Twenty four years ago, after a Panorama program, The Secrets of Seroxat (Paroxetine), the BBC was flooded with nearly 1400 emails, then a new way to communicate, about your experiences on SSRIs.
This led to a follow up Panorama program – Emails from the Edge – and then two more follow ups. Your emails outlined your experience with suicidality and dependence on SSRIs. In fifty years before that, Panorama had never repeated an issue.
Charles Medawar and Andrew Herxheimer, consultants to the program, sat down and analyzed these emails, along with nearly a thousand other emails on an antidepressant website centered on SSRI dependence. They concluded your emails were richer in detail than standard medical reports to regulators on the same problems. They also thought – back then – the Internet might be a liberating, democratic force. There is no hint they figured it might become a source of growing conformity – a force to Stepford us, or transform us into Handmaids. Their article Paroxetine and Panorama is here.
Just this month, Norwegian researchers have rediscovered the same thing – without being aware that this has all been done before – see Norwegian RxISK.
Lots of innocent people ending up incarcerated in jails or hospitals need your input on SSRIs. Read the vignettes below and send in as many related and perhaps differing accounts as possible.
These two articles add more vignettes. Antidepressants and Violence was published in 2006. It focused on the ‘science’ with the cases in an Appendix. I now realize your cases are the science. The so-called data could have been put in the Appendix.
Antidepressant Induced Suicidality outlines the transformation of two healthy volunteers put on Zoloft into women capable of suicide and perhaps homicide.
Delirium
Had Katinka Newman killed her two children when she thought she had – see The Troubled Dream of Life she would have had a perfect Not Guilty by Reason of Toxicity (NGRT) defense. Delirium is an absolute defense against Guilt. There are many other cases like this but medics are likely to misdiagnose delirium as psychosis and lawyers have no idea about what delirium is. All they see is an unreliable historian which for them is a kiss of death to the case rather than a Get out of Jail Free card.
Personality Change 1
In 1990 Martin Teicher and colleagues reported suicidality emerging in 6 patients taking Prozac and linked this to akathisia. Three years later in a Further Article they discussed several other routes to suicidality including a transformation into a borderline personality.
Personality change is not unbelievable. Listening to Prozac also came out in 1993 claiming dramatic personality changes on treatment, including switches from homosexuality to heterosexuality. Roland Kuhn describing the discovery of imipramine, also a serotonin reuptake inhibitor, in 1958 said the same thing.
Our personalities are largely reflex based – our typical automatic responses are the major shaper of our personalities. Character is not the same as personality. And our reflexes are driven by sensory inputs on which SSRIs work. Rosie Meysenburg created SSRI Stories in part because it was clear to her that the change in people’s personalities made it easy to spot who was on an SSRI.
Personality Change 2
In our healthy volunteer study, one of the volunteers, a remarkably easy-going and friendly woman, while her mother was looking on horrified assaulted a young man whose driving was annoying her, surviving perhaps because he was so taken aback at this reversal of gender roles. A few days later she was actively thinking about hanging herself but told no-one because despite working in a psychiatric unit and knowing she was testing an SSRI, she believed she’d be locked up if anyone knew the thoughts she was having.
There are several SSRI Stories (which we hope to resurrect soon) posts linked into these issues. SSRIs and Violence, SSRIs and Different Violence SSRIs and Research on Violence.
Personality Change 3
In addition to the above there are a host of posts on SSRIs and marriage busting, with the partner left behind certain that what has in fact happened has been driven by a change in the personality of their partner. While sometimes an SSRI may enable a person to do the right thing, there unquestionably are also cases where it looks more likely that the drug has caused the problem – as the Consent to Waltz post hints at.
There are a series of cases involving female school teachers who have taken sexual advantage of teenage males where the courts have implicated the antidepressant she has been taking – see Notes on a Scandal.
There are the likely tens of thousands of cases who have been driven to drink or consume other substances by SSRIs – that we know about thanks to your input. See Alcohol a RxISK Triumph . In these cases SSRI driven alcohol intake have led to manslaughter cases through drunken driving.
Automatism
SSRIs can abolish pupillary reflexes making it dangerous to drive at night as your pupils will not constrict and you risk being blinded by oncoming car headlights. They can also make your vision two-dimensional so you do not see through to the consequences of going too fast on what can seem more like a computer game than real life, especially at night. Famous for making you unable to cry, SSRI are also the drug most commonly reported to FDA as making you cry for no apparent reason – as wonderfully also reported by Bruce Springsteen in Homicide.
