Editorial: This evening a Panorama program aired on the issue of antidepressants and violence. The driving forces behind this were Andy Bell and Shelley Jofre, prompted in the first instance by Katinka Newman. The story is to my mind compelling. There have been considerable efforts to cloud the picture – see Honey I Shrunk the Shrinks on DH.
Prescription for Murder was not scaremongering about antidepressants. It said nothing new about antidepressants. The new message is about the legal system. If something like this happens to you, you will end up in the same quandary James Holmes found himself in – stuck with a legal system which has no idea how to defend you.
A MIND POISONED AGAINST ITSELF
In July 2012 James Holmes entered a movie theater in Aurora Colorado showing a premiere of Dark Knight Rises, and opening fire killed twelve and left 70 injured. From May through to July 2015, he stood trial. His lawyers were in an invidious position. It was certain from the start he would be found guilty – of manslaughter at the very least. Their role boiled down to playing the mental illness card as mitigation to avoid a death sentence. They nearly lost.
They nearly lost for a good reason. Holmes did not have a serious mental illness. Despite defence experts torturing every little personality quirk back to his pre-teen years, nothing could change the fact that before walking into a University clinic in March 2012 with social anxiety problems, Holmes was very average with no mental health problems.
The doctor seeing Holmes in the University clinic viewed him as being socially isolated, a loner, with anxiety and a certain misanthropy. She prescribed a benzodiazepine, and a Selective Serotonin Reuptake Inhibiting (SSRI) antidepressant, sertraline.
A week later, he complained of memory problems in class, and the benzodiazepine was swapped for a beta-blocker. His memory problems continued and the beta-blocker dose was reduced. Beta-blockers and benzodiazepines can cause memory problems – as can sertraline. Both can also act as antidotes to the anxiety and agitation sertraline can cause.
Meanwhile Holmes sertraline was increased from 50mg to 100mg to 150mg per day.
- He began flirting in a way that was out of character for him.
- He began spending wildly, where he had been frugal.
- He began visiting dating sites, where he had never done so before.
- He signed up for motorcycle classes without a reason to do so.
- He terminated a friendship in a way he would never have done before.
- He began talking for the first time of violence.
One friend said: “He began to “loosen up a bit” on medication and “became more talkative to random people.”
In a notebook, Holmes began keeping, he made clear he had lost his sense of fear and developed a “dysphoric mania.” This is a good description of the emotional instability that SSRIs can cause – a state in which anyone affected can rapidly swing from feeling energized and reckless, to depressed and suicidal.
SSRIs cause sexual dysfunction. Holmes had it. The higher the dose, the worse it became. Sexual numbing goes hand in hand with emotional numbing and this too was present and became more marked as the sertraline increased. His feelings were blunted.
Prior to sertraline, Holmes had thoughts that it might be no harm to “nuke” the human race. Thoughts not uncommon in introverts, and the socially anxious.
He told his doctors about these ideas, and it is clear that they didn’t regard this as mental illness.
But on sertraline, he began to think about specific homicidal acts. These new thoughts were entirely different to his former vague hostility. They were focused and specific, and “realistic.”
This is exactly what SSRIs can do to anyone – even normal volunteers. People who have been suicidal in the past, and who become suicidal on SSRIs, can distinguish the new ideas from their usual ideas. Some can hold both sets of thoughts in their mind at the same time.
SSRIs can also disrupt our motivational hierarchies (our values and priorities) leading to alcoholism, and disinhibited behaviors not usual for us.
Holmes did not just have thoughts that differed from those he had before, he had a different motivational link to his thoughts. There was now a possibility he might act on these thoughts in a way he would never have done before.
He tried to tell his doctors what was going on.
Their response was that he was responsible for his own thoughts and actions.
I face people threatening to kill themselves and others and react in exactly this way every week of the year – nine times out of ten this is the correct reaction and reduces the risk of violence to others. It is not the correct reaction when treatment with an SSRI goes wrong.
Holmes attempted to communicate the changes he was experiencing in messages to classmates but no-one knew him well enough to pick up.
There are difficulties in conveying alien thoughts of the kind that can be triggered by an SSRI.
- Few of us think a drug could do something like this making it difficult to make a link.
- At first when thoughts like these happen no-one knows how to manage them.
- With problems like this we often communicate obliquely. We think we have hinted enough for others to understand what is going on, only to find they don’t.
