The Hidden Gorilla

Three weeks ago What would Batman do Now covered the issue of suicide in the military – an issue that had Batman missing in action, and the Joker suffering the adverse effects of psychotropic drugs. Then along came James Holmes to the premiere of Dark Knight Rises in Aurora.

Most drugs that can cause suicide, including the antidepressants, mood-stabilizers, antipsychotics, smoking cessation drugs and others, can also cause violence. The akathisia, psychotic decompensation, or emotional disinhibition these drugs trigger that lead some to suicide, lead others to violence (see Healy et al 2006).

A medical blind-spot

There is some awareness that these drugs can cause suicide but considerable resistance to the idea. There is less awareness and even greater resistance to the idea that they can cause violence. Treatment induced violence lies in a medical blind spot – no doctor wants to contemplate the possibility that she may have had a role in the deaths of innocent third parties.

This may be the grim prospect facing Dr. Lynne Fenton. Dr Fenton we are now told had been seeing James Holmes, the killer at Dark Knight Rises in Aurora, and had seen him just a week before the killings. Given the current reliance of American medicine on medications it seems likely that medications are involved in the Aurora case.

For many the instinctive reaction to Holmes will be that he is either mentally ill, evil or a street drug addict. This makes sense. Violence is one of the associations we all make to the ideas of evil, mental illness and illicit drug use. In contrast most of us know people on antidepressants none of whom are violent. This makes it difficult to accept a link to prescription drugs. For many even raising the idea that Holmes may have been crazed by a prescription medicine is likely to sound deranged or the excuse of a bleeding heart liberal.

No other risk so hidden

But in fact there is a great deal of publicly available clinical trial (Hammad 2004, p40-41) and other data highlighting the risks of violence from psychotropic drugs. There is far more hidden data. There is in fact no other area of medicine in which there is so much hidden data on a risk that has consequences for the lives of so many innocent third parties.

With each “outing” of suppressed data lately companies have been beating their breasts about the lack of transparency “in the past” and have committed themselves to greater transparency. Here’s a chance for our major companies to prove things have changed by making the data on hostility, aggression and violence on their drugs publicly available. These data might tell us something about who is at risk, and allow us to better manage these risks. If there were a conspiracy to keep the details of all plane crashes out of the public domain, would airlines or the authorities have any incentive to make travel safer?

Instead, we are likely to see a vigorous marketing of articles that deny the possibility of a link. It takes really great science to overcome our biases. But if an article fits in with our biases (our associations), almost anything can be published, and doctors can be depended on to treat it as respectable science.

While 9 + of us out of 10 find the idea that an antidepressant might have caused Holmes to behave the way he did unbelievable, those whose lives have been touched by these issues are in a completely different position. News of another mass shooting immediately raises the suspicion that an antidepressant or related drug will be involved. And as, Rosie Meysenburg has shown on SSRI Stories, the drugs are all too often involved.

Slogan for the NRA – no drugs, no killing?

The drugs have been involved so often in campus or mall shootings that for some the surprise is that the medication question is so slow to get asked, as Peter Hitchens who is not a bleeding heart liberal has pointed out. What political considerations keep the NRA out of the debate? When Batman tells America “no guns, no killing”, there must be a temptation to respond “no drugs, no killing”.

But if Holmes turns out to have been on a drug that can cause violence, it is a quite separate matter to establish that in his case the drug he was on did contribute to what happened. It may not have. Without details of the case it is difficult to offer a view.

But this will not stop the debate in the public domain about an easier question for drug companies to control – do psychotropic drugs cause violence. And here, even though in some jurisdictions companies are legally obliged to say their drug can cause violence, a recent article in Psychopharmacology by Paul Bouvy and Marieke Liem denying the possibility of a link is certain to be marketed heavily.


Bouvy and Liem’s article has much in common with recent articles by Robert Gibbons in Archives of General Psychiatry (see Coincidence a fine thing & May Fool’s Day). These articles may have no links to or input from industry, but they fall on the fertile ground of a distribution system complete with public relations companies geared up to make sure that messages like this get picked up and equally that messages about problems that treatment may cause do not get heard.

