Making medicines safer for all of us

Adverse drug events are now the fourth leading cause of death in hospitals.

It’s a reasonable bet they are an even greater cause of death in non-hospital settings where there is no one to monitor things going wrong and no one to intervene to save a life. In mental health, for instance, drug-induced problems are the leading cause of death — and these deaths happen in community rather than hospital settings.

There is also another drug crisis — we are failing to discover new drugs. [Read more...]

Author Archive for Jo



Days of Reckoning?

A little over a year ago, there was consternation in psychiatric circles as a French psychiatrist, Daniele Canarelli was found guilty after her patient hacked a man to death. She had not recogized the hazard he posed. Doctors didn’t like the implications they saw.

In a series of lectures I have raised the question as to how long it might be before a doctors would be found guilty for a suicide or homoicide linked to an antidepressant, given that we have known that these drugs can cause suicide or homicide for over 50 years. See RxISK’s Violence Zone.

New Zealand

In March 2008 17-year old Toran Henry who was on Fluoxetine (Prozac) committed suicide, fifteen days after starting the drug. Maria Bradshaw, his mother, convinced that the drug had caused the problem refused to have his death attributed to a depression or other disorder he didn’t have.

Unbeknownst to her, the company that marketed it in New Zealand, Mylan, had looked internally at the case and decided their drug had caused Toran’s death. Maria had to fight to get this information. Mylan withheld their assessment and forced her to get the High Court to agree she was her child’s legal representative.

Following her efforts for her son, Maria and others formed CASPER, a New Zealand based organization aimed at raising awareness of suicide and the role that treatments like the antidepressants can play in provoking this. It is now spreading to other countries and its profile is rising steadily.

Old Zealand

Meanwhile in 2011 in Old Zealand (Denmark), Danilo Terrida, 20, committed suicide eleven days after he was prescribed antidepressants following an eight-minute-long conversation with a doctor.

The doctor never followed up on the consultation and was recently found responsible for the suicide by the National Agency for Patients’ Rights and Complaints.

The health agency, Sundhedsstyrelsen, has decided to make it harder for doctors to prescribe antidepressants to 18-to-24-year-olds after Danilo’s suicide.

From now on, young patients will have to face an assessment and an in-depth conversation with a doctor before antidepressants can be prescribed.

“Along with the Danilo case, there have been other cases that we, as the oversight authority, are not satisfied with. That is why we are now tightening the rules for this vulnerable group,” Sundhedsstyrelsen spokesperson Anne Mette Dons told TV2 News.

Danilo’s family said that they were pleased that the rules had been tightened for prescribing antidepressants.

“It doesn’t change the fact that we have lost our son,” Danilo’s mother, Marianne Terrida, told Jyllands-Posten newspaper. “The fact that it’s a dangerous drug is not new, it’s been known a long time.”


The case has sparked a debate in Zealand about the dangers of psychiatric drugs, and in Politiken newspaper today Peter Gøtzsche, medical researcher and leader of the Nordic Cochrane Center at Copenhagen’s Rigshospitalet, wrote that antidepressants have caused healthy people to commit suicide.

“It is true that depression increases the risk of suicide, but antidepressants increase it even more, at least up until the age of 40,” he wrote.

He added that psychiatric medication often does more harm than good and that patients would often be better off without medication.

“Doctors cannot cope with the paradox that drugs that can be useful for short-term treatment can be highly dangerous when used for years and even create the illnesses that they were supposed to prevent, or even bring on an even worse illness,” Gøtzsche wrote.

Editorial Note: The risk of suicide and violence affects all age groups – up to 100. If they go wrong, these drugs are likely to be highly dangerous in the short term.

RxISK Stories: Go Ask Alice

Editorial Note: RxISK is all about people discovering things for themselves and alerting others to something that can make a real difference.

There have been some wonderful examples outlined in posts here on RxISK from Anne-Marie Kelly’s discovery of a cure for Alcoholism – stop your SSRI and perhaps try a serotonin-3 antagonist like mianserin or ondansetron – to Samantha Dearnaley’s discovery that Champix (Chantix) had caused her epileptic convulsions. These were things that none of the experts knew.

Johanna Ryan gives another example below. As the resident psychiatric and psychopharmacologic expert, it’s worth noting that I had never heard of ‘Alice in Wonderland Syndrome’. It just shows that putting people with interest and/or motivation together can do far more to solve problems than going to see an expert – there are far too many things out there for one expert to know. Even if you think your expertise doesn’t amount to much, we have reached a point where pooling our expertise is a much better bet than relying on experts. (DH)

Go ask Alice

One pill makes you larger, and one pill makes you small
And the ones that Mother gives you don’t do anything at all
Go ask Alice, when she’s ten feet tall.

“White Rabbit,” by the Jefferson Airplane


I first heard of “Alice in Wonderland Syndrome” last year while reading Oliver Sacks’ book, Hallucinations. Sacks is a neurologist who is fascinated with the range of experiences, good, bad and strange, that the human nervous system can give rise to.

In Alice in Wonderland Syndrome (AIWS), objects in the environment and even parts of your own body are strangely distorted. Just like Alice, you may perceive your own head or arms as huge, while the people around you seem tiny – or you may feel suddenly shrunk, while the furniture in the room towers over you. It’s best known as a rare effect of migraine headaches and Sacks speculates that Lewis Carroll may have gotten some of the trippy inspirations for his classic story from his own chronic migraines. It’s also been known to occur in epilepsy and in viral infections, especially in children. Anticonvulsant drugs used to control epilepsy and migraines are a standard treatment. Which was why it startled me to stumble across a case on – as a side effect of an anticonvulsant drug!

RxISK patient narratives link Topamax & hallucinations

On the Patient Narrative page for Topamax, someone reported the following:

“Intense visual hallucinations. Objects in the visual field (e.g., computer monitor, hands, arms, desk, etc.) would move far, far away in regular time then come back and be grossly enlarged. It is almost like making an MS Word document change font sizes, from 12 pt to 2 pt to 350 pt, but it was everything I saw.”

Using’s features gave me some clues about this person’s experience, and how common it might be. Using the “A-Z Search” function under Reported Side Effects I found the FDA had eight reports of Alice in Wonderland Syndrome on Topamax, with a “PRR” of 438.8. That means the odds were overwhelming that the drug and the AIWS were connected.

The “Location” tab in Reported Side Effects told me that six of these were from Germany! One was from the UK, but absolutely none from the USA, even though Topamax is widely used here. Checking the Location tab for All Side Effects, well over half have come from America, with no other country even coming close.

Checking “Gender” and “Age” told me that all eight were female, and seven were teenagers.

Our friend on RxISK sounded more like an American adult than a teenage girl from Germany. Was she (or he) the first? Well, she’d probably never heard of Alice, so she reported this as a “visual hallucination.” Maybe others had too.

Back to the Reported A-Z side effects, where I found 69 reports (PRR 4.9) for Visual Hallucination, 103 (PRR 1.6) for plain old Hallucination, and 73 (PRR 3.2) for Visual Disturbance. “Disorientation” might be relevant too, and there were 106 reports of that (PRR 2.4).

Fifteen of the 69 Visual Hallucination reports came from the USA, 18 from the UK, and only two from Germany. Two-thirds were female. There were nine children and 21 teenagers, but there were also twenty adults, and nineteen cases were “age unknown.”

Going to the “Outcomes” tab, I found that 39 of these 69 people had been hospitalized! That told me that probably only the more extreme cases were being reported – those where the person was terrified by their experience or it happened alongside more serious side effects.

Treatment of migraines

By now I was hooked, so I went to Google. I found one professional paper on Alice in Wonderland Syndrome as a side effect of Topamax – a case report on a teenage girl in Germany who was taking the drug to prevent migraines. The authors had probably made that initial report to the FDA and may have alerted other German headache specialists to a symptom that certainly breaks up a dull workday.

There were a couple of American papers as well, though, including one about two patients with “palinopsia” and one with AIWS. All were taking Topamax for migraines. Fellow medical wonks can Google palinopsia – it’s even stranger than AIWS but I could not find a single report to the FDA.

Another paper described “Steroid-induced Psychosis Presenting as Alice in Wonderland Syndrome” and implied that the patient, who was on heavy steroids for severe asthma attacks, had been misdiagnosed with “schizophrenia.”

I also found several reports on patient discussion boards of AIWS on Topamax, including both  (“Feeling a Bit Like Alice in Wonderland on Topamax”) and the psych board CrazyMeds. They were mixed in with reports of other strange symptoms – hallucinations, delusions, feelings of unreality or of standing outside one’s own body.

I was struck by something the moderator of CrazyMeds (who by the way is resolutely pro-med and will not tolerate any psychiatry-bashing on his board) said: “As with all anticonvulsants, anything Topamax can fix is also a potential side effect.” In other words, a range of symptoms of epilepsy, migraine and even bipolar disorder could also be side effects of an anticonvulsant drug taken to treat these conditions.

