A Prescription For Murder

Wow! What a title! Sounds like an Agatha Christie novel or a cheap horror movie. It’s actually the title of a BBC Panorama documentary which hypothesises a link between SSRI antidepressant medication and an increased propensity to commit violent acts. 

Is there a link? Statistically yes maybe. A very tiny percentage of people taking SSRIs experience psychosis as a side effect, but statistically more people are killed as a result of trying to put on a pair of trousers. So why is there not a documentary about trouser deaths called Leg Ends Of The Fall? I believe it is because of the manner of the respective causes of death. 

Accidental deaths caused by embarrassing wardrobe malfunctions would be uncomfortable, voyeuristic subject matter. You don’t kick a man when he’s down through no fault of his own. So what’s the difference between that and someone who’s mentally ill through no fault of their own?

It’s because violent mentally ill people are juicy subject matter. A ratings winner. The subject retains a ghoulish car crash fascination. The notion that mental illness equates to violent, dangerous derangement is deeply embedded in the public’s psyche. Why else were lunatics locked in mental asylums, strapped in straitjackets, if not to prevent them from being a danger to others?

There are many variations of the escaped mental patient urban myth, with invariably innocents being slaughtered by the rampaging, almost supernatural human monster. The thing cannot be reasoned with; it is beyond reason. It is animalistic, bloodthirsty, evil. Something to be hunted and killed on sight. 

The factual reality is that mentally ill people are more likely to be a victim of violence than the general population. Only 3% of mentally ill people ever commit a criminal act of aggression. That means that 97% never commit an act of aggression. The person a mentally ill person is most likely to harm or kill is themselves. Suicide is the biggest cause of death in men aged 20-49 in the U.K. and the biggest cause of death of teenage girls worldwide. 

What then is the basis for a 21st century documentary about mentally ill killers, that lingers over gory details? According to Shelley Jofre, the BBC reporter who made the documentary, it is a public interest story. I see that it’s a story the public will be interested in, but is it in the public interest?

The Panorama programme claims that the incredibly rare side effect of SSRI medication causing psychosis, potentially leading to aggression and violence, needs to be more widely known to both the general public and to people taking SSRIs. The problem with this argument is that family doctors and prescribing psychiatrists already weigh up potential side effect risks and discuss them with patients before prescribing. And there are many possible side effects from taking SSRI medications, the most common of which include weight gain, sedation, fatigue and loss of sex drive. The average person taking an SSRI has been informed by their doctor of likely side effects, thoroughly read the leaflet that comes with the medication, probably read up some more about the risks on Wikipedia and discussed the risks with other people taking the same medication. The vast majority of mentally ill people are already very well aware of the potential and actual side effects of taking SSRI medications. 

What about the wider population? Don’t they deserve to know the danger too? If the 40,000,000 prescriptions for SSRI medications in the U.K. every year are going to trigger a nationwide bloodbath, don’t the public have a right to be warned? Therein lies the central weakness in the programme’s premise. 40,000,000 SSRI prescriptions per year already in the U.K., no mental patient slasher movie apocalypse as a result. 

I don’t deny that there are records of isolated cases where an SSRI may have contributed to a tragic incident. But is the potential danger both proven and statistically significant enough to warrant making an hour long documentary about it? What about the much more prevalent side effect of an increased risk of death by suicide among teenagers when they first start taking some, but not all, SSRI medications? That kills more people. Surely that’s more newsworthy?

The unpalatable reality is that few care about mentally ill teenagers killing themselves. It’s dull TV, compared to bloodsoaked rampaging mental patients. Real Hannibal Lecters lurking in our midst. 

This perpetuates the myth that mentally ill people are inherently violent and a well behaved one is just one waiting to explode in a killing frenzy at any moment. Drugs are supposed to suppress this huge danger, not enhance it. A dribbling, sedated, locked up mental patient is the only safe one. 

This is of course total nonsense. One in four of us will suffer a mental illness in our lifetime. The vast majority of people will be treated with a combination of medication and therapy. Out in society. Not locked up. Normal, but unwell people, not dangerous in any way. 

What are the likely outcomes of the documentary being aired?

