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A forensic sleep thriller

2013; Elsevier BV; Volume: 12; Issue: 7 Linguagem: Inglês

10.1016/s1474-4422(13)70081-4

1474-4465

Álex Iranzo,

Sleep and related disorders

Sleep disorders—particularly sleepwalking—are rarely portrayed in TV series or films. When they do appear, they are usually introduced as something unknown or disturbing, or, by contrast, as an innocent comic element. For example, in the episode The Sleeping Brother (1962) from The Dick Van Dyke Show, there is a rather shy character who turns out to be a great comedian and banjo player only when he sleepwalks. Side Effects, a film by Steven Soderbergh (director of Sex, Lies and Videotape, Traffic among others) goes far beyond other films in which sleep disorders are depicted by making the disorder central to the plot. The film also draws attention to several interesting and controversial pharmachological, psychiatric, ethical, and medico-legal issues, which will keep the audience on the edge of their seats. Side Effects tells the story of Emily Taylor (Rooney Mara), a 28 year old woman who has depression and a history of suicide attempts. Emily is referred to Dr Jonathan Banks (Jude Law), a psychiatrist who prescribes her the antidepressant sertraline, but this medication soon has to be withdrawn because of the side-effects Emily experiences—vomiting, dizziness, insomnia, and absence of sexual drive. Dr Banks, at Emily's request, agrees to consult Dr Victoria Siebert (Catherine Zeta-Jones), the psychiatrist who had treated her on her first depression episode 5 years before with bupropion, fluoxetine, and venlafaxine, with which she had adverse effects such as insomnia, nausea, and shivers. Dr Siebert suggests that Dr Banks prescribe Emily a recently approved antidepressant called Ablixa (alipazone), which is manufactured by Sadler Benelux (the drug names and the pharmaceutical company are fictional). Ablixa dramatically improves Emily's mood and energy. Yet, Emily has an unexpected side-effect that Dr Banks and the dispensing pharmacist did not mention: sleepwalking. Despite her husband's request, Emily is reluctant to give up a drug that is effectively controlling her depression. This decision sets into motion a chain of events that results in a criminal case being brought against Emily. Any doctors in the audience will pick up on several points, some of which are more accurately described than others. A great deal of the scientific precision is attributable to the script by Scott Z Burns' (who also wrote the sceenplay for another medical thriller, Contagion) and his expert consultant Dr A Sasha Bardey, a forensic psychiatrist who worked in the prison ward of Bellevue Hospital in New York (NY, USA). Mara's characterisation of Emily as a somnambulist is veracious: she wears a nighty, walks barefoot, and has a fixed look and blank expression; her eyes are open and her movements clumsy, but she does complex activities such as chopping vegetables or turning the radio on; she is unresponsive. Finally, she returns to bed and upon awakening has amnesia for her sleepwalking episodes. Emily also has two variants of sleepwalking while she is taking Ablixa. First, one episode of sexsomnia is shown during which Emily has passionate sex with her husband Martin (Channing Tatum). Second, even though we never see Emily eat during her episodes, a sleep-related eating disorder can be suspected since she is always cooking or setting the table. Sleepwalking is a quite uncommon side-effect of antidepressants. In fact, I have noticed that some sleep specialists use antidepressants to treat sleepwalking. By contrast, sleepwalking is a known side-effect of some hypnotics, such as zolpidem. Interestingly, the generic name used in the film for Ablixa, alipazone, sounds more like a hypnotic name (eg, zopiclone, zaleplon) than an antidepressant. However, some small expert touches are woven into the fabric of the film—it's working title was The Bitter Pill, and the soundtrack features songs called Acute parasomnia and Malingering. During Emily's trial, Dr Banks is an expert witness. Partly on the basis of his testimony, Emily will be declared guilty or not. Notably, the UK's Civil Procedure Rules, the American Academy of Neurology, and the American Medical Association guidelines for expert testimony state that the expert witness must be impartial. A notable omission in the trial was that neither the defence attorney nor the prosecutor asked for polysomnograms, neuroimaging brain studies, or toxicolegal tests to assess whether Emily was a true sleepwalker or not. The film shows the great responsibility that doctors have in watching over their patients and that an oversight or imprudence could lead to the ruin of a long, hard-earned career. The Ablixa case ruins Dr Banks: he is chased by the paparazzi, his patients mistrust him, his colleagues turn their backs on him, he is about to lose his medical licence, a pharmaceutical company stops him from participating in a clinical trial, and his marriage is broken. Side Effects is a stimulating forensic sleep thriller, which makes a fierce criticism of pharmaceutical companies and the mispractice of certain doctors working with them. This clever film has much to offer to neurologists, providing a stark reminder of the importance of considering all possible outcomes when prescribing a new drug, and keeping the patient's wellbeing at the centre of decision making.