‘RxISK allows us to describe what’s going on and how it affects us’

If this is true then RxISK and similar efforts could make a huge contribution. As Kalman Applbaum noted, many FDA reports filed by doctors consist only of ticking a box on a list, say for “hallucination” or “anxiety.” RxISK allows us to describe what’s going on and how it affects us, as the Alice in Wonderland sufferer did. If we know people taking anticonvulsants for one condition (say, depression) experience symptoms typical of other conditions (weird visual effects associated with migraine auras), the link to the drug becomes clearer.

In the case of Cymbalta, another drug highlighted on RxISK, people taking the drug for back pain have experienced the same side effects (nightmares, moodswings, etc.) as those taking it as an antidepressant. Observations like this could teach us more about the drug and help prevent patients from being misdiagnosed with new “diseases”, like that asthma patient with AIWS.

Reporting to RxISK

I looked at a few of the other anticonvulsants (Neurontin, Lyrica, Lamictal). No reports of AIWS. However, all have a fair amount of Visual Hallucination and Visual Disturbance reports and all include far more Americans and adults as opposed to German teenagers. So who knows! The FDA has a category called “Feeling Abnormal” which is very large and could be hiding almost anything including Alice. We need people to report to RxISK to find out what’s going on – FDA is like Humpty Dumpty for whom words where what he chose them to mean.

RxISK reporting could help bring together communities of doctors and patients who seldom talk to each other, even though we are increasingly prescribing or taking the exact same drugs. Reading the discussion boards, I noticed psychiatry patients complained that their doctors denied these problems could be happening or connected to the drugs. Neurology patients found that their doctors were much quicker to concede that these effects were drug related, although they complained of being told to just ‘hand in there’ by doctors who didnt take the side effects seriously enough. We can also share reports from various countries where the drug-use practices can be very different, even for the same illnesses.

Reports to RxISK could also reveal a lot about the brain and the mind. Oliver Sacks first made me aware how much neurologists owe to accidents, breakdowns and “side effects”, and the reports of non-scientists who had lived through them. Who could forget poor Phineas Gage, the railroad worker who survived a sharpened crowbar being driven through his left frontal lobe? Doctors and experts flocked to examine and quiz him, trying to learn more about the brain works. Fortunately, most people logging on to RxISK don’t have anything nearly as awful as Phineas Gage had but because we know more now about the brain than we did then, reports of much less dramatic things can teach us a huge amount.

Editorial Note: The only thing a psychiatry expert can add to this is that it’s not a surprise that the recognition that this is ‘Alice in Wonderland Syndrome’ came from Germany. For well over a century, the Germans have been much interested in paying close attention to superficially similar things and distinguishing between them than anyone else has.

Left Hanging: Suicide in Bridgend


The Figures

In the England and Wales there are roughly 5000 suicides in roughly 60 million people per year. This would until recently have led to around 2000 hangings per year, 34 hangings per million people per year, 3.5 per 100,000 people per year.

Bridgend in South Wales has a population of 40,000. The greater Bridgend area has a population of 130,000. There should be 18 hangings per 100,000 people over a 5 year period, 24 per 130,000 per year.

In recent years however in both the US and UK there has been a rise in the number of hangings so that this mode of death now accounts for 50% of cases. If this applies in the Bridgend area, we might expect 28 hangings per 130,000 over a 5 year period, roughly 6 per year.

There were in fact 79 hangings in Bridgend between January 2007 and February 2012. The hangings continue unabated, so the true figure may be in the 90s. This means there have been 16 per year – an excess of 10 or more hangings per year.

Vanishing suicides

There have likely been a lot more self-destructions than this in Bridgend. Coroners have considerable discretion and recently a great deal of encouragement to use narrative, open or death by misadventure verdicts rather than to record a verdict of suicide. To record a suicide verdict they should be satisfied that the person intended to kill themselves. One of the primary indicators of intent is a suicide note. In the Bridgend cases, there have been few suicide notes. This has made it easy for coroners to manage perceptions of what might be going on.

Having a narrative or open verdict can be extremely important for families. I have written reports in over 20 inquests arguing that it would be appropriate to return a narrative rather than a suicide verdict, in the case of people whose suicide has been triggered by an antidepressant.

But this use of narrative verdicts has produced a situation where suicide figures are close to worthless. The British suicide rate is comprised of cases recorded as suicides along with a proportion of narrative, open or other verdicts, with the proportion chosen down to bureaucratic whim. We do not have a self-destruction rate and absolutely no idea as to how many verdicts, either suicide or narrative, are linked to antidepressant or other drug intake.

A website antidepaware was recently set up to track deaths by suicide or misadventure or related that are related to antidepressants. It has logged over 1600 UK suicides involving antidepressants of which 43% were recorded as suicides by the coroner, 26% as narrative verdicts, 19% as open verdicts, 5% as death by misadventure and 7% as accidental.

Hanging & kneeling

While the suicide rate has become ambiguous, it is not possible to conceal the number of hangings.

Bridgend has had an unusual number of hangings. An apparently odd feature is that these hangings have involved a lot of kneeling. The fact that many victims have been found hanging but with their feet on the ground or close to kneeling has given rise to speculation about internet or other cults, and about serial killing rather than self-destruction.

I had been exposed to relatively few SSRI suicide cases when Linda Hurcombe came to me telling me of her daughter Caitlin, who after 6 weeks on Prozac hung herself using her horses’ lanyard (see Let Them Eat Prozac).

Soon after that with colleagues I ran a healthy volunteer study designed to test how antidepressants work. In this study, two completely normal women while taking the SSRI sertraline (Zoloft) became suicidal. One of these two had vivid imagery of hanging herself.

Around this time too I got involved in the Miller case. Matt Miller was a 13 year old boy who had just changed schools and was feeling nervous. His parents prompted by the teacher brought him to a doctor who put him on Zoloft. Seven days later he hung himself in the bathroom between his parent’s bedroom and his bedroom.

Pfizer, the makers of Zoloft argued that this was not suicide but auto-erotic asphyxiation gone wrong. As evidence, they pointed to the fact he was not suspended several feet above the floor but had his feet on the ground, almost kneeling. They went so far as to scour the carpet in the bathroom to collect potential evidence for seminal stains.

It was Yvonne Woodley’s case in 2010 that explained the hanging issue to me – something that anyone with an interest in the area could in fact have found from Wikipedia.

Yvonne Woodley was a 42 year old woman who was having marital difficulties. She presented to her doctor with sleep problems. The doctor viewed her as being under stress, and as posing absolutely no suicide risk. She gave Yvonne citalopram. A week later the doctor noted that Yvonne was more agitated and there were fleeting thoughts of suicide – so she doubled the dose of citalopram. After a suicide attempt, she doubled it further and a short while afterwards Yvonne hung herself.

She hung herself in the attic of her house. Given the kind of person she was, the rest of her family found it unbelievable that she would have hung herself in the house with her two daughters downstairs but a common feature of SSRI suicides is the apparent lack of concern for the effect on others.

The fact that Yvonne was close to kneeling enabled the coroner to return a narrative rather than a suicide verdict. The pathologist explained that when people are weighing up the possibility of hanging themselves, wondering about it, they might put a rope in place and test themselves against it. If they do this, it is in fact very easy by putting pressure on the carotid sinuses that are in the side of the neck to slip out of consciousness and falling forward to end up asphyxiated. If you have begun with your feet on the ground you can end up kneeling or close to kneeling.

The first cases in bridgend

Dale Crole, 18 Found hanged, 5 January 2007
David Dilling, 19 Found hanged in his home, February 2007
Thomas Davies, 20 Found hanged from a tree, 25 February 2007
Allyn Price, 21 Found hanged in his bedroom, April 2007
James Knight, 26 Found hanged at his home, 17 May 2007
Leigh Jenkins, 22 Found hanged, June 2007
Zachery Barnes, 17 Found hanged from a washing line, August 2007
Jason Williams, 21 Found hanged at home, 23 August 2007
Andrew O’Neill, 19 Found hanged at home, September 2007
Luke Goodridge, 20 Found hanged, November 2007
Liam Clarke, 20 Found hanged, 27 December 2007
Gareth Morgan, 27 Found hanged, 5 January
Natasha Randall, 17 Found hanged, 17 January
Angie Fuller, 18 Found hanged, 4 February
Kelly Stephenson, 20 Found hanged on 14 February while on holiday
Nathaniel Pritchard, 15 Kelly’s cousin, found hanged, died 15 February

Reports in the media

Jenna Parry was the next person to die. She was found hanging, almost kneeling. Her death triggered the list above and this account in the Independent in February 2008:

“Bridgend was yesterday mourning yet another addition to the alarming number of suicides in the area, after a 16-year-old girl was found hanged in a wood five miles from the town.

Police insisted there was no link between the 17 deaths in the past 13 months and no evidence of a suicide pact or an internet cult.

Jenna’s death came just days after two cousins died after apparent suicide attempts. Kelly Stephenson, 20, was found dead in a bathroom during a family holiday. Hours earlier she had learnt that her 15-year-old cousin, Nathaniel Pritchard, had hanged himself. The two lived a few doors away from each other in Bridgend…….

