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...]

Archive for RxISK Stories

Antidepressants and The Tell-Tale Heart 2

Could it be your meds?

Editorial Note: This is Part 2 of Antidepressants and The Tell-Tale Heart. It fits into a sub-series about Pharmaceuticals: Rape and Consent. It also maps straight on to Antidepressant Withdrawal: A Prozac Story and Saving Grace both of which are on RxISK. Saving Grace picks up the Bipolar theme running through Tell Tale Heart.

For the record, there is no question but that citalopram and escitalopram have significant effects on the heart, and astonishingly almost none of these are at present understood. We talk about QT interval changes but even these are not understood. There are EKG – ECG – cardiogram Apps but not one that can handle some of the problems SSRIs cause. Someone who could design one would help a lot of people.

Withdrawing again

After 6 months my GP suggested coming off the antidepressant again. I had learned a little about tapering by then and asked to be referred to Addaction. Maybe I was addicted.

Addiction was added to my file notes… another nail in my coffin, as addiction, I later discovered is often considered to be co-morbid with SMI – Serious Mental Illness. My GP referred to it as “chemical dependency”…. but addiction was the only thing that appeared in my notes.

My GP wanted me off the antidepressants quicker than the 3 month taper I had researched through an online support group called CITA. However, she prescribed drops and tolerated my request to do it slowly.

Addaction were very helpful and supportive but knew nothing about citalopram. They researched withdrawal but found no advice. We were in the dark and followed the withdrawal charts I had downloaded from CITA.

I went through the tapering without too many problems until I got to the final few drops, then all hell broke loose. I dispensed with the last few drops and braced myself. This was a big mistake. I should have re-instated and stabilised instead of giving up on the taper. There was no advice available.

Withdrawal kicked in with physical as well as emotional symptoms. Profuse sweating, jaw clenching, no saliva, leg jerks, brain zaps, blood sugar feeling like it cleared too quickly leaving me shaking and sweating. An awful confused dream processing with images whizzing through my head kept me awake and I had unbearable restless legs.

This will help…

After a holiday in the sun, where I was unable to leave my hotel room, and was taking diarrhea remedies to deal with the blood sugar problems, I begged my cardiologist for help. “Ah yes,” he said, “this is the fainting condition. A corticosteroid will sort that out…just one tiny pill….” I asked about withdrawal being the cause and was told that the antidepressant had cleared my system long ago and it was impossible that it’s impact could be felt due to it’s half life. Therefore this could not be withdrawal.

He placed me on the steroid… and admitted me for a pacemaker implantation.

On the corticosteroid my mood plummeted as it built up in my system. I became slightly puffy and moon faced and then seriously depressed. This time it really was depression. I became convinced I was dying and couldn’t stop crying. I made memory boxes for my children and kept telling my husband about my wishes for a Dignitas type death.

My GP referred me for CBT as I wouldn’t take the antidepressant again. I got 9 sessions and was discharged in the same state. It was a complete waste of time and it added to my misery.


After the pacemaker operation I was in shock, tearful and repulsed by the new lump in my chest. There was a long scar. I felt disfigured and violated and couldn’t come to terms with it, although everyone kept telling me it was a marvelous device keeping me alive and I should be grateful. I didn’t feel grateful at all.

I recovered at home then went back for a check up. My pacemaker had automatically changed setting to a more aggressive form of pacing. The technicians pronounced this wrong and dangerous for me and re-set it, saying it shouldn’t have happened.

After being interfered with again, something couldn’t cope. On arrival home I couldn’t co-ordinate my limbs to walk and the stiff legs returned and Parkinson type jerks came on. I became tearful and afraid and we rang the pacing clinic. They pronounced my symptoms “impossible” but changed the setting back to the original more aggressive pacing, writing up that the new pacing didn’t appear to “suit me”. The physical reaction was ignored and written up in my notes as anxiety.

The aggressive pacing was left in place for 5 years and a condition which should have been paced 2% of the time, was being paced over 80% of the time by the end of this period. I was becoming pacemaker dependent… but no one would listen to me as that “bipolar?” comment had found it’s way through to all concerned.

Faint hearted

In the midst of all of this I was still trying to contest my diagnosis of a fainting disorder and asked for a referral to the autonomic nervous system clinic in Paddington to have the diagnosis challenged. My GP agreed, as he didn’t think I should be on the steroid… probably because “bipolar?” was in my notes.

