Back in early Covid times, I was asked by Cecile aan de Stegge to talk at a meeting:
Suicide and its Prevention.
Contemporary and Historical Perspectives in Nursing, 1880–2020
This finally happened in May 2022. Cecile asked me to talk on the issues around suicide and antidepressants, which seemed particularly pertinent as an increasing number of cases that go wrong involve nurse prescribers – not because the nurses do not do the job as well as doctors but because an increasing number of prescribers are nurses.
The lecture Caught in the Firing Line was recorded. The post gives the text.
This talk covers 3 current US medico-legal cases that raise issues for all of us, as clinicians or patients, as prescribers or takers of prescription drugs. I list some of those issues at the end and will end the talk early so you can ask me questions about the cases and the issues.
A happily married man with three children, in his early 50s, the owner of a health service business, was under stress and sleeping poorly. He went to a family doctor who prescribed sertraline 50 mg. A week later, he was worse. The family doctor referred him to the premier psychiatric treatment facility in the area. This facility had 54 psychiatrists. He was seen and his dose of sertraline was increased. Two weeks later, he was worse, as measured by a rating scale, and his dose was increased to 200 mg – 4 times the original dose. A week later he was even worse and was switched to escitalopram.
On the day he was next due to be seen in clinic, he shot his wife and three children and himself.
The clinic argued they were not to blame – that no one can foresee violence stemming from mental illness. That it would not be appropriate to go around warning everyone who might come in contact with anyone put on antidepressant medication that this person might be a threat to them. The case has gone through an Appeal Court to the State Supreme Court.
Before he was treated this man did not have a condition that posed a risk to anyone. He was put on medicines that come with Black Box warnings about agitation and suicide.
The hazards of antidepressants ordinarily do not appear out of blue. They emerge several days or weeks later. They are preceded by evident deterioration over the course of several days or weeks while on treatment. This man’s clinical course is a textbook example of the kind of evident deterioration that SSRIs can cause.
Far from dealing with a condition that poses little risk, and where any risks are unpredictable, the patient’s ultimate clinical state after 5 weeks of treatment was one of delirium – a state where harm is predictable. The only unpredictable thing is the nature of that harm and the sequence of events leading to it.
There is a clinical duty to bear in mind the possibility of treatment induced adverse effects, to enquire about whether this possibility is being realized, to take reasonable steps to safeguard the patient and others if there is evidence the hazards are being realized, and for the sake of the service, if not the patient, to document those steps.
The medical notes indicate this man was getting progressively worse. His family saw an obvious deterioration in him. Increasing toxicity was overwhelmingly more likely (100-fold more likely) to be the cause of this than any disease progression.
This man was being treated in a premier clinic but the clinicians were nursing staff. I do not know if the psychiatrists there have all become managers, whether the service had a policy to cater for suspected treatment hazards. He was seen by no doctors. So, if the Supreme Court action fails, you’d imagine the nurse will likely be blamed.
A lady in her late 50s sought treatment for anxiety and depression from the Health and Welfare system in Idaho. She was being treated on the State rather than by a premier facility.
Two decades earlier she took Prozac for a week before stopping because it did not suit her. Amitriptyline and citalopram subsequently did not suit her – both are SSRIs. In 2018 she had just been prescribed citalopram when she arrived at the Health and Welfare clinic. This was switched to Prozac, because she was clearly not responding to it.
Within 48 hours, by phone, she reported Prozac did not suit her, but was advised to continue. Two weeks later, in clinic, she reported she had not taken all her Prozac because it did not suit her. She was again advised to continue.
Reports like this to a clinic by phone, or in person two weeks after an initial assessment, will often not mention suicidality. Medication induced toxic states are not ones in which a crystal-clear thought of suicide emerges. They are states of increasing agitation, accompanied by apathy, or emotional blunting, so that housework, and even personal cleanliness, may be neglected. This is what this lady reported at the two-week assessment point.
Patients will often quietly stop treatment and even lie to their prescriber about this, but in many cases, they get trapped. If they are uncertain what is happening, the prescriber can seem to be the way out of their difficulties and obeying a prescriber can seem the right course of action.
She drove to the clinic a week later and shot herself in the face in the clinic carpark. The nature of her problems and their timeline is consistent with what is known about SSRIs and suicide induction. There were no factors in this case pointing to anything other than Prozac and the lack of warning about its hazards as the cause of this attempted suicide.