Following the deaths, a suicide prevention strategy has been announced for Wales. The Welsh Assembly has said it wants a 10 per cent reduction in suicides by 2012.  [As of 2012, the rate has in fact gone up despite the many abilities of coroners and bureaucrats to lower it].…

However, despite the spate of suicides around Bridgend – a county with a population of 130,000 people – police have said there is nothing to link the deaths….

[The coroner] Mr Morris criticized the media’s reporting of the deaths. “The media reporting is influencing young people in the Bridgend area.

“I have noticed an increase in sensationalist reporting, and the fact that Bridgend is becoming stigmatised. The link between the deaths isn’t the internet – it is the way the media is reporting the news.”

Death by coroner?

Fourteen deaths in Bridgend are logged on antidepaware. There are nine hanging verdicts in which antidepressants are mentioned. There are no hanging verdicts where antidepressants or other prescription medications are ruled out.

What’s happening? One contributory factor to these deaths is coroners. I have been writing to UK coroners for 15 years making the case that they should note where people have been on antidepressant or other drugs at the time of death. The list of drugs now linked to suicide and homicide up to and including school shootings includes anticonvulsants, weight loss pills, some asthma medications, some analgesics, some contraceptives, some medication for acne, a number of antibiotics, medications for malaria, in addition to antipsychotics and antidepressants. See below.

But coroners often do not record drug intake, unless the person has actually died from a drug overdose. In the case of Liam Clarke above he had had some cannabis, and alcohol and was on antidepressants.  The coroner decided that the alcohol he had had affected his judgement. Coroners are under no obligation to explain their thinking on a matter like this and are rarely if ever challenged. There is little doubt that antidepressants can lead to a craving for and increased consumption of alcohol – did this happen in Liam Clarke’s case?

Many of the cases listed above were on antidepressants but we only know this because the police or families mentioned it at the inquest and reporters from the media then reported it. Unless the antidepressant or other pill was the cause of death by poisoning coroners typically don’t mention medication.

In Bridgend, the coroner seemed to play down the role of antidepressants. In one of the inquests involving antidepressants, he refers to “lack of anything in the system that would have altered his judgement”. In others he makes similar comments.

Gary Speed the former manager of the Welsh soccer team is Wales’s most famous recent suicide. A common feature in the extensive reporting of his death was that family and friends found it baffling. The coroner opted not to reveal if there were prescription drugs in his system. Why?

The role of the media

The idea that the media reporting of suicides might cause copycat suicides in Britain stems in part from the work of Keith Hawton in Oxford. As a result students in Cardiff University, which is near to Bridgend, are steered to regard the report in the Independent above as sensationalist. Other countries have more striking suicide cohorts – Japan being the most famous – and in the case of copycat suicides by pairs of lovers jumping into Mount Fuji there is a good case for thinking the media might fuel events.

But equally decent and proper media reporting may do just the opposite and bring to light what is going on. There is probably more chance that a good journalist, or someone who has lost a family member or a friend to suicide, is going to solve this rather than bureaucrats or experts brought in to work out what is going on. In this case neither the experts nor bureaucrats linked to this case seem interested to respond to emails from me.

Having coroners refuse to keep a public record of drug intake and browbeat the media into keeping silent seems like the worst of all possible worlds.

What’s happening?

We have an excess of 60 hangings to explain in Bridgend. The number is growing by the month. If some have happened by accident as outlined above, it needs a public education campaign through the media to alert people to the risks.

Some of these suicides may be copycat. In the same way school shootings may have a copycat component to them. But a copycat needs an original or several original examples to get them going. The distress that leads to school shootings or clusters of hangings needs an original exemplar to shape it into more shootings and hangings – an original event to open this door to others.

There are obvious factors to explain some clusters like a pair of well-known Japanese loves committing suicide together by jumping into Mount Fuji. In the Bridgend case, if we are going to invoke a chemical – a medicine – the scale of the problem almost suggests that some factory in the Bridgend area must be pumping out some chemical that is having the same kind of effect as drugs like Cymbalta or Pristiq. This might seem improbable. But looking at the list of drugs that cause suicide and homicide, below, the improbable begins to look possible. It almost looks probable that this array of drugs will give rise to a cluster like this somewhere if not in Bridgend.

What to do next?

The problem of drug induced suicide and homicide is not vast like climate change or famine in Africa. You can make a difference. As things stand your Human Rights are being infringed. The supposed rights of some unspecified group of people to use (doctors) or take (patients) without having to be deterred by warnings that these drugs can cause suicide or homicide are being used to justify the deaths of people that you know that could be avoided with proper warnings. This is a breach of the Human Rights Act.

The drugs listed below are not listed as a matter of personal judgement. They are either drugs that companies are obliged to state can cause suicide or for which there is convincing evidence that they have in fact caused suicide. There are likely many more drugs that some government officials and company personnel know cause suicide but about which they keep quite.

  1. Some coroners are wonderful. Others are misguided. You do not want to assume your coroner knows what they are doing. You need to establish if they are bringing biases to bear on the issue. You have a right to interview them before an inquest.
  2. Drug regulators deal in the wording of advertisements. Public health is not their brief. If you are waiting for a regulator or a drug company to suggest a drug may have contributed to a death, you will be waiting for ever.
  3. These problems are rarely solved by outside experts. Communities need to take the issues into their own hands and to this end the media are their allies not the enemy.
  4. Contribute details of any deaths by someone’s own hand, accidental or on purpose, to Antidepaware. Contact
  5. Be aware that the following drugs and likely many others can all cause suicide and in many cases homicide. The statement cause here is based on compelling challenge-dechallenge-rechallenge cases – see Doxycycline causes suicide – or clinical trial data or legal requirements for companies to agree their drug can cause suicide for instance

Drugs that can trigger & cause suicide or homicide


Mefloquine Lariam
Doxycyline Doryx
D-cycloserine Seromycin
Fluoroquinolones Levaquin, Cipro
Oseltamivir Tamiflu


Drospirenone Yasmin
Drospirenone Yaz
Cyproterone and ethinyl estradiol Dianette


Varenicline Chantix
Buproprion Zyban


Montelukast Singulair
Roflumilast Daxas
Zafirlukast Accolate

 Anti – Acne

Isotretinoin Roaccutane
Doxycycline Doryx


Diphenhydramine Benadryl, Sominex
Chlorphenamine Chlortimeton
Cyproheptadine Periactin

 Urinary Drugs

Duloxetine Yentreve
Tamsulosin Flomax
Finasteride Propecia
Dutasteride Avodart


Prochlorperazine Stemetil, Compro
Metoclopramide Maxolon, Reglan


Clonidine Catapres
Doxazosin Cardura
Guanabenz Wytensin
Guanfacine Tenex
Hydralazine Apresoline
Methyldopa Aldomet, Aldoril, Dopamet
Prazosin Minipress


Atorvastatin Lipitor
Fluvastatin Lescol
Lovastatin Mevacor
Mevastatin Compactin
Pravastatin Pravachol
Rosuvastatin Crestor
Simvastatin Zocor


Methylphenidate Ritalin
Amphetamine Dexedrine


Lorazepam Ativan
Diazepam Valium
Alprazolam Xanax
Chlordiazepoxide Librium
Bromazepam Lexotan
Oxazepam Serenid, Serax
Cloabazam Frisium
Medazepam Nobrium
Clorazepate Tranxene
Clonazepam Klonopin


Citalopram Cipramil, Celexa
Escitalopram Cipralex,   Lexapro
Duloxetine Cymbalta
Fluvoxamine Luvox,  Faverin
Fluoxetine Prozac
Paroxetine Paxil, Seroxat, Deroxat, Aropax
Sertraline Zoloft
Venlafaxine Effexor
Desvenlafaxine Pristiq
Mirtazapine Remeron
Trazodone Desyrel
Buproprion Wellbutrin, Zyban
Amitriptyline Tryptizol, Elavil
Imipramine Tofranil
Nortriptyline Allegron, Aventyl
Desipramine Pertrofran, Norpramin
Clomipramine Anafranil
Dosulepin Prothiaden
Lofepramine Gamanil
Doxepin Sinequan
Trimipramine Surmontil


Phenytoin Epanutin
Sodium Valproate Epilim, Depakene
Divalproex Depakote
Carbamazepine Tegretol
Oxcarbazapine Trileptal
Lamotrigine Lamictal
Gabapenin Neurontin
Pregabalin Lyrica
Leviracetam Keppra
Topiramate Topamax
Tiagabine Gabitril
Felbamate Felbatol


Chlorpromazine Thorazine, Largactil
Perphenazine Fentazine
Trifluoperazine Stelazine
Haloperidol Haldol
Flupenthixol Fluanxol
Pericyazine Neulactil
Sulpiride Sulpitil
Molindone Moban
Aripiprazole Abilify
Olanzapine Zyprexa
Risperidone Riserpdal
Ziprasidone Geodon
Quetiapine Seroquel
Paliperidone Invega
Zotepine Zoleptil
Iloperidone Fanapt
Amisulpiride Solian
Tetrabenazine Xenazine

RxISK Stories: If You’re Going To Look After Patients, Man Up

Man up!