- There are recognized difficulties in communicating the adverse effects of a drug to the doctor who has put you on the drug hoping to help you. When things go wrong, the doctor can seem like the only way out of the problem and no-one wants to antagonize their doctor for this reason. Push too hard and the doctor gets nasty.
Holmes dropped out of College at the end of June 2012. After 3 months on sertraline, he stopped abruptly from a dose of 150mg unaware of the risks of dependence and withdrawal.
Over the next three weeks, he became confused and emotionally labile. The emotional blunting and depersonalization that started on sertraline continued as it can do for months after stopping treatment.
On Friday July 20 2012, he entered the movie theater, and opened fire.
He was arrested and hospitalized. Four months later, he became disturbed in hospital and was prescribed a variety of tranquilizers.
At the end of December, he was put on another SSRI for the first time since the end of June and 5 days afterwards attempted to kill himself.
Every expert who later interviewed him, interviewed a man on a cocktail of meds. He spoke reasonably but was blunted. There was no evidence of psychosis when I saw him.
This suicidal response on re-exposure to an SSRI makes Holmes’ case for a not guilty verdict very strong. In fact he had a prior bad response to a serotonin reuptake inhibiting antihistamine and unaware of her son’s treatment his mother had a very disturbing reaction to an SSRI after the event. But his attorneys felt the uncertainties were too great to risk playing the medication card even for mitigation.
Going with a mental illness defense, he escaped execution only because of the last minute qualms of one juror and ended up with 12 life sentences and 3300 years.
Why would his lawyers have found it impossible to grasp the treatment nettle? After all we banned some closely related drugs during the 1960s on the basis that they unquestionably caused violence, and criminality.
In part, this 1960s ban has meant the courts have not had to grapple with the issue of when we should agree that a person under the influence of a prescription drug is guilty and when not. Simply being on a proscribed drug is a crime.
Staking the amphetamines and LSD through the heart, we effectively declared that drugs available on prescription only cannot cause problems – if there are problems these can only stem from the mental illness for which the drug has been used.
Another problem arose 170 years ago when Daniel M’Naghten killed Edward Drummond, believing him to be the Prime Minister Robert Peel. This homicide triggered one of the most celebrated legal cases ever. M’Naghten was mad. The Court struggled with the question of his guilt. As a result the insanity defence to this day is discussed in terms of the M’Naghten Rules. We decided that individuals who are insane are almost always responsible for their actions. This seems right and tallies with the experience of those of us with mental disorders, even serious mental illness, who know we remain largely responsible for our actions.
But the drama in the M’Naghten case did not lie in the Courts agonising over whether to acquit someone who was mad. It lay the Court deciding to convict a madman. For over a century before that, faced with people who were delirious – raving mad – Courts had no trouble finding them Not Guilty.
Among the causes of delirium, or frenzy as it was called then, were high fevers and poisoning. So as Lord Chief Justice Matthew Hale put it in 1676 if you were slipped a drug by your enemies or poisoned by the incompetence of your physician and, under the influence of treatment, committed a crime you were Not Guilty.
The novelty in M’Naghten’s case was that he was mad but not frenzied. The Courts had never had to tackle this kind of problem before.
Every treatment with a drug or combination of drugs risks producing a frenzy. When the confusion is gross both medical and legal systems feel able to blame the drug, such as when a person goes berserk within 48 hours of having the drug as Don Schell did on Paxil in Wyoming in 1998, killing his wife, daughter and grand-daughter. The Wyoming jury in a civil case blamed the drug, not Schell. It might have been a different matter though if Schell was there in Court and it was a matter of letting him go free.
The problems arise if the delirium is masked and there is an extended period of time during which the person appears to function. Drugs from Zoloft to LSD can introduce thoughts of violence or suicide that the individual would never in the ordinary course of events have. Some of us can distinguish between drug induced thoughts and those linked to an illness but most of us at least first time round fail to make the distinction.
In some cases, believing these thoughts to be part of our illness we will increase the dose of treatment – or our doctors will do it for us as Holmes’ doctor did. Exactly the wrong thing to do if the treatment is causing the problem.
Some drugs simply produce a delirium but SSRI antidepressants also produce a partial chemical lobotomy. If the drug suits us and our doctor gets the dose right, there is just the right amount of disconnection from our feelings, especially our anxiety, so as to enable us to get on with life. Too great a disconnection and we are left able to contemplate thoughts of violence with an equanimity that others don’t possess. Over time some of us accommodate even to this – we know what’s wrong, make a rational adjustment and cognitively rather than emotionally inhibit behaviors harmful to others.