These reflex based changes are all automatisms. Automatisms can give you a defense against a guilty plea in the case of manslaughter at the very least and perhaps homicide. They can be present for weeks on end rather than just for seconds.
Neurologists, psychiatrists and neuropsychiatrists have difficulties with the idea of an automatism – variously talking about sane automatisms, insane automatisms and non-insane automatisms, when all that is involved are altered reflexes and SSRIs alter reflexes. These are not side effects. This is the core action of these drugs.
Everyone who takes an SSRI or SNRI and often tricyclics and other drugs has some alteration of their reflexes – the question is whether this is intense enough and prolonged enough in the circumstances of the case to provide a defense. In the case of the person above, who had a crash at night it did – but his lawyers didn’t listen.
Trance
Deirdre Morley, who was on an SSRI – See The Eclipse of Us – talking to a policeman shortly after killing her three children said:
I was thinking I wanted to stop, that I didn’t want to do it, but I had to.
Why did you have do it? he asked
Because I had started it – I can’t explain it.
Another of our healthy volunteers, a doctor taking a low dose of Zoloft, outlined in the article above, said on day 11:
I felt like I was spiraling out of control. I started to write things down and then very abruptly there was nothing. My mind was almost numb. Everything seemed to have disappeared, I don’t remember being able to see anything in the room. I knew with absolute clarity and certainly that I had to go through door out to the road and wait for a car. It had to be very final. Yes it would be violent but that was vital and necessary.
I was incredibly calm and peaceful, not because I wanted to but because I knew I had to. There was no choice. It was so simple. Obvious. Irresistible. It was almost like being in a sort of trance or hypnotic state.
Then I was phoned. The spell started to break. If I hadn’t been, I wouldn’t still be alive, and my family would not ever have known why.
Someone else I met recently when on an SSRI found himself standing on a ledge on the open top of a tall building looking down and feeling peaceful that he was about to put an end to the misery he was going through, when a car horn began to blare and getting louder and louder broke the trance he was in. Just like our medical volunteer, his family would not have known why either.
Intrusions 1
Lindsay Clancy appears to have had what are variously called intrusive thoughts and/or command hallucinations.
I was called to see a 80 year old man rehabilitating more slowly from a minor stroke than his doctors thought he should be. Doctors commonly think stroke patients are depressed and they for psychiatric input after starting the patient on an SSRI.
The man didn’t seem depressed to me. He was not doing push-ups as the stroke team might have liked but he was in a good mood. I stopped his SSRI, partly to check if off them he was depressed. A week later I came back to see him. He was even better, more alert and engaged. I was about to leave, when he put a hand on my arm and said – ‘I need to tell you one more thing’.
Pointing to a man in a bed across the room, he said he had no idea who the man was. He had never seen him before. But on those pills, he was having impulses to get up during the night and go over and strangle him. He had no idea why. ‘Those thoughts have gone since you stopped the pills’.
Intrusions 2
Many normal people have hallucinations on falling asleep (hypnagogic) or waking up (hypnopompic). These can be visual, auditory, tactile or indefinable and vivid to the point of being mistaken for reality. These sleep phenomena are related to lucid dreaming, where the person experiences themselves as awake rather than dreaming.
A very normal 30 year old woman consulted me. From time to time she had these experiences on falling asleep, which were not disturbing. During a period of stress she was put on mirtazapine often used as a sedative in lieu of hypnotics. Mirtazapine is not an SSRI but it acts on the serotonin system.
Since starting it, on sinking toward sleep she was now having repeated horrific imagery of a a metal grid on a spring, with razor sharp knives sticking out it. As she sank into sleep the grid sprang toward her, looking as though she would be impaled. While she accommodated to some extent, knowing she was still alive, it was impossible to fall asleep. The problem stopped when mirtazapine stopped.
Intrusions 3
A young woman withdrawing from Prozac, navigating a dark room at a party had to step over strangers to get to the bathroom. A violent impulse to assault one of them took her breath away. This returned at regular intervals over the next 10 years causing her to panic every time. It took a decade to stop panicking. It took a further decade to tell anyone about it but when she did, the person she told who had also stopped an SSRI reported a similar thing. There are aspects to what she experienced that are still so disturbing, she has still told no-one.