There is a small possibility that a handful of people who are taking SSRIs and experiencing psychosis as a side effect will realise what has been wrong and seek help and advice from their doctor. This is a good thing. 

Something which is much more likely is that some mentally ill people currently benefitting from taking SSRI medications will stop taking them, to avoid the remote possibility of becoming violent. The benefits of that medication will then stop. Clinically depressed people will slide back into the abyss. People with anxiety disorders will retreat back into tormented Hell. Some of these people may well take their own lives as a result. The documentary could possibly cause more deaths, not fewer. 

Then there is the stigma issue. Some think that the term “mental health stigma” is overused. In the face of the ongoing tide of derision, fear, mistrust and demonisation of mentally ill people, I can assure you that the term could be used much more indeed. Just like black people and gay people have had to stand up and say enough is enough, mentally ill people are now standing up to be counted. 

My name is Patrick. I suffer from clinical depression, severe OCD and PTSD. I am a mentally ill person, a loving husband, a good father. I take a high dose of Prozac, an SSRI medication. It helps me to function normally. I’m not an unquestioning fanboy of Prozac. I have side effects from taking it, but I’m zero danger to anyone. Enough is enough. The unwarranted stigma against all the ordinary people just like me has to stop. This documentary will perpetuate stigma and prejudice. That is harmful and dangerous. Much more dangerous than a rare medication side effect. 

Advertisements

PLMD

Imagine receiving a good hard kicking every night as you go to sleep, being kept half awake for the next five hours, then forgetting that both have happened and waking each morning feeling exhausted and aching all over, apparently for no reason. That’s basically the effects of PLMD. 

PLMD. It sounds like a comedy terrorist group from The Life Of Brian. The People’s Liberation Movement of the Desert. …SPLITTERS!

It’s not. It is Periodic Limb Movement Disorder. In layman’s terms, twitching and convulsing in your sleep for prolonged periods. It is apparently caused by stress and lack of sleep. The irony of that is not lost on me. It’s quite a weird thing to experience. To be absolutely accurate, it’s quite a weird thing for the partner of the sufferer to experience. This is nearly always how the condition is discovered and diagnosed. 

I have always tossed, turned, twitched and shuddered in my sleep. I thought it was either how everybody sleeps or how everybody with Obsessive Compulsive Disorder sleeps. I make too many silly generalised assumptions in life. 

Just over a year ago, the medication I was taking for OCD and depression was changed to Fluoxetine (commonly known as Prozac), because I was having troubling side effects with my previous medication. Fluoxetine is an SSRI (selective serotonin reuptake inhibitor). It does its job of keeping my mood stable better than any medication I have been on previously. Unfortunately, an uncommon side effect of SSRIs can be PLMD. In the case of people like me who already suffer from PLMD, it can make the condition much worse. 

Along with the most noticeable results of PLMD – constant, extreme fatigue and aching muscles, there are also clues like frequently pulled back muscles and regularly bitten tongue and cheek tissue. I’ve even managed to tear the cartilage in one knee and also dislocate my jaw while asleep. I had previously assumed that all of the fatigue I felt was due to the constant demands of severe OCD and also asthma problems during the winter. Yes, these contributed a lot, but surprisingly turned out not to be the main culprits. 

My wife’s sleep pattern had been so disturbed that she too was beginning to suffer the effects of long term sleep deprivation. So one night, when I was convulsing badly, she filmed me using her mobile phone. She showed me the video the following morning. It was horrific. So disturbing that I have chosen not to embed the video in this post. I had no idea that it was any more than some twitching while falling asleep. It looked like a horror movie special effect, as if I was being electrocuted or was possessed. My whole body went rigid and all limbs jerked in unison repeatedly. Each violent burst lasted between five and ten seconds, with a gap of 20 to 40 seconds between bursts. It eventually turned out that I was doing this every night for between 3 and 5 hours. No wonder we were exhausted. 

Another clue that something had gotten much worse was the bedsheet. While my side of the fitted sheet had always been badly creased and rumpled, in the previous eight months I had managed to wear a 40cm hole in not one but two fitted sheets. Pretty hardcore. 

IMG_4320

I wasn’t fitting, having seizures or blackouts when awake. It was something which only happened when I was asleep. 

