Furious Seasons

December 11, 2008

"Prozac Nation, Prozac Violence?"

The following is an op-ed by Christopher Lane, Professor of English at Northwestern University, and the author most recently of Shyness: How Normal Behavior Became a Sickness. He wrote it soon after the tragic NIU massacre of Feb. 2008 and submitted it to several newspaper editorial pages. Not a single one would publish it, even though Lane is a well-respected scholar, a fine writer and has a solid track of publishing op-eds. He recently published it to his own website. I have preserved his own links in the piece and will let his work speak for itself. Let me add, however, that I am deeply discouraged that my colleagues in the media would blow off Lane's contribution and that they continue to largely ignore the very crucial questions surrounding anti-depressants and violence, and the far more widespread problems of anti-depressant withdrawal. I interviewed Lane about his book last year.

March 1, 2008

"Prozac Nation, Prozac Violence?"

Five days after the February 2008 shooting rampage at Northern Illinois University, which killed six and wounded eighteen, the Chicago Tribune ran a headline that caught my eye: “Doctors: Prozac, Violence Rarely Linked.”

Given the ambiguous grammar, it was difficult to tell if the headline was warning doctors about links between the antidepressant and violence or was quoting doctors as saying the links should not concern us.

A complete ruling on the matter would of course be reassuring. It might calm nationwide jitters that the cocktail of drugs—-Prozac, Xanax, and Ambien—-that Steven Kazmierczak had abruptly stopped taking, days before he went on his shooting spree, was connected with the violence that followed.

The Tribune headline implied that although there was a connection between Prozac and violence, it wasn’t a significant one. When I read the article, however, I learned that Jeremy Manier, its author, wasn’t quite so sure. Quoting deep-seated concern by experts at renowned local hospitals, including the University of Chicago Medical Center and Northwestern’s Feinberg School of Medicine, he wrote: “About one-fifth of people who halt a course of Prozac-like drugs report symptoms associated with a condition known as discontinuation syndrome, which can include abdominal pain, dizziness, crying spells, irritability and even a sensation similar to an electrical shock in the patient’s arms or legs.”

A disturbingly large number of studies corroborate Manier’s statement. Warnings from experts about a host of problems tied to ending S.S.R.I. (selective serotonin reuptake inhibitor) treatment have spotlit other areas of concern about this class of medication—-areas that will need exhaustive investigation before they can be considered resolved. These include the drugs’ effectiveness relative to placebo, and their published track record. The New England Journal of Medicine recently disclosed that the drugs’ successes have been consistently exaggerated over a period of seventeen years. As a result of such distortion, drugs like Zoloft appear in the pharmacological literature to be 70 percent more effective than the data tell us they actually are.

Given the prevalence of discontinuation syndrome and the erratic effect of mixing different classes of medication, no one should rush to judgment. Many variables are in play, including how differently people respond to S.S.R.I. medication; how severely disordered they were before taking it; and whether they are using it in combination with other drugs like Xanax and Ambien. But the sheer amount of guesswork surrounding such combinations, and how common they have become, should give us pause. The current concern about S.S.R.I. medication intensifies when one considers how many patients are cycling through other kinds of drugs at the same time, interactions that are not fully known or studied.

Not all discontinuation symptoms result in self-inflicted or externalized violence, a point I mention rather than minimize. But the reason the Food and Drug Administration added black-box warnings to S.S.R.I.s, alerting physicians to the risks of prescribing them to children and adolescents, was concern about their spotty track record and, in particular, indications of a link to violence. Numerous studies over the years pointed to a significant number of patients on the drugs who either attempted suicide or obsessed about doing so. The agency decided that it needed to take action. No one wanted a disturbing pattern to balloon into an established trend.

The drug companies want to relabel these symptoms as a resurgence of the original disorder. The problem they face in doing so is that discontinuation syndrome is entirely drug related. Prozac’s maker, Eli Lilly, has fought several protracted legal battles trying to dislodge evidence that its psychotropic is linked to violence—-and Lilly is not the only drug maker that has had trouble making its case convincing.

As the Tribune’s Manier reminds us, Eric Harris and Dylan Klebold, the shooters at Columbine High School, abruptly stopped taking the same class of antidepressant medication days before they opened fire on their classmates. Jeff Weise, the Red Lake High School killer in Minnesota, was taking Prozac before he killed nine people and then himself. Pekka-Eric Auvinen, the eighteen-year-old who began shooting in Jokela High School, Finland, had a history of S.S.R.I. use. According to investigators, so did Seung-Hui Cho, who killed thirty-two people at Virginia Tech and wounded dozens more.