This post also appears on and can be viewed here.

Pharmalot has just posted a piece – ‘Controversial FDA official, Tom Laughren, retires.’

This is a must read for anyone with anything to do with mental health – both the post and the comments afterwards where some have posted that they still believe the Black Box warnings on antidepressants arose because of pressure from the Church of Scientology rather than in response to the data.

Despite my billing as a must-read, the Pharmalot post will likely seem boring to many. But the comments won’t – they seethe with anger. This is one of those cases in which if you weren’t there its hard to appreciate the depth of feeling this man generated in many as he – and a few others including Paul Leber and Bob Temple – appeared to stand in the way of natural justice and patient safety. The most comprehensive cover is on the AHRP website where Vera Sharav dubs Laughren a double-agent.

He seemed a quiet man. He was grey. He behaved like a functionary. But he was the focus of one of  the most dramatic moments I have ever witnessed. This was at the FDA hearings about antidepressants and suicide in children, some 8 years ago now. Because of FDA procedures, the public get a chance to offer views. There were 73 three-minute slots. At this hearing a range of doctors and other men usually with affiliations to pharma spoke against the Black Box warnings and it was down to a series of mothers to plead for warnings.

Many of the pleas were aimed straight at the bureaucrats – Laughren and Temple. The moment is at the center of Pharmageddon, where I compared what happened then and happens over and over to the Greek Myth in which Demeter implores Zeus to restore her child to life. It is appropriate perhaps in that unlike the other Gods, who were dashing and colorful, Zeus often seems to have the character of the bureaucrat who ran Olympus rather an all-powerful Jehovah.

Demeter’s stories

Demeter was the Greek goddess of the Earth and of fertility whose daughter, Cora, was forcibly abducted and carried off to the underworld by Hades. Demeter protested to Zeus, who professed himself helpless, until Demeter threatened Earth with permanent Winter. Zeus intervened and restored Cora to her mother as Persephone. Because Persephone had eaten some pomegranate seeds while in the underworld, however, she must return to Hades each year, the several months of Winter each year.

Winter’s tale

Mary Ellen Winter confronted Laughren and the FDA about her 23-year-old daughter, Beth:

“Beth was looking forward to a career in communication and was experiencing some anxiety and having trouble sleeping when she consulted our family physician. He prescribed Paxil and said she would start feeling better in two weeks. Seven days later Beth took her own life.

We, like most of you in this room, grew up with confidence in the strides made in medicine and accepted with faith antibiotics and vaccinations prescribed. We believed the FDA would always act to protect our family’s well being. When my daughter went to our family GP last year, we trusted that our doctor was well educated and informed. We were wrong. We now know that pharmaceutical sales are a high stake business, driven to increase shareholder wealth. The consolidation of pharmaceutical companies like GlaxoSmithKline has resulted in increased sophistication in the quest to market and distribute pharmaceutical products. Priority has moved from health to profit. Not all doctors are equipped to understand the marketing targets they have become. The FDA has allowed our daughter to be the victim of a highly commercial enterprise that selectively releases clinical data to maximize sales efforts and seeks only to gain corporate profits…

As residents of the State of New York, we thank our Attorney General, Elliot Spitzer, for addressing issues that the FDA has been unwilling to address…”

[This action on the part of Ruth Firestein within Spitzer’s department in many ways triggered the Access to Data issues that have since engulfed GSK and gave rise to the recent EMA hearings and a debate within RxISK and its supporters about what to do with the data that arises from people reporting to RxISK].

Thy neighbour’s child

But Demeter came right into the room in the last but one slot when Mathy Downing singled out Tom Laughren:

“On January 10, 2004 our beautiful little girl, Candace, died by hanging four days after ingesting 100 mg of Zoloft. She was 12 years old. The autopsy report indicated that Zoloft was present in her system. We had no warning that this would happen. This was not a child who had ever been depressed or had suicidal ideation. She was a happy little girl and a friend to everyone. She had been prescribed Zoloft for generalized anxiety disorder, by a qualified child psychiatrist, which manifested in school anxiety… . She had the full support of a loving, caring, functional family and a nurturing school environment.

Her death not only affected us but rocked our community… When Candace died her school was closed for the day of her memorial service, a service that had to be held in the school gym in order to seat the thousand or so people who attended. How ironic, Dr. Laughren, that your family attended Candace’s memorial service. Our daughters had been in class together since kindergarten. How devastating to us that your daughter will graduate from the school that they both attended for the past eight years and that Candace will never have the opportunity to do so.

Candace’s death was entirely avoidable, had we been given appropriate warnings and implications of the possible effects of Zoloft. It should have been our choice to make and not yours. We are not comforted by the insensitive comments of a corrupt and uncaring FDA or pharmaceutical benefactors such as Pfizer who sit in their ivory towers, passing judgments on the lives and deaths of so many innocent children. The blood of these children is on your hands. To continue to blame the victim rather than the drug is wrong. To make such blatant statements that depressed children run the risk of becoming suicidal does not fit the profile of our little girl.” [1]

Laughren’s defence

I cannot remember seeing anything ever about or by Tom Laughren where I have thought you know the man’s right on that – except the bits where he has been dragged screaming to a table and been forced to agree. But in the Pharmalot obituary on his career there for the first time was something where I jumped and said “Yes, he’s right on that”.

In another setting, faced with a barrage of criticism of FDA, “Tom Laughren, director of the FDA’s division of psychiatry products, told the panel that the agency could do little to fix the problem and, instead, pointed the finger at medical specialty societies, which he insisted must do a better job educating doctors about side effects”.

He’s right. Doctors are failing patients far more than FDA. (See Professional SuicideModel DoctorsWe need to talk about DoctorsScaremongers of the world uniteSo Long and Thanks for all the Fish). Doctors have become infantilized for whatever reason and turn to a parental figure, a Zeus, to rescue them. If you take on the responsibility of looking after people the very least you can do is Man up – or better again Mother up.


The next two Crusoe posts will deal with these issues. It seems right to mark the end of one year and the start of the next by stepping back from the realm of real human drama and place these in their mythic context. Taking the issues out of the domain of data, science and real clinical histories into the realm of myth seems to confuse some readers – the hope is rather to engage with a wider readership and get artists or story-tellers or poets to engage with RxISK and its issues – as Bill James has done with his cartoons and images. We are dealing here with lives and in particular the fact that we each have one life only. The two Crusoe posts will attempt to capture the spirit of RxISK.

[1] Joint Meeting of the CDER Psychopharmacologic Drugs Advisory committee and the FDA Pediatric Advisory Committee, Bethesda, Monday Sept 13th 2004, p 435.

[2] Joint Meeting of the CDER Psychopharmacologic Drugs Advisory committee and the FDA Pediatric Advisory Committee, Bethesda, Monday Sept 13th 2004, p 332.

RxISK Stories: Listening to Parents



When you lose a child or a partner from a rare illness, everyone is supportive, no-one denies you. They listen. But if a child dies from suicide or a complication of treatment with a drug especially a psychotropic drug no-one listens. Our culture has no place for this kind of death. They say maybe it’s for the best. He’d never have been able to face the life he’d have had – something they would never say this about a child with cancer.

The system tells you that your child had a serious mental illness, when in fact he might have started on drugs for ADHD or anxiety. It tells you his diabetes was a complication of his schizophrenia when it was caused by Zyprexa or Quetiapine. If you are like me, you assume no doctor would give your child a drug that wouldn’t benefit him. You see the deterioration but unless you keep a record and can show that each time things got worse the change coincided with treatment, you do not think it could be the drugs. It’s easier to live with the idea that the problems come from an illness rather than from the treatment. I told my son he had to take the treatment when he begged me to let him stop.

If he fails to get better the dose will go up – in other areas of medicine a failure to respond leads to a change of strategy. But in this case drugs are added to drugs. If he becomes edgy or paranoid or can’t sleep these are all excuses to add more drugs rather than stop the treatment. Cold turkey from one drug might be thrown into the mix of other drugs.

If you later figure out somehow that what happened was drug related – you get angry. You phone the doctor – you want to talk to them. They tell you no it’s not the drug – your son was mentally ill. They’re in denial. Their vested interest lies in not believing the treatment they gave might have caused the problem.

You meet other people who introduce you to all that was known about the problem before you ended up locked in it – because they have been there before you. You may get in contact with the few experts who seem to accept there is a problem. You cannot believe that others new about this but still nothing was done.

You want to correct things and you try to use the system. You’ve discovered this problem and you think if people hear the issues they will be as horrified as you and will say we mustn’t let this happen again. You might look for an inquest, get in touch with the Department of Health, the body responsible for licensing the doctor, the regulator, local politicians.

The regulator will refer you to the Department of Health, who will refer you to the licensing body for doctors, who will refer you to the professional body, who will refer you back to the regulator. We have all written to the regulator and the minister for health and we all get the stock letters back (Ed: See Margaret’s Story).