I phoned the GP surgery immediately and booked an appointment for later that day. 

LATER THAT DAY: “You know how every time I have an appointment, l always comment on how exhausted I am? I think I’ve figured out why”.

I showed him the video. 

“WOW! The neurologist is going to love this! They love seeing videos!”

I had apparently made the GP’s morning by presenting with something unusual. 

I told him that in the hours since booking the appointment I had researched the symptoms and narrowed it down to PLMD, which seemed likely, and Serotonin Syndrome, which seemed like a long shot. He agreed. Given that it was most likely being made worse by the 60mg dose of Fluoxetine I was taking, the GP suggested that the first thing I should try was cutting the daily dose down to 40mg. I agreed to give this a try, with the proviso that I would raise the dose again if my mood destabilised. 

Within ten days my mood destabilised badly. And the convulsions hadn’t diminished at all. I raised my Fluoxetine dose back up to 60mg. This was a great disappointment to me in terms of how I perceived my mental health recovery. I hadn’t realised that, despite making huge progress in the previous year, I am still very much reliant on the medication for mood stability. I really don’t like having to rely on any medication. 

I eventually had an appointment with a neurologist. He too watched the video and was moderately impressed. He confirmed that it was a textbook case of PLMD, but for certainty of diagnosis, I would have to undergo a sleep study, overnight in hospital, wearing electrodes or monitors. The waiting list is long for sleep studies, so they started me on medication a week later. 

The medication I’ve been put onto is Ropinirole, a dopamine agonist, which is a compound that activates dopamine receptors in the absence of the neurotransmitter dopamine. The initial dose starts at 0.25mg, then 0.5mg and building weekly in 0.5mg increments to the maximum dose of 4mg. My wife and I didn’t notice any beneficial effect until the end of my 2.5mg week. 

By then, my wife said that the intensity of the convulsions hadn’t diminished, but their duration had reduced significantly. I wasn’t waking us both up repeatedly through the first half of the night. I started to feel less chronically exhausted. For the first time in years, I didn’t have to sleep at all during the day. I also didn’t need to go to bed for the night at between 5pm to 7:30pm. 

I started to gain some energy and motivation to do things again. It’s good to know that I’m not a lazy malingerer, as my OCPD continually said I was. My mood has improved significantly. My asthma has improved slightly. I have been able to swim a few lengths in the local swimming pool again, a great psychological victory. 

I still don’t sleep normally every night. As I relax into sleep from my ever tense, hypervigilant waking state, I start to convulse. It starts with my left arm, then my whole left side, then the spasms start to pass through all of me, as if like a shockwave. I have tried to consciously not convulse, but once the first involuntary spasms happen, I cannot prevent further convulsions. I still have the occasional very bad night, but they are the exception rather than the norm now. 

Something which had been lurking in the background for God knows how long, impacting on both my physical health and mental wellbeing, has been exposed. It’s not yet eradicated completely, but I’m happy to cope with the occasional bad night in the meantime. 

EDIT 9/10/15: The full beneficial effect seems to have been temporary. Even though I am on the maximum medication dose, I am still having extended periods of convulsions 25% to 30% of the time. Whilst this is better than it was, I now yo-yo between complete fatigue/muscle pain, to gradual onset of daily fatigue and back again. Unpredictable, physically debilitating, frustrating and demoralising. Sleep deprivation is an excellent torture method. 

EDIT 22/10/15: Neurologist has increased the ropinirole dose to 6mg. No additional beneficial effect so far. Very very tired. 

EDIT 9/11/15: Back to being completely symptomatic for the last  week. Utterly exhausted. All muscles physically aching. So tired, but afraid to go to sleep or even relax. Phoned neurology department. Nurse phoned back. “Just stick with it for another couple of weeks”. Utterly useless. Clearly beyond her remit to be able to alter medication dose or make any other therapeutic alteration. Going to try reducing the SSRI dose again to see if if makes any difference. I will just have to suffer the mood instability in the short term, with my wife observing me. Give me a break God. I am trying so hard to get well. Tearful. 

EDIT 30/12/16: Quite a lot has happened since the last edit.