Shooting reopens debate over drug, violence link

February 26, 2008

CNN

Mon February 25, 2008

Story Highlights:

Girlfriend: Kazmierczak stopped taking Prozac three weeks before NIU

shooting

Most experts say there is little data to provide link between drugs,

violence

FDA: Prozac withdrawal can make a person irritable and aggressive

Other drug interactions make it difficult to conclude whether a link

exists

(CNN) -- The revelation from Steven Kazmierczak's girlfriend that he

had stopped taking an antidepressant a few weeks before his rampage

at Northern Illinois University has reopened debate about whether the

drug can cause violent behavior.

Kazmierczak was taking a common combination of three medications, a

psychiatrist said.

Jessica Baty told CNN that she had seen no hint during their two-

year courtship that the 27-year-old might be capable of killing five

people and injuring 17 before committing suicide.

Kazmierczak had stopped taking Prozac three weeks before his shooting

spree on February 14 and had been taking two other medications, she

said.

Experts differ on whether Prozac and other similar antidepressants

might be linked to violence.

" There's very little likelihood that withdrawal from Prozac could, by

itself, cause someone to become violent, said Dr. Nada Stotland,

professor of psychiatry at Rush Medical College and president-elect

of the American Psychiatric Association.

If people with other psychiatric illnesses had a propensity to

violence, then discontinuing drug use " could make them irritable, and

that could be one trigger, " said Stotland, who has accepted speaking

fees from the drug industry, but not in recent years.

But, she said, " discontinuation syndrome " does not cause someone to

become violent.

" We understand that tragic and frightening events make people

desperate for explanations, " she said in an e-mail. " The explanations

are seldom simple or straightforward, and, especially when attempts

to understand would intrude on the confidentiality of medical

records, we seldom know enough about perpetrators' lives and minds to

determine just what caused their behaviors. "

She added, " We have much, much more to fear from untreated

psychiatric illnesses than from the effects of psychiatric

medication. "

Dr. Fred Goodwin, research professor of psychiatry at the George

Washington University, agreed.

" In general, there is no evidence at all of these drugs producing

increases in violence, " he told CNN. " If anything, it was a

withdrawal effect. "

Goodwin, the former director of the National Institute of Mental

Health and host of National Public Radio's " The Infinite Mind, " said

he tells his medical residents " until I'm blue in the face " to change

doses gradually rather than abruptly. " You taper up, you taper down, "

he said.

Health Canada -- the Canadians' version of the U.S. Food and Drug

Administration -- changed its labeling in 2004 for the class of

antidepressants to warn that " patients of all ages taking these drugs

may experience behavioral and/or emotional changes that may put them

at increased risk of self-harm or harm to others. "

And a medication guide approved by the FDA warns of the possibility

that users could act " aggressive, being angry, or violent. "

The labeling also cites concern over " thoughts of suicide "

and " anxiety, agitation, panic attacks, difficulty sleeping,

irritability, hostility, aggressiveness, impulsivity, restlessness,

or extreme hyperactivity. "

Labeling in both countries warns patients not to stop taking the

medication abruptly.

Baty did not say whether Kazmierczak stopped taking Prozac abruptly

or whether he consulted with his psychiatrist prior to doing so.

An increased risk of violence occurs around the time of dose

transition, according to the FDA.

Dose transition is when a person who begins taking an antidepressant

changes dose or stops taking it, said Dr. David Healy of the North

Wales Department of Psychological Medicine at Cardiff University.

Prozac, which has been available in the United States for more than

20 years, is one of a class of drugs called selective serotonin re-

uptake inhibitors. They increase the accumulation in the brain of the

chemical messenger serotonin, which is linked to feelings of well-

being.

Though researchers have compiled the most data about Paxil, another

antidepressant in the same class of medications, there is " no reason

to think Prozac is any different, " since all the drugs in that class

work the same way, said the British psychiatrist and author of " Let

Them Eat Prozac.

" In the case of Prozac, because of its long half-life, the problems

are likely to come several weeks after the last dose, " said Healy,

who has been critical of the drugs and has testified as an expert

witness on both sides of the matter.

Though millions of people take antidepressants, researchers have had

a hard time disentangling the many variables that affect behavior to

determine whether the drugs are associated with episodes of violence.

But that alone doesn't explain the scant data. A study published last

month in the New England Journal of Medicine and carried out by

researchers at the Oregon Health & Science University found that the

results of almost a third of antidepressant studies were never

published, and nearly all of those had concluded that the drug did

not work.

" Not only were positive results more likely to be published, but

studies that were not positive, in our opinion, were often published

in a way that conveyed a positive outcome, " concluded the authors,

led by OHSU's Dr. Erick Turner.

" By altering the apparent risk-benefit ratio of drugs, selective

publication can lead doctors to make inappropriate prescribing

decisions that may not be in the best interest of their patients and,

thus, the public health, " they concluded.

Healy himself wrote one study that did get published, in PLoS

Medicine in September 2006. It tallied the overall risk of violence

among more than 9,000 antidepressant users at 0.65 percent, more than

twice the 0.31 percent seen among people who were taking placebo.