I remember being terrified in the tunnels of the London Underground travelling down to the appointment and having an anxiety attack on the station. Just 10 years previously I had lived in London and had traveled on the underground daily in my sales job as a confident young woman. What was happening to me? I was a nervous wreck, jumping at my own shadow.

I had two negative tilt table tests at the clinic and the professor suggested that my diagnosis was wrong. It was probably a cardiac problem. His letter to my doctor was full of sarcasm regarding my account of my symptoms such as “paresthesiae, burning sensations” etc. The emphasis, again, was on delusions concerning my mental health and this overshadowed everything else.

My GP agreed that I should come off the steroid. I did so and the depression and thoughts of death disappeared as the drug cleared from my system. But the delusions were now in my file along with health anxiety relating to drug use… another nail in the SMI coffin.

Falling apart

My life outside medicine was in bits by then. My husband had lost his job and his shares had plummeted, his father had died and his mother was in a care home. We were trying to live on a pittance and an overdraft against our house. My son developed school phobia and I suddenly couldn’t cope anymore feeling I was to blame for my son’s problems….which I probably was as my behavior on the steroid must have frightened him, coupled with the heart admissions.

At some point, I became suicidal and made plans. Everything was my fault – I was a hopeless mother, I had failed and I was doing more harm than good being alive. My husband discovered the stash of razor blades and drugs and took me to the GP who prescribed the same antidepressant again. “It can’t hurt you this time” the GP patronised,” because you have a pacemaker”. I reluctantly took it as I knew there was no choice.

After 6 months I came off it and again had withdrawal symptoms and roller coaster mood swings. I think there was one more bout of suicidal ideation after this and I had been experiencing hypervigilance and paranoia when anxious. I asked for a referral to psychiatry. This suicidality, roller coaster mood swings, and paranoia was not normal for me and was becoming too frequent to be ignored. My GP agreed.

After a few sessions, I was told that the psychiatrist and my doctor had already decided what was wrong with me, it was just a question of time. Every letter following my psych appointments pulled out evidence to support a diagnosis of SMI….detailing “dramatic behavior”, the suicidal ideation, health anxiety etc. All I remember was sitting there, feeling out of it and worrying that I was like my father. I was told they were considering two serious diagnoses… and I joined up the dots and panicked.

Fighting back

I was having private psychotherapy at the same time, and that Achilles heel from my past, and my suggestibility had come up. I was working through those issues and realizing where I had gone wrong – seeing patterns of behavior that I was misinterpreting as hereditary mental illness.

My sons and husband had decided by then that I was quite mad. They wanted me medicated and safe. According to them. the therapist was putting nonsense in my head and validating me, when he should be listening to my doctors. I resented them all bitterly and withdrew to an online mental health forum for support.

I found a group of MH patients online who were far more knowledgeable than me about withdrawal issues and who put me in touch with another doctor, who saw me without a referral. I was afraid of seeing another psychiatrist and worried myself to distraction. But I needn’t have worried as he understood. He cut through the crap and saw what was happening. This was a turning point for me, and I will be eternally grateful for someone in a position of “knowledge” intervening and helping me fight my corner.

My doctors were not so grateful and branded him “out for his own ends and using me as a tool in a fight against the pharmaceutical companies”. I disagreed.

On my therapists advice I withdrew from psychiatry. He felt that I went backwards every time they suggested hereditary SMI as the cause of my issues and this was the cause of my problems. That psychotherapist was right! I never went back… but the self doubt was hard to shift.

Feeling slightly more validated I sent off for my father’s notes and discovered that he was diagnosed with personality issues and reactive depression. This made sense as he had been brought up by a step father who was a Polish Jew and had fought in the world war. This man had resented my father as a stepson and his upbringing had been very difficult as a result. I began to unravel my beliefs about hereditary MI.

Listening against me

I complained to my GP about being placed on psych drugs and misunderstood withdrawal and obtained copies of my notes which were full of inaccuracies. It was then that I discovered the “bipolar” comment which had been read by all who treated me. I began to realize that I had not been taken seriously for years.

I requested a re-diagnosis of my heart condition. This was translated as “health anxiety” again as my doctors maintained that I had received a full and comprehensive investigation previously. The consultant used the opportunity to gather information… supplied by me…. and placed it on file under relevant psychiatric history / reactions.

