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Link Between Antidepressants, Violence Unclear: Role in Suicidal Behavior is More Definite, Some Say

Posted on: Sunday, 29 January 2006, 12:00 CST

By Karen Garloch, The Charlotte Observer, N.C.

Jan. 29--Can antidepressants lead people to become violent?

The question has been raised frequently in recent years, often by lawyers representing murder defendants who had been taking drugs, such as Prozac, Paxil and Zoloft.

It surfaced in Charlotte with the stabbing deaths Jan. 20 of 5-year-old twin girls. Their father, David Crespi, who was taking antidepressants and sleeping pills, was charged with murder.

Without details of Crespi's treatment, experts say speculation is dangerous. Even when specifics are known, answers aren't always clear. "Sometimes it is hard to accept (that) we don't know why for sure," said Dr. Ranga Krishnan, chairman of psychiatry at Duke University Medical Center.

It's always wise to monitor a depressed person for suicidal behavior, Krishnan said. "But homicide is more rare. The evidence is less clear than it is for suicide."

The connection some draw between antidepressants and violence is controversial.

Dr. Joseph Glenmullen, author of "Prozac Backlash," argues antidepressants can cause both suicidal and homicidal behavior. "These really are terrible tragedies, but antidepressants can do this to people."

The debate came to a head in 2004 when the U.S. Food and Drug Administration ordered that Zoloft and similar antidepressants should carry warnings that they "increase the risk of suicidal thinking and behavior" in children with depression and other psychiatric disorders.

The FDA already requires a less stringent warning for adults, noting that antidepressants can cause anxiety, irritability, hostility, aggressiveness and impulsiveness. Canada and European countries have more explicit warnings about antidepressants causing violence toward other people, Glenmullen said.

The FDA is reviewing whether to require a stronger warning about suicidal behavior in adults taking antidepressants.

Dr. Ervin Thompson, medical director of Carolinas Medical Center-Randolph Behavioral Health Services, said that if a person is severely depressed, "You could be worried about murder-suicide ... but the main concern is with suicide."

Energy grows, some say

Depression is a common factor among parents who kill their children.A 2005 Canadian study of 77 child deaths by 60 fathers found that one-third were so depressed they were psychotic, meaning they had lost touch with reality, Thompson said. The study also showed that 60 percent of the homicides were followed by suicide. Of fathers who killed more than one child, 86 percent killed themselves.

People who are deeply depressed, experts said, usually do not have the energy to commit suicide. But many believe the risk of suicide goes up as depressed people begin taking antidepressants. The reason is that energy may increase before feelings of hopelessness lift.

"Just prescribing a drug alone is not enough," Krishnan said. "Follow-up is key. When you're treating someone, the highest risk time is when they're actually beginning to feel better."

Depression can be treated well with medicines and therapy, either separately or together, doctors said. Some patients benefit from drugs alone, but others, especially those with "significant life problems contributing to the depression," Thompson said, should get therapy as well.

While rare, violence can happen, Thompson said, if patients become psychotic. That can happen if medicines are prescribed inappropriately. For example, he said, in someone with bipolar disorder who is misdiagnosed with depression, antidepressants can cause mania that can lead to violent behavior.

Also, untreated depression could worsen to the point of psychosis, and that could lead to violence.

"You can become so depressed that you lose touch with reality," Thompson said. That could bring hallucinations in which people "hear things and see things that are not there."

Thompson added that it is standard practice for sleep medicine to be prescribed along with psychiatric medicines, partly because a side effect of antidepressants is insomnia.

"Anybody who's sleep deprived, their judgment goes down," said Glenmullen.

Another possible trigger of violence is akathisia, a feeling of restlessness that is a possible side effect of antidepressants.

"Akathisia makes people profoundly agitated, uncomfortable in their own skin, jittery, impulsive," said Glenmullen. "It erodes judgment. It can lower their threshold to become violent toward themselves or others."

Lawyers in the Florida trial of Leslie Demeniuk, accused of killing her 4-year-old twin sons in 2001, claimed antidepressants caused her to crave alcohol to relieve feelings of restlessness and anxiety. The jury rejected her insanity defense and on Jan. 17 found her guilty.

