Wednesday, April 18, 2007

Depression = Murderer?

The term psychological autopsy is now being thrown around by the talking heads on cable news shows in the analysis of Cho Seung-Hui, the Virginia Tech gunman. The first words from the TV medical experts are that this kid was not only depressed but also being treated with medications. I also found it interesting that an article from the Associated Press has this as the second paragraph...
News reports said that he may have been taking medication for depression and that he was becoming increasingly violent and erratic.
The article goes on to outline some of his other characteristics as they try to profile this individual: a loner; a writer of disturbing plays; a writer of the suicide note against "rich kids," "debauchery," and "deceitful charlatans."

I could be wrong, but I'm starting to see people in the press making the association between depression and murder. Of course, this kid had mental illness and of course he was undergoing treatment for it. But, the implication that everyone with mental illness has the potential "to snap" and kill people - as being suggested in the media - This bothers me.

With the Virginia Tech story as a backdrop, I was scanning the health headlines and ran into a different Associated Press article today with this title: Antidepressants' benefits trump risks for kids

If you remember, three years ago, the Food and Drug Administration made a statement warning the public about use of antidepressants in children and teens. At the time, they stated that there was an increased risk of suidical thoughts and behaviors. There was a huge uproar then. All my patients were talking about it - particularly parents. Now, the research is stating that those concerns are not as serious as once thought.
Researchers analyzed data on 5,310 children and teenagers from 27 studies. They found that for every 100 kids treated with antidepressants, about one additional child experienced worsening suicidal feelings above what would have happened without drug treatment. In contrast, the FDA analysis found an added risk affecting about two in 100 patients.

There were no suicides in any of the studies. The antidepressants included Prozac, Paxil, Zoloft, Celexa, Lexapro, Effexor, Serzone and Remeron.

"The medications are safe and effective and should be considered as an important part of treatment," said study co-author Dr. David Brent of the University of Pittsburgh School of Medicine. "The benefits seem favorable compared to the small risk of suicidal thoughts and behavior."
Now, this is by no means the final word on this issue. Some may even say this study complicates the discussion. So, what is a doctor to do? What is a parent to do?

I think this study emphasizes the close communication that is needed between docs, patients, and their parents - especially when it comes to mental illness diagnosis and treatment. I realize that's easier said than done.

But, as more of this Virginia Tech case is uncovered, it seems as if improved communication could (and I emphasize could) have changed the outcome of this tragedy. Of note, N=1's comment in my previous post makes an excellent point.


twilite said...

Hi Dr A. I thot of your post on depression when I heard about the Virginia Tech carnage. There seems to be more depressive teens and young adults these days. Why?

Recently in Japan, as a result of Tamiflu drug, there were a spade of suicides and violent behaviors especially among the teens and young.

Mental illnesses are on the rise?How do the medical and mental health professionals to offer help?

Thanks for your interesting and thot provoking post.

Dr. A said...

Actually, there are some people out there who believe that depression is only unique to the United States. See the comments to my post below: "Is depression really depression?"

I believe that there is more depression that is seen because we (as a society and medical community) are doing a better job at recognition. Now, the best treatment after diagnosis - is still up for debate - meaning pills or no pills - or talk therapy with or without pills. You get the idea.

As far as what the medical community could have done, there are a lot of the press and public pointing the finger at the doc who prescribed the medication and at the counseler who worked with this kid. Many are saying that they are to blame for this tragedy. Why didn't they warn university officials?

I don't have all the facts on this one, but as I discussed in my previous post, at this point in this tragedy, people/press are more interested in assigning blame.

jbwritergirl said...

Hey Doc,

The med debate will always be there. Having seen my fair share of these passing through my medicine chest I believe that if someone is suicidal, no medicine is going to change how they feel and its only a matter of time. Not everyone can be saved.

It's like buying a dozen eggs. When you look at the open box they all seem perfect until you find one whose bottom is cracked and it only breaks when you try to remove it from the crate.

The same can be said of peophiles or rapists. If you medicated them, do they lose the urge to do harm...not likely because its part of the genetic makeup that makes them who they are.

This shooting is just another example of how someone has reached the edge of sanity. As to laying blame, let's just blame the one responsible...the murderer.

jbwritergirl said...

