Special Reports, Psychopharmacology, SuicidePsychiatric TimesBy Robert D. Gibbons, PhD and J. John Mann, MDDecember 31, 2014[full text on-line with free registration]There has been much debate about whether certain classes of medications [eg, antidepressants] increase the risk of suicidal behavior and whether that risk is greater in children, adolescents, and young adults. In 2004, the FDA placed a black box warning on all antidepressants because of concerns that the medications increase risk of suicidal thoughts and behavior in youths; in 2006, the warning was extended to include young adults [up to age 26]. The FDA based its black box warning on results of its meta-analyses of randomized controlled trials [RCTs] conducted in pediatric and adult psychiatric and nonpsychiatric populations.
Questions regarding a possible relationship between antidepressants and suicide were first raised in 1990 with the publication of a series of case reports in which the then newly introduced SSRIs were associated with the apparent emergence of suicidal thoughts and behavior. This led to FDA hearings in 1991, but no evidence of an increased risk of suicidal acts associated with antidepressants was found. In October 2004, concerns raised over paroxetine use in children and adolescents eventually led the FDA to issue a black box warning regarding antidepressants and suicide for children younger than 18 years…
… My husband was given Prozac on January 24 of 1990. On the evening of February 8, 1990, he killed himself. I am told his death was instantaneous, but I believe his cleat actually began the moment he took his first dose of Prozac. Before Prozac, my husband was very involved with people, our family, and his work. He was very much in charge of his business. But within days after he started taking Prozac I noticed a personality change in him. He showed sign of restlessness, akathisia, agitation, pacing, and his appearance was very drawn. He developed severe insomnia, extreme fatigue, chills, racing heart, dry mouth, and upset stomach. His hands would shake uncontrollably at times. This really alarmed him. I would ask him what was wrong and his only reply was, "I don’t know, I don’t know."
My own experience as a low prescriber was that when Prozac® first came out, I had a couple of patients who took it for a day or two, then stopped saying, "That stuff made me crazy" and "I was coming out of my skin." I was told by colleagues that it was activating, but I stopped prescribing it anyway. Over the years, I had occasional new patients who described the same agita talking about being given an SSRI by someone else before I saw them. The Black Box Warning came after I retired, and I was oblivious. Not long after I started volunteering, I gave Celexa® to an adolescent, who had an extreme Akathesia reaction with suicidal thoughts. That’s how I learned about it. Since then, I’ve seen two suicides in other peoples’ cases that I’m sure were SSRI induced, and multiple others with the Akathisia syndrome who immediately stopped the medication and it cleared quickly [I warn all patients]. In both suicide cases, the people around them mentioned personality change as part of the picture.
- APPENDIX 1 SSRIs & MECHANISMS OF SUICIDE: David Healy
- SSRI-Induced Akathisia’s Link To Suicide and Violence, Evelyn Pringle
Your mention of Akathesia as a syndrome with affective components (as opposed to the seemingly more conventional use of the term to refer to a narrow conceived complex of motor activities) is welcome and rings a bell with me, because my wife, who is disabled (with schizoaffective disorder), recently went through a harrowing six-month ordeal on Latuda, which we thought would be more tolerable, for her, than Haldol, with perhaps fewer side effects. We were grossly mistaken. My wife did well initially, but in the final month of Latuda (160 mg daily) she developed not only agitation (with constant pacing) and racing thoughts but a peculiarly hardened state of dysphoria with very serious suicidality. As things reached an emergency state, we decided on a bold experiment: go off Latuda entirely, and substitute Abilify. She improved dramatically the very next day. Nearly a month later, her Akathesia is still gone, she has had no suicidal thoughts, her mood is positive, and she is serene and able to enjoy life again. That’s not to say Abilify has “done the job” entirely, because it hasn’t. She now has what I would call a mild (but definite) problem with paranoia; not disabling, but a cause for concern. We will be seeing our nurse practitioner in a few days about that.
But the main point is, Akathesia is definitely a full blown syndrome, not a narrow problem of motor activity. I saw my wife’s life turn upside down as a result of Latuda-induced Akathesia, something I would not wish on anyone.
