a clinical impression…

Posted on Monday 30 March 2015

David Healy has up a post about the Pilot Suicide/Murder last week [Winging it: Antidepressants and Plane Crashes]. There’s also one on his Rxisk site by Julie Wood [Pilots and Antidepressants]. Meanwhile, the Psych Listserves and Twitter feeds have been abuzz with speculations that this was an SSRI [or other Psych Med] reaction. David, who has done more than anyone to bring these reactions to our attention, does a yeoman’s job of laying out how this is likely to play out. So I’ll stay out of his way on that score, deferring to his expertise, but I do want to briefly comment on a statement he makes along the way:
There are likely to be a number of features to the current debate.
    First an impression will be created that we know more about these drugs than we in fact do.
We know almost nothing about what antidepressants actually do – we still don’t know what they do to serotonin. Rather than being effective like an antibiotic, these drugs have effects – as alcohol does. Their primary effect is to emotionally numb. Patients on them walk a tightrope as to whether this emotional effect is going to be beneficial or disastrous.
I’ve never actually read those bolded parts said that way – their primary effect is to emotionally numb – but that’s exactly what I have also concluded on my own that the SSRIs do – emotionally numb. It’s just confirming to read it in print. And I sure agree that We know almost nothing about what antidepressants actually do
    March 30, 2015 | 6:27 PM

    It is probably never a good idea to ignore what we don’t know about human consciousness to make a favorite point about an antidepressant:




    March 30, 2015 | 7:19 PM

    Really disappointing to read this post. Gee, how did that speculation go for that police officer in Ferguson Missouri last summer? What’s the antipsychiatry crowd gonna do when the next mass murderer not only was not on any psych meds, but actually was found to be a supporter of antipsychiatry narratives?

    Sure they will find a way to again blame it on psychiatry. I guess when in Rome, eh, Dr Nardo?

    I’m sticking with my assumption until irrefutable facts prove me wrong, which I don’t know what that does for everyone else: Axis 2 was a primary player to this guy, and no one really picked it up, certainly could not medicate it, and doubt whatever psychotherapy was in place, did not account for it enough to have a significant impact to improve his life.

    Oh, and what about the eye sight issue? Oh yeah, the meds did that too!?!?

    March 30, 2015 | 10:24 PM

    Oh, by the way, probably NOT going to have any body parts of the co pilot to do an autopsy, so then we will speculate if he was taking meds at all until the end of time. I guess we will see who controls the narrative, truth, or personal gain.

    Here is the real comedy to this post for me, it shows exactly what the last refuge of the scoundrel of race hustlers is racism, and the scoundrel of the antipsychiatry crowd is the presence of medication. Because it is easy to hide behind emotionally charged accusations that inherently make people wary and uneasy. Meds are a gray zone, we all know there is a sizeable population that honestly and effectively benefit from them, but, extremes have to be maintained, and narratives must be won. So, the minority few who have been harmed control the dialogue.

    It is a good thing that these antipsychiatry folk weren’t around when Penicillin came about, those 10% with allergic reactions would have risked making those other 90% be miserable with infections, if not just plain die.

    But, again, I am sorry I don’t cooperate with the narrative. Shame on me?

    Nah, shame on you who cooperate!

    March 30, 2015 | 10:52 PM

    Antidepressant withdrawal syndrome and DUI evaluation.
    By: Spiller, Henry; Sawyer, Tama S.
    Publication: The Forensic Examiner
    Date: Saturday, September 22 2007

    Full text at http://acfei-forensics.blogspot.com/2008/03/antidepressant-withdrawal-syndrome-and.html

    Abstract at https://www.ncjrs.gov/App/publications/Abstract.aspx?id=247046


    Millions of Americans annually receive selective serotonin reuptake inhibitor antidepressants and dual-action antidepressants for their symptoms of depression. These patients are at risk for a well-documented withdrawal syndrome if they abruptly stop their medication. This withdrawal syndrome may produce significant effects that may impair a person’s ability to drive, putting at risk both the driver and others on the road. In a situation of the antidepressant withdrawal syndrome, the impairment is due to the absence of drugs in the patient, producing the paradox of a potentially impaired driver because of an absence of the influence of a drug. This article reviews the antidepressant withdrawal syndrome and describes the effects on cognition, memory, vision, and motor performance and reviews how these clinical effects might be misinterpreted using standardized field sobriety tests suggesting the patient is intoxicated in the absence of other drugs or alcohol.