I went through the thing of doing suicide statistics to show there is a problem but got nowhere. The data are in fact corrupt and useless but not even the media want to know about this newsworthy story. The government is going broke because of its spending on drugs and you think it could use this as an opportunity to cut back on drug spending – but no. The professional body will decide that at least some fraction of other doctors would have done the same.

If an inquest implicates the drugs, you think that the next set of practice guidelines which you have heard are in development will reflect this but they never do.

You lose your faith and become a zombie. On TV there is always a good guy to put things right but here there isn’t. You will never be the same person again.

You’re alone with each other – husband and wife. First you blame yourself – then the other. It’s very hard to not blame each other. Husbands and wives break up. You need to be able to give to keep any relationship going, but you’ve got nothing left to give. You can’t make love anymore because love was all about children. You’re doing things because you know you have to, not out of any sense of fun. You can’t stand the memories even though you don’t want to lose them. You may be told you are depressed and your doctor is highly likely to suggest you need a pill.

You meet others who have lost children who have become advocates for more treatment. Other members of your family think you are deluded and family meetings become difficult. After time you find that the parents who see things the same way as you stop getting in touch, not because they have changed their mind but in an effort to get on with their lives. It just isn’t possible to grieve to a conclusion.

I was once you. I was middle class too. I believed in the system. I totally believed in the medical system. I used to pass the wastelands and see the disenfranchised, smoking dope or taking drugs, who rejected the system and were rejected by it – and thought can they not see if you just approach the world trustingly you bump into people whom you can in fact trust. Now I know no certainty. I have no choices. I have a wonderful GP but even there I have to be suspicious. I have become one of the disenfranchised.


You want to forgive but you can’t forgive people who don’t ask for forgiveness. The doctor thinks he is doing a good job – all doctors think they are doing well. Maybe they couldn’t function if they thought otherwise.

I have – many of us have – fantasies about getting a hired gun – Clint Eastwood in Unforgiven. He might set up as a sniper near a pharmaceutical company, bomb its premises or lock up the doctor and force feed him the pills he put our loved one on.

The system needs to stop Listening to Prozac and start Listening to Parents and Partners. We need to be acknowledged. This will not be through an adversarial forum which has to rule one way or the other. It should have the power to acknowledge that drugs come with unavoidable risks and perhaps offer a 60-40 judgment that your husband or son was caught in a spiral that is easier to see in hindsight than at the time.

Doctors need a forum like this because if the drugs are not poisons that need expert input, they may end up being administered by nurses and pharmacists. At present treatment would often be safer if it were dispensed by a machine – the machine could be programmed not to keep you on treatments that don’t suit.

Doctors might have a more interesting and rewarding job if they recognized the problems treatment can cause. This is the moment when they could engage in genuine team work with patients or with parents or partners. Instead their default is – come back when you have had 10 years of medical training. They are fundamentally not team players.

We are the second hand sufferers of adverse events – the ones who get driven to suicide or premature death from heart attacks by the effects of prescription drugs on our children or partners. A grisly inversion of the DES story, where the daughters of mothers who had taken diethylstilbestrol developed cancer of the vagina in their teenage years. Rather than DES Daughters we are DSE Parents. Where are the doctors who want to recognize this side effect of treatment and bring healing?

RxISK prize

I would like to establish an annual prize for a piece of work covering the adverse effects of treatment – the wider impacts these can have and the ways people or families may have found to overcome them. I cannot afford to fund this on my own. I would like to call for donations through to help fund this. RxISK has foundations in the US, Canada and the UK.

Report drug side effects

Help us make medicines safer for all of us by reporting drug side effects at Less than 5% of serious drug side effects are reported. Our mission is to capture this missing data directly from patients through’s free drug side effect reporting tool and use this data to help make medicines safer for all of us.

When you report your drug side effect on, you also receive a free RxISK Report to take to your doctor or pharmacist. This report serves as a means to initiate a more detailed discussion of your treatment and the option to send a report to your country’s health authority — beginning with the FDA in the United States and Health Canada in Canada (more countries will be added soon).

Adverse events are known to be the 4th leading cause of death. Our goal is to knock these off the top 10 list. We can only accomplish this with your help.

Tell us your story today at

RxISK Stories: Night of the Living Cymbalta – B’s Story

scary pumpkin face

This blog post has first been published on the website. If you would like to comment on this post, please do so using this link.

I myself had been on and off a long series of antidepressants, but never had really dramatic withdrawal symptoms until I stopped the SNRI inhibitor Cymbalta. It started when I tried to step down from 120 mg per day, back to the standard 60 mg dose. From simply feeling depressed and tired, I shifted into full meltdown mode: crying uncontrollably; unable to concentrate; simultaneously groggy and agitated. At this point I realized the drug was part of the problem, and resolved to try going drug-free, for the first time in years.

Cymbalta nightmares

That’s when the strangest withdrawal symptom hit me: Cymbalta nightmares.

I can only describe them as a “highlights reel” of all the worst Hollywood slasher/horror movies ever made. The Texas Chainsaw Massacre? Night of the Living Dead? I don’t really know – I’m the type who refuses to see those movies because I can’t handle the images. Yet there they were – crazed killers, spattered brains, severed limbs, the whole nine yards. In godawful living color, and even with a smell of blood I could clearly recall on awakening. That was another curious thing, because I usually don’t have vivid dreams; I’m doing well to remember them at all. These dreams were incredibly vivid.

I was VERY lucky in one sense: by this time I began hitting the Internet and discovered that this was not coming from my own mind, but from drug withdrawal. Lots of others had experienced gory nightmares that were startlingly similar to my own. Recently I checked a website called Here are a few comments:

‘… horrible nightmares. My husband woke me from a few last night. He said I was talking in Latin. My family is Catholic but the only Latin I know is from Lent at church which I haven’t been to in 10+ years. I took a nap a little while ago only to wake up crying from some Exorcist-type dream … Is anyone else having crazy, vivid religious dreams?’

‘… I have had the worst dreams of my life as well. Nice to know I’m not alone. I had no idea my dreams could be so horrible!!! Not religious but sexual, and in a bad way.’

‘… completely horrific. They are in HD, widescreen, surround sound, full colour and Smell-O-Vision … in other words, a real horror film in my head every night. What’s worse, they’re repetitive. I’ve had some of them more than 50 times. How many times can you put up with your zombie mother climbing out of her grave and lurching around your front door? That’s just one of my nightmares. I scream in my sleep and wake everyone in the house.’

‘… I never imagined that anyone else suffered from this bizarre withdrawal symptom. I eventually made the connection and it scared me and had me feeling ashamed that such brutal creations could be a product from within my brain. My nightmares vary greatly but always involve unfathomable slayings, terror, bloody massacre, dismemberment. Pretty much the most terrifying, disgusting & sad images I’d ever thought possible.’

‘… Weird. I am having terrible dreams which I can only recall parts. One of them involved an invisible being who spoke a language I didn’t understand and I was afraid of. Once in the dream, I accepted it in my mind I started to understand it and try to convince my wife (in the dream) to accept it/him too. Looks like a movie plot.. freaking out.’

‘… Each time we’ve tried to wean off Cymbalta, my sister and I have both experienced awful nightmares that are not like anything we’ve ever known. I’ll be honest, I’m a Christian and I had some long talks with God about the dreams because they were so disturbing..’

Too much for some to take

The first thing that strikes me is that this side effect needs to be taken seriously. Even those of us who knew we were experiencing drug withdrawal felt some fear and shame to think, as one woman put it, “that such brutal creations could be a product from within my brain.” To have these nightmares without any inkling they were drug-induced could be too much for some people to take. It might be much worse for those who had survived real war or other extreme trauma, or for those who held strong religious beliefs about Satan or Hell. People may also be at risk of being quickly misdiagnosed as psychotic, treated with more powerful drugs, and seen as “crazy” by those closest to them.

One of the oddities is that even the FDA recognize there is an issue, but likely few doctors who give this drug to people ever warn them about this problem. The label of the drug gives no hint.

Where do they come from?

The second thing is that we might learn a lot from side effects like these if we tried. At first I wondered if there was a place deep in our limbic system full of gory images left over from our caveman past. Or could we really just be remembering gory movies? Probably not – after all, I hadn’t even seen these movies. Most likely “horror movie” is just a shorthand way to explain the dreams to others – and to distance ourselves from them. In any case, how could a chemical cause so many very different people to dream practically the same dreams?

RxISK Stories: Cora’s Story – A Benzodiazepine Story

This blog post has first been published on the website. If you would like to comment on this post, please do so using this link.

In RxISK Stories, we regularly take you to dark places where few would wish to go. We have perhaps become too used to the horrific consequences of medicines going wrong that we fail to appreciate how off-putting this sequence of posts can be. It is like a doctor taking a friend into an operating theater just when the surgeon is sawing through the breastbone failing to appreciate that the friend is likely to faint away.