N never equals one in a suicide. Looking at this from an anthropological view point we see the removal of an adult from a functioning unit removes a care giver, provider, or both, from the unit.
Today suicide remains one of our last great taboos. Contemplating suicide means breaking down cultural and religious barriers that stretch back millennia. These barriers are woven into the fabric of most cultures to assure the continuation of that population.
Treating suicide as a simple numerical issue within a population represents a callousness that can not be defined by our modern standards of conduct. Knowing this is a possible outcome of prescribing a certain medication is unfathomable to many of us outside medicine. Not providing the proper monitoring of the patient on this medication will lead to suicide, and a loss to not only a family unit, but to the community at large.
Medicine has lost its trusted position within our society. With cases such as this how can one question the skepticism of the public, and the rage expressed in the various legal actions taken against drug and device companies.
Steve Lucas
Gotta love pharma telling us one size fits all. I was the only resident in my program who did not write for Prozac the first couple of years until I learned how to open the 20mg cap and mix it in an acidic solution to have patients drink a half or quarter each day for the 5-10mg dose.
Then voila, Lilly came out with the 10mg cap and then the tablet. Problem moreso solved. Again to any readers interested, no psych drug, or in my opinion most meds in general, should be prescribed as daily long term dose is day 1 dose.
But, the real current scandal is antipsychotics being prescribed for anything psychiatric in nature. And multi antipsychotic use in average patients with psychotic issues, WTF is that?!
“”inner restlessness, agitation, aggressive thoughts and actions, disinhibition, and sometimes lethal violence. It’s distinct from the depressive syndromes being treated – something else.””
That is exactly what my experience was on 5mg of Celexa several years ago. Due to feeling extremely restless and agitated, I could barely sit still at work and had to get up several times to take breaks.
I also felt extremely aggressive and took it out on a co-worker over a trivial issue. Amazingly, he never complained to my supervisor as I think he was so shocked by my behavior that it stunned him.
“”Far and away, the commonest outcome is for the medication to be discontinued abruptly by the patient and it clears quickly.””
I disregarded my then psychiatrist’s advice to continue with the medication. There is no doubt in my mind if I had heeded his advice, I would have encountered very tragic circumstances such as some type of lethal violence.
And at the risk of sounding like I am tainting an entire profession, unfortunately, Mickey, many of your colleagues like my then psychiatrist, do not take these reactions very seriously. They react like Dr. Gibbons and incredibly even increase the medication because they see it as a sign of the person’s illness.
Kudos to you, Dr. Hassman, and any other psychiatrist visiting this board who do understand that these drugs can cause serious adverse reactions and will quickly discontinue the meds.
I heard about antidepressant induced suicide in the late eighties, and was told by a friend that it gave people who were suicidal the energy and focus to commit suicide, but didn’t make people suicidal. That’s the word that was going around at the time. I didn’t think it would take a lot of energy or focus to swallow a bottle of antidepressants, but I was never suicidal. It did strike me as a butt covering or wishful thinking maneuver on the industry’s part.
The lack of a shared meanings concerning suicidality caused by medication-induced akathisia has always been very puzzling to me. Even if you’ve only seen it two or three times in clinical practice, it’s pretty obvious that it’s a totally different animal from other kinds of self-harming ideation. It seems more disconnected and alien than symptoms of depression; clients sometimes are at a loss to explain why they hurt themselves, or felt like doing so.
It doesn’t surprise me that so many clients feel like their feelings and experiences are being deliberately ignored. It’s almost as if the medication induces some kind of disassociation in the clinician as well– what we’re seeing makes no sense to us, it scares us, so we retreat and construct a different narrative, even if that narrative doesn’t make sense.
There are many detailed descriptions of akathisia in the comments on this blog https://akathisiainfo.wordpress.com/2013/08/13/my-akathisia-experience/
From what I have seen, people often feel they’re completely losing control of their minds and bodies. This sends them into a tailspin of high distress, in which suicide might seem like a reasonable solution. In others, it seems the excessive stimulation itself evokes terror-filled images of harming oneself or others.
We need to look at the relationship of desperation to thoughts of suicide. My guess is, in situations of high stress, many people think of it even if fleetingly, it’s one of many solutions and not necessarily irrational or pathological.