    March 30, 2015 | 11:14 PM

    So, that warning the FDA put on SSRIs about suicidal an homicidal reactions should just be conveniently ignored right now, because it makes some psychiatrists feel defensive?

    How sciency.

    James O'Brien, M.D.
    March 31, 2015 | 12:06 AM

    This is already off the rails.

    I will refrain from comment until we know more.

    berit bryn jensen
    March 31, 2015 | 1:38 AM

    A new book by Peter Gøtzsche is coming out in september, aptly titled “Deadly psychiatry and organized denial”.

    James O'Brien, M.D.
    March 31, 2015 | 1:57 AM

    No sense waiting for the actual facts to come out when some of us are chomping at the bit to promote rigid agendas.

    Not that there will be any mea culpas if the favored theory doesn’t work out…

    berit bryn jensen
    March 31, 2015 | 2:32 AM
    March 31, 2015 | 3:43 AM

    The fact still remains. 23.8% of pilots who took part in Aircraft-assisted suicides between 1993-2012 were on psychiatric medication/or had taken psychiatric medication prior to the suicide.


    March 31, 2015 | 7:10 AM

    I agree with Dr. O’Brien that there are still too many unanswered questions to be making any determinations.

    Dr. Hassman, vision problems are quite common with all psychotropic medications. How much that is relevant regarding the pilot’s situation is another issue. Did he have vision problems prior to being placed on antidepressants or did this occur after he was put on the medication?

    Regarding med side effects, as one who ended up in the ER due to an adverse reaction to a regular med, no,I definitely don’t think it should be banned just like I don’t think psych meds should be. But what was frustrating about my experience is the feeling of being subtly blamed for my plight when I absolutely did nothing to deserve that. That is why many people are so angry about the issue of meds as they feel their complaints about side effects are blown off.


    Steve Lucas
    March 31, 2015 | 7:53 AM

    Another issue is the straight jacket we place on mental health professionals regarding reporting mental health issues to employers and others that may be harmed. While the intention is to prevent a stigma being attached to the person, here we have the very real issue of the loss of life.

    Additionally, in my limited experience, I have found a great deal of paranoia in those dealing with any number of conditions. Fear of exposure drives them to a place where any action becomes permissible.

    I dealt in the past with a minister who would be professionally diagnosed as a psychopath. Today I am trying to deal with two ministers with very different mental health profiles, but both are equally destructive. The denomination will not act on the management or financial issues and simply ignore the mental health issues driving these behaviors.

    One can only remember not to drink the kool-aide and not buy into their crazy.

    This loss of life with this issue is tragic. We do need to wait for all the information to be presented before passing judgment.

    My reality is this situation is being repeated over and over as employers and co-workers are not aware of the mental health issues of co-workers. GP’s prescribe very powerful SSRI’s to an ever increasing number of people with little or no follow up and privacy laws put large numbers of people at risk.

    We need to deal with mental health issues as adults, not placing a stigma on the person receiving treatment, but also recognizing their condition and medications may place others at risk.

    Steve Lucas

    March 31, 2015 | 8:08 AM

    SL- He was German. The laws on reporting may be different.

    JH-I worry much less about the anti-psychiatry backlash than I do about (NB: SL) overzealous reporting of mental health treatment that will deter people from seeking help. We need a culture where it is okay to ask for help. Because not all suicidal ideation is going to be the same. You could easily have someone who thought some about killing himself and even an actively suicidal person who considered himself a burden to others but would never dream of hurting others.