On an SSRI, some of us skirt the edges of delirium as shown in the fact these are the drugs most commonly linked to reports to regulators of horrific nightmares and sleepwalking. Sleep-walking is an absolute defence against murder.
Walking a Legal Tightrope
Because we banned all our problem drugs in the 1960s, neither medical experts nor the Courts have had to work out what the right outcomes are in scenarios of treatment induced dysphoric mania, emotional lobotomy and delirium.
There have been some cases where even the prosecution agrees the drug caused it and people have walked free but these cases don’t assist lawyers or experts in getting to grips with the underlying issues in the way a case like Holmes might have done.
But a lawyer brave enough to think about taking a case has to find an expert but most doctors figure it’s the kiss of death for a career to get involved in this way. Most doctors also come from a background of applying the law as it relates to mental illness to the situation and a mental illness defense doesn’t apply in cases of drug induced delirium. Few medical experts realise it requires a different expertise to marshal a drug related argument.
If she does find an expert, a lawyer can find herself with a set of pharmaceutical company new best friends keen to explain how treatment cannot be part of the picture. We don’t know if this played a role in the Holmes case.
If she finds an expert, the lawyer then needs to shepherd a jury along a narrow ledge. Questioning a prescription drug in a case like this questions the entire regulatory system on which most of us believe our safety depends. For many, better a James Holmes gets executed than we lose confidence in those responsible for looking after us.
After a horror like Aurora, families and the jury need someone to blame. Holmes was put on Zoloft by a doctor, to whom he clearly hinted on several occasions things were getting worse. Informing him about a possible link might have left him able to adjust. Should the doctor be in the dock? In 2013, French psychiatrist Danièle Canarelli was found guilty of manslaughter, when a patient of hers killed a third party. She had failed to recognize the risks.
In 1980 Dr Erling Oksenholt in Seattle put a patient on an antibiotic, Myambutol. She went blind and sued him for negligence. He settled. But then sued the drug company on the basis that it had withheld information that Myambutol could cause blindness from him which meant that he could not treat his patient safely. He won.
There is no doubt that Pfizer and Lilly and GSK are withholding more information about the risks of violence on SSRIs than was ever withheld from Dr Oksenholt about Myambutol.
There was compelling data from the Zoloft trials in adolescents that it could cause violence. These and other SSRI trials led to a Black Box warning on antidepressants, aimed particularly for those up to the age of 25 – Holmes was 24. The evidence shows that while these drugs trigger suicidality in some, they increase the risk of violence in others who like Holmes are more anxious and introverted than depressed.
But none of the experts who might be called upon to argue a drug or a mental illness defense have ever had access to the data underpinning company claims that the drugs work well and are safe. What does anyone do about the fact that in the Holmes case, every statement made by experts about sertraline or other SSRIs can only be based on ghost-written articles? Not even FDA has accessed the data.
Whose Mind was it?
The key thing for the Courts in deciding whether a James Holmes was guilty or not and what should be done about him hinges on what can be said about his intentions. Whether ill or not, on a drug or not, did his mind command his actions?
But if the question of whose mind commanded the action is key, then the first call has to be made by a James Holmes or you. Faced with the horror of what happened, especially if faced with evidence of some control, the person who has to make the call might, like Holmes, prefer death. It is all too easy to imagine being torn apart if he walked out of Court a free man.
It’s only if the jury in James Holmes’ head or your head gets to a point of wondering whose mind it was when these events happened that a proper case can be mounted.
The people best placed to shed light on the question of guilt are those of us who have experienced just what can happen when treatment goes wrong and can speak to what these drugs can do to our thinking and to the emotional ties in which our thoughts are bound.
The person in the dock has to be brave enough to take the risk of playing a card that has for all these reasons never been successfully played before.
They have to make a case to the jury that will require a jury to return a verdict of guilty against all of us. We are guilty for letting the bulk of the academic literature be ghost-written, for letting companies commandeer the data that would be needed to show their drugs can cause this problem and guilty for letting an immune-deficiency disorder like Sense about Science and related bodies colonize the public space with close to fascist denunciations of anyone who might raise questions.
This all matters because if it can happen to James Holmes it can happen to you or someone you love.