But Healy cautioned against concluding that there was indeed a causal

relationship between the drug and Kazmierczak's outburst.

" While the data shows the drugs can pose a real risk, in each

individual case you still have to look closely for alternate

explanations and definitely not assume too quickly that it has been

the drug, " he said.

Baty's assertion to CNN that Kazmierczak was also taking Xanax, an

anti-anxiety agent, and Ambien, a sleep aid, before the NIU

shootings, make establishing a causal relationship even more

difficult, said psychiatrist Stotland.

It is not unusual for doctors to prescribe anti-anxiety agents and

sleep medication along with antidepressants, since they can cause

anxiety and interfere with sleep, she said.

But, she added, " The more things you add, the more unpredictable

things can get. "

Dr. Joseph Glenmullen, a clinical instructor in psychiatry at Harvard

Medical School who has given expert testimony in cases against the

pharmaceutical industry, raised concerns about the drug combination

Baty said her boyfriend was taking.

Health Library

MayoClinic.com: Health Library

Prozac withdrawal can make a person irritable and aggressive, and

Ambien and Xanax each can cause a person to shed inhibitions,

according to the FDA's drug labeling. The result " could be a pretty

deadly combination, " said Glenmullen, author of " The Antidepressant

Solution - A Step-by-Step Guide to Safely Overcoming Withdrawal,

Dependence, and 'Addiction. "

He called for " some governmental organization " to investigate whether

anecdotal reports of violence linked to the drugs are backed up by

hard data.

A spokesman for Prozac drug maker Eli Lilly and Co. said the cause of

the killing spree may remain elusive.

" There is much information that is still unknown about his life and

medical history and therefore it may never be known as to why he

ultimately chose to take the lives of others as well as himself, "

said spokesman Charles McAtee, in an e-mail.

" Because the authorities have not confirmed at this time any use of a

specific medication by this young man, it is not appropriate for us

to speculate on the matter. It's important that patients should not

stop taking any medication without first talking with their doctor. "

Rights Reserved.

February 26, 2008

At 01:29 PM 2/26/2008, you wrote:

I must say, while I initially got a knee-jerk reaction, the article

presented a pretty balanced view. Something else to consider - he may not

have gotten his meds from a psychiatrist. That being said, I know my POV

isn't popular, but I get so tired of people blaming someone or something

else for someone's actions. If he would have still been on the

medication, it would have been the medication's fault. He stopped taking

it 3 weeks before, and it was still the medication's fault. Not to

mention, they didn't say what 2 other medications he was on. Let's say,

theoretically, that he needed to be on Prozac - was it then not his

responsibility to continue taking it? Or, to wean himself of properly?

Ultimatley, I think it's easier to blame a medication for someone's

behavior, that to really find out what made this guy lose it.

Lynn

Shooting reopens debate over

drug, violence link

CNN

Mon February 25, 2008

Story Highlights:

Girlfriend: Kazmierczak stopped taking Prozac three weeks before NIU

shooting

Most experts say there is little data to provide link between drugs,

violence

FDA: Prozac withdrawal can make a person irritable and

aggressive

Other drug interactions make it difficult to conclude whether a link

exists

(CNN) -- The revelation from Steven Kazmierczak's girlfriend that he

had stopped taking an antidepressant a few weeks before his rampage

at Northern Illinois University has reopened debate about whether the

drug can cause violent behavior.

Kazmierczak was taking a common combination of three medications, a

psychiatrist said.

Jessica Baty told CNN that she had seen no hint during their two-

year courtship that the 27-year-old might be capable of killing five

people and injuring 17 before committing suicide.

Kazmierczak had stopped taking Prozac three weeks before his shooting

spree on February 14 and had been taking two other medications, she

said.

Experts differ on whether Prozac and other similar antidepressants

might be linked to violence.

" There's very little likelihood that withdrawal from Prozac could,

by

itself, cause someone to become violent, said Dr. Nada Stotland,

professor of psychiatry at Rush Medical College and president-elect

of the American Psychiatric Association.

If people with other psychiatric illnesses had a propensity to

violence, then discontinuing drug use " could make them irritable,

and

that could be one trigger, " said Stotland, who has accepted speaking

fees from the drug industry, but not in recent years.

But, she said, " discontinuation syndrome " does not cause

someone to

become violent.

" We understand that tragic and frightening events make people

desperate for explanations, " she said in an e-mail. " The

explanations

are seldom simple or straightforward, and, especially when attempts

to understand would intrude on the confidentiality of medical

records, we seldom know enough about perpetrators' lives and minds to

determine just what caused their behaviors. "

She added, " We have much, much more to fear from untreated

psychiatric illnesses than from the effects of psychiatric

medication. "

Dr. Fred Goodwin, research professor of psychiatry at the George

Washington University, agreed.

" In general, there is no evidence at all of these drugs producing

increases in violence, " he told CNN. " If anything, it was a

withdrawal effect. "

Goodwin, the former director of the National Institute of Mental

Health and host of National Public Radio's " The Infinite Mind, "

said

he tells his medical residents " until I'm blue in the face " to

change

doses gradually rather than abruptly. " You taper up, you taper

down, "

he said.