20-year controversy

The possible link between antidepressants and violence has been argued since the late 1980s, when the FDA approved Prozac, the first in a class of drugs called selective serotonin reuptake inhibitors or SSRIs.

In a high-profile case, the family of a Louisville man sued Eli Lilly & Co., the maker of Prozac, claiming his four-week use of the drug caused the 1989 rampage in which he fatally shot eight people and wounded 12. Lilly won, but the judge later changed the verdict to "dismissed as settled" after it was revealed Lilly had struck an agreement with the family during the trial.

A link between antidepressants and violence was also argued last year in the case of Christopher Pittman, accused of killing his grandparents in Chester County, S.C., in 2001, when he was 12. Attorneys claimed Zoloft caused his violence. He was found guilty and sentenced to 30 years in prison.

One jury in a civil trial has concluded that an antidepressant, Paxil, caused a man to commit murder. In June 2001, a jury in Cheyenne, Wyo., ordered SmithKline Beecham (now GlaxoSmithKline) to pay $6.5 million to the relatives of Donald Schell. He had been taking Paxil for 48 hours when he shot and killed his wife, his daughter, his granddaughter and himself. The company appealed, but then settled the case, for undisclosed terms.

People need treatment

Many doctors worry that focusing on violence could make people wary of antidepressants and prevent them from getting treatment. More people are helped by the drugs, doctors say, than harmed.Betty Cobb is one of them. She became severely depressed after the death of her husband last May.

"I just became a hermit in my house," said Cobb of the National Alliance on Mental Illness-Charlotte. "I didn't want to go out. Everything I ate tasted terrible. I couldn't make any decisions at all. I just felt hopeless....My family was saying 'Pick yourself up by your bootstraps and get going,' and I couldn't."

In October, she said, she was hospitalized for "suicidal tendencies" and began treatment with Remeron.

"I started to feel much better, but it wasn't overnight," she said. "I feel like I'm perfectly normal now, but I'm taking my medicine....Mental illness can happen to anybody, from the poor to the very rich. I feel if I talk about it, maybe it will help somebody else." -- Staff researcher Maria Wygand contributed to this article.

-- Karen Garloch: (704) 358-5078

Depression and Treatment

About 18.8 million American adults (9.5 percent of the population) suffer from depression.

MAJOR DEPRESSION

Symptoms: Depressed mood, inability to experience pleasure, loss of appetite, loss of energy, inability to sleep and suicidal thoughts.

Treatment: The newest antidepressants, such as Prozac and Zoloft, are selective serotonin reuptake inhibitors, or SSRIs. They increase the amount of serotonin, a chemical that stimulates receptors in the brain. A variety of psychotherapies can help. Electroconvulsive therapy is useful, particularly for those whose depression is life threatening or who cannot take antidepressants.

BIPOLAR DISORDER

Symptoms: Dramatic changes in energy, behavior and mood, from mania to depression and back, often with periods of normal mood in between.

Treatment: Mood stabilizers, such as Lithium and Depakote. They may be combined with antidepressants or anticonvulsants, such as Lamictal.

SOURCE: National Institute of Mental Health, Dr. Ervin Thompson of Carolinas Medical Center

Warning Signs of Depression

-- Persistent sadness or anxiety.-- Feelings of hopelessness helplessness.

-- Loss of interest or pleasure in activities that were once enjoyed.

-- Decreased energy, fatigue.

-- Difficulty concentrating, making decisions.

-- Insomnia or oversleeping.

-- Loss of appetite and weight, or overeating and weight gain.

-- Suicidal thoughts, suicide attempts.

-- Restlessness, irritability.

SOURCE: National Institute of Mental Health

Resources

-- National Alliance on Mental Illness-Charlotte. (704) 333-8218 or www.nami-charlotte.org .

-- National Institute for Mental Health. Toll-free (866) 615-6464, www.nimh.nih.gov .

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Copyright (c) 2006, The Charlotte Observer, N.C.

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Source: The Charlotte Observer (Charlotte, N.C.)

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