEGs), including 14 who showed slower electrical activity in their brains, the study reported.
Thirteen of the 24 with neurological symptoms needed to be placed on ventilators and 15 needed medication to improve their heart contractions, Dr. Abdel-Mannan said. By contrast, only three of the 22 children without neurological issues needed ventilators and seven needed such heart medication, he said. None of the children with hallucinations needed psychotropic medications.
Three children had to be hospitalized again after their initial stay, one for another episode of encephalopathy and two for infectious complications, Dr. Abdel-Mannan said, but he added that there were no deaths and “almost all children made a complete functional recovery.”
Dr. Abdel-Mannan said a team led by the study’s senior author, Dr. Yael Hacohen, will be following patients who had the syndrome — both those who had neurological symptoms and those who did not. They will conduct brain scans and cognitive assessments to see if the children experience any long-term cognitive or psychological effects.