    March 31, 2015 | 2:02 PM

    There probably is no way to determine exactly what Andreas Lubitz intended to do or what caused his intention.

    For some people, initiating or changing antidepressants causes irrational, suicidal, or even homicidal thoughts. Quitting or inconsistent dosing, such as skipping doses, can cause the same.

    There are always a few people on my site who, in the midst of withdrawal syndrome, are preoccupied with suicide because of the bizarre symptoms, discomfort, and emotional anesthesia, where no such intent existed before.

    Spiller, 2007 (link above) mentions withdrawal-induced eye symptoms, which could indeed be a concern for an airplane pilot, as they are for someone driving any vehicle.

    James O'Brien, M.D.
    March 31, 2015 | 2:38 PM

    It is completely irresponsible and foolish to speculate on his ophtho issues until we have all the facts.

    Same with the “numbing” theory. Some people say watching porn causes emotional numbing and we know he did plenty of that. But I’m not going to stick my neck out and say that’s why he killed 149 people.

    What’s wrong with we don’t know enough and let’s hold off until we do?

    Agendas uber alles…

    March 31, 2015 | 7:27 PM

    AA: yes, visual problems can be caused by meds, but, where are the irrefutable facts what the copilot took and when he last took them?

    And, it appears the visual issues might be irregardless of meds use.

    East Coaster: not really clear what your point is, I agree we need a culture that is not biased and discriminatory, hence why getting involved in assessing people for employability is a big risk for all involved.

    Read this link and decide if applicable:

    Ends with this: “There is also the risk of placing too much stigma on mental illness. Extremely few mentally ill people go on to become mass killers. Even among schizophrenics, the rate is much lower than one person out of every 100,000.

    There are no cheap or easy answers. If someone poses a true danger to others, why not lock them up? Or provide outpatient caregivers to monitor them?

    No one wants a dangerous person to have a weapon. But our mental-health system can’t be the last line of defense. There are just too many mistakes.”

    March 31, 2015 | 8:00 PM

    I hear you, Dr. O’B. And just for the record: no one, least of all Healy, is going on the record to state that “The antidepressants made him do it.” Because we have not been given enough facts to make any firm conclusions.

    But here’s the problem: We will not be getting anything close to “all the facts” unless there is a public discussion (including both wise and foolish voices) and a DEMAND for the facts. That’s been the lesson of maybe the past dozen “mass killing” cases in this country. We learn VERY little at first and absolutely nothing later. Then we are told with great authority that “mental illness” is the explanation, no matter how peaceable or rational the perpetrator seemed to his friends and family.

    A suicidal impulse triggered by antidepressants is a possibility. So is non-suicidal recklessness with the same source (and the RxISK article actually contains more of these incidents than suicides). So is a blackout of the type I experienced when a combo of AD’s and antibiotics caused my heart to start skipping a beat (and not in a good way).

    The authorities will not even allow for comment on these possibilities unless they have to. The clout of the manufacturers and distributors of these meds is enormous. Deferring to it is by far the easiest course.

    In a different sort of world, we could wait for an objective investigation to provide us with all the facts. But in this world, we need people — particularly people with some expertise and reputation on these issues — to stick their necks out. Not to give us the answers, but just to ask the questions.

    March 31, 2015 | 9:20 PM

    Oh come on. He crashed the plane next to the glider path he frequented as a child. The answer– at least in part– is in history, his history and all that we now don’t consider relevant because “psycho-dynamic” and “psychoanalysis” are forbidden terms and concepts in present day psychiatry.