Apparently, I was delusional (whilst on the steroid), the dream disturbances I had experienced in withdrawal were hallucinations and I had experienced paranoia. I clearly had health anxiety regarding psychiatric drugs and my notes showed marked episodes of depression and relapses. I had reacted to small doses of antidepressants and steroids which was indicative of bipolar disorder and there was evidence of mental illness in the family with my father and my son’s school phobia.

I tried to go back to work but was told that I may have a hereditary form of mental illness and my GP would only sign me off part time. “Do you think I’m too dangerous for a classroom?” I asked.

I withdrew again, afraid, misunderstood and with a huge amount of self doubt. No one would back me up or believe in me. I felt hurt, angry and abused by a system that would not admit it’s own shortcomings or be open minded about drug side effects and expected me to accept a serious mental health diagnosis because as my GP said, “so many professionals could not be wrong”.

All this, when I had been dismissed by psych services after just two sessions of counselling 10 years ago with no significant symptoms or need for help apparently!! This did not add up.

We mark our destinies with our fears

Although my logical brain tells me that they cannot diagnose me with anything, I am terrified to go to the doctor now. Terrified to ask for help if I have heart symptoms for fear of them being diagnosed as health anxiety and terrified of what lies ahead with my heart condition which is still being treated as a fainting condition 6 years on despite no fainting during the intervening years and no drugs to prevent fainting either.

I have lost many friends, my dignity and my self-confidence. I have deep rooted fears surrounding hospitals. I nearly lost my husband’s respect and my marriage when I became suicidal and I have had to battle to regain the trust of my children, who lost all respect for me too as I fell apart whilst in withdrawal or on steroids. I worry about the effect on them.

I will never visit another psychiatrist and I will never take another psych drug or steroid unless I become suicidal again, which I think is highly unlikely now that I am two years drug free and back to the relatively calm and stable person I originally was.

Worst of all though is the specter of that SMI diagnosis. It probably won’t happen now but it still frightens me to know that there is evidence on my file. What if I become unwell or confused in later life or the menopause throws up depressive symptoms… will they pluck it out of my file again? I need to put it behind me… but that’s easier said than done.

They say that history within families repeats itself. Maybe this is true if you allow it to and buy into hereditary mental illness as a possibility like I did. It can become a self-fulfilling prophecy…. but that’s nothing to do with genetics really is it?

We mark out our own destinies sometimes with our fears…. and that’s where I went wrong.

Antidepressants and The Tell-Tale Heart

We have slightly detoured from the Persecution theme. The detour came after a lawyer, a woman, representing a company that markets escitalopram said it wasn’t appropriate to compare the lack of consent in pharmacotherapy to rape. This gave rise to a Consent-Rape mini series of posts which this two-part post continues. Persecution will resume very soon.

This post feeds into a series of posts about antidepressant withdrawal on RxISK – see Antidepressant Withdrawal: A Prozac Story and the dangers of letting a strange medication into your life – see Saving Grace.

Perhaps linked to the Rape theme, in healthcare at least it seems to be mostly women who stand up to power, who want to reclaim the streets or in this case our clinics, and whose oratory echoes great men who have spoken out in other settings. But no-one has made a movie of their march from Selma to Montgomery yet…


Like many of us I have an Achilles heel. For me, that topic is familial mental health. This is due to my father who had a breakdown when I was a teenager. He behaved erratically, desperately for a few weeks, and then disappeared into the local mental health hospital, before re-emerging tearful and vulnerable.

This was frightening to witness, difficult to understand and – being a teenager – embarrassing. Due to my parent’s subsequent divorce I became estranged from him for years and those memories of his mental health deteriorating, leading up to his business collapse, divorce and losing our home are traumatic ones. They made me susceptible to suggestions of hereditary mental illness. Usually reasonable, I am quite the reverse around this topic, and easily frightened by it.

Becoming depressed?

Twelve years ago, I was exhausted and tearful and had moved from a town where I had employment as a teacher to an idyllic rural location away from my family… the ripples of divorce and my father’s behavior yet again having caused problems for me in my thirties.

Once away from my home town and in the sticks, I no longer needed to work as the mortgage was paid off and I had no money worries. My husband had a good job and commuted to the city. I had the children to ferry around and care for and a beautiful home, but family events preceding the move had got on top of me and the empty days provided too much time for reflection. I went back to bed a lot during the day and became exhausted and tearful. “I think you may be depressed” said my kind and gentle husband, “let me take you to the GP”.