Health Canada -- the Canadians' version of the U.S. Food and Drug

Administration -- changed its labeling in 2004 for the class of

antidepressants to warn that " patients of all ages taking these

drugs

may experience behavioral and/or emotional changes that may put them

at increased risk of self-harm or harm to others. "

And a medication guide approved by the FDA warns of the possibility

that users could act " aggressive, being angry, or

violent. "

The labeling also cites concern over " thoughts of suicide "

and " anxiety, agitation, panic attacks, difficulty sleeping,

irritability, hostility, aggressiveness, impulsivity, restlessness,

or extreme hyperactivity. "

Labeling in both countries warns patients not to stop taking the

medication abruptly.

Baty did not say whether Kazmierczak stopped taking Prozac abruptly

or whether he consulted with his psychiatrist prior to doing so.

An increased risk of violence occurs around the time of dose

transition, according to the FDA.

Dose transition is when a person who begins taking an antidepressant

changes dose or stops taking it, said Dr. David Healy of the North

Wales Department of Psychological Medicine at Cardiff

University.

Prozac, which has been available in the United States for more than

20 years, is one of a class of drugs called selective serotonin re-

uptake inhibitors. They increase the accumulation in the brain of the

chemical messenger serotonin, which is linked to feelings of well-

being.

Though researchers have compiled the most data about Paxil, another

antidepressant in the same class of medications, there is " no reason

to think Prozac is any different, " since all the drugs in that class

work the same way, said the British psychiatrist and author of " Let

Them Eat Prozac.

" In the case of Prozac, because of its long half-life, the problems

are likely to come several weeks after the last dose, " said Healy,

who has been critical of the drugs and has testified as an expert

witness on both sides of the matter.

Though millions of people take antidepressants, researchers have had

a hard time disentangling the many variables that affect behavior to

determine whether the drugs are associated with episodes of

violence.

But that alone doesn't explain the scant data. A study published last

month in the New England Journal of Medicine and carried out by

researchers at the Oregon Health & Science University found that the

results of almost a third of antidepressant studies were never

published, and nearly all of those had concluded that the drug did

not work.

" Not only were positive results more likely to be published, but

studies that were not positive, in our opinion, were often published

in a way that conveyed a positive outcome, " concluded the authors,

led by OHSU's Dr. Erick Turner.

" By altering the apparent risk-benefit ratio of drugs, selective

publication can lead doctors to make inappropriate prescribing

decisions that may not be in the best interest of their patients and,

thus, the public health, " they concluded.

Healy himself wrote one study that did get published, in PLoS

Medicine in September 2006. It tallied the overall risk of violence

among more than 9,000 antidepressant users at 0.65 percent, more than

twice the 0.31 percent seen among people who were taking

placebo.

But Healy cautioned against concluding that there was indeed a causal

relationship between the drug and Kazmierczak's outburst.

" While the data shows the drugs can pose a real risk, in each

individual case you still have to look closely for alternate

explanations and definitely not assume too quickly that it has been

the drug, " he said.

Baty's assertion to CNN that Kazmierczak was also taking Xanax, an

anti-anxiety agent, and Ambien, a sleep aid, before the NIU

shootings, make establishing a causal relationship even more

difficult, said psychiatrist Stotland.

It is not unusual for doctors to prescribe anti-anxiety agents and

sleep medication along with antidepressants, since they can cause

anxiety and interfere with sleep, she said.

But, she added, " The more things you add, the more unpredictable

things can get. "

Dr. Joseph Glenmullen, a clinical instructor in psychiatry at Harvard

Medical School who has given expert testimony in cases against the

pharmaceutical industry, raised concerns about the drug combination

Baty said her boyfriend was taking.

Health Library

MayoClinic.com: Health Library

Prozac withdrawal can make a person irritable and aggressive, and

Ambien and Xanax each can cause a person to shed inhibitions,

according to the FDA's drug labeling. The result " could be a pretty

deadly combination, " said Glenmullen, author of " The

Antidepressant

Solution - A Step-by-Step Guide to Safely Overcoming Withdrawal,

Dependence, and 'Addiction. "

He called for " some governmental organization " to investigate

whether

anecdotal reports of violence linked to the drugs are backed up by

hard data.

A spokesman for Prozac drug maker Eli Lilly and Co. said the cause of

the killing spree may remain elusive.

" There is much information that is still unknown about his life and

medical history and therefore it may never be known as to why he

ultimately chose to take the lives of others as well as himself, "

said spokesman Charles McAtee, in an e-mail.

" Because the authorities have not confirmed at this time any use of

a

specific medication by this young man, it is not appropriate for us

to speculate on the matter. It's important that patients should not

stop taking any medication without first talking with their doctor. "

Rights Reserved.

February 27, 2008

At 01:26 PM 2/26/2008, you wrote:

At 01:29 PM 2/26/2008, you

wrote: