1 Boring Old Man

Emergence of Intense Suicidal Preoccupation During Fluoxetine Treatment
^{by Martin H. Teicher, M.D., Ph.D., Carol Glod, R.N., M.S.C.S., and Jonathan O. Cole, M.D.}
American Journal of Psychiatry. 1990 147:207-210.
[full text on-line]

^{Six depressed patients free of recent serious suicidal ideation developed intense, violent suicidal preoccupation after 2-7 weeks of fluoxetine treatment. This state persisted for as little as 3 days to as long as 3 months after discontinuation of fluoxetine. None of these patients had ever experienced a similar state during treatment with any other psychotropic drug.}

^{"Antidepressants occasionally promote suicidal actions in severely depressed-patients by enhancing drive and counteracting psychomotor retardation. However, standard antidepressants are not known to induce severe and persistent suicidal ideation in depressed patients free of such thoughts before treatment. We have recently observed several complex patients who appear to have had serious paradoxical responses to fluoxetine that were characterized by intense, violent suicidal thoughts…"}

This 1990 article is where most of what I knew about Prozac started. When it was published, it created a firestorm [see David Healy’s Let Them Eat Prozac – in Google Books, Preview]. What I had missed along the way was that Akathisia had been noted by Eli Lilly from the very start [even before]. Prozac was introduced not long after I left academic medicine and went into practice. Then, as for the rest of my career, almost all of my patients were referred psychotherapy cases – and so I used very little medication. I heard about Prozac mostly from people who had taken it and had adverse reactions – agitation, "made me crazy." I recall hearing about the suicidality from friends, who attributed it to a Scientology campaign. I gave Prozac to one patient who had showstopping PMS on the recommendation of my partner [an OB/GYN who had changed to psychiatry] and it was a miracle cure. By the time I began to occasionally prescribe SSRIs, I almost always started with Celexa at a low dose. So I may be one of the few psychiatrists around who skipped the whole Prozac scene. Why would anyone refer a person successfully treated with a medication for psychotherapy? I was in the dark by circumstance. Now I see patients in a very different setting, a lot are on antidepressants, some prescribed by yours truly. And I’ve seen Akathisia up close with my own eyes enough times to know that it’s very real [adults and adolescents].

The Akathisia being described here doesn’t happen often, but when it does occur, it’s dramatic – easily noticed from the outside as well as from within [if there’s a high index of suspicion on the part of clinician and patient]. If the problem arises and you know it, it’s very easily treated:

Correspondence: Fluoxetine and suicide
^{by David Healy and William Creaney}
British Medical Journal. 1991 303:1058.

^{… The significance of the emergence of suicidality during treatment with any psychotropic compounds as opposed to during the course of a depressive episode is that during treatment it can be anticipated and forestalled by warning patients.}

Simple Rules:
1. Warn people about Akathisia.
2. Stop the medication if it happens.
3. It goes away.

In the comments section to a recent post, I’m asked the question, "SO on balance: HAVE ANTIDEPRESSANTS DONE MORE HARM THAN GOOD?" followed by a confrontation, "What is this rally against the biological psychiatry? You can dig up as much crap as you want. [actually you can do it in any field.] But unless you can address the above, all you’ve got going here is a morality play in SSRI-landia." It deserves an answer. It implies that the point of this blog is an attack on Biological Psychiatry or the antidepressants. I think that question is a false dichotomy, or maybe addressed at the intent of some other blog. I’d rather answer this question, "Have the antidepressants done more harm than they would have if they’d been used carefully, based on the honest scientific evidence?" I’d say "You’re damned straight they have! By a mile!" And as for "all you’ve got going here is a morality play in SSRI-landia." That’s pretty much exactly what I intend – morality. And if being put off by those Lilly emails from the dawn of time where people are lobbying for accurate reporting of Clinical Trial data, but then caving in, saying "Of course, at the end of the day, we will do what we are told to do" is my being a goodie two-shoes, I accept the designation gladly and wish I’d known to put them on sooner. I still practice general psychiatry in an out-patient clinic and use these medications in that practice every time I work – at least some of them. With the depressed, I mention and describe Akathisia to every SSRI/TCA naive patient I prescribe for, and give them a number to call if they have any problem [and they do sometimes – have any problem and call]. I try to paint a realistic picture of what is to be expected from the medication and stop the drug if there’s no response. When people discontinue SSRIs, I taper them slowly and warn about withdrawal symptoms [my track record treating withdrawal symptoms by adding another drug is somewhere around zero]. I never use the short-acting SSRIs because the withdrawal is often so difficult. I learned to do all those things by reading studies and writing this blog [because I didn’t know all the dangers before]. I expect by national standards, I’m a light-weight prescription writer. No apologies for that. And in the time available in a charity clinic, I have a go at finding out what’s going on in the patients’ lives that might be making them or keeping them sick, and help if I can.