Suicides & Homicides in Patients taking SSRIS - Why They Keep Happening

[Guest guest]

Friends,

While I don't believe that improper dosage is the only underlying cause

which explains why some people have extremely adverse reactions to the SSRI

class of drugs, this certainly is one factor which should be addressed.

Dawn

=============================================================

http://www.medicationsense.com/articles/oct_dec_03/suicides_homicides.html

Suicides and Homicides in Patients Taking Paxil, Prozac, and Zoloft:

Why They Keep Happening -- And Why They Will Continue.

Underlying Causes That Continue to Be Ignored by Mainstream Medicine and the

Media.

From almost the day that they were introduced in the late 1980s and

early 1990s, sudden, unexpected suicides and homicides have been reported in

patients taking serotonin-enhancing antidepressants such as Prozac, Paxil,

and Zoloft. I'm not surprised this problem hasn't disappeared, nor will it

unless we look deeper.

I never hesitate to say that these drugs -- selective serotonin

reuptake inhibitors (SSRIs) -- help millions of people. But any drug that

can cause positive changes in people's brains can also cause negative ones

unless care is taken to avoid it. We do not take such care. So it was no

surprise to me when, in August 2003, more headlines appeared. These were

based on reports by British authorities and the U.S. Food and Drug

Administration about unpublished studies showing an increased risk of

suicide in children and teenagers taking Paxil (1-3).

Prior reports of suicidal and homicidal acts in adults taking SSRIs

have been explained away by drug industry defenders and mainstream doctors,

who claim that suicide is common in depression anyway. And that no type of

antidepressant helps everyone. Some depressed patients don't get better and

choose suicide. That's true sometimes, unfortunately. But these reports

describe more impulsive, violent acts than expected. As I said fifteen years

ago at the time of the first reports and again in Over Dose in 2001 (4),

SSRIs could create a unique combination of side effects that might severely

impair judgment and impulse control. This has been described by others as

well (5-16).

Psychosis After Three Days of Treatment

One of my first cases with Prozac involved a 35 year-old woman with a

job and family, who had a mild depression with no suicidal tendencies. This

changed after just three days on Prozac, when she became acutely psychotic.

Any psychiatrist will tell you that excessive doses of antidepressants can

cause brain dysfunctions including disorientation, confusion, and cognitive

disturbances. This was commonly seen with old-time antidepressants like

Elavil and Tofranil (17). But more than the older drugs, SSRIs can also

cause a severe degree of agitation or restlessness that may become

intolerable and reduce impulse control (5-6A). Impulsive behavior,

especially if coupled with impaired cognitive functioning, can be dangerous.

Antidepressants can also trigger similar, manic-like symptoms in people

whose depression is part of a manic-depressive syndrome, which often gets

overlooked when people are given SSRIs. " Some of these individuals may have

serious adverse reactions to antidepressants including irritability,

aggression, and mania, " wrote Dr. Pies, professor of psychiatry at

Tufts University (18).

The Devil Is in the Dosage

My book Over Dose opens with a man whose anxiety and depressive

symptoms got much worse rather than better with the standard 20-mg starting

dose of Prozac (4). A letter to the editor in the August 11, 2003, issue of

the New York Times described a similar reaction to Celexa:

" During the first month, I experienced extreme, almost manic tendencies. My

mind raced, I was restless, I couldn't sleep. Eventually that restlessness

subsided (18). "

Sometimes the symptoms don't subside. Sometimes the symptoms get out of

hand. The writer of the letter made an another important point: " They need

new dosing and treatment strategies to counteract the manic effect. "

Exactly.

These reactions are occurring because the standard starting doses of

many antidepressants are excessively strong for many people. One clue is

that most of these reactions occur shortly after people have been started on

SSRIs or after the dosage has been bumped up. These are called " first-dose "

reactions by mainstream medicine, and they almost always indicate a mismatch

between the patient and the dosage. With the Paxil study, the New York Times

reported:

" Some experts suspect that in the first few weeks of therapy, drugs like

Paxil can shove a small number of patients toward a mental precipice,

perhaps because they can cause a severe form of restlessness known as

akathisia. Patients who make it through the first weeks of drug therapy

uneventfully do fine on the medication on the long term, these experts say

(3). "

But it doesn't have to be a sink or swim situation. Merely reduce the

dose awhile, allow patients to adapt to the medicine, and then increase it

again gradually. Sometimes it doesn't need to be increased, because lower

doses work for many patients.

