One of the great pitfalls of being a physician is something medical students call Zebras – those cases of rare or obscure diseases that get missed in the course of routine practice. These days, they’re the stuff of medical television like the series "House" where the exotic disease becomes an everyday occurrence. Most of the time, physicians spend their time treating anxiety or symptoms of the stresses of living. A patient to be notices something unusual, feels anxiety, and consults a physician. My favorite example [oft told] is of my old dermatologist who said, "You psychiatrists think you’re the only ones that can treat anxiety. Watch this! That ain’t cancer" pointing to the mole I was sure was going to kill me. The doctor’s job is to thoroughly look into things, and the vast majority of times the outcome is "don’t worry about it." A good doctor is someone who doesn’t say that until he/she knows it’s right. A bad doctor is someone who jumps too soon and misses the cases that should set off alarms. You can’t "doctor" statistically or even cost-effectively, because the overwhelming majority of new patients in a civilized society are "just fine." Hurrying along at the rate that Managed Care longs for is a guaranteed formula for missing the Zebras. And that’s why "case reports" are as important to medical education as the sea of statistical reports that scroll through our literature. Doctors see patients one at a time, and if you are a Zebra, all the statistics about those other routine cases are of no interest.
As anyone fortunate enough to have seen the African migration knows, there are places where the Zebras abound [Masai Mara, Amboseli, Serengeti, etc.]:
In Africa, it’s natural, but in medicine, it’s something else. Physicians who have run across such off the beaten track cases get interested and begin to collect others as a way of understanding them. Such was the story of Alois Alzheimer who had a case [Auguste Deter], a Zebra, that lead he and colleague, Emil Kraepelin, to make a great discovery:
A contemporary person who has collected his share of Zebras is Dr. David Healy, whose early experience with patients who became violent on SSRIs has elevated him to expert status on the subject. He’s currently blogging about the cases every few days [
e-alert sign-up here]. Today’s offering is called
Professional suicide – the Clancy case – and is particularly instructive. It’s short and worth a read in full. It’s the story of a young man in Dublin who was having a hard time after a break-up. His former girlfriend had moved on to another relationship, but he continued to feel unhappy:
His mother took him to his doctor on July 18. The doctor told him to go away and exercise and eat properly for a week to see if that would make him feel any better. A week later, his mother took him back to the clinic, and on July 27, he was prescribed a month’s supply of citalopram 20mg. He took them as prescribed but after the first few days began to get agitated. He rang the doctor on July 31 to say his tongue felt very swollen [a recognized side effect of citalopram]. He left a message but got no response. On August 3 he wrote on Facebook that he felt unwell and thought he had the flu [this is consistent with the effects of the drug]. On August 5, feeling increasingly unwell, Shane took the remainder of his month’s supply of tablets in an attempted suicide. He slept for 24 hours and only then told a friend what he had done. His mother brought him back to the clinic where he saw a different doctor who continued the prescription for citalopram.
Since it’s a blog about unusual events, and it’s Dr. David Healy, and I’m barely recovered from a rage about an irresponsible journal article or two about this topic, you know where this is headed. But if you’re a busy practitioner with no such cues, this is one of those Zebras. Would you have gotten it? "began to get agitated" "tongue felt very swollen" "thought he had the flu" "feeling increasingly unwell" "an attempted suicide". Again, the lead-in is being laid out for us by Dr. Healy’s presentation. The patient himself may have mentioned little of this on a doctor’s visit, saying perhaps that he "thought he had the flu" – and being truthful in saying that only. Would he have said he was suicidal on the HAM-D17 Item 4 that he filled out in your waiting room [if you were into such things]? Frankly, I doubt it, or at least think it would be possible that he didn’t put that down, maybe didn’t even feel suicidal or homicidal. Would the fact that after being on Citalopram for a short time [days] he called complaining of side effects? and by a week was feeling flu-like symptoms? or that his Mom was bringing him back early have been enough to tip you off? even if you weren’t his primary physician? Unlike the Zebras in nature, this kind of Zebras don’t have such characteristic external markings.
A week later, not long after a friendly chat, this young man fatally stabbed his girlfriend’s new beau, wounded she and her brother, and stabbed himself repeatedly until dead. I’ll leave it to Dr. Healy to describe what happened in the aftermath [Professional suicide – the Clancy case]. This case and many others described on his site or collected by others [The Story of SSRI Stories] each tell a story of their own. This "suicidality" in young people and some adults on SSRIs isn’t really "suicidality" – it’s a state with vague physical symptoms, odd behaviors, and sudden acts of violence or dysinhibition without much warning. I doubt that ‘screening questionnaires’ or maybe even direct questions would be a sure fire way of detecting it. My guess is that most cases pass un-noticed because the person doesn’t feel good, stops the medication, and it passes [of course I don’t know that for sure]. The things that are warning lights are like this case – physical symptoms, a worsening mental state, impulsiveness. It’s typical of Zebras that one has to have a high index of suspicious for any of them, and this one is no exception.