We want you to give us some good news stories – about new uses for drugs, or discoveries about how to manage side effects. The supporters of drugs classically say that critics fail to take into account all the lives that would be lost if the drug were not used – nowhere more so than in the case of the antidepressants where warnings they argue will deter people from seeking and getting the benefits of treatment. But the efforts to persuade doctors to prescribe and the rest of us to take antidepressants went hand in hand with efforts to persuade doctors to stop prescribing and the rest of us to stop taking benzodiazepines. And this gives rise to deaths also.

Cora’s story

Cora was 18 and beautiful. Slim, with long blond hair, about average height. She had just finished high school, where she had been the homecoming queen. She was set to attend college, though she wasn’t certain what direction to take there. She had a boyfriend but was worried he might want to leave her, while at the same time knowing her parents didn’t approve of him.

At a rock festival with her boyfriend, she got lost and, trying to find him, had taken a fall and injured her arm. She was admitted to a local hospital for treatment and sent home from there. Several days later, in a state of perplexity she was brought to the psychiatric unit where I have inpatient beds.

Had she been traumatized or abused in some way? Had she been taking drugs and had a trip gone awry? Had her boyfriend left her? Her mental state was quite unstable, but despite having input from the many people involved in looking after someone in hospital I couldn’t make a diagnosis. Cora was not hearing voices, did not have delusional beliefs, and was not consistently depressed, elated or anxious. But she was volatile. At times in the ensuing weeks, apparently improved, I gave her leave to go out with her parents, but she was typically brought back severely confused again – sometimes only minutes after having walked out through the hospital doors. At other times she was almost completely unresponsive and inaccessible. I could see no reason to give her an antidepressant or an antipsychotic. On occasion when she seemed particularly agitated I wrote her up for a minor tranquilizer – a benzodiazepine.

Finally after about 6 weeks she went on weekend leave with her parents, held her own, and did not come back. I was happy to file her case as diagnosis unknown. I heard she was doing well at college and was still dating the same boyfriend.

I saw her again a year later – 8½ months pregnant. She was clearly too unwell to be managed at home. But where she had been mute and inaccessible previously, now she was over-active, manipulative, and attention-seeking while still seeming confused; her actions did not seem fully under her own control. She looked as though she might go into labor at any moment, so I held off medication.

After the birth, I sent her to a hospital that had a mother and baby facility. The psychiatric team that took over her care there, I learned, thought she had schizophrenia. She was put on regular antipsychotics, but apparently was not making much progress and the baby was taken from her. Some months later, I heard she had been given weekend leave; one evening of that weekend, having told her parents she was going out for a walk, she laid her neck on the track in the face of an oncoming express train.

Looking back at Cora’s confusion, emotional lability, and switches between immobility and overactivity, I came to see that she had a textbook case of uncomplicated catatonia. Few readers of this blog will know what catatonia is, as it has supposedly vanished, even though 50 years ago up to 15% of patients in asylums were estimated to suffer from it, and it was one of the most horrifying mental illnesses, with a much greater fatality rate than any other disorder except General Paralysis of the Insane (tertiary syphilis). While mental health professionals are aware catatonia is listed in the DSM, few would spot a case if faced with it.

If Cora had a rare condition that doctors do not now need to recognize, if she was the exception that proves the rule of medical progress, she would have been unfortunate. But in fact up to 10% of patients going through mental health units in America and worldwide still have the features of catatonia – if they are looked for (Chalasani et al). Sometimes the only condition they have is catatonia; other times catatonic features complicate another disorder and resolving the catatonia may make it easier to clear whatever other problem is present. But almost no-one thinks of catatonia and so, like me, they miss the diagnosis. Cora was given antipsychotics, which are liable to make a catatonia worse. She died when a few days’ consistent treatment with a benzodiazepine would almost certainly have restored her to normal, making her death scandalous rather than accidental.

But the benzodiazepines are a group of drugs that are no longer on patent, and no company has thus any incentive to help doctors see what might be in front of their eyes when it comes to a disease like catatonia. Instead, all of the pharmaceutical exhortations are to attend to diseases for which on-patent drugs are designed, even if this means conjuring diseases out of thin air—disease mongering—such as  fibromyalgia, to market  on-patent medications such as Pfizer’s Lyrica, or restless legs syndrome, a disorder conjured up as a target for GlaxoSmithKline’s Requip (ropinirole).

Catatonia and other vanishing diseases are part of the “opportunity cost” of disease mongering, lost in the chatter about disorders that match up with on-patent drugs.

No one has any idea how many versions of Cora’s story play out in daily clinical practice — versions in which the diagnosis of a treatable disease goes unnoticed by doctors pleased with themselves for making a fashionable diagnosis like fibromyalgia and who, even in the face of treatment failure, will add ever more on-patent drugs to a patient’s treatment regimen rather than go back to the drawing board and look more closely at the patient in front of them. Once upon a time the height of medical art lay in being able to go back and look at cases afresh and match the profile of symptoms against less fashionable or apparently uncommon disorders – no longer.

The dark side

Studies this week in BMJ and BMJ Open linked benzodiazepines to an increased risk of developing dementia and early death. For many the benzodiazepines like Valium remain much darker drugs than Prozac, Cymbalta, Pristiq and other drugs. The risks of getting diagnosed with dementia are quite likely to turn out to be much higher in those given an antidepressant than in those given benzodiazepines and the risks of suicide and premature death are certainly greater on antidepressants. The antidepressants are in many ways much darker drugs than the benzodiazepines. We need to find a way to bear this in mind while still holding on to the idea that for the right person either of these drug groups could be life-saving.

Cora’s story can be found in Pharmageddon which was written as a tribute to many who have died like her and especially to the people, mostly women, who have campaigned to make treatment safer for all of us.

RxISK Stories: Gambling on the Side Effects of Antidepressants – Does Pfizer Play Dice?

Editorial note: This post also appears on and can be viewed here.

This piece by Daniel O’Sullivan was first posted on Our interest was stimulated by a query to RxISK from Daniel who had been told by the Australian regulator (the TGA) that they only had one report of this. Looking for gambling in RxISK, gives 1 case in Australia, but 4 cases of pathological gambling – more than from all the rest of the world combined, and 8 cases of impulsive behavior. In the FDA database, there are many more reports from the US and Europe with a Proportional Reporting Ratio for impulse control disorder of 11.2 and for impulsive behavior is 10.0. These are very strong signals.

This illustrates how RxISK can be useful for anyone interested in the effects of drugs including journalists – once RxISK reporting takes off we will be able to tie reports not just to Australia or the US but to Charlotte and Tampa, and Brisbane. It also illustrates that you cannot depend on the word of regulators – you need to research for yourself. It is not a lie that there is only one report of gambling on Efexor in Australia. It also clearly is a lie that there is only one report of gambling on Efexor in Australia or at least deeply misleading.

Betting your brains on antidepressants

(Click on the image to read the text)

In June last year, three months into a prescription for anti-depressant drug Efexor, former financial analyst Tim Hillier left his hotel to wander the empty streets of Alice Springs in an attempt to clear his head. An hour earlier, he had wagered $80,000 — almost the entirety of his life-savings — on a first-round Wimbledon tennis match featuring Aussie hope Sam Stosur.

With Stosur faltering in the opening set, Tim knew he should be sick with panic. Instead, the fear just gnawed away at the fringes, relegated to the background by a thick, medicated haze from the Efexor intended to dull his severe obsessive compulsive disorder. “I was walking the streets just thinking ‘f-ck, have I actually placed this bet?’,” Tim said. “Have I actually wagered all this money on a single tennis match?”

“Paul”, a father of two from Adelaide, took Efexor for almost three years after being diagnosed with depression on his first visit to a psychologist. Initially hesitant at jumping head-first into the world of anti-depressants, Paul was reassured by his doctor about Efexor’s high success rate. But Paul too began to suffer crippling gambling addiction.

“It’s not a targeted drug, it doesn’t target depression specifically, it targets everything. It takes away all of your feelings, so you become a shell of a person. You’re still able to function, but you just don’t feel anything, you don’t feel any fear of consequences at all,” he said.

Paul and Tim, both in a search to understand their unexplained gambling binges, came across an online discussion thread entitled “Efexor and Gambling”. The thread, first started in 2007, reads like the rawest form of group therapy as strangers congregate to offer up accounts of reckless and compulsive behaviours acted out while being prescribed Efexor. There are tales of thousands of dollars frittered away on pokies machines, on casino floors and at the track, stories of ruined relationships and shattered careers. The common theme is an unexplained and seemingly unnatural disregard for consequences.

Jolted by the possibility of a link between his destructive behaviour and his long-term medication, Paul decided to seek more information from Efexor manufacturer, Pfizer. When he contacted the pharmaceutical giant directly, he was met with a surprising admission.

“I contacted Pfizer and I asked if they knew that Efexor could possibly cause gambling and sexual misconduct and they responded with, ‘oh yes we knew that, 0.8% of people will get that’,” he said. Pfizer informed Paul these dangers were presented as a possible side effect in the medication packaging under the umbrella term “uninhibited behaviours”.

