Katinka Newman’s The Pill that Steals Lives brings out the hazards of being put on a treatment that then becomes the problem that other treatments are used to treat. In her case she could have easily killed herself – or her children.
The website 100Families.org lists 1250+ cases where mental health is linked to homicides. The thrust of the website is that mental illness is causing the problem. There is no questioning of the possibility that the drugs may be doing so.
As part of a submission to the Suicide Prevention inquiry underway within the Department of Health, this post and related material looks in more detail at the contribution of treatment to both suicide and homicide.
The long-term use of most psychotropic medications starts with their prescription for conditions that are less serious, transforming these into more serious, and permanent conditions. This “manufacture of mental illness” is enabled by many well-meaning physicians who do not notice the negative effects of the medications they prescribe, even when their patients directly complain about them.
Here is how it works: a patient comes to his/her doctor complaining about anxiety, or depression, related to some situational problem. The patient may directly ask for something to help them cope, or the doctor may suggest it, and a prescription is written. If the patient returns complaining of unpleasant side effects, they are not attributed to the medication, they are perceived by the doctor as a worsening of the original complaint. The doctor usually increases the dose of the original medication, or adds another. This causes more side effects which get medicated and the patient is trapped in a vicious circle.
This does not mean that nobody benefits from psychoactive medication. Medication can be wonderfully helpful for the short-term management of crisis situations from delirium to shock, for people whose symptoms have persisted for months without let-up, and for some who have tried other first line treatments without success.
The medication alone is not the problem. The problem arises when the consequences of being on the wrong medication for you are not recognized. This is particularly unfortunate when the initial problem was an exam anxiety, a debt, or a relationship problem. In circumstances like these, many of us take pills for a magic solution to a life stress and often end up with much more serious problems. “The Pill That Steals Lives” documents this beautifully.
The MHRA, in common with other western regulators, has not changed their medication advice to reflect the emergence in recent years of the actual data from clinical trials of antidepressants and antipsychotics showing an excess of risks over benefits on treatment where ghostwriters had portrayed only efficacy and safety. While warnings about suicidality have been slightly strengthened to reflect this, warnings about violence are deficient. We know that antidepressants and antipsychotics are associated with a much higher rate of violent reactions than other medications; the data from FDA and Health Canada on RxISK shows greatly increased rates for suicidality, paranoia, aggression, homicidal and suicidal ideation, violent acts and completed suicides that are well above what would occur by chance. Yet physicians appear not to be aware of this.
Hundredfamilies and NHS mental health services
It is one thing to accept that research shows that medications worsen mental illness as a general concept, but it is more alarming to spot the phenomenon in individual cases. Of course, in specific cases, it is impossible to know for certain what would have happened without medication. However, when many people in a defined population all exhibit serious worsening as they take medication, then one has to conclude that one is observing the macro effect at ground level. In other words, while we cannot say definitively that drugs caused the problem in any given case, we can be pretty sure that in many cases, they did.
One unfortunate population is that group of individuals who have received mental health services from the U.K.’s National Health Service (NHS) and committed a homicide. This is a small group of about 1,300 people, not enough to show up as a percent of the population. In some of these cases the NHS requests that the service provided be reviewed or investigated.
A typical description of purpose in the Terms of Reference is:
“The purpose of an independent investigation is to discover what led to an adverse event and to audit the standard of care provided to the individual. An independent investigation may not identify root causes or find aspects of the provision of healthcare that directly caused an incident but it will often find things that could have been done better.
These inquiries/reviews/investigations are thus aimed at preventing deaths wherever possible.
Hundredfamilies is an organization dedicated to raising awareness about the connection between mental illness and violence. They note that:
“Accurate information about mental health and violence, particularly homicides, is not easy to find. Many mental health professionals don’t like talking about the subject, and if they do, they consistently underestimate the true scale of the problem. What information there is, is often partial, inaccurate or incorrect. This section examines the problem of mental health homicides and violence using official reports, sources and evidence. It looks at: The true Numbers of mental health homicides in Britain each year.”
On its website, Hundredfamilies cites over 30 studies that purport to show that mentally ill people are responsible for more homicides than others. All of these studies do show that people who have been diagnosed commit violent crimes at a higher rate. The confounding factor is that these people are also under the influence of medication. So while perpetrators may well have been in a disordered mental state at the time of their crime, it is possible this was caused or exacerbated by medication.
It makes little sense to invest in trying to find ways to avoid future tragedies while avoiding examination of a primary contributing factor. Yet that is exactly what is happening. The belief in the value of psychoactive medications is so strong that the role of medication in tragedies is never explored, leaving the medicated perpetrator to take full responsibility for his/her crime. This is unfair in cases where the perpetrators were taking medication prescribed – and sometimes forced on them against their will – by mental health services. Wherever the possibility exists that it is medications causing violence, then this possibility should be explored, to be consistent with the stated NHS goal of avoiding preventable deaths.
