Meds that can make you crazy (literally)

bottle labelled poison

We work so hard on our mental health, but sometimes we can get knocked down by an unexpected source: prescription medication.  Sure, we all know that some street drugs can adversely affect mental health, but there are also a number of prescription medications for conditions totally unrelated to mental health that can trigger symptoms of depression, mania, and psychosis.  The actual degree of risk varies depending on the specific medication and the patient context, and it’s always a question of risk versus benefit when deciding whether or not to take something.

Antibiotics: There have been a small number of reports of depression associated with norfloxacin and sulfa antibiotics.

Antiparasitics: Chloroquine and mefloquine, which are used in the prevention and treatment of malaria, can cause psychosis and mania.  My opinion is that there’s no reason for a person with a psych history to take either of these drugs, as there are other safe and effective alternatives.  If I’m visiting a malaria risk area, I always take Malarone, which is pricey but I can live with that to avoid psychosis; my second choice would be doxycycline.

Antivirals:  High-dose acyclovir, which can be used in the management or herpes or shingles, can trigger psychosis or depression.  Amantadine, which is used both as an antiviral to manage influenza and as an anti-Parkinsonian agent, can cause psychosis or mania, most frequently in the elderly.  Interferon is not technically an antiviral, but it is used in the treatment of viral hepatitis C; it can cause psychosis, mania, depression, and suicidal thoughts.  Luckily there are other treatment options available now, which is certainly more desirable for people living with mental illness.

Blood pressure and heart medications: Beta blockers have been linked with depression and mania.  Digoxin can trigger psychosis and depression.  The calcium channel blockers diltiazem and nifedipine have been associated with depression.  Diuretics in the same class as hydrochlorothiazide have been linked to depression and suicidal ideation.

Gastrointestinal: High doses of medications from the H2 receptor blocker class for acid reflux, such as ranitidine and cimetidine, can trigger psychosis, depression, and mania, particularly in the elderly or those with renal dysfunction.  Metoclopramide, which is used to boost GI motility, has been linked to mania and depression.

Analgesics and muscle relaxants: Abrupt discontinuation of the muscle relaxant baclofen can bring on depression, psychosis, or mania.  Cyclobenzaprine can also trigger mania and psychosis.  Some NSAIDs have been linked with psychosis and depression.

Hormonal agents:  Oral contraceptives can trigger depression; one study found that this happened in up to 15% of users.  The initial doses of thyroid hormones like levothyroxine in vulnerable patients can trigger mania, depression, and psychosis.  Steroids, including anabolic steroids and corticosteroids such as prednisone, can cause mania, depression, or psychosis, particularly when used at high dose or in withdrawal.  Topical or inhaled steroids have much lower systemic absorption and thus carry far less risk.

This is by no means an exhaustive list, and it’s not intended as a “do not take” list.  For most of these medications, the incidence of psychiatric side effects is low, and most people can take them without any problems.  I take the beta blocker propranolol on a fairly regular basis to manage my lithium-related tremor, and I’ve never noticed it impacting my mood.  I also take birth control and in my case it boosts my mood rather than making me depressed.  I’d say the important thing is to be aware that meds for physical health problems can impact your mental health, and listen to what your mind and body are telling you.

As a final word of caution, I would say be careful with steroids that are taken orally; in my experience they’re the top culprit for medication-related psychiatric symptoms.  Generally with something like prednisone it’s the kind of thing that if you need it, you need it, but there should always be a discussion with your doctor on how to do it most safely and make sure you’re monitored appropriately.

As always, knowledge is power!

 

Image credit: qimono on Pixabay

Advertisements

Adjusting expectations

steering.jpg

I have a volunteer gig with a local community services agency doing presentations to high school students on suicide awareness.  There’s a pretty standardized format for these workshops, and they are usually done for various grade 9 classes a few times a semester.  I started doing this about a year ago to try to give myself more of a sense of purpose and hopefully aid in my recovery from depression.  I’ve done public speaking about mental health in the past related to my work as a nurse, and it was something that I typically enjoyed and didn’t get overly nervous about.  I’m not sure why I thought that ease of public speaking when well would translate into some degree of ease when depressed, because that has definitely not been the case.