The list of other killings involving S.S.R.I. psychotropic medication is troublingly long. It includes Michael McDermott, the software engineer who went on a rampage in Wakefield, Massachusetts, killing seven; Byran Uyesugi, who shot eight of his colleagues in Hawaii (seven of them fatally); and Charles Carl Roberts IV, who assassinated five Amish school girls before shooting himself.

Such incidents may, in the end, amount to nothing more than an awful set of coincidences. The trouble is, few people-—and even-fewer reporters and editors—-are willing to investigate either way. All the same, many people are sufficiently alarmed by signs of a pattern to suggest that the repeated use of psychotropic medication is involved—-that drugs are part of the problem here, rather than, as commonly assumed, its solution. From the disturbing pattern that is emerging, the standard defense by psychiatrists and drug companies—-that patients’ quitting medication before such violence merely demonstrates how much they needed it in the first place-—holds less water, especially in light of the black-box warnings, added to these drugs by the FDA, that indicate the drugs can increase aggressiveness and suicide ideation in patients, including those who stop taking their medication abruptly.

Was the Tribune headline correct, then, when it called Prozac and violence “rarely linked”? The answer to that complex question depends in large measure on how one defines “rarely” and “linked.” Some would say that “rarely” is not a word to generate much concern, because the number it refers to is statistically insignificant. Yet according to the International Review of Psychiatry, more than 67.5 million Americans-—almost a fifth of the country-—have taken a course of S.S.R.I. medication. Twenty percent of them constitutes a sizable crowd—-roughly the metropolitan populations of New York City and Los Angeles combined.

What about “linked”? Interestingly, Manier’s statement about the one in five patients who experience discontinuation syndrome on Prozac corroborates the exact words of Paul N. Jenner, who in 1998 distributed a confidential memo on this subject to executives at GlaxoSmithKline. Jenner was at the time the company’s Director and Vice President of Worldwide Strategic Product Development, so he was well placed to warn that Paxil too presented a “20 percent relapse rate.” Nevertheless, when highlighting what his report dubbed “Issues Management,” Jenner assured colleagues that “our highly skilled sales and marketing efforts” would spin “the discontinuation issue,” deflecting negative publicity by playing up Paxil’s “flexibility and control.”

In the report, at least, Jenner voiced not a shred of concern that one in five patients on Paxil was experiencing mild-to-serious side effects. (A later health report from GSK would list these as including risk of coma, birth defects, blood aggregation problems, and renal failure.) He was far more worried about the “fight for market share,” with competitors like “Lilly and Pfizer resorting to aggressive tactics to undermine Seroxat/Paxil’s growth.”

“Lilly,” Jenner complained, was “currently focusing on the issue of discontinuation, on trying to turn a disadvantage into an advantage by playing to the supposed strength of [Prozac’s] long half-life . . . providing an in-built tapering mechanism. This is clearly a marketing ploy,” he concluded, “already seen through by most psychiatrists, and a sign of desperation in the fight for market share.”

Coming from the makers of Paxil, such complaints might sound like the pot calling the kettle black. But Jenner was correct that Lilly had tried to sugarcoat grave concern among clinicians and researchers about Prozac’s discontinuation syndrome—-concern that helped prompt the FDA to take action, but that has not gone away, because discontinuation syndrome afflicts all ages.

As there are still so many “unknown unknowns” about S.S.R.I. antidepressants, what is needed now is a frank, open dialogue about the evidence we do have, including the efficacy and erratic effects of these medications when combined with other drug treatments. Longer clinical trials representing the full spectrum of patient reaction over six months—-rather than, as is common, two weeks-—would give us a clearer picture of how the brain and central nervous system react when patients come off this class of medication. As the Tribune article and a litany of studies make disturbingly clear, the evidence is mounting that these psychotropics have far more worrisome, unpredictable effects than large numbers of prescribers and drug makers would have us believe.