When my patient became psychotic in 1988, I researched the problem and

found an article that shocked me. This large study, published before Prozac

was marketed, showed that 54% of the patients with severe depression

improved with just 5 mg -- one-quarter of the standard 20 mg starting dose

(19). But Prozac wasn't marketed with a 5 mg recommended dose. 20 mg was the

recommended initial dose for everyone -- 400% more than many people needed

-- a huge difference pharmacologically. No wonder these reactions were

occurring.

I wasn't the only expert to recognize the problem. A 1993 study

concluded " that starting fluoxetine [Prozac] at doses lower than 20 mg is a

useful strategy because of the substantial fraction of patients who cannot

tolerate a 20-mg dose but appear to benefit from lower doses (20). " Similar

dosing problems have been seen with and other SSRIs.

Informed Consent Means Having Enough Information to Make an Intelligent

Choice

Unfortunately, most doctors don't understand that many problems with

SSRIs are caused by standard doses that are excessive for substantial

numbers of patients. And although Prozac, Zoloft, and other SSRIs now come

in lower doses, many doctors still start patients on the stronger, standard

doses.

As I've said when invited to speak at the FDA and at other major

conferences, drug companies must define the lowest, safest, effective doses

of drugs. They must include this information in package inserts and the

Physicians' Desk Reference, and they must market pills that make lower

dosing possible. And they must do it from the start.

Unfortunately, marketing trends in recent decades have gone in the

other direction. Many drugs are marketed one-size-fits-all. Many drugs are

dosed exactly the same for big and small, young and old, healthy and frail.

The same strong doses are prescribed to people taking no other medications

and people taking a dozen. Such methods defy medical sense and common sense.

Shortly after the reports from the British authorities and U.S. FDA

about higher incidences of suicide in youngsters taking Paxil, Dr.

Friedman, director of the psychopharmacology clinic at Weill Medical College

of Cornell University, wrote:

" For too long, drug companies have been allowed to tell us only the good

news about their products. Now we're ready for the whole story (21). "

The whole story begins with patients and their doctors knowing about

the lowest, safest, effective doses of drugs. Most people don't like taking

medications. If they must, they prefer taking as little as possible. But

this isn't possible if we aren't given adequate information. Informed

consent is denied when information is withheld. We need to know the full

range of effective doses, and we need enough pill sizes to make

individualized dosing possible. Prevention begins with complete information.

In the meantime, you have to be your own researcher, using books and

the Internet, learning enough to choose selectively from the information you

see. Since 1996, I have published 15 medical journal articles and Over Dose

to help inform you and your doctor about lower, safer, proven-effective drug

doses because such information was unavailable to most people. Using all of

the resources available today, you can learn a lot, and when you do, tell

your doctor -- doctors respect good, scientifically-based information -- so

that your doctor can inform others following you.

References

1. Waechter, F. Paroxetine must not be given to patients under 18. BMJ, June

14, 2003;326:1282.

2. FDA statement regarding the antidepressant Paxil for pediatric

population. U.S. Food and Drug Administration, June 19, 2003:www.fda.gov --

accessed 9/18/O3.

3. , G. Debate Resumes on the Safety of Depression's Wonder Drugs. New

York Times, Aug. 7, 2003:nytimes.com.

4. Cohen, JS. Over Dose: The Case Against The Drug Companies. Prescription

Drugs, Side Effects, and Your Health. Tarcher/Putnam, New York: October

2001.

5. Medawar, C, Herxheimer, A, Bell, A, et al. Paroxetine, Panorama, and user

reporting of ADRs: consumer intelligence matters in clinical practice and

post-marketing drug surveillance. International Journal of Risk & Safety in

Medicine 2002;15:161-169.

6. Donovan, S, Clayton, A, Beeharry, M, et al. Deliberate self-harm and

antidepressant drugs. Investigation of a possible link. British Journal of

Psychiatry, 2000;177:551-6.

6A. , L, Waterhouse, R. Prozac Makers Told to Warn of Side-Effects.

The Sunday Times [britain], July 8, 2001:www.sunday-times.co.uk/news.

7. Glenmullen, J. Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft,

Paxil, and Other Antidepressants with Safe, Effective Alternatives. Simon

and Schuster, March 2000.

8. Healy, D. The Antidepressant Era. Harvard University Press, Sept. 1997.

9. Hickling, L. Questions Persist concerning Prozac's Role in Suicide Risk.

Www.drkoop.com Health News, May 11, 2000:

www.drkoop.com/dyncon/article.asp?at=N & id=11009.