Intrusions 4
A marvelous grandmother looking after a grandchild had been put on an SSRI for pain relief. We were friends before that which may have made it easier for her to tell me she had intrusive thoughts of harming the child bad enough to remove all knives from her house. Luckily I didn’t increase the dose of the SSRI. There are behavior therapy approaches to intrusive thoughts in OCD, which it is now clear this wasn’t – it was much closer to Tics. Telling her to imagine putting the baby on the kitchen table and choping it up with a cleaver in her case forced a development of the capacity to manage these intrusions.
Commands 1
CP was a 12-year-old, 5’2” boy with considerable family dislocation. Despite these difficulties, he had no record of violence or behavioral disturbance. Following an argument with his father, he ran away and was admitted to a behavioral center where he was started on paroxetine. His behavior worsened. He was discharged against medical advice to the care of his grandparents, who, when his paroxetine ran out, took him to their doctor who prescribed sertraline 50 mg and 3 weeks later increased this to 100 mg.
On sertraline, CP was involved in aggressive incidents at school, the first on record for him. On the day of the killings, his grandparents told him that he could not take the school-bus following an episode of aggression toward another boy on the bus. He attended choir practice with his grandparents that evening, who in response to his restlessness in church said he might have return to his father.
That night CP reported: “something told me to shoot them”. It was “like echoes in my head saying ‘kill, kill’, like someone shouting in a cave”. This began after he went to bed. He had never considered harming his grandparents before nor heard voices. The voices bothered him so much that he got up and stating he couldn’t control himself, he shot his grandparents. He reported the voices stopped after that.
Commands 2
SC 21 years old, grappling with college exams, a house move, and a new partner, went to his family doctor and was given prescriptions for two SSRIs in sequence. He overdosed on each after a few days and was then given paroxetine. Increasingly agitated he asked “what is wrong with me?”
One evening both he and his car went missing. After midnight, he was refused help at the local psychiatric unit and shortly afterwards drove his car through the glass entrance into the foyer, got out of his car and lit a cigarette.
Back home his parents were alarmed at how angry and unstable he was. He frequently disappeared. No one consulted, including the mental health services, mentioned his medication.
He was having rage attacks where he paced and shook and screamed for help, then would quieten down, until the next wave came over him. He alternated between seeking help, with some relief if help seemed to be on the horizon and then a depressed state when he would say “They’re not going to help me are they”.
One evening he seemed to be losing control in waves every twenty minutes or so, each lasting maybe ten or fifteen minutes. He asked to be kept safe whilst saying the next wave was coming and then totally losing control. He was taken to a psychiatric unit where for the first time, he mentioned voices that seemed to be controlling him. These had appeared 3 months before on starting on paroxetine. The voices said to get rid of everyone who was letting him down. Asked if he was obeying them, he said “I try not to but it’s getting harder”.
He was jailed for a year for driving through the doors of the psychiatric unit. Over the following decade he was given multiple diagnoses, including bipolar disorder, and put on antipsychotics. None helped. He began to improve when the diagnoses were jettisoned and the medication reduced to almost zero. His voices persist 25 years later but he learnt to manage these in a Hearing Voices group. He is now a Church Deacon among other things.
Commands 3
The couple were more than usually well-heeled. When wives come to consult, I don’t let their husbands in. But he insisted she wouldn’t tell the truth unless he was there.
The story of her life was unremarkable. There was no good reason for her to be put on venlafaxine. But she was. Tell him what happened, her husband said.
She told me, she had taken off all her clothes in the hallway of their house, opened the front door, walked out and stood naked in the middle of a busy road. Why did you do that I asked. A voice told me she said.
Sleep Walking
There have been several bizarre sleep-walking incidents, several lasting hours
One involved a 20 year old who had developed narcolepsy 4 years previously, a condition characterized by automatic behaviors, especially at intervals between waking and sleep when subjects can appear to function but are close to sleep-walking. One of these automatic states, cataplexy, produces collapses. The standard treatment for cataplexy is low dose of a serotonin reuptake inhibitor. He was put on too high a dose of venlafaxine which helped his cataplexy but caused teeth grinding, nosebleeds and sexual dysfunction. His doctor agreed to swap him to a low dose of another drug.