The difficulties reported by this lady were registered by her prescribers but were put down to other factors. Her anxiety was put down to work difficulties. She was drinking more and blamed for this when alcohol is a way to manage SSRI agitation.
Stopping Prozac would have solved this problem or switching to mirtazapine as was later shown.
This lady’s case was in the hands of a series of nurse practitioners who in depositions all agreed that they knew about the Black Box Warnings and that these warnings were a national standard of care in respect of what this lady should have been told and that they had failed to notice warning signs of a developing problem.
In this case, the nurses are not being hung out to dry, even though they missed the glaringly obvious. A statute in that State means that officers of the government cannot be found legally liable. This is being challenged by this lady’s lawyers.
A nurse veered across the road into oncoming traffic and badly injured an older woman travelling in the opposite direction. The nurse was relatively unharmed but appeared confused. She gave no clear account of where she came from and claimed the other car had hit her. She was over the legal limit for alcohol but could not explain how this happened. As she was on probation for driving under the influence of alcohol some years previously, she risked a jail term, loss of her job, and custody of her daughter. The events were out of character.
She had been put on SSRIs in her teens with little evidence they helped. She had graduated to drug and alcohol abuse but then settled down, did nurse training, was holding down a job, had a young daughter but had separated from the daughter’s father. Her history in her 20s had left her with health problems, a bad back, fibromyalgia, raised blood pressure along with anxiety.
She was on analgesics, opioids, antihypertensives and a variety of antidepressants. She reacted badly to Tramadol which is closely related to Venlafaxine. She was switched to Venlafaxine which helped with pain but stopped working. While on it she had a Driving Under the Influence of Alcohol offence.
She was switched to duloxetine, Cymbalta, which agitated her and was stopped because she had become pregnant. She was well while pregnant on nothing. After the birth, she had a blue spell and duloxetine was restarted. Over a period of ten weeks, she became disinhibited and stopped duloxetine saying it helped with her pain but was making her manic. A year later, after several other drugs were tried for pain, she returned to duloxetine – she and her prescriber thought things might be different now that she did not have postpartum depression.
At one point I was to be a lead investigator at a North Wales site for a Eli Lilly trial of duloxetine, which was slated to be Lilly’s successor to Prozac. The trial and duloxetine were abandoned. Boehringer-Ingelheim went on to develop and market it for bladder stabilization in Europe as Yentreve.
Lilly focused on R-Fluoxetine (Zalutria) instead but FDA turned this down because it caused cardiac QT interval problems which clearly Prozac must also do. Lilly turned back to duloxetine, ran trials and applied to FDA to market it as an antidepressant and bladder stabilizer.
FDA said no to it as a bladder stabilizer – in trials too many healthy women had gone on to suicidal acts or completed suicide on it. There was a crisis when Traci Johnson a 19 year old woman in a healthy volunteer trial of the drug committed suicide.
But FDA still approved it. And Lilly magicked up a fibromyalgia marketing niche for it, possibly originally designed for Zalutria.
At a debate in the Maudsley at the time, on whether psychiatrists have a thought in their head other than what is put there by one pharmaceutical company or another, I predicted that Cymbalta soon would be a billion dollar blockbuster. The audience were mortally offended at the thought.
Initially Cymbalta helped our nurse but after a few weeks her behaviour changed at work and at home. She became irritable, labile and her timekeeping fell off. Because of her DUI offence she had regular alcohol tests and all were normal. The crash came at the end of a week when she seemed to be deteriorating badly.
What happened? One possibility is that our patient was trying to commit suicide. The only way to avoid jail is to be found not guilty by virtue of an automatism. As automatisms are ordinarily understood, this would not apply in her case. There is however a case to be made that Cymbalta caused here to be delirious.
It may also have caused her to take a drink – See Driven to Drink.
And it may have caused her to have raised blood alcohol levels – See Petra’s Story and Every Drink Spiked.
This lady’s medical care for several years before this, including all prescriptions of antidepressants had been in the hands of a nurse prescriber.
The legal system looks it might have great difficulties believing FDA would approve a drug that could cause delirium.
There are few ways to convey to doctors what is wrong in cases like these. The only thing that gets medical attention is to say “if these drugs work so well and are so free of hazards you guys are out of business” Health service companies will see you as expensive prescribers compared with nurses or pharmacists. Nurses of course risk being replaced soon by robots on the same basis.
