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Part 2: "A Walking Nightmare"-- Antidepressants and suicidality

Better than well



Sadness, sorrow, and despair have been a part of the human condition from the beginning. More than two thousand years ago, the author of The Book of Job wrote, "I will speak in the anguish of my spirit; I will complain in the bitterness of my soul." Around the same time, Siddhartha Gautama is said to have told his followers, "Life is suffering." It is only in the last 150 years that these conditions have come to be regarded as diseases that can and should be treated by the pharmaceutical industry.
Related:
  1. “They’re very safe”
  2. "Better than well”
  3. Dead bodies
  4. "I can't enjoy anything"
Most antidepressants belong to a class of drugs called Selective Serotonin Reuptake Inhibitors, or SSRI's. Despite their alleged selectivity, these drugs have been touted for a dizzying variety of human woes, including depression, anxiety, eating disorders, phobias, obsessions, compulsions, drug and alcohol addiction, migraine headaches, social phobia, schizophrenia, post-traumatic stress disorder, panic disorder, attention deficit/hyperactivity disorder, borderline personality disorder, and something called "premenstrual dysphoric disorder." Fluoxetine, better known as Prozac, was the first of the SSRI's to be marketed in this country, and its history is instructive. Its release in 1988 was quickly followed by a laudatory cover story in Newsweek magazine. "The Promise of Prozac," which teased "We are only beginning to fathom the mind's exquisite chemistry. Who knows? Maybe wit and insight will eventually come in capsule form. For now, the good news is that afflicted people are escaping their torment." In his book Listening to Prozac, psychiatrist Peter Kramer reels off a series of anecdotes of patients who found this marvelous drug rendered them "better than well." Dr. Kramer recalls his astonishment at learning that the effects of these wonderful pills extended to "social popularity, business acumen, self-image, energy, flexibility, sexual appeal..." While never explicitly claiming these results were typical, Kramer did very little to disabuse readers of that notion.