Luckily anxiety hasn’t been too much of an issue; it helps that I know the subject matter well and it’s essentially the same spiel each time.  My feelings leading up to these presentations have been a strange mix of antipathy and forced pseudo-excitement.  I want to feel good about speaking to youth on suicide prevention.  It’s certainly a topic that matters to me and that fits with my desire to combat stigma, but wanting to care and wanting to be excited aren’t translating into actually caring and being excited, no matter how hard I try to convince myself.  I post about it on Twitter in an attempt to stir up some advocative fire, but it only fuels my apathy.  That in and of itself bothers me; I want to be able to feel corresponding emotions to things that are important to me in a cognitive sense.  It’s just not working out that way, though.

I did a presentation yesterday morning to a class of grade 9’s, and the kids were ok; not great about participating, but not terrible.  Once again I disappointed myself with my own performance; it was ok, but not what I would have expected of myself under normal circumstances.  My thinking is slow, and it’s hard to be spontaneous.  There were times when I lost my train of thought or stopped to search for words that I just weren’t coming.  I’ve noticed for some time now that in many situations when I’m having to think hard about what I’m saying, I look up at the ceiling as I speak.  This isn’t something I do consciously, and I’m guessing I do it to minimize visual stimulation in order to focus better.  Normally it’s just a quirk of depressed Ashley, but while speaking in front of a class of kids it certainly doesn’t add to my effectiveness as a presenter.

I’ve had to come to terms with having my level of functioning impaired by depression across multiple contexts, but it seems just a little bit harder when it comes to something like this that I want to be passionate about.  I feel like in a sense I’m letting down my values and ideals.  I’m fully aware that this idea is ridiculous, but there you have it.

I was able to give myself some credit, though, for an email I received yesterday morning from the editor-in-chief at the Journal of Psychiatric and Mental Health Nursing.  The email invited me to apply to be a member of their editorial board.  I’m fairly certain that this was a form letter sent out to anyone that has had a paper published in journal over the last while, but I still thought it was pretty cool.  That’s not to say I’m actually going to apply; without a PhD I’m not properly qualified, plus the workload would be more than I’d be prepared to take on.  Still, I have to remind myself not to discount the positive when I find it.  The email triggered a glimmer of an idea for a new research project looking at mental health blogging; I’ll have to give it some more thought and evaluate whether I have the energy for it or if I’d just be setting myself up for failure, but if I decide to go ahead with I’ll be asking fellow bloggers to get involved.

No matter what it is I’m doing I try to adjust my expectations based on what my illness will or will not allow at the time.  Sometimes I’m able to do that without too much difficulty, and in other situations it can be a real struggle. I guess what’s most important, though, is that I’m attributing my limitations to my illness rather than a fundamental flaw in myself, so it’s a dynamic work in progress.  And as Marsha Linehan would remind me in her DBT assumptions, I’m doing the best I can.

 

Image credit: Maximilian Weisbecker on Unsplash

 

Book review: No One Cares About Crazy People

No One Cares About Crazy People by Ron Powers book cover

I first heard of this amazing book in a post by A Journey With You, and immediately after finishing the post I put a hold on the book at my local library, eager to get started on it.  No One Cares About Crazy People is Pulitzer Prize-winning and New York Times bestselling author Ron Powers’ exploration of his two sons’ journeys with schizophrenia combined with a sweeping social history of mental health care and attitudes towards those with mental illness.  He skillfully interweaves these separate threads, drawing the reader along from the early days of Bedlam to the tragic loss of one of his sons.  The toll that mental illness has exacted on the Powers family and the obstacles that arose in accessing care for sons Dean and Kevin are heartbreaking, while the historical picture painted is both eye-opening and profoundly disturbing.

Bedlam has made its way into the modern English lexicon, but its origins were in England in 1247, and it was officially designated as a mental institution in 1666.  Powers starkly captures the abuses that occurred at Bedlam and other institutions like it, including overcrowding, poor hygienic conditions, use of shackles for prolonged periods, and physical and sexual assaults.  Such practices were slow to change, and as the book points out, even now the mentally ill are often mistreated, particularly in correctional institutions.  Powers deftly ties these elements together, giving the reader a strong sense of the connectedness between past and present.