A diagnosis of mild anxiety/depression with no suicidal thoughts was confirmed and a course of antidepressants – escitalopram 10 mg – followed during the six week wait for counselling. The drug was new to the market. It felt like little light bulbs were exploding behind my eyelids when I took it. I couldn’t shut my eyes or sleep through it but I felt my fatigue lift. How, I wondered, could one little white pill cut through the exhaustion and make me feel like this? It was obviously exactly what I needed. This was depression for sure, what luck it had been spotted.

When I went back to the GP to tell her that I couldn’t close my eyes, she reduced the dose by half and added to my notes…”bipolar?” She put me back up to 10 mg after a couple of weeks and this time there were no exploding light bulbs. I felt energised, happy and well. I could put up with the dry mouth, lack of orgasm, funny feelings in my brain like zaps and bloated stomach and tummy pains which developed – I put this down to IBS.

Six weeks later, counselling passed in just 2 sessions. I told them I felt great and told them a little of the events leading up to moving house. I was rewarded with a gentle smile and a letter to my GP which said there was nothing significant wrong. I was discharged. On reflection, I think the counsellor was quite right… it was just life getting me down and I needed to recharge my batteries and deal with the crap rather than “medicate” it. But I could have done with some talk therapy to uncover the misinformation that my “Achilles heel” was causing.

I went back to my GP. She felt I looked and sounded so much better that it would be a good idea to keep taking the drug as depression could be long lasting. Eight months’ worth of pills were prescribed. I was happy to take them as they made me feel better.

Hints of withdrawal

After eight months, I stopped, following GP advice – dropping a pill every other day over two weeks. The exhaustion and tearfulness returned pretty quickly. I went back to the GP. “Ah yes, the depression hasn’t gone yet,” she said. “I’ll re-prescribe your drug, but this time NICE suggest that in the case of a relapse you should stay on the drug for a year. You may not need to though, so don’t worry.”

….and so the roundabout turned. Every time I tried to come off the drug, no tapering, as I knew nothing about this, I had what I now know are withdrawal effects… they got worse each time and I found I was emotionally labile, flying into rages, driving erratically and susceptible to the slightest stress. I believed myself to be mentally ill and getting worse. I needed that drug to keep my children safe from my mood swings as I was a monster when I stopped. I feared I was an unfit mother. I drew comparisons with my father.

My periods became unmanageable. I bled so profusely that I couldn’t leave the house. My stomach blew up with painful IBS type symptoms and I collapsed one day, without warning, whilst on the loo, waking up on the tiled floor with a banged head. It didn’t enter my head that any of this could be caused by the drug. I put up with it, passing off the collapse as an embarrassing incident probably linked to constipation.

Eventually, I saw a different GP who looked at my notes, scoffed and said, “what on earth are you on these for?” By then I was sleeping more than I had been sleeping when first put on the drug, I had gained weight and although calm I was very lethargic and didn’t have much energy. I was no longer energised. I accepted that I needed to come off the drug. I had been on it for 5 years.

My world was turned upside down within weeks of the quick taper as per packet instructions. I became that rage filled, over-reacting, crazy woman I had come to fear. I mentioned the rages to my GP and a look of concern crossed her face… but it was too late. I’d been off the drug for some weeks. I wasn’t going to go back on it. Enough was enough, and the doctor had told me I didn’t need it.

Under the ribs lies a tell-tale heart

Following an argument which made me anxious, I felt something lodge in my chest. Some hours passed but the feeling wouldn’t go away. I rang an NHS out of hours advice line who told me they thought I’d had a heart attack. I thought this was ridiculous, I was too young (43) and had no indicators for heart disease. After a lengthy chat and some scare tactics, I agreed to go to A&E when my husband got home.

In A&E I was placed on an ECG and kept in the cubicle for a very long time. Eventually I was told I had an arrhythmia and a slow heart beat. I had a positive troponin test for heart attack and was kept in. I remained in hospital for 2 weeks. I was terrified.

No one knew what was going on – the doctors gave me heart attack drugs which caused my blood pressure to plummet. They gave me zopiclone to make me sleep at night and gave me various diagnoses from heart attack to sick sinus syndrome. My anxiety went through the roof when I was told I would need a pacemaker as my heart was going too slowly and I was at risk of stroke.

