Doctors: Prozac, violence rarely linked — (Chicago Tribune)

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Chicago Tribune

The NIU shootings

Experts doubtful that halting medication led directly to shooting at NIU

By Jeremy Manier | TRIBUNE REPORTER

February 19, 2008

In the wake of Steven Kazmierczak’s murderous shooting spree at Northern Illinois University, law-enforcement officials noted he had begun to behave erratically after he recently stopped taking psychiatric medication.

That fact might seem to offer a tidy explanation for his rampage, or at least some insight into his troubled mind. But psychiatrists say suspending a patient’s use of antidepressants — Prozac, in Kazmierczak’s case — is rarely linked to violence toward others.

When used under a therapist’s supervision, they stress, such medication can help people overcome depression and other mental ailments. And while the source of Kazmierczak’s state of mind remains a mystery, experts said it’s unlikely that halting his Prozac therapy would have led directly to his shooting plot.

At the same time, psychiatrists say, his case may help reinforce a key lesson: Stopping antidepressant therapy suddenly can be risky if patients do not follow a doctor’s instructions and don’t report any negative effects.

About one-fifth of people who halt a course of Prozac-like drugs report symptoms associated with a condition known as discontinuation syndrome, which can include abdominal pain, dizziness, crying spells, irritability and even a sensation similar to an electrical shock in the patient’s arms or legs.

Kazmierczak’s former girlfriend, Jessica Baty, told CNN on Sunday that he had stopped taking Prozac because “he said it made him feel like a zombie.” One crucial detail left unanswered is whether Kazmierczak stopped the medication under the advice of a doctor or if he did it on his own.

Several experts said that because of discontinuation syndrome, they advise patients who stop to do so gradually and to call if they experience worrisome symptoms. With most patients, that’s enough to forestall any serious adverse effects.

“Your body has to adjust to being off the medication,” said Dr. Joan Anzia, an associate professor of psychiatry at Northwestern University’s Feinberg School of Medicine. “Some people are more sensitive to it than others.”

For some people, stopping antidepressants abruptly may leave them briefly worse off than they were before they took the medication. That’s because of the effect that Prozac and similar drugs have on serotonin, a chemical messenger in the brain that plays a key role in depression, obsessive-compulsive disorder and other psychological conditions.

Serotonin carries signals among brain cells that affect mood, appetite and sexuality, among other brain functions. Although the biological roots of depression are a source of controversy, some research suggests it may stem in part from low levels of serotonin.

The Prozac class of antidepressants — also called SSRIs — works by producing a surplus of serotonin in the brain. The excess serotonin can ease anxiety, curb unwanted impulses and relieve depression. It can also lead to diverse side effects, including the “zombie”-like lack of motivation that Kazmierczak’s former girlfriend described. But other patients experience virtually the opposite problem in the form of akathisia, a state of extreme restlessness.

The added serotonin may also change how some brain cells function, by decreasing their normal response to the chemical. That may worsen the effects of low serotonin levels when patients abruptly stop taking antidepressants.

“The issue is how fast you reduce the serotonin activity,” said Dr. William Scheftner, chair of psychiatry at Rush University Medical Center. “If the drug dosage is lowered gradually you have the opportunity to make adjustments.”

It’s rare for patients who are stopping antidepressants to report severe psychological effects, but such reports do exist. Last month, doctors from Stanford University published a case study of a woman who began having symptoms of delusion within days of halting her Prozac therapy. The patient imagined hearing her son’s voice even though he wasn’t there, had uncontrollable crying spells and at one point said, “I am Jesus.”

In one other case of multiple homicides, the Columbine school shootings, assailant Eric Harris had been taking the antidepressant Luvox before the murders. Harris claimed on a videotaped message that he stopped taking the pills in order to let his anger grow without the restraint of the medication.

It’s true that antidepressants such as Prozac can reduce impulsive aggression in patients who are prone to such problems, said Dr. Emil Coccaro, chair of psychiatry at the University of Chicago Medical Center. For such patients, going off the drug may lead to loss of impulse control and more aggressiveness, he said.

Yet Coccaro noted that the NIU murders did not appear to be a case of impulsive killings. Kazmierczak planned the spree in advance, and apparently sent goodbye messages and phone calls the night before the murders.

“That looks like premeditated behavior,” Coccaro said. “He didn’t just snap.”

In addition, unlike Zoloft and other similar medications that disperse from the body rapidly once patients stop taking them, Prozac persists in the body for weeks. That can cushion the sudden effects of going off the drug, experts said.