Powers touches on social Darwinism and eugenics, which were practiced far more widely than is generally known.  It’s unsurprising that forced sterilizations of the mentally ill were carried out in Nazi Germany, but Powers informs us that in the United States an estimated 60,000 forced sterilizations of the mentally ill were performed in the 20th century.  Between 2006 and 2010, 148 female sterilizations were carried out in the state of California, and this practice was not made illegal until 2014, a jaw-dropping reminder that, as the book title suggests, those with mental illness are treated as somehow “less than”.

Powers covers a broad range of 20th century influences on mental health care in the United States, including the anti-psychiatry movement, “treatment” strategies such as lobotomies, and misguided  beliefs that antipsychotic drugs such as chlorpromazine could “cure” schizophrenia.  John F. Kennedy’s Community Mental Health Act began a wave of deinstitutionalization, which led to a ballooning of the homeless population and large numbers of mentally ill ending up in the criminal justice system.  Powers points out that in many ways this approach criminalized mental illness, and the effects remain widespread to this day.

As any questioning parent might, Powers tries to identify factors that could potentially have contributed to his sons developing schizophrenia.  Both Kevin and Dean were highly artistic and passionate about music, raising the as yet unsolved question of whether mental illness is linked to traits like artistic creativity or scientific genius.  In his teens, Dean was socially vilified after a female passenger was seriously injured when the car he was driving crashed.  He was falsely accused of drunk driving and made into a sort of social pariah, and Powers suspects that the stress related to this incident likely contributed to the development of his son’s mental illness.

Powers raises the contentious issue of involuntary treatment.  The precedent for modern legislation in the United States can be found in the era of former president Ronald Reagan; deinstitutionalization was a key aim and decision-making was placed in the hands of the courts rather than medical professionals.  This can mean significant delays in accessing much needed treatment.  Powers argues strongly that involuntary treatment should be more readily available before a mentally ill person reaches a crisis stage where they present a risk to self or others, as by this point it may be too late.  He addresses anosognosia, a common symptom of schizophrenia experienced by both of his sons, that impairs one’s ability to recognize the nature of their illness and the need for treatment.  This caused significant negative consequences in the Powers family, which Powers points out to strengthen his argument.

The powerlessness that can go along with loving a mentally ill person is heart-wrenchingly captured in Powers’ account of his son’s illness journeys.  Kevin was initially diagnosed with bipolar disorder before the full extent of his psychotic symptoms unfolded, leading to a delay in getting him started on antipsychotic medication.  Before his suicide, he had been seeing his treatment team regularly, and was still passionate about his music and future-oriented.  Not once did he speak openly to anyone of suicide, leaving those who loved him powerless to intervene.

Powers openly challenges the social stigma and lack of understanding regarding mental illness. He likens the mental health condition of schizophrenia to the physical health condition of cancer: “a predator without peer and impervious to cure”.  He identifies numerous ways in which those with mental illness can contribute to their communities, and emphasizes the importance of having the right types of supports that can make that happen.

The book concludes with a call to action: “The mentally ill people in our lives, as they strive to build healthy, well-supported, and rewarding lives for themselves, can show us all how to reconnect with the most primal of human urges, the urge to be of use, disentangling from social striving, consumer obsession, cynicism, boredom, and isolation, and honoring it among the true sources of human happiness.  To put it another way: the mentally ill in our society are awaiting their chance to heal us, if we can only manage to escape our own anosognosia and admit that we need their help.”

There are many voices that can contribute to the dialogue around mental illness.  It is essential to hear the voices of those with lived experience of mental illness, and those voices can’t be replaced by the voices of love ones or professionals.  However, embracing all of these voices can allow us to construct a more coherent social narrative regarding mental illness.  This book makes a strong contribution to that narrative by improving awareness and challenging stigmatizing beliefs, and it will also resonate deeply with those whose lives have been touched in some way with mental illness.