I was sent for a scan of my arteries – no blockages – and then discharged back to my GP’s care. She didn’t know what to do with me as there was no diagnosis and my pulse was very faint and arrhythmic. When I mentioned the antidepressants role in all of this, she said “maybe….” She placed me back on an antidepressant – citalopram 10mg this time which she said was half the strength. I can’t remember if it helped or not, I was in such a mess.

Two weeks later I was back in hospital again with the same problems. They took me off the citalopram – saying antidepressants were no good for the heart….you don’t say!! I was put on the stroke ward but they couldn’t cope with me there as the bell attached to my heart monitor, which indicated that my pulse had fallen below 30 went off all night and my blood pressure plummeted.

They tried felodipene to help the pumping action of my heart and my pulse increased to about 45 but my legs stiffened and I couldn’t walk. God knows which other heart drugs I was on – they were swapped around like smarties. The stiff legs weren’t possible apparently – I was told I had to keep taking the drug for 3 months.

My mood by then was frankly on a rollercoaster and I threw an embarrassing tantrum unable to put up with not being able to walk. I called my husband and discharged myself despite nurses trying to persuade me I was in danger of stroke and should stay. When I got home I panicked and realized that I had over reacted to stress and was an emotional wreck. I broke down, but refused to go back. I felt like no one could help me and no one understood.

My GP was furious with me and I was placed back on the antidepressant again. She took me off the felodipene though and suggested “I put it to one side….” This felt very wise.

When your problem doesn’t fit their boxes

I got referred to an electro-cardiologist who put me on a tilt table which is designed to induce faints in people with certain heart conditions. My heart stopped after 10 seconds of tilt and I lost continence. I woke up shaky and afraid.

I also had a cardiac stress MRI which consisted of a drug being administered that made my heart race. Afterwards, in a hotel room, I kept losing consciousness and was in a mess. The procedure had obviously been too much for my heart.

I felt at risk from the men in white coats who thought they knew everything, but didn’t think to listen to me. They knew best… but clearly knew very little.

A fainting condition was diagnosed caused by an arrhythmia – neurally mediated syncope.

“But I’m not fainting” I said.
“It’s your autonomic nervous system which is faulty causing low blood pressure and an irregular heart beat which causes you to collapse”.
“But I’m not fainting and my blood pressure is normal”.
“Your blood pressure was really concerning in hospital and you felt faint during an exercise test” they said.
“Yes, but they took me off the antidepressant and gave me loads of heart drugs which lowered my blood pressure…” I argued to no avail.

The condition was treated with 6 teaspoons of salt per day and 2 litres of water to increase blood pressure. My blood pressure went through the roof to hypertensive levels. This was not expected, as low blood pressure typified the condition.

I was also told that my veins were dilated and that this was causing “low blood volume”. I was offered Prozac which I refused. I didn’t want any more drugs. Later on I was told that the same hospital were using Prozac in patients with congested arteries as it helped with vasodilation. The exact opposite of the use proposed for me.

The consultant was puzzled by my blood pressure reaction as it didn’t fit the diagnosis of neurally mediated syncope, neither did the night time dips in heart rate. Heart rates usually dip in fainting conditions when you stand up… not at night in bed. But this was ignored and my protests that the diagnosis was wrong were ignored.

After 6 months my GP suggested coming off the antidepressant again…

Continued in Part 2.

We are the Ninety Nine Percent

99 percent

Editorial Note: This is a Coda to the four posts about Sense about Science and AllTrials – Follow the Rhetoric, First Admit no Harm, Follow the Lawsuit & Follow the Patient.

The last post ended on this note:

Over 18 months ago, RxISK attempted to open up a debate on the ambiguities and conflicts at its heart. Doing what it does, could it operate as a business in the marketplace or should it be a Foundation or an Occupy your Doctors’ Office movement?

It seems clear that although legally obliged to access any adverse event data they are aware of, pharmaceutical companies seem unlikely to endorse RxISK in the way they have endorsed AllTrials. They seem to be pushing us toward finding something more co-operative – perhaps something that is not out there yet – perhaps something that David Graeber or Thomas Piketty might have views on.