Of course peophiles have problems too, and so they should because it sounds like they suffer from bladder problems, but what I meant to say was pedophiles.

Anonymous said...

One aspect that strikes me (being as old as dirt) is the full pendulum swing of mass institutionalization of people with chronic mental illness to mass deinstitutionalization with concomitant failure to provide adequate safe and supervised housing and social safety net services, such as medication access and administration supervision, ongoing counseling and therapy, and jobs with supervision. Instead, we have effectively criminalized this same formerly institutionalized population to the extent that over 50% of ALL inpatient psychiatric care is provided in prisons.
I think it's worth at least looking at developing long term institutionalization again, but with a different treatment and quality of life outlook. I'm not convinced that not providing enforced shelter, safety and therapy to some extent is entirely a bad thing.
The argument against it was the curtailment of freedom and civil rights. But how are those any more protected by incarcerating those patients, who are indeed suffering?
I taught a class about nutrition where a class assignment was teaching patients. One of my adult students discussed nutrition in the chronically ill and homeless schizophrenic - and she referenced her own adult son as the csae study. She tried to track him down at least weekly to assure that he's alive, will eat finger foods that she has prepared, and will take his meds (she has to see if he even has them on his person to take). Because he's an adult, and he's not suicidal or homicidal, she can't demand that he be hospitalized. Because he's paranoid, he won't seek shelter.

Nico said...

Thank you for this post. Having depression myself, the LAST thing that I need is to have my condition linked to some maniac killer.

Anonymous said...

Interesting comment by n=1.

I was just speaking with someone about this very topic today. Once you've recognized an individual in need of help ( I'm speaking hypothetically here), and they refuse to take the help offered them - now, what do you do with them? How do you protect the public at large? There would be an identified moving threat through society, yet how do you protect the public? Something needs to intercede at this juncture to break the cycle.

Anonymous said...

How do we keep people from falling between the cracks ... ?

No matter what sort of dysfunction you're talking about - physical or emotional, not everyone is going to do as well with the treatment, and some are going to do badly. That's the way it is. You can't stop treating everyone because of a few who don't react well.

I think you're right about communication, Dr. A ... I think it's the bottom line.

Anonymous said...


About falling between the cracks, I think we have huge chasms at this point. So many don't have access to any care, let alone the right kind and quantity of care.

Perhaps, the dialogue about mental health will reopen in general.

Your keep talking point is well taken. Thanks for writing this post and for the thoughtful comments.

Dr. Deb said...

Of course, I am all over this. Much more is involved with this young man than just depression - I suspect psychotic disorder (delusional), and the media jumping to conclusions and making ill-formed diagnoses doesn't help. We need to clarify and help keep data clear as events like this take place. Only this way can parents make educated decisions about treatment, etc.

Anonymous said...

Okay, I'm with Deb and all over this too.

First yes, the media doesn't know what on earth they are talking about and it is just like them, basically their job anyway to pretty much sensationalize this.

And I'm sorry but I am going to blast the US Media Empires for doing so. They always do this sort of thing and they have such unbalanced, biased and incorrect views! Man!

Along the same lines as Deb, when did the media become medical professionals! Is it their job to diagnose?

And since I'm reading your blog backwards, this sort of leads, to my mind anyway, just how things will just go completely awry if confidentiality is not maintained. This is the kind of inane BS that will happen! People with mental illnesses will be "tarred and feathered" with such things as violence and rampant criminalized behaviour and before you know it--again, mass stigmatization. Worse than it already is.

The media has already shown it here.

Sorry...getting a little ranty on your blog.

And as far as treatment for anyone, children or adults--as I've always said, individual case by case basis paying strict attention to presentation, histories etc... etc... I don't know how to tell you how to do your job...I'm not a doctor but always with a lot of care and always keeping a steady, watchful eye.

Anonymous said...

Current Depression Medications: Do The Benefits Outweigh the Harm?

Presently, for the treatment of depression and other what some claim are mental disorders, as they are questionable, selective serotonin reuptake inhibitors are the drugs of choice by most prescribers. Such meds, meds that affect the mind, are called psychotropic medications. SSRIs also include a few meds in this class with the addition of a norepinephrine uptake inhibitor added to the SSRI, and these are referred to SNRI medications. Examples of SNRIs are Cymbalta and Effexor. Some consider these classes of meds a next generation after benzodiazepines, as there are similarities regarding their intake by others, yet the mechanisms of action are clearly different, but not their continued use and popularity by others.