Posted by Philip Dawdy at December 11, 2008 12:01 AM

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Comments

I know people still brush off -- as poor science -- our website, www.ssristories.com, that Rosie works so very hard to maintain and represents a database of stories going back twenty years collected by her and others, but the fact is these stories and narratives do suggest something seriously amiss with clinical practice and, for those of us who have witnessed these things firsthand, demonstrable evidence that antidepressants lead to bizarre, out of character violence to self or others over and over again. Yes, it may be fairly rare for things to get so out of hand that life is lost but even when it isn't lost the symptoms are very often pointing in that same direction, most often when dosages are changed or the drug is stopped. This is playing roulette with people's lives and not just the patients taking the drugs but innocent bystanders who may be in their path when things go south. We created the site to make a point with the cumulative power of hundreds, even thousands, of stories and narratives. This kind of data is worth something and it shouldn't be two AARP-aged ladies working from their homes creating this database. It should be the CDC or the FDA. Let's get real about the danger and cost to society of what these drugs are doing. And please don't get back to me telling me it was the "underlying disease" -- many of these people who go on to kill or maim themselves or others weren't even given the drug for any serious disorder in the first place -- try biting their fingernails or pulling their hair. Sure some of these people were disturbed but it wasn't until they were given the antidepressant that they became violent. The patterns are too consistent not to be anything but drug use that caused these tragedies. I know some of you are going to differ with me but people who have been through it and come out the other side believe it and so do I.

Posted by: Sara at December 11, 2008 08:23 AM

I have seen this issue popping up in various places. Thanks for putting some of it together. My family looked at me like I had monkeys flying out of my tail when I noted this association regarding the Paula Abdul Stalker Issue - you guessed it: the woman was on SSRIs until her demise.

I mentioned Columbine and got the monkey-flight look.

I told them (my captive audience): "when you hear these news reports about some killing or suicide, nowadays I say suspect SSRI until proven otherwise." I then said: Heath Ledger, Columbine, and I can't remember who else came to mind.

The LINK issue:

You will be VERY SLOW to detect a LINK until you begin to systematically survey.

There is absolutely no decent system for anyone or any agency to monitor such events. Suicidality is not even decently monitored (or at least not reported) in NIH-funded RCTS with SSRIs. Some studies do. Some don't. There are three ways to incorporate side effect info into a pharmaceutical study - and also into observational, survey-based studies. 1. if a person spontaneously reports a side effect, you might record it somewhere, according to however you want to record it (i.e., patients don't say 'akathesia,' but will say 'i feel reestless' but the clinician has libertyto record either if anything is recorded); 2. you ask a generic 'side effect' question (again, lots of liberty: 'any problems?' versus 'any side effects?'); 3. you give a checklist (two variants: one, a handful of known or likely side effects, or two, a thorough list - generally at discretion of researcher).

So, even in a RCT, side effect data may not be sufficiently measured to link to anything, such as dose.

In clinical practice, things are much more loose.

My guess is that local law enforcement does not systematically assess prescription and illicit meds in cases of violence.

Thus: how would a "link" ever be detected?

Exactly the same phenomenon as Erin Brochovich: it took a layperson with a hunch to gather the data.

Also, same phenomenon for detecting endometrial cancer due to estrogen: early in the estrogen fad, some cancer docs noted that most of their endometrial ca cases happened to be Rx estrogen. Their case-control tissue analyses (questioned but ultimately acknowledged by Wyeth's own docs once these doc were able to take their own look at the slides of the cancerous tissue from the exact cases) basically led to the end of "unopposed estrogen" for menopause or personal beauty or whatever else Wyeth was pushing it for [for info, start with pubmed id: 196195].

So, it is not foolish to suspect that SSRI, or SSRI withdrawal has the unfortunate side effect of significantly disposing some to violence (to self or others).

In my opinion (I may have posted this opinion here already), this is a decent suspicion to explain the phenomenon of the many suicides and attempts in the gulf war ptsd vets (Newsweek ran a story this yr on vet suicides but did not put their finger on the SSRI dimension - maybe next year).

The VA is in an extraordinary position to analyze any link.

Posted by: MedsVsTherapy at December 11, 2008 08:33 AM

There is about 5 mg of serotonin in the human body, 4 mg in the gut and 1 mg in the brain. Messing with this relatively rare neurotransmitter that is the primary regulator of mood has profound effects. For example, LSD binds to one specific sub-type of the receptors for serotonin. It would be surprising if there wasn't a significant psycho-neurologic reaction to sudden withdrawal of an SSRI.