10. Teicher, MH, Glod, C, Cole, JO. Emergence of intense suicidal

preoccupation during fluoxetine treatment. American Journal of Psychiatry,

1990;147(2):207.

11. Fichter, CG, Jobe, TH, Braun, BG. Does fluoxetine have a therapeutic

window? Lancet 1991;338.

12. GM; Segman RH; King RA. Serotonin and suicidality: the impact

of fluoxetine administration. II: Acute neurobiological effects. Israel

Journal of Psychiatry and Related Sciences, 1995, 32(1):44-50.

13. Lancon, C, Bernard, D, Bougerol, T. [Fluoxetine, akathisia and suicide].

Encephale, 1997 May-Jun, 23(3):218-23. Abstract.

14. Liu, CY, Yang, YY, et al. Fluoxetine-related suicidality and muscle

aches in a patient with poststroke depression [letter]. Journal of Clinical

Psychopharmacology, 1996 Dec, 16(6):466-7.

15. , A. Drug Turned Loving Man into a Killer, Says Judge. Sidney

Morning Herald, Fri., May 25, 2001:www.smh.com.au/

16. Donovan, S, Clayton, A, et al. Deliberate self-harm and antidepressant

drugs. Investigation of a possible link. British Journal of Psychiatry,

2000;177:551-6.

17. American Society of Hospital Pharmacists. American Hospital Formulary

Service, Drug Information 1999. Gerald K. McEvoy, Editor. Bethesda: 1999.

18. The Debate Over Antidepressants (5 Letters). Letters to the Editor. New

York Times, 8/11/O3:nytimes.com.

19. Wernicke, JF, Dunlop, SR, Dornseif, BE, et al. Low-dose fluoxetine

therapy for depression. Psychopharmacology Bulletin 1988;24(1):183-188.

20. Louie, AK, , TB, Lannon, MD. Use of low-dose fluoxetine in major

depression and panic disorder. Journal of Clinical Psychiatry

1993;54(1):435-438.

21. A. Friedman. What You Do Know Can't Hurt You. New York Times,

8/12/O3:nytimes.com.

Copyright 2003, Jay S. Cohen, M.D. All rights reserved.

_________________________________________________________________

It’s our best dial-up Internet access offer: 6 months @$9.95/month. Get it

now! http://join.msn.com/?page=dept/dialup

[Guest guest]

Friends,

While I don't believe that improper dosage is the only underlying cause

which explains why some people have extremely adverse reactions to the SSRI

class of drugs, this certainly is one factor which should be addressed.

Dawn

=============================================================

http://www.medicationsense.com/articles/oct_dec_03/suicides_homicides.html

Suicides and Homicides in Patients Taking Paxil, Prozac, and Zoloft:

Why They Keep Happening -- And Why They Will Continue.

Underlying Causes That Continue to Be Ignored by Mainstream Medicine and the

Media.

From almost the day that they were introduced in the late 1980s and

early 1990s, sudden, unexpected suicides and homicides have been reported in

patients taking serotonin-enhancing antidepressants such as Prozac, Paxil,

and Zoloft. I'm not surprised this problem hasn't disappeared, nor will it

unless we look deeper.

I never hesitate to say that these drugs -- selective serotonin

reuptake inhibitors (SSRIs) -- help millions of people. But any drug that

can cause positive changes in people's brains can also cause negative ones

unless care is taken to avoid it. We do not take such care. So it was no

surprise to me when, in August 2003, more headlines appeared. These were

based on reports by British authorities and the U.S. Food and Drug

Administration about unpublished studies showing an increased risk of

suicide in children and teenagers taking Paxil (1-3).

Prior reports of suicidal and homicidal acts in adults taking SSRIs

have been explained away by drug industry defenders and mainstream doctors,

who claim that suicide is common in depression anyway. And that no type of

antidepressant helps everyone. Some depressed patients don't get better and

choose suicide. That's true sometimes, unfortunately. But these reports

describe more impulsive, violent acts than expected. As I said fifteen years

ago at the time of the first reports and again in Over Dose in 2001 (4),

SSRIs could create a unique combination of side effects that might severely

impair judgment and impulse control. This has been described by others as

well (5-16).

Psychosis After Three Days of Treatment

One of my first cases with Prozac involved a 35 year-old woman with a

job and family, who had a mild depression with no suicidal tendencies. This

changed after just three days on Prozac, when she became acutely psychotic.