Some Definitions:

Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrist’s bible, which is the DSM, states that the definite etiology of depression remains a mystery and is unknown. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected with limited scientific evidence. In fact, diagnosing diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.

Norepinephrine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med.

And depression is only one of those mood disorders that may exist, yet possibly the most devastating one. An accurate diagnosis of these mood conditions lack complete accuracy, as they can only be defined conceptually, so the diagnosis is dependent on subjective criteria, such as questionnaires. There is no objective diagnostic testing for depression. Yet the diagnosis of depression in patients has increased quite a bit over the decades. Also, few would argue that depression does not exist in other people. Yet, one may contemplate, actually how many other people are really depressed?
Several decades ago, less than 1 percent of the U.S. populations were thought to have depression. Today, it is believed that about 10 percent of the populations have depression at some time in their lives. Why this great increase in the growth of this condition remains unknown and is subject to speculation. What is known is that the psychiatry specialty is the one specialty most paid to by certain pharmaceutical companies for ultimately and eventual support of their psychotropic meds, as this industry clearly desires market growth of these products. Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders are suspected by a health care provider. Yet these meds discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related disease states.
Over 30 million scripts of these types of meds are written annually, and the franchise is around 20 billion dollars a year, with some of the meds costing over 3 dollars per tablet. There are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to being promoted for treatment for menopause. The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.

Furthermore, these meds have received additional indications besides depression for some really questionable conditions, such as social phobia and premenstrual syndrome. With the latter, I find it hard to believe that a natural female experience can be considered a treatable disease. Social phobia is a personality trait, in my opinion, which has been called shyness or perhaps a term coined by Dr. Carl Jung, which is introversion, so this probably should not be labeled a treatable disease as well. There are other indications for certain behavioral manifestations as well with the different SSRIs or SRNIs. So the market continues to grow with these meds. Yet, it is believed that these meds are effective in only about half of those who take them, so they are not going to be beneficial for those suspected of having certain medical illnesses treated by such meds. The makers of such meds seemed to have created such conditions besides depression for additional utilization of these types of medications, and are active and have been active in forming symbiotic relationships with related disease- specific support groups, such as providing financial support for screenings for the indicated conditions of their meds- screening of children and adolescents in particular, I understand, and as a layperson, I consider such activities dangerous and inappropriate for several reasons.

Danger and concerns by others primarily involves the adverse effects associated with these types of meds, which include suicidal thoughts and actions, violence, including acts of homicide, and aggression, among others, and the makers of such drugs are suspected to have known about these effects and did not share them with the public in a timely and critical manner. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others, such as those in the medical profession as well as citizen watchdog groups. The reasons for this attention are due to the potential off-label use of these meds in this population, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, including the decreased efficacy of SSRIs in general, which is believed to be less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding such important information- Elliot Spitzer specifically, as I recall.
And there are very serious questions about the use of SSRIs in children and adolescents regarding the effects of these meds on them. For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect could cause harm rather than benefit? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring in their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist. It is observed in some who take such meds, but not all who take these meds. Yet health care providers possibly should be much more aware of these possibilities.

Finally, if SSRIs are discontinued, immediately in particular instead of a gradual discontinuation, withdrawals are believed to be quite brutal, and may be a catalyst for suicide in itself, as not only are these meds habit forming, but discontinuing these meds, I understand, leaves the brain in a state of neurochemical instability, as the neurons are recalibrating upon discontinuation of the SSRI that altered the brain of the consumer of this type of med. This occurs to some degree with any psychotropic med, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs, it is believed.

SSRIs and SRNIs have been claimed by doctors and patients to be extremely beneficial for the patient’s well -being regarding the patient’s mental issues where these types of meds are used, yet the risk factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug. Considering the lack of efficacy that has been demonstrated objectively, along with the deadly adverse events with these meds only recently brought to the attention of others, other treatment options should probably be considered, but that is up to the discretion of the prescriber.

“I use to care, but now I take a pill for that.” --- Author unknown

Dan Abshear