But, lets remember, these drugs save lives. 10% of people with depression commit suicide. SSRIs are not better than older anti-depressants, they just have fewer side-effects, so patients are able/willing to take them. Stopping a variety of drugs suddenly is quite dangerous as the biologic systems of the body adapt to the drugs presence. When the drug is suddenly removed the adapted physiology becomes pathophysiology (bad). Is it a surprise that psychologically troubled individual who will later go on to kill innocent people and themselves are noticed to being having trouble and are treated with available drugs? Is it a surprise that some of them would suddenly stop the drugs? Is it a surprise that this would cause problems worse than the disease? No

Posted by: Kokopilau at December 11, 2008 11:27 AM

Kokopilau said "10% of people with depression commit suicide. " This is a darn sweeping statement given that just a few days ago we heard that a huge percentage of the population is now being labeled as depressed. I think you mean 10% of the most seriously ill, probably hospitalized, probably already medicated depressed patients go on to commit suicide. This percentage dates way back to some very specialized studies of the most dangerously ill patients. I'm afraid I don't "remember that these drugs save lives." But yes, I agree with you that withdrawing a whole variety of drugs from the human body abruptly can create life threatening problems, but rarely as distinctive as those from antidepressants and other psychotropic drugs.

Posted by: Sara at December 11, 2008 12:11 PM

The problem here is how to separate "correlation" from "causation," and to define the acceptable safety level.

Can SSRI's cause violence in some people? We'll never know, because you can't separate the correlation (i.e., homicidal maniac was taking an SSRI) from causation (i.e., the SSRI transformed a person into a homicidal maniac).

If you re-packaged M&Ms and sold them as a drug, you'd get adverse reaction reports. Some people to eat M&Ms go on to commit murder. Did the M&Ms transform them into a homicidal maniac? Wait a minute, you're saying, that's a food. OK, but you can say the same thing about any drug - say, Zocor. Zocor affects cholesterol, which is needed by the brain. Some people who take Zocor will go on to commit murder. Is this disturbing?

And just what is the acceptable safetly level? The article mentions 7 homicidal maniacs and that 67.5 million people have taken SSRIs. That works out to a homicidal maniac rate of about 1 patient in 10 million treated. Is that too high? Ok, that's just the 7 you mentioned; the ssristories website lists ~727 murders; that leads to a homicidal maniac rate of about 1 in 100,000 patients. Is that too high?

There is no risk-free drug. Your life will not be risk-free.

Posted by: Blackeneth at December 11, 2008 12:18 PM

Blackeneth:

You make some excellent points. It is difficult to find causation versus correlation, but the latest studies pretty clearly show that SSRI's and SNRI's increase the rate of suicidal ideation and gestures by 1.5x in those under the age of 25 with a NNH of 143, i.e. 1 person will be harmed if 143 people use the drug.

They have not been found to increase the rate of completed suicides, however. The small increase in suicidal ideation and gestures is a rare occurrence, likely due to the induction of mixed states or akathasia, that should nonetheless be mentioned as a risk to patients during their informed consent.

Posted by: dguller at December 11, 2008 01:11 PM

Kokpilau:

The actual suicide rate in those who are depressed is difficult to figure out. The original figure was about 15% lifetime prevalence of completed suicides in those with major depression, but that was from a paper dated 1970. This figure was decreasd to about 3.4% with men having 7% and women having 1% (see J Affect Dis. 1999; 55(2-3):171-8).

Major depression is a significant risk factor for suicidal behaviour, particularly in men, and must be identified and treated properly.

Take care.

Posted by: dguller at December 11, 2008 01:26 PM

SSRIs do not have fewer adverse effects than the tricyclics or MAOIs...they have different side-effects...and a lot of people would argue SSRI side effects are worse.

Being sexually dead in my mind is worse than a bit of dry mouth and hypotension...I've suffered both, by the way, among many other side effects from the SSRIs.

the who myth of fewer side-effects was conconcted by pharma and kept alive by psychiatrists and now patients...ask people who have taken both...the old and the new...I think you'll find they both have a lot of potentially extremely uncomfortable side effects and in the case of SSRIs it seems these "side-effects" are at time deadly.

Posted by: Gianna at December 11, 2008 01:57 PM

Yes, and hats off to Douglas Bremner for writing a post relevant to this issue on the occasion of his attending the ACNP Conference going on right now.
http://www.beforeyoutakethatpill.com/2008/12/acnp.html

Posted by: Sara at December 11, 2008 02:22 PM

"Exactly the same phenomenon as Erin Brochovich: it took a layperson with a hunch to gather the data."

Sometimes I think so.
I have already said here that I became violent and for two time I've tried to commit suicide while tapering Effexor blah blah blah....

The UK Parliament has made the distinction of drug-induced suicidal thought that has nothing to due with the depression.

Traci Johnson was a healthy volunteer and hanged herself at Eli-Lilly's facilities... yadda yadda yadda....

