Author: Dr. David Healy MD FRCPsych
Up to 500 medicines can cause any of us, even the most balanced people with no prior medical history of any sort, to become suicidal, homicidal, severely agitated or confused. See Drugs That Can Cause Depression, Agitation and Suicidality.
Some of the 500 come with clear warnings – in some countries. With some, companies mention the problem in the drug’s label doctors see, but these labels appear designed to mislead doctors. For some, there are clear medical articles establishing cause and effect.
What do warnings, recognition or established cause and effect mean? They mean these medicines even when used as prescribed can cause suicidality, homicidality, agitation or confusion.
If you are on one of these drugs and are suicidal, homicidal, confused or agitated, they do not mean that the drug for sure has caused this in your case.
If you are on these meds and doing well and become suicidal in response to other things that can make us all suicidal, your medicine is not likely to be the trigger for this.
Many of us, if we become suicidal, especially out of the blue for no obvious reason, visit helplines or websites in an attempt to understand what might be happening and get advice or support.
Even though our meds are more likely to make us suicidal than our conditions, even mental health conditions like schizophrenia, these helplines and websites never mention that your drug might have caused or be causing your problem.
Why do they not mention this?
The helplines or websites have been given legal advice that to raise these issues with you would be to engage in the practice of medicine, for which no-one manning these lines is trained. Even if they were doctors, assessing whether your drug is causing your problem is ideally best done by a doctor who knows you – and has seen you on and off treatment.
This is the traditional legal view of the practice of medicine.
Cause and effect
RxISK is about to take you beyond what helplines or even perhaps what your doctor can offer.
Forty years ago the scientific practice of medicine involved consulting a doctor who brought his or her experience of seeing many patients in the same position as you to bear on assessing you. Doctors then also had a better sense of how to establish whether a drug is causing a problem than they have now.
In terms of establishing if a drug is causing a problem, the basic rules are:
- Did the problem start after starting the drug?
- If the dose of the drug was increased, did the problem get worse?
- If the person lowered the dose of the drug, did the problem ease?
- If the person stopped the drug, did the problem clear up?
- If they restarted the drug, did the problem come back?
It helps if the person on treatment senses the drug has caused the problem, perhaps because:
- They’ve had this problem on this or a related drug before
- They know what problems their illness causes and this is different
- They can distinguish between suicidality caused by an illness and a drug
Things can get more complicated with antidepressants, antipsychotics, and benzodiazepines:
- The problem may only appear on reducing the dose or stopping the drug
- The problem may only appear some time after stopping the drug
- The problem may clear up on restarting the drug
Many doctors have lost the skills to recognize when treatment is causing a problem. This is partly because in clinical practice these days, you often don’t see the same doctor every time. A good doctor is better placed to help you if s/he can see, smell, or hear a difference in you from the last time s/he saw you – assuming of course s/he is looking at, listening to and smelling you rather than looking at a computer.
May contain nuts
There is a more important reason why doctors do not practice medicine scientifically these days and why you need access to this statement in order to work out how to move forward.
In 1990, 3 clinicians reported on 6 patients becoming suicidal on Prozac. Based on the above criteria, there was no doubt that Prozac caused these suicidal episodes.
In response, Eli Lilly, the makers of Prozac, facilitated by the British Medical Journal, claimed their clinical trials showed no evidence Prozac could cause people to commit suicide.
In fact their clinical trials showed an excess of suicidal events on Prozac, along with what look like regulation breaching attempts to hide the problems. With access to the data, it was clear Lilly’s trials showed Prozac could cause suicide.
By then, however, Lilly had won a propaganda war. Doctors had been cancelled – told that their views about whether a drug could cause a problem could not be believed. Only company trials could tell us what the effects of drugs are.
Close to 100% of clinical trials of the medicines we take are run by drug companies. These are ghostwritten, often to the point where studies in which the drug didn’t work and wasn’t safe are reported as showing the drug worked and had no problems, with these articles appearing in the best medical journals. Even when articles have led to fraud charges, the studies remain built into the guidelines that tell doctors what to prescribe.