The problem is the drugs don’t work well and aren’t free of hazards and both companies and regulators do a lot of things legislators have no idea about. Such as:
We prescribe poisons, hoping to bring good out of their use. We could use alcohol to treat social phobia or nicotine to treat OCD or ulcerative colitis. These are over the counter because we believe they are less risky than prescription drugs. Everyone knows that they are poisons and that if you take them chronically, you will age and die prematurely.
The same has to be true for some of the prescriptions drugs we are on and anyone my age on average is on 5 to 10 of these – drinking and smoking and snorting every day of the year for decades.
As outlined in Shipwreck of the Singular, life expectancies were falling and our reproductive replacement rates were below zero – before Covid.
Whether you are a prescriber, or a patient, company trials are used to displace our experience as a way to evaluate a drug or what is happening on a drug. Medicine used to be and still should be like law – where we make a judgement call based on the evidence in front of us. But we are reaching a point where if you insist that your judgement in an individual case is likely right despite what the guidelines say, you risk being out of a job.
If you want to keep your job, it’s safer for you to let the patient die.
And if it is safer to let the patient die, you are going to sleep better if you don’t notice problems on treatment. Better to think the patient must have had a malignant condition – there are some people no-one can save.
Polypharmacy is a great help in this regard. It makes it harder to link a treatment to a problem.
I have taken these problems to Supreme Courts, health ministers, guideline makers etc and laid them out in Court cases. No-one denies a single point you have heard here – not the lawyers for GSK or Pfizer. But no-one does anything.
Perhaps its time to think about raising the matter with those who are worried that white people are being replaced. It is mostly white people who are on drugs. Perhaps someone from the Great Replacement camp needs to ask Pharma what is going on.
Or perhaps, the American Right could embrace a national health service so non-whites could get access to the same number of drugs as white people.
My sense is the answer has to involve a fostering of communities because it is in communities that answers other than an ever increasing turn to pills lies.
The painting above Edouard Manet’s Le Suicidé is from the Meeting Brochure.
People Acknowledgement © Nina Otulakowski April 2022
RxISK acknowledges that the experiences of those who have been harmed by medical treatments are the cornerstone on which it is built. This cornerstone has been rejected by a set of invaders who now claim control over our healing spaces. These invaders pose a threat to our spirits and our bodies.
Thank you for this further compelling and deeply moving lecture. How can prescribers continue to apparently remain unaware of the critical importance of cases such as these, and the ever-growing GENUINE evidence base that supports the ADRs behind these tragedies?
Someone here, who does a thoroughly good job of discerning where some of the problems come from – the ‘someone’ went through Paroxetine’s worst, was publicly humiliated by Simon Wessely, Wendy Burn and John Crichton but, to be honest, came out the better man..
Take the Trip…
The Narrative Controllers
Professor Sir David Haslam, Chair of NICE Guidelines, in an interview in June 2016 said “The mantra that I’ve given in every lecture is that they’re guidelines and not tramlines.” This is advice that I agree with, but in practice where doctors are regulated, the fear of departing from evidence means that practitioners are more likely to practice defensively and so follow the tramlines.
GP land is in crisis in UK If Nurses hitherto lower in the medical pecking order are being being used to fill gaps they are going to take the rap for harms due to following ‘guidelines’. Now is the time they should take action Perhaps the scandals over deaths from vaccines with data kept secret should alert them to support demands for full data before they prescribe. I wonder how they would access it if the day arrived ?A prescriber wouldn’t be able check through all the trials data before prescribing in a consultation I imagine.. Would it be set out in an accessible form by yet another organisation ? Then how could that be trusted not to become corrupted.
A very sick system fuelled by those who do not give a damn.
The people who are sincere and genuinely care sadly pay the price for this scandalous corruption.
The apprentices on the low pecking order, as Susanne eloquently put it, end up being the scapegoats for those who have not got the courage to administer the so called ‘SAFE and EFFECTIVE’ vaccine.
I feel for those who are so brainwashed and are unable to see beyond the smoke and mirrors.
We need a brave and courageous activist to set the record straight.
Seems all but GPs are sitting around twiddling their thumbs Which of those named as potentially able to issue ‘fit notes’ will accept the ‘burden’ They may as professionals be equally in/competent to do it .Depends on the extra cash on offer probably.