Any psychiatrist will tell you that excessive doses of antidepressants can

cause brain dysfunctions including disorientation, confusion, and cognitive

disturbances. This was commonly seen with old-time antidepressants like

Elavil and Tofranil (17). But more than the older drugs, SSRIs can also

cause a severe degree of agitation or restlessness that may become

intolerable and reduce impulse control (5-6A). Impulsive behavior,

especially if coupled with impaired cognitive functioning, can be dangerous.

Antidepressants can also trigger similar, manic-like symptoms in people

whose depression is part of a manic-depressive syndrome, which often gets

overlooked when people are given SSRIs. " Some of these individuals may have

serious adverse reactions to antidepressants including irritability,

aggression, and mania, " wrote Dr. Pies, professor of psychiatry at

Tufts University (18).

The Devil Is in the Dosage

My book Over Dose opens with a man whose anxiety and depressive

symptoms got much worse rather than better with the standard 20-mg starting

dose of Prozac (4). A letter to the editor in the August 11, 2003, issue of

the New York Times described a similar reaction to Celexa:

" During the first month, I experienced extreme, almost manic tendencies. My

mind raced, I was restless, I couldn't sleep. Eventually that restlessness

subsided (18). "

Sometimes the symptoms don't subside. Sometimes the symptoms get out of

hand. The writer of the letter made an another important point: " They need

new dosing and treatment strategies to counteract the manic effect. "

Exactly.

These reactions are occurring because the standard starting doses of

many antidepressants are excessively strong for many people. One clue is

that most of these reactions occur shortly after people have been started on

SSRIs or after the dosage has been bumped up. These are called " first-dose "

reactions by mainstream medicine, and they almost always indicate a mismatch

between the patient and the dosage. With the Paxil study, the New York Times

reported:

" Some experts suspect that in the first few weeks of therapy, drugs like

Paxil can shove a small number of patients toward a mental precipice,

perhaps because they can cause a severe form of restlessness known as

akathisia. Patients who make it through the first weeks of drug therapy

uneventfully do fine on the medication on the long term, these experts say

(3). "

But it doesn't have to be a sink or swim situation. Merely reduce the

dose awhile, allow patients to adapt to the medicine, and then increase it

again gradually. Sometimes it doesn't need to be increased, because lower

doses work for many patients.

When my patient became psychotic in 1988, I researched the problem and

found an article that shocked me. This large study, published before Prozac

was marketed, showed that 54% of the patients with severe depression

improved with just 5 mg -- one-quarter of the standard 20 mg starting dose

(19). But Prozac wasn't marketed with a 5 mg recommended dose. 20 mg was the

recommended initial dose for everyone -- 400% more than many people needed

-- a huge difference pharmacologically. No wonder these reactions were

occurring.

I wasn't the only expert to recognize the problem. A 1993 study

concluded " that starting fluoxetine [Prozac] at doses lower than 20 mg is a

useful strategy because of the substantial fraction of patients who cannot

tolerate a 20-mg dose but appear to benefit from lower doses (20). " Similar

dosing problems have been seen with and other SSRIs.

Informed Consent Means Having Enough Information to Make an Intelligent

Choice

Unfortunately, most doctors don't understand that many problems with

SSRIs are caused by standard doses that are excessive for substantial

numbers of patients. And although Prozac, Zoloft, and other SSRIs now come

in lower doses, many doctors still start patients on the stronger, standard

doses.

As I've said when invited to speak at the FDA and at other major

conferences, drug companies must define the lowest, safest, effective doses

of drugs. They must include this information in package inserts and the

Physicians' Desk Reference, and they must market pills that make lower

dosing possible. And they must do it from the start.

Unfortunately, marketing trends in recent decades have gone in the

other direction. Many drugs are marketed one-size-fits-all. Many drugs are

dosed exactly the same for big and small, young and old, healthy and frail.

The same strong doses are prescribed to people taking no other medications

and people taking a dozen. Such methods defy medical sense and common sense.

Shortly after the reports from the British authorities and U.S. FDA

about higher incidences of suicide in youngsters taking Paxil, Dr.

Friedman, director of the psychopharmacology clinic at Weill Medical College

of Cornell University, wrote:

" For too long, drug companies have been allowed to tell us only the good

news about their products. Now we're ready for the whole story (21). "

The whole story begins with patients and their doctors knowing about

the lowest, safest, effective doses of drugs. Most people don't like taking

medications. If they must, they prefer taking as little as possible. But

this isn't possible if we aren't given adequate information. Informed

consent is denied when information is withheld. We need to know the full

range of effective doses, and we need enough pill sizes to make

individualized dosing possible. Prevention begins with complete information.

