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New Zealand Journal of Psychology
by Nicola Gavey, Rachel Liebert
Evidence that selective serotonin reuptake inhibitors (SSRIs) may elicit suicidal and/or aggressive thoughts and behaviours has been circulating for nearly thirty years. Despite a growing body of knowledge around these serious adverse effects, however, they continue to be surrounded by controversy. In particular they are subject to (arguable) counter-arguments that any risks from using the drugs are outweighed by benefits and/or more attributable to a person’s underlying disease’. Moreover assessments of risks often use rates of completed suicides as the ultimate measure. In this paper we draw on people’s own accounts of their experiences of serious adverse effects associated with SSRI use. In depth semi-structured interviews were undertaken with nine people who had either used SSRIs themselves or had witnessed the use of SSRIs by a close family member. We present four themes identified across the interviews relating to adverse effects from SSRIs: experiences of akathisia, aggression and suicidality; out of character’ behaviour; harm to relationships; and accounts of responses from the medical profession. Participants reported that the experience of adverse effects had marked impacts on general wellbeing, identities and relationships. These accounts cast doubt on notions that serious adverse effects associated with SSRI use may stem from an underlying condition and/or be outweighed by benefits from SSRI use. In addition they offer a persuasive and poignant plea to further consider non-fatal adverse effects and their consequences in assessing the risks of these drugs.
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Rachel Liebert & Nicola Gavey, The University of Auckland
Evidence that selective serotonin reuptake inhibitors (SSRIs) may elicit suicidal and/or aggressive thoughts and behaviours has been circulating for nearly thirty years. Despite a growing body of knowledge around these serious adverse effects, however, they continue to be surrounded by controversy. In particular they are subject to (arguable) counter-arguments that any risks from using the drugs are outweighed by benefits and/or more attributable to a person’s ‘underlying disease’. Moreover assessments of risks often use rates of completed suicides as the ultimate measure. In this paper we draw on people’s own accounts of their experiences of serious adverse effects associated with SSRI use. In depth semi-structured interviews were undertaken with nine people who had either used SSRIs themselves or^ had witnessed the use of SSRIs by a close family member. We present four themes identified across the interviews relating to adverse effects from SSRIs: experiences of akathisia, aggression and suicidality; ‘out of character’ behaviour; harm to relationships; and accounts of responses from the medical profession. Participants reported that the experience of adverse effects had marked impacts on general wellbeing, identities and relationships. These accounts cast doubt on notions that serious adverse effects associated with SSRI use may stem from an underlying condition and/or be outweighed by benefits from SSRI use. In addition they offer a persuasive and poignant plea to further consider non-fatal adverse effects and their consequences in assessing the risks of these drugs.
Menkes, 2006, regarding the links between SSRIs and violence). Although pharmaceutical regulatory bodies in the United States, the United Kingdom, Europe, Canada, Australia and New Zealand have responded to this evidence of serious potential adverse effects by issuing warnings about the risks associated with SSRIs (e.g., ADRAC, 2004; EMEA, 2005; FDA, 2005; Health Canada, 2004; Medsafe, 2004; MHRA, 2003), proponents of the drugs nevertheless continue to argue that their benefits outweigh the risks. For instance, it has been claimed that SSRIs are associated with a decrease in the rate of suicide at the population level (e.g. Khan, Khan, Leventhal, & Brown, 2001), although more recently others have countered that there is no evidence for any causal relationship between increasing use of SSRIs and declining rates of suicide (e.g. Safer & Zito, 2007). As well as this debate about whether SSRIs ‘on balance’ may help more people than they hurt, the currency in which such cost-benefit analyses are calculated is often restricted to measures of completed suicide. This can give a distorted view of the suicidal effects of these drugs because nonfatal experiences (including suicidal ideation, suicide attempts, akathisia and aggression) tend to be overlooked, or their seriousness minimised, by proponents (Liebert & Gavey, submitted for publication). For example, although one study reported a decreased risk of completed suicide with antidepressants.