 

You can read my previous book review here:

Birth of a New Brain by Dyane Harwood

Finding safety without armour

woman wearing suit of armour

I’ve had a pretty shitty last couple of years.  There have been multiple people in a variety of different contexts who have treated me like crap, including people whose role (in theory) was to help me.  While I don’t have PTSD, I do feel traumatized by the things that have happened to me, and that (in combination with my depression) has made me really withdraw into myself.  I don’t trust people, and I don’t feel safe with people.  I feel like anyone could harm me or turn on me at any time.  I expect to  be thrown under the bus because I have learned that this is how people treat me.  So for the purpose of self-preservation, I opt to hide beneath a heavy suit of armour, hoping that people won’t be able to get through it to hurt me.

There is one exception to this psychological mess-fest of mine.  He’s someone I work with, and right from the beginning I felt safe with him.  To some people “safe” may sounds like an odd choice of words, but for those of us living with mental illness psychological safety is huge.  And I trusted him.  I’m not sure why, but it just felt right.  I told him about my illness very early on, and he was totally ok with it.   As time has passed I’ve shared with him some of the really messy bits, but it’s almost as though the more I show my imperfections the more perfect he thinks I am.  It seems like he’s able to look past the illness and see the real me, which helps me feel a little more connected to the real me that’s lying buried beneath the depression.  In a lot of small ways he takes care of me.  While I am fiercely independent, it feels nice to be taken care of once in a while, and it had been quite a while since I last felt that way.

holding_handsLately we’ve started communicating quite a bit outside of work, which has been really nice.  I’m not sure where exactly this will end up taking us, but I’m enjoying the ride.  It’s interesting to reflect on how easily I felt safe with this person despite my internal scars and deep-seated mistrust of others.  Is it possible to “just know” that someone is not going to hurt you?  Probably not, but I guess it’s reassuring that I am still able to trust, albeit highly selectively.  I’m not so completed disconnected from the world that trust is impossible, which on some level kind of surprises me.

I think we all put on armour as needed to protect our vulnerable inner selves from the world around us.  The challenge is finding some sort of balance so that we’re not completely closed off, and establishing a dividing line between self-protection and avoidance.  I have a lot more work to do on relaxing my own armour, but at least I’m making a start.

What sort of armour do you wear to keep yourself safe?

 

Image credits:

bstad on Pixabay

Elvis Ma on Unsplash

You always remember where you were when…

Sandy Hook elementary never forget sidewalk

There are certain moments in time that become etched in our memories, and we remember exactly where we were and what we were doing when an event happened.  Sometimes that’s because of the significance of the event itself.  For my parents’ generation, that might have been the assassination of John F Kennedy or the moon landing.  I remember that on the morning of September 11, 2001, I was in university but for some reason didn’t have classes that morning.  When I got up my roommates had the tv on, and we watched in stunned, horrified silence as the 2nd tower collapsed.

Then there are the moments we remember not so much because of the event itself but because of our own circumstances at the time.  For me, the Sandy Hook elementary school shooting was one of those moments in time.  Don’t get me wrong, it was a terrible event, but sadly these types of events occur with disturbing regularity.  I remember Sandy Hook, though, because it is burned in my mind what was going on for me at the time.  I was in the small psychiatric emergency ward in a suburban hospital near the city where I lived.  It was a single large room with curtained off beds and a small seating area with a tv.  There was nothing else to do, so I watched tv and picked at the rats nest that my hair had become during the delirious days prior to my admission.  The tv was tuned to CBC Newsworld, the 24 hour news channel of Canada’s public broadcaster.  As I watched the story unfold, I felt a curious sense of indifference.  The only thing that really struck me was that I wished Adam Lanza could have shot me rather than those innocent kids.  Why did they get to escape this world while I was stuck rotting on the psych ward? Aside from that thought, I just kept mindlessly picking away at my hair.

I don’t like the heartlessness that depression brings about in me.  I previously blogged about my own non-reaction to the Las Vegas mass shooting; I was disturbed more by my lack of reaction than by the event itself.  Indifference was not a “normal” way to look at such a horrific tragedy.

I find it interesting that my life’s chronology has come to be defined very little by external significant events and much more by illness events.  Hospitalizations and relapses form the major milestones as I look back at my life over the past 10 years.  Everything else is situated in relation to those milestones; either that, or it just blurs into a fog of meaninglessness.  I regularly watch the news and so am aware of major world events, but unless things somehow relate to my depression journey my brain relegates them to the discard bin.