Antipsychotics and antidepressants
To understand the significance of certain facts that can be gleaned in many of the cases, it is important to know about the medications. Although many people in care were on benzodiazepines, all those people were also on either neuroleptics (antipsychotics) and/or antidepressants. These latter are the medications most likely to have played a role in violence.
In the case of the antipsychotics, conventional wisdom holds that these medications are necessary to control the symptoms of psychotic illness, and they somehow “clear up” the thinking of people who take them and keep the takers sane, much as insulin corrects the blood sugar of diabetics. When schizophrenics stop taking their medicines, the story has been, they will relapse and their underlying illness will show up again. The natural corollary was that these people should be kept on these drugs for life. Those who do not want to take the drugs that keep them well, “have no insight into their illness” and must be forced to take the medication for their own good. Despite the fact that it does not fit with the evidence, this remains the prevalent thinking. This misunderstanding is costing a vast number of people their health, and others their freedom and their lives.
Antipsychotics can be extremely helpful but they are essentially tranquilizers that are useful in acute situations – provided the drug given in fact suits the person. The wrong drug or even the right drug at times of changing dose can lead to suicide or homicide.
There are a number of types of antidepressants. The most common are the older tricyclics (TCAs). There are newer sedative agents like Mirtazapine (Remeron). But the most frequently prescribed antidepressants are the selective serotonin reuptake inhibitors (SSRIs) and the serotonin-norepinephrine reuptake inhibitors (SNRIs).
All these medications carry warnings that they can increase suicidal thoughts and actions in young people, although the data is essentially the same for adults. In common with antipsychotics, antidepressants can cause akathisia, psychosis, and impulsive rage reactions. These extreme negative effects are most likely to occur within hours, days or a few weeks after starting the medication, or following a dosage change, or during withdrawal.
Interpreting the NHS review reports
These reviews provide a unique opportunity to challenge the myth that mental illness causes violence. The media and the public accept that diagnosed people who commit crimes do so because of their illness, and this is reflected in news accounts of the crimes. However, the NHS reviews provide an opportunity to look behind the scenes, where in almost every case we find a medication change, akathisia, or other medication-related phenomenon.
Keeping in mind the above facts about antipsychotics and antidepressants, many of the reviews reveal that just prior to many of the tragedies, there was a change to the perpetrator’s medication involving an SSRI or SNRI. In other cases, the perpetrator had a long history on antipsychotics, and was clearly doing poorly shortly before killing someone. Reading the stories from the perspective that prescriptions may have played a role allows for completely different interpretation of the situation.
None of the independent investigations/reviews allow for the possibility that medication was a contributing factor. Some reviewers have meticulously recorded prescriptions, with dates and drug names – as support for the case that the people received good care.
Many reviews, precisely because they do not consider medication a potential factor, omit this type of important detail, making it difficult to determine what role medication might have played. For example, in one case (Marvin Bailey) there are 76 references to medication over 108 pages. However, there are no prescription dates mentioned, and the names of the prescribed drugs are mostly omitted. In the glossary several medications are listed, including fluoxetine, flupentixol, olanzapine, quetiapine and zuclopenthixol, but only three are mentioned in the main report. Mr Bailey had been given depot injections and was under a community treatment order, but medication compliance is the focus of references to medication. Because of the lack of information, this case and others without sufficient detail are difficult to analyze. This does not mean that one can dismiss the possibility that medication played a role. The only valid conclusion is that there is insufficient information, and the original review should have considered the role of medication and collected relevant facts in that regard.
For several cases in different geographic regions of the U.K., an analysis of the case reports has been done from the perspective of allowing for the possibility that medication played a role. In these cases, a typical news article from the time, reporting the killing, is included to illustrate the story that is being fed to the public, for comparison.
Twenty-five such reports, and summaries of the cases can be viewed on SSRIstories.org Behind the Scenes at the NHS. These are mainly drawn from the East of England. They were drawn consecutively so they include at least one case where the drugs seems unlikely to be involved. We would greatly appreciate it if any of you have the time to go in and assess the cases from other regions in the same way.
Katinka Newman’s site The Pill that Steals Lives gives a further series of cases like hers showing the same dynamic but where the outcome is primarily suicide. This series is growing.
What’s in a name?
Another post on this site used the word Prescripticide to label the phenomenon being dealt with here. It might be pushing things too far to add Suicide by Patient – even Inadvertent Suicide by Patient – to the term Suicide by Cop to cover cases of some people who end up dead.
But this is a world where good intentions can be put to other ends. The suicides of patients are used by groups like the American Association for the Prevention of Suicide to increase rates of detection of and treatment of nervous problems – See How Pharma Captures Bereaved Mothers. It is very common to meet people advocating for the detection and treatment, even forced treatment, of mental illness, who do so with all good intentions having had a child or partner or parent die from suicide, when a review of the case points to treatment as the culprit. Exactly the same thing can happen with homicides and violence.
Provided the message remains simple, philanthropic money can be generated to support State or Insurance money to assist. Nobody likes a complex message.
We would be interested in other accounts from across medicine where people have become advocates for treatments not realizing that the treatment may have caused the problem they are now advocating to remedy with further treatment.