Over the last decade David Healy.org and RxISK.org have both featured a series of posts about SSRIs and alcoholism and about Anne Marie Kelly.
There has been Out of my Mind Driven to Drink and related posts, Petra’s Story and Every Drink Spiked on DavidHealy as well as Driven to Drink: Antidepressants and Craving for Alcohol, Prescription Drugs Spiking your Cocktail, and Did My Doctor make me a Substance Abuser as well as Caught in the Firing Line on RxISK. And in particular see When is a Drug Guilty.
The person who put this on the radar for us was Anne-Marie, whose case – New Onset Alcohol Dependence linked to treatment with SSRIs – was written up in the International Journal of Risk and Safety in Medicine.
Anne Marie’s name should have been first on the authorship line of this paper. She did all the work. To this day I’m astonished that having dropped out of school early and with no background in research or psychopharmacology, she taught me who has a PhD in the psychopharmacology of the serotonin system things I didn’t know about that system – and she continues to educate me. Her drive also led to the phrase Motivation is worth more than Expertise.
The two Driven to Drink posts have had over 400 comments making them the most commented on posts linked to RxISK. These comments and reports to RxISK that followed these posts laid the basis for a RxISK article detailing Ninety-three cases of Alcohol Dependence following SSRI Treatment.
The cases outlined in this 93-case article pretty well nailed a phenomena that is now widely accepted and risks landing doctors in trouble if they don’t know about it.
Many people linked to RxISK or SSRI Stories or who read RxISK posts or have ever dipped into SSRI Stories when they hear about mass shootings figure wonder what psychotropic drug the shooter was on. Many are on drugs – but where the media once reported this, they simply now refer to a person’s mental illness – that might have been non-existent till they began a drug.
Some of us also though when hearing about public figures who have had terrible things happen to them, which are openly linked to their alcohol problem, also wonder about the drug they were likely on and wonder if they are going to get a fair hearing in court or from the public.
A Decade Later
A week ago, the Canadian Medical Association Journal published another Case of a lady who developed a significant alcohol problem on an citalopram. I was fortunate to have my name on the authorship line – although it should have been Anne Marie. Severe Alcohol Use Disorder following initiation of SSRI Therapy.
This was a learning example published to coincide with an even more important paper – Guideline for the Clinical Management of High Risk Drinking and Alcohol Use Disorder.
The guideline makes some pretty strong recommendations against initiating treatment with a serotonin reuptake inhibiting drug in someone with an alcohol problem and the need to monitor apparently recent onset escalation in alcohol intake following SSRI therapy. Both the article and the Guidelines make a case that is completely consistent with what Anne Marie put on our radar over a decade ago.
Evan Wood, the first author on the Guideline, has also been talking recently of a wider psychotropic drug induced substance abuse problem – leading to cocaine, opioid and other drugs of abuse. Could SSRIs have contributed to the recent opioid epidemic?
The Guideline points to other guidelines aimed at reducing alcohol use during pregnancy but does not point to the evidence that SSRI use in pregnancy has been linked to a 10-fold increase in Fetal Alcohol Syndrome in infants.
Guidelines can be tricky. This one leans toward saying don’t use SSRIs to treat the depression that can often be seen in people with excessive alcohol use. This can seem clear enough except the doctor facing a patient who is anxious, with panic attacks, may argue later when things have gone badly wrong – but the patient wasn’t depressed and I wasn’t treating depression so this was not my fault.
The same happens with the warnings for suicide. The doctor says I wasn’t giving this drug to treat a depression.
Unless warnings and Guidelines state clearly that even an absolutely normal, healthy volunteer can become suicidal or start drinking to excess on these drugs – that the drug can cause the problem without any contribution from the condition – they risk misleading some people. In this case SSRIs can make completely normal people start drinking. And equally, there may be people with an alcohol use disorder that could be helped with an SSRI. The key thing is a warning so the person knows they are starting a poison and may be poisoned rather than starting a sacrament. Someone also needs to monitor the person who starts treatment to ensure nothing is going wrong as sometime the person on the pill can miss what is happening to them.
A Remaining Mystery
Anne Marie’s case alerted us to a another problem that features in some of the posts above – some people going on SSRI and related antidepressants can end up with raised blood alcohol levels compared with what they would normally have when not on treatment.
For a decade, we’ve been searching for an answer for this mystery. Several leads have been chased without getting any nearer an explanation.
At least 5 convincing cases of this problem leading to criminal entanglements have come RxISK’s way. These have been supported by evidence from blood alcohol tests done under police supervision on and off the SSRI. This is solid evidence – but courts and the public like to know how this could come about rather than just that it can come about.
We desperately need leads on this so any suggestions readers have would be great to get.
Anne Marie Comment
Mulling over this post and the comments that came in, Anne Marie added a comment to the next Empathy for Drug Induced Injuries that is too important to leave as a comment on a different post.