Mental illness changes how we interact with the world around us, and that can be distressing and even frightening.  It can be hard to separate how much of our reactions are truly our own and how much are the illness.  Why are both 9/11 and Sandy Hook burned in my mind when so many other events have gone into the dusty filing cabinet of my brain?  Why did 9/11 trigger stunned horror while Sandy Hook triggered nothing?  It’s not something I try to beat myself up over, but I do find it curious.  As in so many other situations, I’m not really sure where I end and the illness begins.  On this journey of self-discovery I don’t think I’ll ever find concrete answers, and maybe there will always just be more questions.  Still, it’s important to keep asking those questions – and maybe that’s what I really need to take away from all of this.

 

Why research literacy matters in mental health

Caduceus symbol for medicine

We are regularly bombarded with news of the latest scientific research findings, and sometimes it seems like you can find a study to tell you just about anything.  My concern with news reporting of research is that many people (including members of the media) have relatively limited research literacy.  Research literacy refers to the ability to draw upon a body of knowledge about research methods in order to interpret and critically evaluate research findings.  Greater research literacy means, among other things, a more effective bullsh** detector.  In this post I’ll break down some of the terminology that’s often used in research.  The concepts involved are not necessarily intuitive, so it’s important to reflect on how we can most appropriately use the information we are given.  The randomized, double-blinded, placebo-controlled trial is considered the “gold standard” for much medical research, and it’s useful to understand why that is.

Peer review

Peer review is an important quality control step before research papers are published.  Reviewers are independent of the journal the paper has been submitted to, and they remain anonymous (except to the journal editors).  Peer reviewers are selected by editors because of their expertise in the field, and they will give feedback to guide the editor in making a decision about whether or not to publish a manuscript.  Most often reviewers will recommend improvements be made before a paper is accepted.

The peer review process can potentially get a little shakier when it comes to “open access” journals.  The articles in these journals are publicly available without a subscription, and instead the journal’s revenue stream comes from authors, who must pay a publication fee.  Some of these journals are credible and reputable, while others are predatory.  Because I’ve had work published in academic journals, my email address is out there in that world, and I regularly get emails from obscure open access journals asking me to do reviews for papers that are so completely unrelated to my research field it’s sometimes laughable.  Hmmmm.

Quantitative vs qualitative research

Quantitative research collects quantifiable data and generally uses statistical methods to analyze that data.  This type of research is the basis of much of the medical knowledge that we have.  However, numbers can never tell the whole story, and that’s where qualitative research comes in.  Qualitative research uses people’s stories to answer questions like what does it feel like to have mental illness, for example.  I’m particularly partial to a research method called autoethnography, which is a study of the self in the context of culture.  I used this in my masters thesis to examine my own experiences of mental illness, and it’s a really exciting way for the voices of people with mental illness to be heard.

Randomization

There is a great deal of person-to-person variability in health status, genetics, and many other factors.  By randomizing which participants are assigned to the intervention group and which are assigned to the control group, the likelihood decreases that one particular group will be stacked with people having certain characteristics.  Greater homogeneity between participants receiving intervention A and those receiving intervention B improves the validity of the results obtained.

Blinding

Blinding refers to who knows what intervention the patient is receiving.  In a double-blinded study, neither the patient nor the investigators evaluating the outcomes know this.  Blinding is considered desirable because it reduces the chance of bias in the results.  In practical terms, in a study of drug A, drug A and a placebo might each be contained in identical gelatin capsules.  Each participant would receive a numerically coded dose, and a member of the research team not involved in administering the drug or evaluating the participant’s response would be responsible for managing the codes.  Specifics vary from study to study, but the purpose is still the same.

Controls

Let’s say you give drug A to 20 people.  A month later 15 of them are doing better.  That’s great, but it doesn’t tell you the extent to which drug A is or is not affecting outcomes.  That’s where controls come in.  A control represents a comparison group that allows researchers to make some determination of what is causing what.  Using a placebo control is often the most desirable research design in separating out how much of the response is actually due to the drug being studied.