Useless.

I've recently posted these facts:

"Neurotransmitter is a specialized messenger cell that transfers or sends information from one type of cell to another. Scientists have managed to identify over 100 neurotransmitters in the human brain alone, but evidence suggests we have significantly more than this number. An unfortunate aspect of not being able to identify all neurotransmitter cells is that researchers, especially those developing medications to act on specific messenger cells, can’t always determine why or how medications work or fail to work.

You’re probably familiar with some of the identified neurotransmitter names. These include dopamine, GABA, serotonin, acetylcholine, and norepinephrine. Each of these performs some specific functions in the body. For instance serotonin is indicated in mood stability, emotional response, and temperature control. Acetylcholine is a neurotransmitter that allows for the person to willfully or voluntarily use his or her muscles. While researchers can suggest the possible effects of certain neurotransmitters, they not only haven’t identified them all, but also are nowhere near determining all effects of the messenger cells that have been identified."

Here: "The neurotransmitters work by interacting with receptors. These are minute areas on the nerve or other cells that make the cell respond in the appropriate way. Some psychiatric drugs block these receptors, reducing the effect of a neurotransmitter. Others increase the level of a neurotransmitter, so its effects last longer. Because they all interact, changing the level of one neurotransmitter will change others; so however well a drug is targeted towards a particular receptor, it will have a knock-on effect on the whole system. One knock-on effect of many psychiatric drugs is to suppress acetylcholine, and this causes some of the side effects people experience."(emphasis mine)

Here: "The SSRIs are not selective for anything except that they act on all serotonin in the body.
Only 5% of this is in the brain. Five per cent. The other 95% is found throughout the body with large amounts being found in: the digestive system (stomach movement); the cardiovascular system (blood flow); blood cells (clotting); reproductive system (genitals); hormonal system (widespread effects on lots of physiological processes). All of which is acted upon by the drug. All of it."

Here: "Since we don’t understand the precise mechanism of each neurotransmitter or the true number of all that exist, we also can’t understand how medications, foods, or environmental exposure may affect these chemical messengers. Scientists and researchers must make educated guesses based on what is known, but the plethora of unknown information on these cells equates these theories to trying to playing darts in total darkness. Sometimes the guesses are pretty good; SSRIs for instance are reasonably effective for a lot of people. Other times these theories fail to work, since we’re guessing about what is essentially undiscovered territory, and we have no idea what other effects might be caused by raising or decreasing levels of certain chemicals made by the body."
The links are Here:

http://justana-justana.blogspot.com/2008/12/100-neurotransmitters-in-human-brain.html

I would like to hear from an unbiased scientist.

Sara,
Thank you for being so sensitive.

Another amazing fact is seeing major depressed people after taking all ADs on the market and not getting better being treated with ECT.

Please Erin Brochovich hurry up!

Posted by: Ana at December 11, 2008 02:34 PM

I agree that we must separate correlation from causation. But before you can do that you must know all the potential sources of the symptoms you list.

Unattributed fear (to the point of trembling), paranoia, panic attacks, strange painful skin sensations, depression, and thoughts of suicide are symptoms of Subliminal Distraction exposure. Yet I see these symptoms given as being caused by discontinuation syndrome.

These same symptoms appear in primitive Miskito Indians of Nicaragua and Honduras when they have episodes of Grisi Siknis (crazy sickness). They don't take or discontinue psychotropic drugs. They do live in too-small single-room traditional housing. That arrangement will allow Subliminal Distraction exposure. An episode of Grisi Siknis includes attacks on imaginary opponents with knives or other weapons.

Other Culture Bound Syndromes include incidents of sudden violence such as Amok in Malaysia, Going Postal in the United States, and iich’aa among the Navajo. When in primitive locations traditional housing allows SD exposure. The Post Office does not provide Cubicle Level Protection for work that should have it to explain mass shooting events in post offices. The Goleta shooter was a mail sorter, which requires long periods of concentration just like a knowledge worker in a business office where SD was discovered as a problem.

No one in medicine or psychiatry is aware of Subliminal Distraction or its symptoms.

Subliminal Distraction is explained in college psychology under psychophysics. It was discovered to cause mental breaks for office workers in the 1960's. The office cubicle was designed to deal with the vision startle reflex to prevent the problem by 1968.

My wife's mental break and our experience demonstrates that doctors cannot distinguish this phenomenon from mental illness. With the identical information and test results each practitioner we saw gave a different diagnosis for her sudden mental break. Each doctor discounted information they did not understand to reach a favorite diagnosis.