Patients who take Prozac in low doses — about 25 milligrams per day or less — tend to have the fewest side effects when stopping the drug, said Anzia of Northwestern. Kazmierczak’s dosage level is unclear.

The idea that Prozac itself leads patients to violence has gained little scientific support. In 2004, the U.S. Food and Drug Administration required drug companies to put a warning label on antidepressants such as Prozac, stating that the drugs may provoke suicidal thoughts in young adults. That move was controversial, and a study last year by University of Illinois at Chicago researcher Robert Gibbons showed that suicide rates among young adults have increased as antidepressant use declined.

Many experts point to such studies as evidence that whatever the risks of antidepressants, they are outweighed by the drugs’ effectiveness at preventing suicide by treating patients’ depression.

For now, the public information about Kazmierczak’s psychological history remains incomplete, making it nearly impossible to guess what mental problems may have affected his behavior.

But experts said it may be significant that Kazmierczak’s former girlfriend said he cut himself as a teenager. Cutting can be a sign of serious psychological problems, Coccaro said, and that history of trouble is at least as important as the medication that Kazmierczak took.

“It’s hard to believe this just appeared from nowhere,” Coccaro said.

 

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CNN.com

Girlfriend: Shooter was taking cocktail of 3 drugs

February 20, 2008

From Abbie Boudreau and Scott Zamost, CNN Special Investigations Unit

(CNN) — Steven Kazmierczak had been taking three drugs prescribed for him by his psychiatrist, the Northern Illinois University gunman’s girlfriend told CNN.

Jessica Baty said Tuesday that her boyfriend of two years had been taking Xanax, used to treat anxiety, and Ambien, a sleep agent, as well as the antidepressant Prozac.

Baty said the psychiatrist prescribed the medications, a fact that made her so “nervous” that she tried to persuade Kazmierczak to stop taking one of the drugs.

She said he had stopped taking the antidepressant three weeks before the Valentine’s Day rampage on the NIU campus in DeKalb, Illinois, which left five students dead and 16 wounded. He then killed himself.

In an exclusive interview with CNN Sunday, Baty said Kazmierczak had been taking the anti-depressant for obsessive-compulsive tendencies and anxiety caused by school pressures.

She told CNN that, during their two-year courtship, she had never seen him display violent tendencies and she expressed bewilderment over the cause of the rampage.

“He was anything but a monster,” Baty said. “He was probably the nicest, most caring person ever.”

Kazmierczak told her he had stopped taking the anti-depressant “because it made him feel like a zombie,” she said during the interview Sunday at her parents’ house in Wonder Lake, Illinois. “He wasn’t acting erratic. He was just a little quicker to get annoyed.”

She said he had also had problems sleeping.

In her second conversation with CNN, on Tuesday, Baty said Kazmierczak began seeing the psychiatrist shortly after they transferred from NIU to the University of Illinois in Champaign in June 2007.

A psychiatrist not familiar with the details of the case said the three-drug combination was not necessarily either unusual or dangerous.

“It’s not terribly unusual to prescribe all three,” said Dr. Nada Stotland, professor of psychiatry at Rush Medical College in Chicago and president-elect of the American Psychiatric Association.

Xanax typically has a sedating, calming effect on users, she said.

“If you take a lot of that class of medication, you can be sort of like somebody who is drunk, out of it, but not violent,” she said.

A person who had stopped taking it might feel anxious and edgy, she said.

And Ambien is commonly prescribed to overcome sleeping difficulties sometimes attributed to Prozac, she said.

Baty also said that Kazmierczak had been on the computer recently, but she did not know what he was doing and did not ask.

“He was being secretive with his computer,” Baty said. “When he would sit on the couch with his laptop he would turn it away from me so I couldn’t see what he was looking at.”

Baty added that she found Kazmierczak’s bank statement on Tuesday, when she returned to their apartment complex for the first time since the shootings.

“He made a big purchase at an ammo store for $143 and some change,” Baty said, adding that she thinks he purchased the ammunition at an online store, but she did not know the name or location.

She said he also had made credit card payments and paid the electric bill for their apartment.

Baty disagreed with a report in the Chicago Tribune that said she had given police a different account about Kazmierczak’s last days than she gave to CNN.

NIU Police Chief Donald Grady said Baty’s statements to CNN contradicted statements she had given to police that her former boyfriend had indeed acted erratically after going off his medication.

“I suppose you could call that being uncooperative,” said Grady.

Baty said the comment “upset” her.“I don’t think I ever said he (Kazmierczak) was acting erratic,” she told CNN. “If I did, I didn’t mean to be contradictory. He was just a little more irritable.”

She said she has spoken with DeKalb police every day since the shooting.