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Panorama's prescription

2017; Elsevier BV; Volume: 4; Issue: 9 Linguagem: Inglês

10.1016/s2215-0366(17)30312-7

2215-0374

Carmine M. Pariante,

Body Image and Dysmorphia Studies

After all the hype and anticipation that preceded it, I have to say that the BBC Panorama programme A Prescription for Murder? was not as bad as I thought. Are doctors “unwittingly prescribing what could be a prescription for murder?”, asks the programme. “No”, is the answer that the programme itself gives, if you have listened carefully to the story of James Holmes, the so-called Batman Killer, and the other evidence presented. What is depicted in the documentary is not the story of someone who suddenly turns from healthy to murderous after taking antidepressants: it is the classic (and tragic) story of a progressive descent into psychosis, with accurate descriptions of prodromal symptoms (the ruminations about killings start in adolescence), severe obsessive thoughts which gradually become quasi-delusional, the sudden onset of a delusional intuition—the “Human Capital” idea that points can be earned by killing people—and increasingly bizarre behaviour. And the desperate attempt of a psychiatrist to treat Holmes's worsening symptoms with a selective serotonin reuptake inhibitor (SSRI), sertraline, which was the correct treatment for the severe obsessive and anxiety symptoms that Holmes was disclosing. To me, the timeline of the relationship between the increased sertraline dose and the worsening of the psychotic symptoms, which the programme places at the core of the argument for a causal effect of the antidepressant, actually confirms the natural, rapid evolution of the psychotic illness and the understandable response of the treating psychiatrist. And indeed, Holmes was off sertraline for 3 weeks by the time of the attack on the cinema. So, what other evidence does Panorama bring in support of the notion that a “small minority” of patients might suffer from murderous ideas following antidepressants? The programme states that antidepressants have been linked to 28 reports of murder and 32 cases of murderous thoughts in cases referred to the UK Medicines and Healthcare products Regulatory Agency over the past 30 years. Of course, association does not mean causation, and for a class of drugs that are currently being prescribed to 9% of people in the UK and 12% of people in the USA, these reports could represent either a chance association, or an association with the mental health problems for which the antidepressants have been prescribed in the first place. In any case, even if these were true cases where antidepressants had “caused” the murderous thoughts or acts, how frequent would these be? A back-of-the-envelope calculation based on the 60 reports in 30 years suggests that the rate of these events is less than one per million people taking antidepressants per year; compare this with the cardiac death risk associated with certain antibiotics of 2·5 to 5 per 1000 person years; or the 1 in 300 000 chance per year of being killed by lightning. Yet nobody is producing high-profile documentaries against antibiotics or lightning. The link between antidepressant drugs and violent thoughts and behaviour is complex and nuanced, as set out by the Science Media Centre's response to the programme. A study in more than 20 000 released prisoners (a population which arguably is at increased risk of violent behaviour) shows no increased risk of violent reoffending rates with antidepressants, and a recent report on more than 60 000 youths shows an increased risk for violent behaviour in young people with depression—the primary indication for antidepressants. However, antidepressants can increase agitation and akathisia in young people, and it is possible that this increased agitation could also contribute to an increase in aggressive behaviour. One thing we do know: antidepressants protect from suicide. The risk of suicide attempt among patients treated with an SSRI is about one-third that of patients who are not treated with an SSRI, and it is two times higher before than after the start of SSRI treatment. Among people who die by suicide, the proportion that die by violent means is lower in those who are taking SSRIs than in those without any detectable blood levels of antidepressants. Most worryingly, when the rates of SSRI prescriptions for children and adolescents decreased after US and European regulatory agencies issued warnings about a possible suicide risk with antidepressant use in paediatric patients, this decrease was associated with an increase in suicide rates. This should raise the concern that any unjustified panic about use of antidepressants might lead to a drop in their prescription, and possibly to an increase in suicide rates. Clearly a more balanced discussion about the safety of antidepressants, without a sensationalist title, is needed.