“How am I supposed to know what an ‘uninhibited behaviour’ was?” he said. “What a cloaking of an evil thing is that? That could be me parachuting or hang gliding or running down the beach with Speedos on! How was I to know it was going to be the type of addictive behaviours that would ruin my life?”

Efexor, first introduced to the American market in 1993, is now well established as one ofAustralia’s most commonly prescribed anti-depressant medications with more than 1.2 million prescriptions serviced in Australia in the past 12 months. At low and moderate doses, it acts only on the brain’s mood control neurotransmitters, serotonin and norephinephrine. But at high doses of over 300mg a day it also effects a third neurotransmitter called dopamine, which is responsible for reward-driven behaviours and has been associated with risk-taking behaviour and addiction.

It’s this dopamine effect that can cause problems, according to world-renowned psychiatrist, psychopharmacologist and author Dr David Healy. “When Efexor is taken at high dosages it triggers a flood of dopamine and becomes what we call a ‘dopamine agonist’. This can be responsible for the types of dangerous impulsive behaviours.”

While dopamine agonist drugs, such as Pfizer’s Cabaser, have been successful in the treatment of neurological disorders such as Parkinson’s disease, they made headlines in 2010 when hundreds of Parkinson’s sufferers filed a class action against pharmaceutical manufacturers after allegedly becoming addicted to gambling and pornography due to their medication.

A data-based research paper published on by Dr Sarah Richards called “Dopamine Agonists for Takers” identifies the major risks associated with dopamine agonists as “uncontrollable gambling, hypersexuality, shopping, binge eating and other behaviours collectively referred to as Impulse Control Disorders (ICD)”.

In the same paper, Dr Richards describes the attempts by pharmaceutical manufacturers to disclose the risks related to dopamine agonists to patients as “shameful”. It’s a valid assessment, says Dr Healy.

“Pharmaceutical companies have absolutely not done enough,” he said. “They have seemingly gone out of their way to deny that such effects could be happening.

“There is a management of adverse effects that at times seems aimed at closing off all loopholes from reporting. Companies are better placed than anyone to bring hazards to light but they seem to go into denial mode instead.”

While declining to comment on a possible link between Efexor and ICDs, Pfizer’s Amy O’Hara maintains all product information provided to doctors and patients is correct. “Pfizer rigorously monitors the safety of its medicines and works with the Therapeutic Goods Administration to ensure that the product information for doctors is up to date … based upon clinical trials and post-marketing surveillance,” she said.

Dr Jon Jureidini, spokesman for the global collective of health professionals Healthy Skepticism, believes it’s this “post-marketing surveillance” that is being neglected. While figures supplied by the TGA show that only one out of 1451 registered adverse reactions relating to Efexor actually link the drug to pathological gambling, Dr Jureidini believes patients aren’t getting the full picture.

“The TGA spends a lot of its money on assessing and improving new drugs which they need to do, but they don’t spend enough proportionately on monitoring what’s in existence,” he said. “The amount of people that test the drug in the research phase is minuscule compared to the amount of people that take the drug when it has gone to market and the reality is, about half of the serious side effects don’t emerge until after the drugs have been on the market for a couple of years.

“It is frustrating that the burden is then put on individuals to monitor adverse affects of drugs instead of regulatory bodies.”

Paul is certainly frustrated. “I can almost understand it from my doctor’s point of view, they get sold all these drugs by these salesmen who give them pens and pads and showbags and probably take them off to Paris once year when they’ve reached certain targets. They get told it’s a great drug by these reps, they don’t actually get emphasised the dangers that can happen — the type of things that happened to me,” he said.

According to Dr Jureidini, the cosy relationship between pharmaceutical companies and doctors is not fuelled by money but is more subtle. “Most doctors are honest about that and wouldn’t accept bribes,” he said, “it actually involves helping their careers along and mutually beneficial research education opportunities.

“It is [these types of relationships] that are going to lead to doctors choosing certain drugs just because they’ve got a free hand to hand [sample] when that might not be the best choice for the patient.”

Dr Michael Baigent, national clinical adviser for depression initiative beyond blue, disputes the notion of undue influence wielded by pharmaceutical manufacturers such as Pfizer.

“There are safeguards in place via the TGA and the Pharmaceutical Benefits Scheme, so there is a lot of pressure on them to be very, very open and forthcoming about any side effects,” he said. “Also, most doctors and most clinicians when they have time with the patient will go through and mention side effects that are commonly experienced, but they may not talk about side effects that affect one in 50,000 because the list is long and it can be very hard to actually go through them all.

“The expectation is that the people will actually have a look at the sheets of the information that go out with the boxes of medication.”

While Dr Baigent is supportive of the current regulatory system, he believes there is still a long way to go in the research and development of anti-depressants in Australia.

“There are two big concerns in this area in my view,” he explained. “One is that people will be prescribed the medication that might not need it. And the second one, which is just as a big a concern, is that people who will really benefit from it — and it would be lifesaving — will not receive it.”

Dr Baigent’s dual concerns are perhaps best reflected in the fortunes of two men inextricably linked by an Efexor prescription and the same fateful Google search.

Almost a year since he gradually weened himself off Efexor, Tim has yet to lay a single bet. But despite conquering his gambling demons, he remains enslaved to the OCD that has dictated most of his adult life. The ongoing search for medicinal help and a shot at normality continues.

“For me, the loss of the money is really a secondary issue. If someone said to me they could take away my OCD for $80,000, I’d do it in a heartbeat,” he said. “I often think it would be nice for once to pursue something that’s going to bring me a little bit of joy rather than just moping around and feeling shit all the time … there needs to be a point to it all at the end of the day. You need a bit of hope and something at the end of the rainbow, otherwise you can lose heart.”

The flipside of the same coin is family man Paul, who remains entrenched in his own, very different, battle for normality.

“I would never ever take an anti-depressant ever again,” he said. “To be honest I don’t think I even needed it to begin with. I was just expecting to be laid down on the couch like they do in the movies, but I came out with a prescription for one of the most powerful anti-depressant drugs there is.”

Four months since extricating himself from Efexor, Paul is still attempting pick up the pieces of a life decimated by ICDs. “You don’t fix three years of that type of behaviour in three months,” he said.

“It’s really the family side of things, its healing the wounds there that is going to be the big thing, I might not be able to keep the family together. I’ve got a wonderful wife and I’ve got to fight for that.”

Now firmly in recovery mode, all that is left to ponder is the endless parade of “what-if” scenarios.

“I honestly believe I just needed a pep talk, I needed to be told to “do a bit of exercise, change your diet, drop the beer, get on with life”. That would have been so much cheaper and easier in the long run.

“And I think that if Pfizer’s aim wasn’t just to get Efexor to the marketplace as quick as possible and they had of invested another half a billion dollars,” he considered ruefully, “they could have come out with a perfect drug.”

[Details of this article also appeared on ABC News]

Illustration: Betting your brains on antidepressants, © 2012 Billiam James

RxISK Stories: Weight Gain on Thyroxine

bathroom scales weight gain

This blog post was first published on the website. If you would like to comment on this post, please do so using this link.

If there is one thing most doctors think they know it’s that weight gain can be caused by an underactive thyroid and having an overactive thyroid leads to weight loss. So the thyroid hormone, thyroxine, will lead to weight loss. And magazines, newspapers and websites, especially in the United States openly invite anyone who is overweight to get their thyroid checked. Thyroxine is now one of the three most commonly prescribed drug groups in the UK.

Q’s story

I am a doctor and was working as specialty trainee for the last three years when it all started going pear shaped (literally). I consulted my GP with complaints of extreme tiredness, weight gain, hair falling out and dry skin. She suggested a blood check including glucose levels and importantly thyroid function. The results came back showing I have an underactive thyroid. I was started on thyroxine with an initial dose of 50 mg which gradually went up to 125 mg. To my surprise I started to gain weight. I have always had weight problems but not as uncontrolled as this.

There have been a few times I have stopped taking thyroxine, usually if I am ill with something else and I forget. When I go back on it I gain the weight again. Recently when I was not very regular taking my thyroxine I noticed a marked reduction in my weight of around 3-4 KG over a period of 3 weeks .

I always thought that thyroxine tablets will do the same job as the natural hormone your body produces. Restoring my thyroid hormone levels to normal I thought was going to get my weight levels back to normal.

Everything in every medical textbook says that having an untreated or under-treated underactive thyroid can lead to weight gain and once thyroid levels are stable and back within the normal range, the expectation is that one should be able to lose the extra weight again. But unfortunately that is not the case. Some of my other symptoms including hair loss, and dry skin have not improved either. But there has been some improvement in tiredness and body aches.

I keep a regular account of my food intake, and calorie count. I eat sensibly. I sometimes skip meals and have reduced my daily calorie down to 1500 a day on average for the last 3 years but with minimal response.

I think of discussing it with my GP, but I am sure she is going to respond with a grin, and I doubt if she will believe me – no doctors do. The other thing is that I don’t really have any choice. The options are lying in bed all day, exhausted, with body aches  and feeling miserable or taking the tablets. I can’t afford to be lazy or complain, or moan all day, because I have two young children to look after and work fulltime as hospital doctor, which itself is quite stressful.

