Shooting reopens debate over drug, violence link
CNN.com
02-25-2008

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.

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.

See a professor talk about Kazmierczak's demeanor leading up to the
shooting >>

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.

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."

All AboutSteven Kazmierczak * Mental Health * Northern Illinois
University

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