Assault after ingestion of antidepressant — (British Medical Journal)

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British Medical Journal (BMJ)

VOLUME 303 21 SEPTEMBER 1991

PHILIP SUGARMAN,  TOM HUGHES

SIR – We were interested in Ms Clare Dyer’s report from the Court of Appeal of murder during mania after ingestion of amitriptyline. We have a 46 year old inpatient who assaulted his daughter and wife the day after taking 75 mg of amitriptyline.

The man does not have a history of violence or criminality, but from the age of 16 he has experienced bouts of severe sleeplessness, irritability, overactivity, poor concentration, and
worrying each spring. His mother has a closely similar history. At 21 he had an episode of considerable overtalkativeness and jocularity followed by several weeks of mild disinhibition.

This year he was sleepless for some weeks. For three days he did not sleep at all, and he developed delusions that his daughter was illegitimate and his wife unfaithful. One night he took three tablets of amitriptyline 25 mg, which had been prescribed two years earlier, which he believed to be sleeping tablets. He woke at 4 am to find himself overactive and his thoughts racing and subsequently experienced his mind being “pushed out by another mind.”  Later he picked up a large pair of scissors and stabbed his daughter repeatedly.  She sustained a pneumothorax.  He then felt an urge to gouge his wife’s eyes out and made some attempt to strangle her, although she was not injured.

The police found him standing on his bed over two ornamental bayonets, which he made no attempt to use.  On arrest he was shouting “God rules.” Later he thought that he had killed his family. Surprisingly, he was not charged but taken to a local hospital.  He had to be restrained from attacking nursing staff, but his symptoms settled over four days with small doses of chlorpromazine and did not recur.

The datasheet for amitriptyline warns that “psychotic manifestations, including mania and paranoid delusions, may be exacerbated,” and it is well known that antidepressants can cause mania.2   In view of these two cases, it may be that severe and uncharacteristic violence may be precipitated by amitriptyline in those with a predisposition to manic-depressive illness.  A similar suggestion has been made about fluoxetine (“The Prozac file,” Dispatches, Channel 4, 1990 Dec 19). Perhaps other such cases are known to readers.