Selective serotonin reuptake inhibitor (SSRI) antidepressants have become the subject of considerable controversy in recent years. Not only have serious questions been raised about the eiBcacy of these drugs (e.g., Moncrieff & Kirsch, 2005) but evidence has long been mounting of an association between SSRIs and suicide. This evidence which has arisen from a range of sources including case reports (e.g., Teicher, Glod, & Cole, 1990), meta- and reanalyses of clinical trials (e.g. Kraus, 2006), legal cases (e.g., Healy, 2004a), epidemiological studies (e.g., Donovan et al., 2000) and primary care databases (e.g., Martinez et al., 2005) – has lead critics to urge far greater caution around the use of these drugs, particularly at the point of starting, stopping or changing dose (Healy, 2004a). According to Healy (2006) the current “best estimate for the likely risk of suicide on SSRIs over placebo is 2.6” (p. 93). Links between SSRIs and a number of other serious adverse (and withdrawal) effects – such as aggression, akathisia, mania and the wider realm of suicidality – have also been postulated (e.g., Breggin, 2003; Glenmullen, 2000; Healy, 2004a; Medawar, Herxheimer, Bell & Jofre, 2002; Whitaker, 2005), although the research evidence is less well established (see for instance Healy, Herxheimer, &
New Zealand Journal of Psychology Vol.37, No. 1, March 2008
Serious adverse effects from SSRI use
use, it also reported a marked increase in the risk of attempted suicide (Tiihonen, Lonnqvist, & Wahlbeck, 2006), yet such findings are rarely emphasised. In addition proponents have been found to employ constructions of depression that allow SSRI adverse effects to be attributed to an ‘underlying disease’, thereby further minimising the drugs’ significance in causing harm and instead suggesting people’s experiences derive from pre-existing suicidal tendencies (Liebert & Gavey, submitted for publication)’. Given these complexities, the debate on SSRIs is threatening paralysis, with many agreeing that we cannot ‘really’ know, in a traditional scientific sense, whether or not SSRIs cause suicidality (e.g., Simon, 2006). Nonetheless, as Simon (2006) has pointed out, “even if randomised trials and large observational studies find no effect [of SSRIs] on average rates of suicide attempt or suicide death, average effects may not apply to all individuals” (p. 1861). In light of this obvious point, it is arguably important to move beyond the broader debate about population level risks and benefits to explore more fully what these adverse drug effects are like for those people who do experience them. Beyond reports of clinical observations (e.g., Healy, 2004a) and an analysis of people’s web-based reporting of SSRI problems (Medawar, Herxheimer, Bell, & Jofre, 2002), there is little detailed documentation in the literature of the nature and impact of such effects, particularly from those who have experienced them personally. In this article, we enter the debate about the risks of SSRIs through suggesting the need to look beyond medicalised assumptions that arguably limit the scope of concem to the relative risk of completed suicide. Instead, through engaging with people’s own descriptions of their experiences with these drugs, we aim to provide more in depth understandings of the phenomenology and consequences of a wider range of serious adverse effects from SSRIs, including those that fall short of death. In doing so, we hope to highlight and illuminate the potential human cost of SSRI use for some people (see also Liebert & Gavey, 2006).
The analyses reported in this article arise within the context of a broader study that sought to explore knowledges of SSRI-induced suicidality and aggression in the New Zealand context through interviews with 24 people who had either professional or personal experiences relating to SSRIs, depression and/or suicidality (Liebert, 2006). Here, we draw on in depth interviews with nine people (six women, three men) about their experiences in relation to SSRIs. Given the broader aims of this study, we have ended up drawing on both interviews with people who have used the drugs themselves, and those who have had intimate contact with another person who was using the drugs. Six participants spoke about their own personal experience of using SSRIs and three spoke about their experiences with a close family member using SSRIs. For those who spoke about experiences in relation to a family member, the drugs had been implicated in the suicide of that person for two participants, and in a suicide attempt for the other. In this latter case, the interview was conducted jointly with the couple – to include both the man who was using SSRIs and his partner, a woman, who talked about her observations and experiences in relation to his SSRI use. By being in a position to include material from these converging sources, we have not only been able to generally enrich our analyses; but also, importantly, we have been able to include accounts relating to people who had died. See Table 1 for summaries of the nature of each participant’s experiences, which are necessarily brief to protect participants’ anonymity. Participants were recruited via the dissemination of a general invitation through the networks of three mental health advocacy organisations. They were informed that the study was being undertaken in response to recent evidence and regulatory responses regarding SSRIs and risks of suicidality and aggression. Subsequently four people offered to be interviewed in Auckland, three in Wellington, and two in central North Island cities. All interviews were face to face, and lasted between one and four hours. The main focus of the interviews was