My wife had a severe reaction to drugs we were told harmless. She began to deteriorate in 2003 while taking Zyprexa. The drugs are dangerous, but there is no objective evidence they cause violence.

Violence appears in mass school shootings like the Joleka, Redlake, and Virginia Tech school events because those shooters created the "special circumstances" for SD exposure. They
took psychotropic drugs because they were being treated for mental distress by doctors completely unaware of the potential for Subliminal Distraction exposure. There is no treatment for it except to find and stop exposure.

There is no evidence that these drugs cause violence. The belief that they do is correlation. Subliminal Distraction is causation.

Posted by: L K Tucker at December 11, 2008 06:23 PM

"There is no evidence that these drugs cause violence."
Tucker: seriously. There is evidence. There are many accounts of people having suicidal thoughts, plans, and actions, sometimes actions whereby they do end up killing themselves. There are also many violent episodes where th common denominator is the use of a SSRI, or recent withdrawal. Also: Qaseem and colleagues published a recent review (Annals of Internal Medicine) of (in)efficacy RCT studies of SSRIs, and noted that the SSRI studies indicated that, while patients on placebo get 2/3 the effectiveness as the patients on SSRI, the SSRI patients were at more than twice the likelihood of suicidal actions. If the suicidality were associated with dep, not SSRI, then that finding would be reversed.

These very consistent patterns make it worth it to be concerned that SSRIs may lead to some affective instability, leading to greater incidence of harm to self or others.

Posted by: MedsVsTherapy at December 12, 2008 06:28 AM

Okay Mr. Furious Seasons, I see you don't like psych drugs. Yes, let's all go back to the days when psych patients were committed to state hospitals for years, decades, their whole life. Yes, let's go back to wide-spread ECT, insulin coma therapy, and water dunking.

Lets go back to the days when there was no effective treatment for depression - except for the psychobabble Freudian stuff where after years of daily analysis we learn that schizophrenia is caused by "refrigerator mothers" and we all want to have sex with our parents.

Or the days when people simply drank their way out of depression. Ever see the TV series Mad Men? We forget how prevalent alcoholism was as the chief method for dealing with anxiety and depression.

Sure, psych meds aren't perfect. No drug is. But I am entirely frustrated with your one-sided take on them. Do they not have ANY benefits? Do you really think that the millions of people who take them are all just being fooled by placebo effect?

I am not a doctor nor affiliated with any drug company. I'm just a regular person who is scared that because of the irresponsible reporting by folks like you, drugs like Prozac - which have greatly improved my life - will be off the market.

Let me ask you this question: If prozac has such a tendency to cause people to be violent... and if millions of people are taking them... then shouldn't we see AT LEAST tens of thousands of homicides and suicides attributed to them?

So, let me see where this is going. I have depression. I take prozac. That means I'm much more likely to be violent. I guess people are right to judge people with mental illness as dangerous - EVEN WHEN THEY TAKE THEIR MEDS. The stigma is right - according to you.

Posted by: Lisa at December 12, 2008 07:56 AM

Now, Lisa, just because the drugs are helping you at the moment does not mean that this violence issue is not real. Philip Dawdy is being very careful just to present facts and to present theories as just that. He is not asking you to stop taking your drugs or telling you you're going to become violent. The incidence of violence is highly correlated with the onset of treatment, changes in dosage, or withdrawal -- and the failure to warn. There is a strong likelihood, given the known adverse effects of antidepressants, that the violence would not have been triggered without the presence of the drug. This is something that needs to be addressed. It doesn't mean you have to stop taking your Prozac if you don't want to. I'm sorry if you don't like it but I would hope that you would want to keep this violence from escalating beyond what it already has even if, from your point of view, the drug is life saving. For others it has been life destroying. Don't deny those people their right to speak.

Posted by: Sara at December 12, 2008 02:18 PM

Just for the record, there's a new Lisa posting & I don't share her views.

Posted by: Not that new Lisa at December 12, 2008 03:16 PM

Sara:

I didn't interpret Lisa telling the people here to silence their voices. She is simply adding her own voice here, and it happens to be one that has found benefit to using antidepressants. She should also be heard.

Posted by: dguller at December 12, 2008 10:13 PM

Oh, and one more thing.