Sometimes another active drug is used as a control.  One example of this is in studies of ketamine for major depressive disorder.  Since ketamine is an anaesthetic, if a normal saline infusion was given as a placebo any attempts at blinding would go right out the window.  Therefore, studies might use something like intravenous midazolam, a rapid- and short-acting benzodiazepine, as a control.  Other types of controls include “treatment as usual”(the receiving whatever treatment is considered standard practice) or “wait list” (patients who are currently on a wait list to receive the intervention that’s being studied).

vials

Risk

Risk is often quantified as a percentage, but a number needs sufficient context to be meaningful.  Absolute risk refers to the probability of something happening, full stop, while relative risk refers to the probability of something happening in relation to some other designated population, factor, or situation.  Relative risk numbers are meaningless unless you know the reference point.  Let’s say drug A causes a 500% increase in the risk of cancer X.  Sounds scary, right?  But what if the absolute risk of cancer X is 0.00001%?  That means taking drug A increases the risk of cancer X to 0.00005%, which is a lot less frightening.

Reports on the news may talk about an increased risk of death from drug B.  Again, that sounds pretty scary.  Except the absolute risk of death is 100%, with no exceptions (at least thus far in human evolution).  That means we need more information.  What time frame are we talking about?  Risk of death within 1 year?  Within 20 years?  It makes a difference.

Correlation vs causation

Correlation refers to things that tend to happen together, and this can mistakenly be taken to mean there is a causative relationship.  If we looked at 100 people who had died, we would find that 100% of them had skin.  Does that mean having skin causes death?  Of course not.  This is a common type of mistake in the anti-vaxxer movement.  Autism can show up at around the same age as children receive some vaccines, but that doesn’t mean there is a causative relationship.  Causation can be difficult to establish definitively, which is why it’s important to have well-designed, rigorous, peer-reviewed research studies.

Significance

The term “significant” is used differently in research studies than it is in general usage.  Significant results in a study indicate that from a statistical perspective the results obtained were unlikely to be due to chance.  It does not mean that the results are large in scale (this would be described as a large effect size) and it does not mean that the results are necessarily important or meaningful.

Related to this is the concept of “confidence intervals”, which gives a range that expected results would fall within a certain percentage of the time, such as 95%.  As a completely arbitrary example, say placebo was associated with a 10% improvement in symptom x, with a 95% confidence interval of +/- 5% (i.e. 5-15%).  Study drug A was associated with 25% improvement in symptom x with a 95% confidence interval of +/- 5% (i.e. 20-30%).  Because drug A is associated with a greater improvement in symptom x, and the lower end of its confidence interval doesn’t overlap with the upper end of the placebo confidence interval, the results are considered statistically significant.  These numbers are completely made up, but hopefully this example gives you the right idea.

Systematic reviews

Review papers evaluate the existing research literature on a topic.  “Systematic” refers to clearly laid out criteria for inclusion and exclusion of studies in the review and elements used to evaluate the quality of the included studies.  Review articles are a great way to get a lot of information all in one place that has already been carefully scrutinized for you.

Conclusion

So there it is, a quick overview on bringing a critical eye to research.  The best way to improve research literacy is by actually consuming research literature.  This is where Google Scholar can be your new best friend.  Full research papers often aren’t available for free access, but for the most part there is public access to a paper’s abstract, which is a concise summary of the key points including method, results, and conclusions.  PubMed is another great source of information, and often hits on Google Scholar are linked to the corresponding PubMed page.  Papers with the results of research funded by the National Institutes of Health (NIH) in the United States are available for free on PubMed.  I’ve read a lot of research papers over the years, and while they can be a bit dry  they can be also be an invaluable source of information.  And the more you read the easier it gets. Trust me.

 

Image credits:

GDJ on Pixabay

PublicDomainPictures on Pixabay

 

A Prescription For Murder?

Prescriptionformurder

 

I have always been a big fan of the documentary program The Passionate Eye on CBC, Canada’s public broadcaster.  Until now.  On January 6, 2018, they aired “A Prescription for Murder?”, which was originally shown on the BBC; links are at the bottom of this page.  The program focused on James Holmes, the young man who shot and killed 12 people and injured 70 in a movie theatre in the United States in 2012.  The central argument is that the SSRI (selective serotonin  reuptake inhibitor) class of antidepressants can, in rare cases, cause people to become psychotic, violent, and homicidal.