on participants’ personal experiences with SSRIS, which they were invited to start speaking about chronologically. We then asked further questions as relevant to invite further elaboration and refiection on their experiences. Where timely, participants were also asked about their views on issues such as current trends and understandings of depression, current trends in the use of antidepressants, and claims linking SSRIs to adverse effects, although these responses have not been integrated explicitly into the present analysis. One to two weeks after the interview participants were contacted and offered the opportunity to add further thoughts or to talk through anything that may have arisen for them from speaking about their experiences. All interviews were audio-taped and transcribed. Our analysis was guided by two sets of principles that informed how we approached the interview material and how we present it here. Firstly, working within a critical realist epistemology, we were aiming to offer a descriptive analysis of people’s experiences that was pattemed by a critical conceptual analysis of the wider debate over adverse effects of SSRIs. We read the transcripts to identify common themes, across the interviews, in terms of salient kinds of experiences and issues discussed by the participants. To this end we arrived at four key themes, which we use below as a framework to organise our analysis. Our choice of themes as ‘key’ was determined in relation to our specific aim of illuminating the phenomenology of adverse SSRI effects. In particular, we wanted to focus on those issues that were brought up in the interviews that have arguably been ‘side-lined’ in previous debate around SSRI use. This led us to highlight those kinds of experiences reported by the participants that directly challenge some of the rhetoric used to minimise and/or discount the nature of adverse drug effects. In this sense, we do not suggest that our analysis necessarily represents the full range of potentially important issues discussed by all participants. Secondly, the way in which we present the ‘data’ within the thematic frames we have chosen is guided by a social justice orientation and a commitment to making space for the
New Zealand Journal of Psycfiology Vol.37, No. 1, March 2008
R. Liebert, N. Gavey voices of people who are most directly affected by adverse drug effects. We have woven a context in which parts of their stories can be told, rather than attempting to re-tell their stories on their behalf (through more intensive ‘topdown’ interpretation of their accounts). We thus made a deliberate effort to use as many of their words as possible, with extracts only edited where necessary to enhance readability, protect anonymity and/or add context. In this sense, a major part of our analytic contribution is in the formation of a framework that allows relevant dimensions of participants’ experiences to be voiced in a way that speaks directly to crucial questions in the wider debate about the human cost of SSRI adverse effects. We have also interspersed psychopharmacologist David Healy’s (2004a) observations of SSRI-linked akathisia, suicidality and/or aggression experienced by patients and by ‘healthy volunteer’ research participants alongside our own material. In doing so we hope to highlight wider resonances between the phenomena described by participants in this study and those reported elsewhere by others. the objectives of this research: (1) experiences of akathisia, aggression and suicidality, (2) ‘out of character’ behaviour, (3) harm to relationships, and (4) responses from the medical profession. she was “cracking up” and “was just feeling very strange”. She was “hyped up”, uncharacteristically “dancing around” and her “face [had] got so little”. Similarly Healy noticed that people looked “pallid and somehow shrunken” when experiencing drug induced akathisia (Healy, 2004a, p. 82). Elements of akathisia were also evident in Trish’s description of her partner, Simon, during their joint interview about Simon’s current use of Aropax: “It’s not like a depression because . it’s angry it’s volatile it’s suicidal it’s agitated. It’s not . wound down, it’s wound up, but wound up in a negative way”. Another informant, Linda, felt “not settled”, “anxious”, and “really odd” on Prozac. She “never slept for six months” while she was on the drug and felt that it “revved up my system . it’s like pushing my brains through my head or something . I was going about rushing all over the place I couldn’t keep still”. Akathisia in particular was a main theme in Debra’s account of her husband, Richard, suiciding twenty months after he was put on a large number of psychopharmaceuticals. Richard became “agitated and anxious” after taking SSRIs. He was “rushing around all the time”, “just could not sit still”, “prancing up and down all night” and wouldn’t sleep in the house he ‘d go and sleep in the motor home at
“He’s irrational angry volatiie and definitely suicidal”: Experiences of akathisia, aggression and suicidality Akathisia One well-known experience linked to SSRI related suicidality and/or aggression is a drug-induced agitation known as ‘akathisia’ (Breggin, 2003; Glenmullen, 2000; Healy, 2004a). Akathisia has been associated with a range of feelings and behaviours including ‘dancing’,pacing, nervousness, emotional lability, insomnia and anxiety, as well as euphoria, paranoia, mania and psychosis (Breggin, 2003; Putten, 1975). At its most extreme, it fosters lucid, intolerable and preoccupying suicidal and aggressive thoughts that can lead to violent and/or suicidal behaviours of the kind that has been associated with SSRI use (Breggin, 2003; Healy, 2004a). Akathisia was described by Heather when interviewed about the seemingly SSRI-induced suicide of her daughter, Sophie. Soon after she started taking Prozac, Sophie told Heather she felt like
In listening to and reading people’s accounts, four recurring themes were considered particularly relevant to
Table 1 Research participants Participant (age) Daisy (mid 3O’s) Debra (mid 5O’s) Gail (mid Heather (mid Jon (early 3O’s) Linda (late 5O’s) Simon (late 4O’s)
Key experiences reiating to SSRI use and suicidality and/or aggression Past and current positive experiences using a range of psychopharmaceuticals including Aropax and Efexor. Made one suicide attempt while on Aropax. Husband, Richard (5O’s), developed akathisia, aggression and suicidality leading to suicide when taking psychopharmaceuticals, including a range of SSRIs. Developed suicidality and made several suicide attempts when taking Aropax in the past. Daughter, Sophie (2O’s), developed akathisia and suicidality leading to suicide when taking Prozac. Developed anger and aggression and made one suicide attempt when taking Prozac in the past. Developed aggression when taking Prozac in the past. Current positive experiences on Aropax, and made suicide attempts when using Cipramil and Aropax in the past. Was interviewed with his partner, Trish, who believed he also developed suicidality and aggression from his current use of Aropax. Developed suicidality and aggression when taking Prozac in the past. Believed her partner, Simon, developed suicidality and aggression from taking Aropax. Was interviewed with Simon, who had made several suicide attempts and believed he had positive experiences when on Aropax.