Treatment guidelines and medicine information sites that look independent of drug companies do not mention harms of treatments like suicidality. They claim this is done to avoid deterring people from seeking medical help.
As a result, doctors don’t now think that drugs approved by regulators could have serious problems. Prominent warnings about hazards like suicide are treated the way people with a serious nut allergy view May Contain Nuts labels – evidence that companies and regulators are covering their backs, not evidence of a real risk.
It used to be standard practice when mentioning problems like suicide in newspaper articles or on media slots to say don’t do anything without consulting your doctor first.
I no longer say this. If you go to a doctor feeling suicidal on a drug, there is an increasing likelihood s/he will double the dose of the medicine you are on, add another drug, or have you committed to hospital.
Scientific practice
What should scientific medical practice look like. The scientific method involves both you and a doctor examining all details of your case closely aimed at achieving a consensus about the best way to explain what is happening.
It is not scientific for a doctor to tell you the medical literature or guidelines do not support your hunch that your drug is causing your problem. If your doctor says this, you need a new doctor.
Unless your doctor comes up with a suggestion that makes solid sense to you, the scientific approach in a situation like drug induced suicidality would ordinarily involve reducing the dose of treatment to see what happens – ideally with a doctor onboard and monitoring you.
If you think your doctor is unlikely to suggest this, you may be better off handling things yourself. Does this mean you are illegally practicing medicine?
No it doesn’t. Scientific medical practice requires your doctor and you to work together to achieve a consensus. An increasing number of doctors are no longer practicing medicine – they are bureaucratically following orders from above.
Over-the-counter serotonin reuptake inhibiting antihistamines are among the 500 drugs that can cause suicidality and agitation. If they don’t suit us, we usually recognize it and stop treatment without consulting a doctor. You are not illegally practicing medicine if you do this.
Medicines are made prescription-only when we have reason to believe they are either more hazardous than over-the-counter medicines or we do not know the extent of their hazards.
The problems from prescription-only medicines now stem from these unavoidably hazardous chemicals but also from the misleading printed information that comes with them and a company colonization of medical minds – facilitated by medical journals and professional bodies.
Benefit – Risk
Except in rare circumstances such as mid-stroke, or heart attack or delirious state, you are the person best placed to make a Benefit-Risk assessment.
Smoking nicotine can be better for Obsessive-Compulsive Disorder (OCD) than taking a Selective Serotonin Reuptake Inhibitor (SSRI). Arvid Carlsson, the creator of SSRIs no less, did a trial demonstrating this.
SSRIs are the first option doctors turn to for OCD. If you are worse off on an SSRI and better after switching to smoking, only you can compare the benefits. The hazards of smoking, especially for decades, are well known. The hazards of SSRIs taken for decades are less well known but as likely to compromise health as nicotine taken for decades and if you are not getting a benefit no risk is worth taking.
The trade-off is yours to make – not someone else’s.
Support systems
If you become suicidal or agitated on treatment, you have two assessments to make. First whether the drug is causing your problem. Second whether your doctor is likely to add to your problems.
You may also find yourself up against your family and friends. While you need to listen to them, it may be that the option of supporting you in striking out alone – going against your doctor and the authorities – makes them nervous.
One option is to bring someone who understands your sense of what is happening to you with you to the doctor or emergency department. Having someone else present makes it more difficult for a doctor to blow you off.
Another option is to file a RxISK Report and show the score to your doctor. The message is twofold. One message may stem from a score that points to a link to treatment. The other is that you have reported your concerns elsewhere.
Family and friends
Someone on treatment may not know they are becoming suicidal – the change in them may be more obvious to people who know them.
The person on treatment may be confused, or episodically confused, or disinhibited and acting out of character. If s/he is not anxious at the prospect of things that would normally make him or her anxious, this can be dangerous.
There are tricky issues here that doctors have been slow to embrace. It is traditional to deal with the patient only, not their family, but in this case we are looking at drug problems that do not just affect the person on treatment but may also lead to the death of a family member, friend or member of the public – most drugs that can cause suicide can also cause homicide.
For more information, see our Suicide Zone.
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