Over the next few weeks on RxISK, we will be featuring a series of just published articles based on RxISK data – one on what is now a Ninety-Nine + case series of SSRI induced Alcoholism. A second on what is an over one hundred and twenty case series of persisting sexual dysfunction following SSRIs, isotretinoin or finasteride. The third will be on a novel ethical dilemma linked to reports of QT-interval changes.

There are several hundred cases embodied in these articles covering most antidepressants and a number of other drugs. Companies who are interested in the safety of their drugs, or companies simply keeping to the letter of the pharmacovigilance law should be contacting us to enquire further whether their drug was involved, as might also the companies gearing up to market S-3 antagonists for alcoholism. How do we deal with this? Who pays for the work involved in establishing which version of paroxetine was involved?

Could RxISK be captured?

Quite possibly. Industry can capture almost anything – they may have captured AllTrials. They are making great efforts to capture, defang or otherwise manage patient adverse event reporting systems. GSK’s ability to hide clinical trial data pales compared to the subtlety of their approach to and lengths to which they appear to go to block or otherwise hide adverse event reporting – See American Woman, American Woman 2.

Some pre-capture RxISK principles

  • Doctors and patients make medicines. Industry make chemicals. A medicine is a combination of a chemical and information about how to use that poison to bring good out of a bad situation. Doctors, nurses, pharmacists and patients make the information that transforms a chemical into a medicine.
  • Doctors and patients are the only bulwark against the degradation of medicines caused by branding and marketing. Regulators and academics or other experts aren’t.
  • Medicine involves following the patient. It’s the inconvenient patient, with the inconvenient problem that points the way forward.
  • The marriage of patient and doctor is often cast as a marriage of scientific and personal expertise with lip-service paid to the equality of both forms of expertise. But in fact faced with an inconvenient fact, a doctor’s expertise almost by definition risks getting in the way – this is the time for doctors to work with patients as genuine equals. This is where doctors find out that a motivated patient, even one with no academic credentials, is far more likely to turn up an answer than a bored researcher. This is where each finds out if the marriage is enduring. As part of a dowry, the patient who finds the answer to a problem will often happily let the doctor take the credit.
  • Embracing adverse events can restore the fun to medicine. It calls on doctors, pharmacists, nurses or others to be generalists rather than partialists. None of our drugs act on one system – there is more serotonin in the gut than the brain and more cholesterol in the brain than in the blood. To work out what is going wrong and put it right you have to draw on everything you have ever learned rather than just stick to the tramtrack of standard practice.
  • This is about making the market work properly. We ultimately are where the value lies.

The RxISK report

The main tool to move things forward is the RxISK report. When some anomalous event happens on the street, its axiomatic that the police get as many eye-witnesses as they can. In clinical practice this means you don’t want to leave reporting to hurried and disengaged doctors and you definitely don’t want to leave it to pharmaceutical companies for whom collecting details on a case is all about collecting excuses to rule out an effect of their drug.

It makes much more sense if a doctor or pharmacist or nurse comes to an agreed account with the person affected who has usually spent time with the problem and is motivated to nail down what is going on.

  1. It’s about good quality rather than degraded quality adverse event reports in the belief that good words come before good numbers.
  2. It’s about us being willing to make a judgement call that this event is likely to be linked to a drug in a way regulators will never do.
  3. It’s about intervening early in adverse events to reduce harms.
  4. It’s about adding local knowledge to the mix – getting people in Swindon and London (or Hamilton and Toronto; or Lyon and Bordeaux, or Verona and Milan, or Chicago and Milwaukee) to account for why something is happening in one place and not another rather than thinking someone with no local knowledge is going to sort it out
  5. It’s about taking on the power imbalance between doctors and patients.
  6. It’s about changing doctors into listeners – this can be done by getting patients to quality mark doctors based on those who agree to engage in the process versus those who don’t. We can force the deaf to hear us. We are the Ninety-Nine Percent.
  7. The RxISK report has led to the idea of a RxISK clinic and report as an even more potent way to equalize the power imbalance.

It’s about medicine as it needs to be if its going to survive. Leaving reporting to doctors alone has not worked – at present only 1% of adverse events are reported. The question is whether doctors have what it takes to save themselves by insisting on the evidence of their own eyes and reporting adverse events. Saving themselves will do more to save their patients than anything else could.

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.

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 and can be viewed here.

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 and can be viewed here.

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 and can be viewed here.

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.