I was reading Dr. Healy's data about the number of completed suicides in antidepressants versus placebo in FDA studies. He cited 16 suicides in 23,885 patients taking antidepressant and three in 14,564 taking placebo. He calculated the odds ratio to be 3.1, which appears to mean that there is roughly three times the risk of completed suicides (BMJ 2005;330:1148).

However, he never included the confidence interval (CI), which my calculations show to be 0.95 to 11.16. Since the CI has a range that dips below 1, the difference between the completed suicides in the two groups is actually insigificant, and thus could be the result of chance alone.

So, according to Dr. Healy's own numbers, there is no increased risk of completing suicide on SSRI's. Funny how he never mentioned that.

Posted by: dguller at December 12, 2008 10:54 PM

Easy there, new Lisa, Philip is always very good about pointing out when things are largely speculative. Your assertion that, considering the number of people taking SSRIs, we should be seeing tens of thousands of homicides/suicides being blamed on them is to take an absurd position. Not all violence results in someone's death. Not all people suffering problematic side effects stay on the SSRIs for long. And, as someone noted above, the police don't ask "have you been taking antidepressants recently?" with the same frequency that they ask about alcohol or illegal drugs when investigating violent crimes. Nobody's going to put Prozac on a tox screen. So the fact is that nobody documents whether or not most assaults/murders/etc. involve someone who was taking antidepressants. The cited handful of cases made major headlines because they were unusual (mass shootings and whatnot). There are tens of thousands of murders/suicides/assaults every week in this country, and until we start documenting whether or not they were on antidepressants, we won't have numbers either direction.

Posted by: Jordan at December 12, 2008 11:52 PM

DGuller and others who think the suicidal risks are minimal,

It is estimated that only 1 to 10% of all adverse affects for all meds are reported to the FDA. So how you can you be sure these studies are accurate?

Again, due to insomnia, as a withdrawal "gift" from these meds, I don't feel like searching for the link. But someone posted it on this site a while back.

As far as drugs not being perfect, let's not confuse the issues. The issue is when you have a psych med label, any complaint you have about a side effect, including serious ones such as suicidal ideation is blown off as due to the "illness". Many doctors do this for non psych meds as evidenced in a survey that showed that statin drug side effects were blown off. But it is more pronounced for people who have the dreaded psych label.

As Sara indicated, that is the purpose of warnings like what Philip posts on this list. It is not to shut you up new Lisa or to minimize your experience but to give a voice to those of us who keep getting blown off by our psychiatrists when we report serious adverse affects.

Posted by: AA at December 13, 2008 03:16 AM

AA:

I am not minimizing the suicide risks. I am just using Dr. Healy's own data and doing a simple statistical calculation that shows it to demonstrate the opposite of what he disingenuously claimed.

He did not say -- and you do not say -- that the matter is unclear, because the data set is limited and incomplete. He -- and you -- shout loud and clear that there are significant risks of committing suicide on these medications, which is not supported by the evidence. You are right that with all the information, maybe it would show you and him to be correct, but it could also show that you are incorrect.

Also, I have stated on several occasions, that in certain vulnerable individuals, SSRI's likely induce a rare mixed episode or akathasia state that results in severe dysphoria and agitation, which can lead to suicidal ideation and attempts. This especially occurs during the first few weeks of starting or increasing the dose of a treatment. Thus, physicians should monitor their patients closely during this time and warn them of the possibility of such side effects. That is what all the new guidelines state, and it has been incorporated in the standards of good practice in psychiatry.

Posted by: dguller at December 13, 2008 07:29 AM

In reference to what AA said, "The issue is when you have a psych med label, any complaint you have about a side effect, including serious ones such as suicidal ideation is blown off as due to the "illness"."

I suspect this happens in the actual research studies, as well. It's the PI of a clinical trial who gets to decide if an adverse effect is related to the drug or not & considering so many of these PI's are depending on the pharm company for a good chunk of their income it wouldn't surprise me in the least if they fail to attribute things like SI, agitation, etc to the drug.