In the meantime, you have to be your own researcher, using books and

the Internet, learning enough to choose selectively from the information you

see. Since 1996, I have published 15 medical journal articles and Over Dose

to help inform you and your doctor about lower, safer, proven-effective drug

doses because such information was unavailable to most people. Using all of

the resources available today, you can learn a lot, and when you do, tell

your doctor -- doctors respect good, scientifically-based information -- so

that your doctor can inform others following you.

References

1. Waechter, F. Paroxetine must not be given to patients under 18. BMJ, June

14, 2003;326:1282.

2. FDA statement regarding the antidepressant Paxil for pediatric

population. U.S. Food and Drug Administration, June 19, 2003:www.fda.gov --

accessed 9/18/O3.

3. , G. Debate Resumes on the Safety of Depression's Wonder Drugs. New

York Times, Aug. 7, 2003:nytimes.com.

4. Cohen, JS. Over Dose: The Case Against The Drug Companies. Prescription

Drugs, Side Effects, and Your Health. Tarcher/Putnam, New York: October

2001.

5. Medawar, C, Herxheimer, A, Bell, A, et al. Paroxetine, Panorama, and user

reporting of ADRs: consumer intelligence matters in clinical practice and

post-marketing drug surveillance. International Journal of Risk & Safety in

Medicine 2002;15:161-169.

6. Donovan, S, Clayton, A, Beeharry, M, et al. Deliberate self-harm and

antidepressant drugs. Investigation of a possible link. British Journal of

Psychiatry, 2000;177:551-6.

6A. , L, Waterhouse, R. Prozac Makers Told to Warn of Side-Effects.

The Sunday Times [britain], July 8, 2001:www.sunday-times.co.uk/news.

7. Glenmullen, J. Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft,

Paxil, and Other Antidepressants with Safe, Effective Alternatives. Simon

and Schuster, March 2000.

8. Healy, D. The Antidepressant Era. Harvard University Press, Sept. 1997.

9. Hickling, L. Questions Persist concerning Prozac's Role in Suicide Risk.

Www.drkoop.com Health News, May 11, 2000:

www.drkoop.com/dyncon/article.asp?at=N & id=11009.

10. Teicher, MH, Glod, C, Cole, JO. Emergence of intense suicidal

preoccupation during fluoxetine treatment. American Journal of Psychiatry,

1990;147(2):207.

11. Fichter, CG, Jobe, TH, Braun, BG. Does fluoxetine have a therapeutic

window? Lancet 1991;338.

12. GM; Segman RH; King RA. Serotonin and suicidality: the impact

of fluoxetine administration. II: Acute neurobiological effects. Israel

Journal of Psychiatry and Related Sciences, 1995, 32(1):44-50.

13. Lancon, C, Bernard, D, Bougerol, T. [Fluoxetine, akathisia and suicide].

Encephale, 1997 May-Jun, 23(3):218-23. Abstract.

14. Liu, CY, Yang, YY, et al. Fluoxetine-related suicidality and muscle

aches in a patient with poststroke depression [letter]. Journal of Clinical

Psychopharmacology, 1996 Dec, 16(6):466-7.

15. , A. Drug Turned Loving Man into a Killer, Says Judge. Sidney

Morning Herald, Fri., May 25, 2001:www.smh.com.au/

16. Donovan, S, Clayton, A, et al. Deliberate self-harm and antidepressant

drugs. Investigation of a possible link. British Journal of Psychiatry,

2000;177:551-6.

17. American Society of Hospital Pharmacists. American Hospital Formulary

Service, Drug Information 1999. Gerald K. McEvoy, Editor. Bethesda: 1999.

18. The Debate Over Antidepressants (5 Letters). Letters to the Editor. New

York Times, 8/11/O3:nytimes.com.

19. Wernicke, JF, Dunlop, SR, Dornseif, BE, et al. Low-dose fluoxetine

therapy for depression. Psychopharmacology Bulletin 1988;24(1):183-188.

20. Louie, AK, , TB, Lannon, MD. Use of low-dose fluoxetine in major

depression and panic disorder. Journal of Clinical Psychiatry

1993;54(1):435-438.

21. A. Friedman. What You Do Know Can't Hurt You. New York Times,

8/12/O3:nytimes.com.

Copyright 2003, Jay S. Cohen, M.D. All rights reserved.

_________________________________________________________________

It’s our best dial-up Internet access offer: 6 months @$9.95/month. Get it

now! http://join.msn.com/?page=dept/dialup