{"id":32117,"date":"2013-01-16T07:00:54","date_gmt":"2013-01-16T12:00:54","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=32117"},"modified":"2013-01-16T16:29:24","modified_gmt":"2013-01-16T21:29:24","slug":"its-not-our-drugs","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/01\/16\/its-not-our-drugs\/","title":{"rendered":"it’s not our drugs…"},"content":{"rendered":"
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Emergence of Intense Suicidal Preoccupation During Fluoxetine Treatment<\/a>
by Martin H. Teicher, M.D., Ph.D., Carol Glod, R.N., M.S.C.S., and Jonathan O. Cole, M.D.<\/sup>
American Journal of Psychiatry<\/font><\/strong>. 1990 147:207-210.
[full text on-line<\/a>] <\/div>\n

<\/p>\n

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.<\/strong><\/sup><\/div>\n

<\/p>\n

"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…"<\/em><\/strong><\/sup><\/div>\n<\/blockquote>\n
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<\/font><\/strong> – in Google Books, Preview<\/a>]. 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]. <\/div>\n

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: <\/p>\n

\n
Correspondence: Fluoxetine and suicide<\/font><\/strong>
by David Healy and William Creaney<\/sup>
British Medical Journal<\/font><\/strong>. 1991 303:1058.<\/div>\n

<\/p>\n

… 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.<\/strong><\/sup><\/div>\n<\/blockquote>\n
    <\/p>\n
    Simple Rules<\/u>:<\/div>\n
  1. \n
    Warn people about Akathisia.<\/div>\n<\/li>\n
  2. \n
    Stop the medication if it happens.<\/div>\n<\/li>\n
  3. \n
    It goes away.<\/div>\n<\/li>\n

    <\/font><\/strong><\/sup><\/ol>\n

    It’s not that different from multiple other situations in medicine with all kinds of medications. So what’s the big deal? Why did Lilly, knowing about Akathisia even before the drug was approved, try to keep it such a secret? Why code suicidality in studies as something else? Why attack doctors who brought it to attention in articles? Why trivialize "anecdotal reports"? By any rational logic, the drug reps should be handing out Teicher’s article on their sales calls. "Watch out for  Akathisia!" "It’s a rare but important side effect!" But none of the manufacturers or the KOLs seem to ever do that. They mumble the warnings at the end of the tele-commercials, or in the scrolling small print on the printed ads. They finance increasingly bizarre articles and meta-analyses claiming a safety and an efficacy beyond the medications’ possibility to deliver. And they do it every time, at least in this modern era. But if these modern psychiatric drugs were presented with their actual efficacy and their side effects had been accurately characterized, they would never have been blockbusters<\/font><\/strong>. They would still be on the market and would still be of value, but they would be used much more carefully, primarily by people experienced in their use. There would have been many fewer doses of Prozac sold to fewer patients. Profits would have been only modest, court settlements rare. It’s not Prozac that’s a problem. It’s just a chemical.  It was the entrepreneurial orgy that accompanied it. <\/div>\n

    In the comments section to a recent post, I’m asked the question<\/a>, "SO on balance: HAVE ANTIDEPRESSANTS DONE MORE HARM THAN GOOD?"<\/em> 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."<\/em> 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?<\/font><\/strong>"<\/em> I’d say "You’re damned straight they have! By a mile!<\/font><\/strong>"<\/em> And as for "all you’ve got going here is a morality play in SSRI-landia."<\/em> 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<\/em>" 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. <\/p>\n

    And as for "You can dig up as much crap as you want<\/em>", psychiatry would be a hell of a lot better off right now if there weren’t so much crap to dig up. Looks like the Augean Stables to me. This isn’t a "rally against the biological psychiatry<\/em>" – it’s a rally against the Eli Lilly and friends that joined in the fun and the lying and way over-promised, minimizing needed truths. And as for our current drugs, I see them kind of like I saw steroids, anti-metabolites, anti-hypertensives, etc. when I was an Internist. If you learn how to use them well and stay on the light side, you can help a lot of people, even cure<\/em> a few, but the potential to do some major damage is always in the room, so you’ve got to be careful. It’s not our drugs that are the problem. It’s not even Akathisia itself. It’s the process that turned a limited and fickle drug like Prozac into a blockbuster<\/font><\/strong> by denying and hiding its foibles…<\/div>\n","protected":false},"excerpt":{"rendered":"

    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 […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-32117","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/32117","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=32117"}],"version-history":[{"count":41,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/32117\/revisions"}],"predecessor-version":[{"id":32176,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/32117\/revisions\/32176"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=32117"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=32117"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=32117"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}