    March 31, 2015 | 10:21 PM

    This crash fits very well into the profile of SSRI-induced suicidality and homicidality. First because of its extreme destructiveness. The first article on SSRI-induced suicidality already described the case of a man who one month after starting fluoxetine began to fantasize “about killing himself in a gas explosion or a car crash.” The severe violence of the suicidal and homicidal thoughts and acts induced by SSRIs is often explicitly noted by authors of case studies as well as by former users. Also regularly noted is the combined suicidality and homicidality, such as in the murder-suicides and mass shootings. Another early article on this issue described the case of a boy who one month after starting fluoxetine began to experience violent nightmares including “about killing his classmates until he himself was shot,” from which he awoke only with difficulty and which continued to feel “very real.” This is not only relevant for understanding the school and other mass shootings committed on SSRIs, but also for understanding this crash. Nightmares and a dissociative, “dream-like” or “zombie-like” state have been frequently described with regard to SSRI-induced suicidality and homicidality (e.g. by Dr. Healy here and here). We know that Lubitz suffered from nightmares and would wake up screaming “we’re going down.” His breathing in the last minutes before the crash, “calm and rhythmic until the end,” could point to a dissociative state. The seemingly impulsive and out-of-character nature of the act is also in line with case studies such as those mentioned above, as well as with testimonies by former users such as given at the various FDA hearings on this matter.

    Does this mean that this act was caused by SSRI-induced suicidal and homicidal ideation? Not necessarily. But it does mean that the possibility should be taken into account. Of a single case in which the perpetrator has died, we can never know for sure whether it was caused by the SSRIs even if we have “all the facts.” But case studies such as those mentioned above with challenge-dechallenge and dose-response, and analyses such as this one and this one by Dr. Healy, leave no doubt that people do become suicidal and/or homicidal on SSRIs. This has also been described by Dr. Nardo.

    It is beyond me how Dr. Hassman can claim that those who have been harmed by SSRIs “control the dialogue.” In the mainstream media I’ve only seen this crash explained by means of the depression and not the antidepressants. Psychiatry has the dialogue in a chokehold by declaring even the suggestion that SSRIs might play a role in this as taboo, as can already be seen in this comment section. If this would lead to more pilots getting “treated for depression” it could be a disaster.

    I hope Dr. Dawson, Dr. Hassman, and Dr. O’Brien are aware that the many case studies in the early nineties on fluoxetine-induced suicidality and homicidality were written by mainstream biological psychiatrists and not “the antipsychiatry crowd.” We know from internal documents that Lilly then started a massive campaign to “save Prozac,” because “Lilly can go down the tubes if we lose Prozac.” This is all documented in Dr. Healy’s book Let Them Eat Prozac and on the accompanying website with background materials. At the 1991 FDA hearing, after a harrowing morning of user testimonies but a “reassuring” afternoon with three presentations by Lilly scientists plus pro-drug presentations by the NIMH and the FDA, the committee voted unanimously that there was no credible evidence that antidepressants cause suicidality or other violent behaviors – a catastrophic mistake of which we might have seen the latest consequence last week. We should be talking more about that possibility, not less.

    PS. Dr. Nardo, thank you for your great blog. I’m a long-time reader but first-time commenter (and former long-time user of various SSRIs).

    James O'Brien, M.D.
    March 31, 2015 | 10:25 PM

    We may be reaching the natural logical endpoint to stigma reduction. The same psychiatrists (see Psychiatric Times, recent APA Presidents) would constantly fantasize about a stigma free society would admit that homicidally psychotic people should not have guns and suicidal people should not fly planes. But you can’t have it both ways. If you are not allowing the severely mentally ill the same rights and privileges as anyone else, you are in effect stigmatizing them. Can we lay off the self-congratulatory sermons and be honest about this issue? It’s not as simple as scolding the bigots. In the real world there are tough choices to make and we can’t have everything. Public safety of hundreds of innocents will rightly win out over disappointed feelings.

    April 1, 2015 | 3:38 AM

    “”Then we are told with great authority that “mental illness” is the explanation, no matter how peaceable or rational the perpetrator seemed to his friends and family.””

    Great point Johanna. And it seems like friends and family of this co-pilot were shocked that he would do what he did. That theme seems to pop up constantly in the case of possible SSRI induced killings.