Unaware venlafaxine causes withdrawal, he stopped it abruptly and had aggressive and automatic behaviors that neither he nor his parents linked to withdrawal.
After a week, he appeared in the family kitchen with a bag on his shoulder. Speaking oddly, he walked out and went to a petrol station near his home along a route where he was likely to meet or be seen by people he knew to a place where he was known, in broad daylight, wearing distinctive clothes. He took out a knife while there, as recorded on CCTV. He has no recollection of this.
He walked away from the petrol station on a route that left him obvious to anyone at the petrol station who had just seen him, making no attempt to conceal himself or his whereabouts. He was detained by the police who wondered if he was on drugs. Later, when interviewed by his lawyer, he was perfectly normal.
The charges against this young man were dropped when both prosecution and defense experts reported that but for the combination of narcolepsy and venlafaxine, this event would not have happened.
SSRIs are the drugs most commonly reported to regulators as causing sleep walking and violent nightmares.
Akathisia
It’s not enough to mutter akathisia to get a verdict. The question is how might akathisia or the combination of akathisia and sensory muting actions of SSRIs shape our Capacity to tell Right from Wrong or our ability to Conform our behavior accordingly.
Would this account from the doctor whose trance was broken by her pager going off help a juror grapple with the issues?
It feels like inside my head there are 2 people. The “old me” and someone else like me but unpredictable. The “old me” is aware of everything happening and what I should do, how I should react but is powerless and can only watch what the “imposter” is doing. It’s like the self-control part has been removed or the connection between conscience and actions cut off. The bit of me that seems to be in control is like a child; easily moved to emotion, gullible, aware of expected social etiquette but not inclined to follow it, impatient and irresponsible.
I can understand how people become deluded and have strange thoughts. If I didn’t know all this was due to pills, I’d be looking for another reason… God, aliens whatever and wondering if they were manipulating my thoughts. If this happens to you for no apparent reason, you would desperately find a cause no matter how improbable, for what you were experiencing, and how you would have to fervently believe it to be able to go on.
Anticonvulsants/Mood Stabilizers
A patient I saw had a febrile seizure when young and was later thought to be having absence seizures. He was put on a now rarely used anti-convulsant – clobazam. This helped him. For over a decade, he appeared to have no problems. He was able to start university and do well.
A year later an episode at university left him slightly paranoid. When he came home to visit his parents, they took him to a doctor, who added a low dose of amisulpride ordinarily thought of as a rather clean antipsychotic. The young man became more paranoid and started to show catatonic features. This led to further assessments in clinics and an admission to hospital. The doses of his antipsychotics were raised and clobazam was replaced by more standard anticonvulsants like valproate.
He started having violent out of the blue episodes and was moved to a secure ward, put on one to one supervision and confined to one room for close to seven years. The treatment remained the same throughout – antipsychotics and anticonvulsants. He was switched to a medium secure unit, where the antipsychotics were stopped and the violent episodes improved. The anticonvulsants were switched around but there was no return to clobazam. The neurological services didn’t use it anymore and had no rationale for returning to it. The fact he’d been on it for a decade and done well didn’t seem to count. After more than a year, the MSU now plans to reintroduce clobazam and stop all other meds. Watch this space.
Anticonvulsants like Keppra – levetiracetam are infamous for causing rage attacks. Others like lamotrigine and zonisamide cause psychosis as do most, possibly all anticonvulsants. Psychosis in this case probably means delirium. None of them act the same way as clobazam.
It’s tough being a neurologist. For decades they’ve had to cope with the drugs they use to cure a patient’s epilepsy – get their EEG to read they like it to read – causing psychosis. And now they’re dealing with an epidemic of Functional Neurological Disorders (FND). Behind many of the FND diagnoses I see entered into records by neurologists lie drug toxicities. If you have had a toxic reaction to a drug, your neurologist is essentially saying you are hysterical. Who is the more hysterical – him or you?
The Catholic Church these days is better able to tolerate the idea that we might be allergic to the Eucharistic host than many doctors, neurologists and psychiatrists included, are to the idea that we might be allergic to the drug they’ve put us on.
There are many more vignettes in the PLoS paper linked above. We need far more cases than we currently have.
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