This is why no statistical survey of old clinical trials is pertinent. The biostatistician doing the survey doesn’t see the patients. The physicians who ran the trials didn’t see the patients. The condition being looked for doesn’t create thoughts in a form to list on a questionnaire. It’s a state that predisposes people to impulsive and often grotesque violence with vague warning signs. Probably most cases go undetected and without incident [luckily], maybe landing in the "lost to follow-up" or "withdrew permission" categories. If you’ve read enough case reports, you’ll be more likely to catch it before things like this happen. If you’ve warned the patient or his family, they might see it for what it is before things happen. And if you remove the warning and listen to Dr. Gibbons and friends tell you it doesn’t exist [statistically], more people will die or kill needlessly.
In many ways, every doctor patient interaction is about Zebras – scanning for something subtle on the horizon that may become a perfect storm. This is one that needs to be made especially clear, because it is so easily missed. Alois Alzheimer didn’t discover Alzheimer’s disease statistically. He saw a case that was not quite ordinary…
Apparently, the answer to abnormal states being caused by antidepressants is that the people who have these episodes are really bipolar, therefore they need a cocktail. It doesn’t matter how odd or singular the episode was for that person, having an odd or paradoxical reaction to a drug is symptomatic of a larger disorder that had been carefully hidden by that person not having had the drug reaction to demonstrate it before. And once you’re labeled “bipolar” it’s understood that not wanting to take what you’ve been prescribed is wanting to experience the “mania” you’re assumed to be enamored with no matter your actual experience.
Even as a child, I thought happiness was too often overrated and preferred peace, engagement, and being thoughtfully occupied to transient mood states.
Since nurses have been given the power to prescribe psychoactive drugs I have heard some of the most stupid pronouncements I’ve ever heard in my life about who I am and what my problem is. I can’t imagine that this new level of drug pushers is not doing a lot of harm. It seems likely that nurses are doing a worse job of reporting the effects of the drugs they prescribe than doctors do; because they’re so very well trained in checklist protocols and appear to believe so strongly in the efficacy of drugs and the definitions of people who don’t respond the way they “should”.
As one who has been called “anti-psychitatry,” a “scientologist.” and worse for pointing out the facts about the dangers of psychiatric drugs, and the abysmal track-record of psychiatry, I am often accused of having “black-and-white” thinking on these subjects.
I would only point out that there is some “black and white” in this world.
Some “science and pseduoscience”
Some “facts and frauds”
Even some “right and wrong.”
Some black and white.
Look no further than the zebra.
The zebra is black and white.
Duane
Doctors frequently miss even obvious and common adverse effects of psychiatric drugs clearly stated in the medication package insert, PDR, on the Web, etc.
First of all, pharma has done a tremendous disservice to patient safety by indoctrinating doctors in “maintenance” despite complaints by the patient.
Second, it’s much easier to believe the drugs are invariably benign than to closely monitor each patient properly.
For example, there are hundreds of thousands of patient complaints all over the Web about withdrawal symptoms. Every single one represents a situation where the doctor either did not give the patient proper tapering instructions or failed to recognize withdrawal symptoms when they arose.
Should adverse effects be noticed, as wiley says, the bias is towards believing the patient is suffering from relapse or some new psychiatric disorder, and pouring on additional drugs.
We are all zebras now.
Thank you so much for picking up on Shane’s story. I read your blog all the time; the information you give out is invaluable. I can only tell you as Shane’s mum that he did not have a violent bone in his body.
To be honest, I had no idea about the adverse effects which can come with Antidepressants, so when the police called to my door and explained what happened, I truly thought that they had made a mistake and that someone else must have been involved.
It was only some days later when a Dr. Corry stated in an Irish Newpaper that “I would stake my reputation on the fact that Shane Clancy would not have done what he did if he was not on Antidepressants”, that it started to sink in.
After contacting Dr. Corry who was able to explain everything and who pushed me into contacting Professor Healy, whom I pestered relentlessly, we were able to get an open verdict at Shane’s Inquest.
But for medical professionals like Dr. Corry, Professor Healy and people like you, the world would be a very sorry place indeed. Thank-you again for telling Shane’s story.
Leonie Fennell (Shane’s mum)