    And by the way, before anyone thinks I am making generalizations, I am not. In the case of Columbine where many people blamed SSRIs on the killings, I definitely don’t. It seems at least Eric Harris, the ringleader was definitely big time bad news before SSRIs entered the picture. Maybe at the worst, they pushed him over the edge but I definitely don’t think they were the culprit.

    Anyway, I still feel there are way too many unanswered questions but definitely agree with you Johanna that they may remain unanswered in the name of blaming everything on mental illness.

    Finally, to the medical professionals who visit this site. Even if you feel that SSRIs were not to blame in this case, have you ever felt they were responsible for homicide and if so, what made you conclude that?

    April 1, 2015 | 8:49 AM

    Why do we keep ignoring undeclared conflict of interest in one of the largest recipients of Pharma money among UK psychiatrists, as well as lucrative paid expert testimony with a known bias. https://dl.dropboxusercontent.com/u/23608059/martyrdom%20of%20healy.pdf

    April 1, 2015 | 9:32 AM

    Once again people are making a gray issue so blatantly black and white, won’t work in the end.

    SSRIs are not toxic if prescribed responsibly, they should be titrated in 25% increments at most to get to usual effective dosages in 4-7 day increments, should never be pushed beyond ceiling dosages, and tapered in realistic increments per duration of use, this last one we have debated before ad nauseum.

    So, the Prozac example is pathetic, Lilly was a fraud in claiming one dose fit all with their solo 20mg dose back in the late 80s-early 90s, I was the only resident NOT writing for it until I learned how to give half to 1/4 dosages by opening the capsule and mixing it in acidic juices, having patients drink a 1/4 to 1/2 a day and save it in the fridge covered; I can’t remember negative side effects when I did write for it apart from headaches or nausea but at least at 5-10mg dosages first!

    And then Lilly belated came out with solutions, then 10mg tabs, so they figured out they were idiots! As to Paxil, well, the med with the highest affinity for Serotinergic receptors, that was a red flag for me, so did not use it much, and always titrated from 5mg first anyway when I cautiously did prescribe it.

    Zoloft and Celexa, my stalwarts, have rarely had sizeable problems for patients apart from not impacting once titrated to 75-150 or 30-60 respectfully, so I have stuck with them thru my career. Effexor has strengths and weaknesses, Lexapro I think is a joke with docs recklessly starting people on 10 and then reflexively thinking most have to go to 20mg, which by the way is equal to 60+mg of Celexa, so again ask your physicians giving out Lexapro would they just reflexively put their patients on 60mg Celexa as the typical dose?

    Anyway, if you are going to debate the problems with SSRIs, know the foundations to the meds and pay attention to who are the most common prescribers these past 10 years, and thus start your bitching at PCP sites!


    April 1, 2015 | 9:38 AM

    Re reading my above comments, titrating meds should take at least 2-3 weeks to get the patient to an effective dose, as example Zoloft one would start at 12.5 or 25 and go up in the increment first dose every 4-7 days to get to 75 mg for 10-14 days, and then go from there. Celexa at 5-10mg and get to 30mg again for 10-14 days and have the follow ups at those dosages and patients seem to tolerate them well.

    Sorry the above was too vague.

    April 1, 2015 | 11:59 AM

    Dr. N. was addressing Healy’s comments about emotional numbness. That has been my experience personally and clinically as well.

    Haven’t we all see this, in our friends or our patients taking SSRIs? And when there is an episode of self-harm, how often do we hear, “Gee, it was like someone else was doing it?” or “You know, it’s funny, I can’t tell you what I was feeling.” I only practiced for a few years, and I saw this at least three or four times. I was only on paroxetine myself for a couple of weeks, and I definitely felt it. It seemed like a different entity from “derealization” or “disassociation” that I’ve felt vaguely when I’ve had a fever or after not getting enough sleep– that was almost a physical sensation, more like cannabis, definitely a cloudy feeling.

    With paroxetine, it seems more like feeling clear-headed, but not being emotionally connected. Very hard to describe.