Staff working in Dept of Work and pensions were/are used to decide who can claim benefits Sickness claims which previously led to horrendous scandals, mistakes, bullying and deaths fom suicide in a push to get people into work and off ‘benefits’. The stigma against claimants which the government ramped up was disgusting. This is likely to happen again and again will partly at least depend on the individual handling a claim for a sick note. The group who sees people who are unwell most often are ‘carers’ But they are even lower in the pecking order so have not been included in the scheme. Nor is there any publicity advising us of the change and what choice anybody might have as to who they request a ‘fit note’ from. Or the information about what qualifications they have to issue them. This is just a woolly statement from the BMA … ‘they’….. should be ‘working in a suitable environment and have the necessary
skills and training to have work and health conversations with
Issuing fit notes also needs to be within their professional ‘scope of
practice’, the BMA said, and that new guidance and training had been
developed to advise on this. There is no information as to who has actually received this training .The scheme begins in a few weeks time.
Emma Wilkinson Pulse Today
09 June 2022
A wider range of health professionals will be able to sign off fit
notes from next month to ease pressure on GPs.
New legislation being laid down tomorrow will enable nurses,
occupational therapists, pharmacists, and physiotherapists to legally
certify fit notes, the Department for Work and Pensions has confirmed
It is the biggest change to the rules around fit notes ….
providing more‘interactive’ advice on workplace adaptations and support.‘
The change in law, which will apply across England, Scotland and Wales
from 1 July follows moves in April to allow for fit notes to be
certified and issued digitally.
In a bulletin, the BMA, who has long been in favour of a wider variety
of healthcare professionals being able to sign fit notes, said not
everybody working within these professions should issue them but
should be ‘working in a suitable environment and have the necessary
skills and training to have work and health conversations with
Issuing fit notes also needs to be within their professional ‘scope of
practice’, the BMA said, and that new guidance and training had been
developed to advise on this.
The changes follow a consultation last summer about reducing
ill-health related job loss to which many respondents expressed views
on the current fit note system despite it not being part of the
original scope of the consultation.
Outlining its plans at the time, the Government said it would also
move to embed electronic fit notes in hospital systems to encourage
hospital doctors to issue them reducing the burden on GPs.
Maria Caulfield, minister for patient safety and primary care said
that improving access to GP services and reducing unnecessary
bureaucracy was ‘vitally important as we tackle the Covid backlog’.
‘Extending powers to provide fit notes to other healthcare professions
will relieve further pressures on GPs and is another step towards
helping to deliver an extra 50 million appointments in general
practice a year by 2024.’
Chloe Smith, minister for disabled people, health and work said the
changes would make it easier for patients to get the support and
advice they need from the right place, ensuring where possible that
they are able to remain in work.
‘These latest fit note changes recognise the valuable role other
professions play in helping manage people’s health and I hope this
will also help reduce unnecessary bureaucracy for doctors and general
practice more widely.’
‘This is just another way in which we’re supporting GPs in primary
care, and we remain on track to deliver 26,000 more primary care staff
by 2024 to help improve patient access to appointments.’
BMA England GP committee deputy chair Dr Kieran Sharrock said: ‘This
announcement is a positive step and we hope that it will go some way
to both improving the process for people who need confirmation that
they are too unwell to work, and free-up GPs’ time to care for
patients who need their expertise.
‘The BMA has been clear for many years that it may not always be
necessary or appropriate for a GP to issue a fit note, especially
where a patient has seen a different member of the practice team for
their condition, such as a nurse or physiotherapist.
RCGP vice chair Dr Gary Howsam said: ‘Allowing other healthcare
professionals working in general practice, where appropriate, to issue
fit notes is something the College has called for and would support.
‘Such a move should help free up GPs’ time to deliver patient care to
those who need their medical expertise at a time when the profession
is working under intense workload and workforce pressures. It would
also recognise the role of some members of the wider practice team in
giving patients advice about health and work – as such it’s important
that appropriate guidance and training is put in place to support them
to do this safely and effectively.
What we need – and have needed for over ten years now, is a practitioner who will certify:
“This person is not fit to work, and will remain unable to return to employment. This is because multi-systems, life-changing and life-limiting injuries have resulted from misdiagnosed akathisia, and then long term, enforced use of highly toxic, prescribed drugs which caused life-threatening adverse reactions. All of these adverse drug reactions were serially misdiagnosed as ‘Severe Mental Illness’.
Diagnostic category: Cascade Iatrogenesis.
This would demonstrate a real commitment to the Duty of Candour.