RxISK response

I didn’t believe this when I heard about it first. I’ve asked several doctors since and none believe that thyroxine could cause weight gain. But almost immediately after I heard about it, perhaps coincidentally I became aware of several patients of mine, all women, who had gained substantial amounts of weight and all on asking had been put on thyroxine. In a number of cases on the basis of blood tests, when there were no clinical signs that they were actually hypothyroid.

Going into RxISK, there were over 600 reports of weight gain with a PRR value of over 4, a clear signal that thyroxine was producing this problem. A quick search shows there are a number of forums where this issue has come up –, healthy pages,, and gransnet.

RxISK Stories: Smoke & Pfizer Get In Your Eyes

This blog post has first been published on the website. If you would like to comment on this post, please do so using this link.

On March 15, Out of My Mind was published on This was one of the first RxISK stories. At the moment it is the blog post that has attracted the most comments. The comments are worth reading – there is close to universal recognition of something that applies to the person commenting that they haven’t found elsewhere. We had no idea the problem would attract such widespread recognition. What we were more struck by at the time was how a woman with no medical or research background was able to put together the pieces of a complicated jigsaw that had defeated many academics, and researchers and almost all doctors. The message from RxISK at the start of the post was that RxISK was created to help ordinary people make just this kind of breakthrough. Smoke gets in your eyes is very similar. A woman with no medical or research background sorts out a problem that few academics or doctors would think it possible to sort. Both women have also been faced with denial, almost hostility, from doctors and the medical establishment.


Samantha’s story

My story begins in January 2008, when I was running three times a week and training at kick-boxing. I had changed my diet and everything to get fit, even had my cholesterol checked. I was fit as a person could be. The only thing wrong was the smoking. I smoked about 5 a day and had smoked since I was 12 years old. I had heard some people talking about a stop-smoking drug that gave you no side-effects. So I went with my mum to the local stop-smoking clinic where we got to see the person who goes through your options.

I was expecting to be offered Nicotine Replacement Patches but they kept going on about Champix and how it would work well for me. They made it out to be a wonder drug. I said I’d give it a try. They asked me about my medical history and my mum said that the only thing I have ever really had was a convulsion when I was 18 months old which was due to the fact that I had whooping cough and she had put me in a fleece bed suit. The temperature had triggered the convulsion.

They gave me a form to sign. I asked why I had to sign a form and was told it was a new drug, and it was normal to do this. All the form said was that it had not been tested on people with a history of epilepsy. My mum asked: “Well, what does that mean? What about the seizure she had as a baby?” The woman said: “Oh, it doesn’t cause seizures, it’s just that they have to inform people of what areas the drug has not been tested in”. As I had never been diagnosed with epilepsy – one convulsion is not epilepsy – I signed the form. It asked about epilepsy not about a history of seizures, two different things.

I had to go to my own doctor to get the prescription for Champix (Chantix, Varenicline). I started to take the tablets the next day. I thought they were great. I didn’t want a cigarette after a few days and no side effects. By week two I had stopped smoking.

When I got to week 10 of a 12 week course, all of a sudden, I felt like killing myself. This was completely out of character for me. I am scared of dying, always have been, so this was not right. I went straight to my doctor and told her and she told me to stop the Champix.

I stopped immediately. The thoughts went away after a few days. I thought I was fine and was still not smoking.

Then on the 25th March 2008 my partner Anthony woke up to me having a grand mal seizure in my sleep. He had never seen one before and did not know what to do. He decided to ring my doctor. She told him it sounded like I had had a seizure and said that she would come out to see me.

She came to see me and gave Anthony a diazepam 10mg rectal tube. She told him what to do with it if it happened again and also told him to ring for an ambulance. I started smoking again due to stress and shock. Nothing was said by my doctor, or anyone else, about Champix withdrawal. I thought it had been caused by hormones or something and it wouldn’t happen again.

Then it did happen again. Just the same, in my sleep, but this time I came round in hospital. It took about a week for my memory to come back and even then not all my memory. It still hasn’t.

Now the neurologist got involved. I had an MRI and a sleep-deprived EEG both of which were normal. I was told they thought I had autosomal dominant nocturnal frontal lobe epilepsy – ADNFLE to them. Apparently, even though nothing shows on tests, you are still diagnosed with epilepsy. This is because more than one seizure is classed as epilepsy.

I was put on anti-epileptic drugs. I had side-effects from all of them and I was still having seizures. I just kept being told that it was all about finding the right drug for me. This went on until 2010. I opted to have a hysterectomy, thinking that this might stop the seizures, as I was still being given the impression this might be caused by my hormones. Up till this point I had been working full time as a director of a paint company.

I had the hysterectomy in July 2010. Big mistake, it made things 100 times worse. More seizures and more drugs that made me unable to function. I became very depressed, could no longer work and Anthony had to become my full-time carer. How could someone so fit have turned into this. I was praying to die because I was too scared to kill myself.

Then a friend came round to see me and told me that he had just been to the smoking clinic to ask for Champix. He had taken it twice before and stopped smoking both times but had always started again within a month. This time they refused to give it to him as he had a history of a head injury and they said there was a small risk of him having a seizure because of that. He asked them why he had not been told this before but they did not answer him.

He left and came to see me. I rang my doctor to ask if my seizures could have been triggered by Champix withdrawal. She checked the dates and told me to report it, on the yellow card, as a possible side-effect of Champix.

Angrily I got the laptop out and looked to see if the Champix side-effects leaflet had been changed to mention seizures. It had not in the UK but it was in Canada.  So I asked my neurologist if Champix could have triggered my epilepsy. Her words:“I am not prepared to put my job on the line by answering that question” were witnessed by my mum. That made me angrier. This is my life – how dare she say that.

My side-effects got worse. I could not eat or function. I told the neurologist I could not live like this for the rest of my life. She shouted at me, saying my choice was side-effects or life-threatening seizures. I ran out crying. That was it. I thought I am too weak to fight any more, what was the point, nobody was listening to me. I stopped all seven anti-epileptic drugs that day. Anthony, the doctors, and my family did not know. And I prayed to God to take me in my sleep.

I was scared to go to sleep and kept myself awake for two weeks solid. I started seeing visions, was told I was psychotic and was sectioned. I tried to explain to the doctors what I had done and that anyone who had not slept for that long would become psychotic. But they wouldn’t listen and just kept giving me more drugs that made me like a “smack rat”.

Anyway, after being assaulted by the unit manager and left bruised, my father and Anthony complained and told them that what I was saying was true. They diagnosed post traumatic stress and sent me home.

From that day, I have studied epilepsy, drugs, DNA, the brain, RNA and, most important, Champix. I have two boxes full of stuff from two years of study. I know how this drug is made – I could make it.

I have found links to ADNFLE and Parkinsons and other diseases that might be triggered in some people by Champix. I am in touch with lots of people who have suffered in the same way, and worse, without any history of disease. All became ill on withdrawal from Champix and are still ill today, years on. All have told their doctors that they know it’s Champix. And all of us have been ignored until now.

It turns out that changes in cholinergic receptors – in either a4 or b2 subunits – can cause autosomal dominant nocturnal epilepsy. Varenicline is an a4 b2 nicotinic acetylcholine receptor partial agonist – it works by binding to the receptors linked to ADNFLE. The gene changes responsible are the first, and to date only, mutations described in an idiopathic epilepsy.

Champix wouldn’t be such a great cost-saver for the NHS if they had to do this gene test every time they gave it. But how much money is Champix saving if you take into account all the hospitalizations I’ve had since I was given it, and others also.

Samantha’s story also featured in UK newspapers recently. This article states that: “In a letter to Mr Birtwistle [Samantha’s MP], Sir Kent Woods, Chief Executive Officer of Medicines and Healthcare products Regulatory Agency (MHRA) said: ‘It is important to note that the reporting of a suspected reaction does not necessarily mean that the drug in question caused the reported event; these may be coincidental occurrences.’In the majority of reported cases the patient had a medical history significant for psychiatric problems and/or concurrent stressful/traumatic events. ‘Based on the currently available data the benefits associated with stopping smoking due to Champix is considered to outweigh the known risks in the vast majority of people who use it.'”

For the record, there is abundant evidence that Chantix-Champix can cause convulsions, suicide, violence, and a doubling of the rate of heart problems in the year after taking it. The heart problems are notable in that the primary basis for taking this drug is to avoid heart problems. In the case of Chantix-Champix, RxISK shows 97 cases of epilepsy,and 975 reports of convulsions.

Makes one wonder if Pfizer want to hide problems on drugs whether they might consider supporting the introduction of an honors system in America, Canada and Australia. Likely a majority of little boys worldwide dream of becoming a Knight, and taking on tasks that require bravery, like riding to the rescue of damsels in distress – except these days the little boys seem to think it a wiser bet to side with the smoke breathing dragon than with a Samantha or an Anne-Marie.

Illustration: How Not to Quit Smoking, © 2012 Billiam James