Stuart (late 5O’s) Trish (early 4O’s)
A/ofe: All names are pseudonyms to protect the anonymity of participants. ‘ See Liebert and Gavey (2006) for more in depth narratives of Heather’s and Gail’s experiences. *40’ New Zeaiand Journai of Psychology Vol.37, No. 1, March 2008
Serious adverse effects from SSRI use
night .he wouldn’t tell me [why] he said it would be better that way he said. “Be better that way “. His head- must have been feeling so bad that he just wanted to get away [to] quiet, he couldn’t stand the TV, couldn’t hardly stand the lights on. Akathisia also seemed referenced in people’s descriptions of their labile moods. Debra further explained how Richard’s mood was “like these waves going through him”: “One minute he’d be OK, and happy, and he’d be walking along and he’d hold your hand or something” and then “next minute he’d be walking on that side of the road and you wouldn’t think you were even with him”. Trish similarly described how on Aropax Simon would sometimes “just, [snaps fingers] bingo! and gets angry or gets . suicidal . [and] there’s no discernable cause for it, it just happens.” These descriptions parallel those of Healy who found people’s moods while on Zoloft were “swingingft-omgloom to doom in a matter of minutes” and “from tears to mania within an hour” (Healy, 2004a, p. 184). When taking Prozac and then Luvox, one of Healy’s patients described his mind “like a video on fast forward”, saying that he felt “dangerous” and wanted to “get into my car and drive a long distance at high speed whilst sorting out the problems of Western civilisation as I went” (Healy, 2004a, p. 42). A similar experience was described in the present research by Stuart who, after taking Prozac, said he developed an anger that translated into a “drugrelated” ‘hypersensitivity’ to perceived injustice and consequently a degree of aggressive social activism: / was very aggressive, but I had the whole of [an area] reserved. I had parks created, I had trees planted, I had beaches fixed up. And I had a . church and house completely repainted, refurbished, new kindergarten started, . All was done was done through anger, anger at people’s failure to understand my vision. And they ‘d lie they ‘d cheat I’d catch them out . It’s all drug related because before those drugs I was just a peaceful relaxed person. Similarly another informant, Jon, described how two weeks after taking Prozac, “I would just not, you know like if I was going to have argument I would not be prepared to lose the battle. I would, for some reason I would try anything to win it.” Jon also explained how on the drugs he felt “out of control” and had his “thoughts running wild”, and how these feelings manifested into anger and aggression: I felt so angry that I really needed to do something just to be able to let it out, either to start yelling at my partner, or pick a fight with somebody else, or really have to do something because the feelings were so overwhelming I couldn’t sit still with that feeling. because I would start, you know how we have the fight or flight feeling, and if I just sat down and let it be, I started feeling out of control. You know my thoughts running wild, and I started getting to an anxious mood, panicking. Indeed, many informants spoke of how they experienced an increase in anger and aggression when taking SSRIs. Aggression Aside from the documentation of legal cases (e.g., Healy, 2004a), there has been little research published on the potential for SSRIs to elicit aggression. The majority of participants in the present research, however, discussed increases in anger and aggression when taking these drugs. Trish explained how she was supporting Simon to come off his Aropax. Every time they shaved a bit off the dose he would get a number of withdrawal effects including becoming “very grumpy, snappy, cross with things, irritable”. Linda noticed that she developed uncharacteristic road rage when taking Prozac to such an extent that she didn’t think she was “very safe”: [I] had road rage from the Prozac. . If somebody . overtook me I’d be driving after them and following after them and that, and I mean I’m really [usually] the most conservative person that ever was. It was scary. / couldn’t help it Ijust went in there and that was it and then I just went away again . it was just me at the time and I was just annoyed . but I mean I’m not even like that. because normally I let somebody pass. Jon also found that, “because of Prozac”, his feelings would become more “intense”. He “started getting angry all the time.