I was reading this post and it made me think of how all my research started.
I was in the courtroom and lost my case and was devastated. I was so angry I asked the barrister why they didn’t believe me. He said it’s not that they don’t believe you it’s that you have to prove it. I asked how do I do that? He mumbled something on the lines of scientific research. I looked at him in disbelief as I didn’t think it was possible to be able to achieve this myself.
I went home exhausted, beaten and felt defeated. I spent weeks feeling irritable and angry because I felt cheated. My life had been destroyed by the tablets and no one could see it or cared. I couldn’t let it go. All I kept thinking in my mind is what the barrister said, “you have to prove it scientifically”.
That’s when I started researching. I felt driven to do it even though I didn’t know how to or want to I knew I had to do it. Thank God for the internet otherwise I would never had been able to do it. The more I researched and learnt the easier it got. I started to realise the answers are there it’s just like a jigsaw that needs the right parts putting together to prove it was the tablets.
I was driven by wanting to show the judge the proof. I wanted the judge to repair the damage done to me. For my life to just be normal again. I just wanted my pre tablet clean record life back again. It had caused me so much unfair damage.
It was coming across Dr Healy and Rxisk that then made me realise there was something far more important to be done and that was to help prevent it happening to all the other people across the world too. In fact I didn’t realise I was entering a new chapter in my journey and how it was a very important one too.
You are so right when you say it is team work that is so important and it’s that that makes it all possible to find the answers we are all looking for.
As it happens on October 16, the same day the Canadian Guidelines were published, the UK published a Draft Guideline for Alcohol Treatment – that anyone can comment on up to December 8..
Its a strange choice of words. Unlike the Canadians, they are not referring to the management of alcohol use disorder – which would include possible triggers to the alcoholism – like an SSRI. Its all about how to treat the acute withdrawal state and then what drugs to use to avoid cravings – acamprosate, naltrexone and baclofen.
But it does have this very very small paragraph buried deep in the middle which you’d miss unless you were lucky
10.5.5 Drugs that should not be used for relapse prevention
Many people seeking help for alcohol use disorders have already been prescribed antidepressant medication. This may be appropriate if you are clear that the purpose of the prescription is to treat a pre-existing or concurrent depressive disorder, but there is no role for antidepressant medication specifically to treat an alcohol use disorder. You should not prescribe antidepressant drugs (including selective serotonin reuptake inhibitors) with the purpose of preventing relapse in alcohol use disorders.
This is a vast document – tens of thousands of words. It focusses heavily on psychotherapy input which is of debatable value – especially in the light of a shortage of folk to deliver the therapy in proportion to the numbers of people with alcohol use disorders.
Nowhere are therapists alerted to the fact that all their efforts might be a waste of time if the person is on an SSRI.
There is a lot of talk about alcoholics not coming for treatment because of stigma, but nowhere are AA or similar groups warned that SSRIs can cause alcoholism and that they too are quite likely to badly stigmatise people by incorrectly telling them that their hunch that their antidepressant might be making things worse is typical alcoholic thinking.
The overall thrust of the document almost seems to be dealing with a new kind of ‘alcoholism’ – one that has featured in media coverage recently – well-placed women who crash a car and kill someone under the influence of alcohol – a Desperate Housewives scenario. These women are highly likely to be ashamed and the surprising emphasis on stigma and a lot else about it suggests the guidance is being drafted with this kind of case in mind. A feminization of alcohol use disorders.
Quite regularly when you dig into these media stories, there is an antidepressant involved – without which there likely wouldn’t be an alcohol use disorder. But none of these women are likely to be given any hint of this. That they should not be ashamed, they should be angry. The shame lies with companies and guideline makers who dare not raise the topic of what might be happening. There now dear, don’t bother your pretty little head about this, let us, the experts, sort you out – and leave you in the dark.
There is a lot about pregnancy but no women or obstetricians are alerted to the data indicating a 10 fold increase in the rate of alcohol use disorders in women taking SSRIs.
There are realms and realms of words about things that are unlikely to help much and nothing about a very simple warning that might make a substantial difference.
The BBC covered the Canadian Guidance very favourably. CBC in Canada has also covered the Canadian Guidance in a manner they could not possibly cover the current UK Draft Guidance – as there is no clear take home message in the UK version comparable to what you find in the Canadian version. Nothing for a journalist to get their teeth into.
All major British newspapers today (Nov 8) report that British women are now the greatest binge drinkers in the world. They are also the largest consumers of SSRIs in the developed world (barring Iceland).
This is a developing story. In March of this year, the National Institute on Alcohol Abuse and Alcoholism in the US reported that College women in the US were now binge drinking more than men. This is a group whose SSRI use has grown rapidly in the last decade.