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Talking Back to Prozac

Others felt differently. In his book Talking Back to Prozac, psychiatrist Peter Breggin devotes an entire chapter to detailing the myriad ways Eli Lilly manipulated the clinical trial data to make it look as if its product was a safe and effective treatment for depression. Almost as soon as Prozac came onto the market, ominous storm clouds began to gather. In the February 1990 issue of the American Journal of Psychiatry, Doctor Martin Teicher described case histories of six patients, none of whom suffered from recent serious suicidal ideation, who suddenly developed intense violent suicidal preoccupations after taking Prozac. One of these patients had to be restrained to prevent her from banging her head. This suicidal state persisted for anywhere from three days to three months after stopping the drug. None of the patients could articulate any reason for why they felt this way, and none of them had experienced similar effects from any other kind of psychiatric medication. In a letter to the October issue of that same journal, he told the story of a 15-year-old boy, with little or no history of depression, who hung himself two weeks after being prescribed Prozac for obsessive-compulsive disorder. Dr. Teicher's colleagues wrote in to describe similar case histories. A 38-year-old woman became intensely preoccupied with killing herself every time she saw a razor; she later attempted suicide by means of carbon monoxide asphyxiation. A 26-year-old man held a loaded shotgun to his own head and later planned to crash his car into a bridge. In both cases these symptoms disappeared soon after stopping Prozac. The following year, Doctor Prakash Masand and his colleagues wrote a letter to the New England Journal of Medicine describing case histories of two patients, neither of whom had any previous history of suicidal ideation, both of whom experienced intense desire to kill themselves shortly after starting Prozac. One of these patients, a 58-year-old man, tried to hang himself with a rope. In both cases, the suicidal obsession abated a few days after stopping the drug. That same year, a paper in the Journal of Clinical Psychiatry described case histories of three patients, each of whom had made serious suicide attempts after starting Prozac. One, a 25-year-old woman had jumped off the roof of the hospital, suffering a subdural hematoma and compound fractures of her arms and legs. The second, a 47-year-old man, jumped off a cliff; he sustained only minor injuries. The third, a 34-year-old woman, jumped off the roof of a tall building. Her fall was broken by a balcony a few stories below, and she sustained "only" a fractured femur. In each of these cases, Prozac was resumed ("with informed consent"), and in each case the suicidal preoccupation returned. A 1992 paper in Archives of General Psychiatry by Doctor William Wirshing and his colleagues described four case histories of women who developed feelings of akathisia, or intense restlessness (just as Brenda did) as well as suicidal preoccupation after starting or increasing the dose of Prozac. One patient referred to her "obsessional need" to kill herself, while another described herself as "jumping out of my skin." In all four cases, the restlessness as well as the suicidal preoccupation disappeared after stopping or reducing the dose. Nevertheless, two years after that, in 1994, another cover story in Newsweek gushed "Now the same scientific insights into the brain that led to the development of Prozac are raising the prospect of nothing less than made-to-order, off-the-shelf personalities." The same article described some research of the effects of a new drug on the brains of rats, and then, going preposterously beyond the available evidence, burbled "If BDP works in people, the history lesson that took hours to learn would take mere minutes...Who could criticize a drug that stamps the rules for long division into your child's head after a single lesson?" Not everyone felt so sanguine about all of this. A 2003 meta-analysis by psychiatrist David Healy and statistician Chris Whitaker reviewed data from randomized clinical trials for eight antidepressants: fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), paroxetine (Paxil), mirtazapine (Remeron), bupropion (Wellbutrin), venlafaxine (Effexor), and nefazodone (Serzone.) (Serzone has since been taken off the market by its manufacturer, Bristol-Myers-Squibb, after the drug was linked to scores of cases of acute liver toxicity.) The authors found that, compared to placebo, these drugs were associated with a two-fold increase in the risk of suicidal acts and an astounding four-fold increase in actual suicides. Can these findings be believed? If anything, they may actually underestimate the risk of suicide in patients taking these drugs. None of these trials actually was designed to assess suicide risk. Actively suicidal patients routinely are excluded from participating in RCT's, and such trials invariably are brief and involve relatively small numbers of patients--hardly ideal circumstances to assess the risk of rare events such as suicides. Next: Part 3: "Dead bodies" List of Sources Cowley, G. and K. Springen 1990. The promise of Prozac. Newsweek 26 March 1990.
  • Kramer, P. 1993. Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. Viking Books.
  • Breggin, P.R. and G.R. Breggin 1994. Talking Back to Prozac: What Doctors Aren't Telling You About Prozac and the New Antidepressants. E-Rights/E-Reads.
  • Teicher, M.H. et al. 1990. Emergence of intense suicidal preoccupation during fluoxetine treatment. American Journal of Psychiatry 147:207-210.
  • Dasgupta, K. 1990. Additional cases of suicidal ideation associated with fluoxetine. American Journal of Psychiatry 147:1570.
  • Masand, P. 1991. Suicidal ideation related to fluoxetine treatment. NEJM 324:420.
  • Rothschild, A.J. and C.A. Locke 1991. Reexposure to fluoxetine after serious suicide attempts by three patients: The role of akathisia. Journal of Clinical Psychiatry 52:491-493.
  • Wirshing W. et al. 1992. Fluoxetine, akathisia, and suicidality: Is there a causal connection? Archives of General Psychiatry 49:580-581.
  • Begley, S. and D. Rosenberg. One pill makes you larger, and one pill makes you small. Newsweek 7 February 1994.
  • Healy, D. and C. Whitaker 2003. Antidepressants and suicidality: risk-benefit conundrums. Journal of Psychiatry and Neuroscience 28:331-337.
  • Spiget, O. et al. 2003. Hepatic injury and pancreatitis during treatment with serotonin reuptake inhibitors: data from the World Health Organization (WHO) database of adverse drug reactions. International Clinical Psychopharmacology 18:157-161.
  • Cosgrove-Mather, B. 2004. Antidepressant taken off market. Retrieved 16 November 2014.


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    Patrick D Hahn -- Bio and Archives

    Patrick D Hahn is the author of Prescription for Sorrow: Antidepressants, Suicide, and Violence (Samizdat Health Writer’s Cooperative) and Madness and Genetic Determinism: Is Mental Illness in Our Genes? (Palgrave MacMillan). Dr. Hahn is an Affiliate Professor of Biology at Loyola University Maryland.



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