    Another huge problem here in the US, and in California specifically, is that licensed therapists are mandated to refer patients with “Major Depressive Disorder” (or patients with mood problems that really don’t even meet the criteria for Bipolar I or II) to psychiatrists. In a perfect world, that would be great– I love consulting with psychiatrists. (Obviously. Here I am, right?)

    Fortunately, at my clinic, I worked with two great psychiatrists who did not always prescribe meds, and frequently helped patients titrate off them. But at most clinics, “psychiatry” is synonymous with “medication.” If I’d been at a different training site, the pressure to misdiagnose– and risk my intern number– just so clients would not be prescribed meds would have been significant.

    Because– and I have to speak frankly, here– I did find it much harder to work with clients who were taking antidepressants because they often became more emotionally numb. You can still do CBT effectively enough, but even in 26 weeks, many clients could have benefited from a more psychodynamic approach. Process work starts becoming more difficult.

    Katie Tierney Higgins RN
    April 1, 2015 | 12:27 PM

    Throughout my 20 year career as a psychiatric nurse, I encountered an obstacle to patient care and safety that could not be surmounted. The great divide, I call it. The superior, authoritarian demeanor of most psychiatrists — which persists even after the evidence for their having claimed authority without evidence has been quite thoroughly documented. It is crucial to witness the responses to the evidence, as it highlights what I see as the greatest evidence of the downfall of psychiatry ;
    Is it possible, to engage in discussion about the serious, life threatening risks of *psychiatric prescriptions* for * poorly substantiated psychiatric diagnosis*?

    A very few psychiatrists have engaged in the process of dialogue on the issues that most clearly speak to the harm done by propagation of bad science and participation in clearly proven marketing schemes with pharma. David Healy stands out as the only psychiatrist who dared to broach the topics that someone like me, a nurse, find the most relevant to psychiatry. IS it a medical specialty, comprised of professionals who are both courageous in their pursuit of alleviating suffering AND concerned about their patients? As a nurse, I found this NOT to be the case. I am not surprised that the criticisms are now rampant from all sectors of society, and simply furious that even now, when the threats to the public welfare are again, called to our attention, there is a prevailing tendency to protect psychiatry as a *noble profession*.

    I encourage all of the commenting psychiatrists here to reflect on– what behavior demonstrates one is both noble and professional? I am providing a link here to a radio interview taped last April, in which Dr. Healy demonstrates that there are, without a doubt, serious issues that must be addressed by his colleagues, and that the process of discussion will not become easier as the evidence for corruption and sheer indifference to it are mounting at an exponential rate.

    Hey check this out: https://www.corbettreport.com/interview-858-dr-david-healy-on-ssris-and-violent-behaviour/

    It never ceased to confound me, as a nurse, that doctors could deny what was right in front of their faces– the patients complaining, getting worse, losing hope. Similarly it was disturbing to be completely discounted as one who cared for and became closely connected to young patients and their families– AND to be disciplined for offering academic, scientific literature to the discussion (until 2010 at a prominent Harvard affiliated children’s hospital and 2014 in a small, corporate owned hospital) was beyond the pale. I fear for the unwitting public that is now encountering psychiatric *treatment* at a very alarming rate.

    I applaud Johann, Altostrata, Martijn and AA for doing their homework and speaking with clarity and compassion. I appreciate Dr. Nardo’s open and ruthlessly seeking mind. The simple truth is that people are suffering from a myriad of maladies– but none seem quite as pernicious or intractable as the condition that causes doctors to lose contact with the purpose of their profession, and seek only to preserve their status as superior authorities.

    If ever there was a case for a DSM label– Axis II– thy name is……but since we have it on psychiatrist based authority that these *disorders* are treatment resistant– well, the only recourse I can support is legal/criminal action. There really is no sane excuse for allowing fraud, causing harm where the benefit is clearly financial profit to be called, a *medical specialty*.

    IF psychiatry were a valid medical specialty, the discussion proposed by Dr. Healy over a decade ago would be the only focus of this *profession*.

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