Posted by: anon at December 13, 2008 08:32 AM

What do confidence intervals mean if you don't have any confidence in the data? Unless I can see the narratives that go with all 19 of those suicides I don't trust their placement in those groups. What if even 1, let alone all 3, of those "placebo" suicides are not really placebo events at all but rather due to withdrawal either during the wash-out phase or after the active drug phase or because of confounding effects of other drugs. Furthermore how can we really be sure all the suicides have really been included? Many people drop out due to adverse reactions and there is no follow up to see what happened to them afterwards. Lots of people are "lost to follow up" in these trials. Furthermore suicides could well be under-reported for other reasons too. In none of these cases were the trials actually designed to study suicidality or suicide so clinicians aren't always asking the questions needed to determine exactly what's going on. Pushing numbers to get at "confidence" levels is meaningless unless the data is really solid, complete, and fully disclosed. Even one or two more suicides in the active group and one or two less in the placebo group makes a huge difference to the confidence intervals so unless we know the data is accurate, which I most certainly do not, confidence intervals mean nothing. Taking any of these studies literally is naive given what we know goes on in academic research at the current time. You can be sure suicidality and suicide itself are grossly understated compared to what is going on in clinical practice. These guys are bending over backwards to disguise or conceal suicide effects and there's still a strong signal. How much stronger is it out in the real world? That's what we need to find out.

Posted by: Sara at December 13, 2008 10:43 AM

Sara:

There are a number of reasons that suicidal ideation, gestures and deaths could be over- and under-reported in studies, and thus you are absolutely correct that we do not have good enough data to conclude one way or another the impact of these medications on suicide.

However, the data that we do have now, as flawed as it is, shows a small correlation between increased suicidal ideation and gestures in those under 25 within the first few weeks of being prescribed antidepressants. And so, it is now standard practice to warn them about those adverse effects until better evidence comes in, as always. :)

A great review article that I'd recommend to you is Eur Arch Psychiatry Clin Neurosci (2008) 258 [Suppl 3]:3–23, which goes over a number of these methodological issues in the available literature, and looks at case reports, drug company databases, national drug authority databases, and epidemiological and cohort studies. I thnk you might find it helpful.

Posted by: dguller at December 14, 2008 05:00 AM

I find it interesting that Ana offers up "facts" about the brain and supports here assertions by linking to wisegeek.com as her authority. I'm not saying she's wrong, but when you highlight your assertion as fact and link to an authority, for goodness sake, your authority should be... well... authoritative.

Oh yes, but the real authorities are all corrupted by drug money. So what do we know about the brain then? Perhaps there are no such things as neurotransmitters.

But alas, many folks here feel very comfy citing to the research literature to support their assertions of suicide risk with SSRIs. There's a lot of cherry picking going on here.

And if I hear one more time about how the old antidepressants are just as effective as SSRI's but with fewer side effects I'm going to throw-up. Not because the statement is untrue, but it completely de-emphasizes the importance of tolerability. The point is that the side effects from the older drugs were so bad that only the most severely depressed people would take them.

SSRI's are no panacea; but they have helped a lot of people. That so many people are so emotionally invested in suggesting otherwise tells us a lot about the messengers of that simple - and notorious - fact.

Posted by: Eva at December 14, 2008 12:41 PM

MedsVsTherapy:

You miss the point. There is no objective evidence that these drugs cause violence. No one can open the box look into the mind and determine the cause of violence.

When the violence happens while the victim is taking psychotropic drugs they are blamed.

Sudden violence, in Culture Bound Syndromes, has happened around the world and to people that could not possibly take the drugs you suspect.

No one investigates the patient's activities that would cause Subliminal Distraction exposure. In my five year investigation of Subliminal Distraction I could not find anyone aware of it or the mental problems it is known to cause.

When doctors give a psychotropic drug and the patient improves the drug is credited. But there is no objective test to prove it was beneficial or did anything. There is no evaluation to find that the patient's contemporaneous exposure from SD dropped thus reducing psychiatric symptoms.

If SD exposure continues or increases, violence is one possible outcome. In that case the drug is changed until there is an improvement. Again without any way to test drug efficacy.

The doctors, in ignorance, think that they finally found a drug that works for that patient. Patients swear by the drug they were taking just before the improvement.

On my site there is a case of a murder happening in a psychotic break that remitted within a week and never returned. Psychiatrists treating Jason Weed claimed one dose of medication caused that remission. Weed had taken a seminar known to cause mental breaks.

On their site Landmark Education warns participants about this problem. They know mental breaks happen from taking their seminar but not why they happen. They claim a rate of less than 1/1000 of one percent for serious outcomes such as suicide. You can link to that page from my 'EST Werner Erhard' page. It's Subliminal Distraction of course.

How many businesses do you know that warn customers of possible suicide from using their product?

You are confusing correlation with causation. Yes they were taking drugs. But they may also have SD exposure to cause those symptoms and eventually cause violence.

If you know of a test that objectively dmonstrates psychotropic drug efficacy tell us what it is.

Posted by: L K Tucker at December 17, 2008 12:29 PM