According to the documentary, Holmes first started seeing a psychiatrist at his university’s student wellness centre 17 weeks before he committed the murders.  He reported social anxiety and intrusive thoughts of killing people; these thoughts were not new, but it was the first that he had disclosed them.  After the killings, he told a psychiatrist that he had experienced thoughts of killing people since his teens as a sort of social avoidance strategy.  The psychiatrist at the wellness centre started him on the SSRI sertraline, at a dose of 50mg per day.  Not long after, he described a theory he referred to as “human capital” that involved intentions to kill people.  The dose was increased over the next 4 weeks to 150mg per day, as his intrusive thoughts were increasing.  A little under 3 months after starting sertraline, he had made the decision to drop out of school, and declined his psychiatrist’s offer to continue treatment and start him on an antipsychotic.  It is not clear when he stopped taking the sertraline, but his last prescription would have run out 3 weeks before the shootings.  The journalist argues that because of the timing it is likely that Holmes’ homicidal behaviour was triggered by the sertraline.  Various psychiatrists are interviewed for the film, with several expressing the belief that the sertraline had triggered psychosis, which led to the killings.  One went so far as to suggest that if Holmes hadn’t been put on sertraline the murders might not have happened.

The documentary bothered me on multiple levels.  If someone wants to make a film arguing that SSRIs can trigger psychosis and people should be aware of that, okay, so be it.  But the choice of title is clearly intended to be sensational, as is the tagline “Is it possible that a pill prescribed by your doctor can turn you into a killer?”.  On the Canadian broadcast that I viewed, on multiple occasions a banner ran across the top of the screen warning that people should not stop taking their medication without first seeking medical advice.  It seemed utterly absurd to be including this message for a film arguing that SSRIs turn people into mass murderers.  If one pays enough attention, the more nuanced argument being made is that SSRIs can cause psychosis and this can precipitate homicidal behaviour; however, what’s missing is the key piece of information that the probability of a psychotic person committing homicide is extremely low.  That is a very different can of worms than simply connecting SSRIs and homicide.

Another flaw in the argument that is never acknowledged is that temporal correlation, i.e. things being related in terms of timing, does not necessarily imply causation.  I’ll talk more about this in an upcoming post about research literacy, but it is flawed logic to think that because Mr. Holmes took sertraline shortly before he committed a mass shooting, the only or best explanation is that the sertraline caused it.  The documentary does not even touch on alternate explanations, the most obvious (at least to me) being that he was started on the medication because he was getting sick, it didn’t work, he got sicker, and he became psychotic, which triggered him to act on thoughts he admitted he’d been having for years.

I worry that some poor person with mental illness is going to watch this and think oh, I don’t want to be on a medication that’s going to make me a killer.  And maybe that person will stop the SSRI they are already taking, or avoid going to see a doctor to seek help for distressing psychiatric symptoms.  Maybe that will mean they get sicker.  And maybe, just maybe, that could have disastrous consequences like suicide.  I have no hesitation whatsoever in saying that the risk of suicide from a depressed person not taking an antidepressant is higher than the risk of someone taking an SSRI and committing mass murder.  There is no indication that the filmmaker has given any thought to these sorts of outcomes that could snowball in response to the messaging that antidepressants can turn people into murderers.

There also seems to be no consideration given as to how this documentary might affect public attitudes toward mental illness in general and psychiatric medication in particular.  There is already more than enough stigma around this, and I for one do not want some random idiot thinking that I might fly into a homicidal rage because of my antidepressants.  Someone who hasn’t lived with mental illness might think this concern is overblown, but the stigma around taking psychiatric medication is very real, as is the potential of this stigma to cause harm.  By choosing to air this documentary, the BBC and CBC have chosen to move backwards in terms of stigma, exactly the opposite of where those of us blogging about mental health are trying to go.

I’m sickened by how irresponsible the BBC and CBC are for broadcasting this documentary.  The same issue could potentially have been explored in a way that utilized much safer messaging.  Being cynical, I’m guessing that this particular approach was chosen in order to generate buzz and viwership.  I can only hope that it won’t do as much damage as I think it has the potential to.

 

A Prescription for Murder? – CBC’s The Passionate Eye

A Prescription for Murder? – BBC One Panorama