When it comes to Adverse Drug Reactions (ADRs) on prescription drugs, there is no such thing as an academic debate with equal airtime for both sides, although Psychopharmacology have published a response to Bouvy and Liem’s article unlike Archives of General Psychiatry which has refused to publish responses critical of Gibbons’ articles.

Bouvy and Liem correlated data on lethal violence in Holland between 1994 and 2008 against sales of antidepressants. The drug sales went steadily up and the number of episodes of lethal violence fell, leading the authors to claim that “these data led no support for a role of antidepressant use in lethal violence”.

This is a marvelous example of what is called an ecological fallacy. An ecological fallacy is when someone claims that if an increase in the number of storks parallels an increase in the number of births that storks must be responsible for births.

Doubt is our Product

The best known example of storkology in recent years were the graphs produced by tobacco companies showing rising life expectancies and even reduced deaths from respiratory illnesses in line with rising cigarette consumption. These were produced as part of a Doubt is our Product strategy to deny the risks of smoking.

Recent sightings of storks include claims that increased SSRI use is linked to falling national suicide rates. The articles making these claims offer data from the late 1980s but disingenuously omit some key facts. One is the fact that suicide rates in most Western countries were falling before the SSRIs were launched. Another is the fact that both suicide rates and antidepressant use rose during the 1960s and 1970s when antidepressants were being given to the most severely ill people at the greatest risk of suicide. This was when suicide rates should have fallen if antidepressants have any effects on national suicide rates (Reseland et al 2008).

Autopsy (post mortem) rates are also left out. The more autopsies done the more suicides and homicides are detected. Autopsy rates rose in the 1960s and 1970s and fell from 1980 before antidepressant consumption began to escalate dramatically. The rise and fall in autopsy rates perfectly mirrors the rise and fall in suicide rates.

Why would Psychopharmacology take an article like this?

For the purposes of this argument, let’s assume the data on episodes of violence in Holland that Bouvy and Liem use is correct. This may not be the case – British national suicide rates are no longer dependable. The national figure is in essence set by a bureaucrat in London, who has scope to make the rate rise or fall as needed. Let us also assume declining autopsy rates play no part.

Before considering what else could be involved, let’s look at the shape of the argument and ask why Psychopharmacology would take an article like this. First alcohol use has increased in Holland during this period but no-one is making the argument that increased alcohol use has led to a decline in acts of lethal violence or the further Bouvy and Liem argument that this means alcohol cannot cause violence. Why not? Because, we associate  alcohol with violence.

SSRIs cause growth retardation in growing children. The clinical trial data show this retardation and the labels for the drugs mention it. During this period SSRI consumption among children has increased in Holland but the Dutch have become the tallest people in the world and are getting taller. Where is the article saying that the increasing height of the Dutch proves that SSRIs don’t retard growth?

In the case of violence, the published trials show antidepressants cause it, probably at a greater rate than alcohol, cannabis, cocaine or speed would be linked to violence if put through the same trial protocols that brought the antidepressants on the market. The labels for the drugs in a number of countries say the drugs cause violence. And there is at least one clear and well-known factor, just like autopsy rates, that can account for the findings – young men. Violence is linked to young men, and episodes of lethal violence are falling in all countries where the numbers of young men are declining.

For ADR read A Dr

Whatever Psychopharmacology were doing taking an article like Bouvy and Liem’s making claims that run counter to the warnings that are already on the drugs, without warning their readers that this was the case, from here on the game for industry is about managing associations. From conmen to hypnotists to Batman, the trick is to hold the audience’s focus so they miss something much more important in their peripheral vision field. This is what public relations companies excel at.

One of the best examples of how we can be tricked can be seen in the Hidden Gorilla video where selective attention can lead to us missing a Gorilla walking right across screen in front of us. But the very best trick must be the one that leaves us certain that serotonin reuptake inhibitors or amphetamines available on the street cause violence while in complete denial that almost identical  prescription-only drugs could do so.

In the case of prescription drugs, the key people are doctors, the Watsons. Always one step behind the smarter Holmes. While it would be nice to see Watson turn the tables for once, in this mystery Sherlock Holmes has the last line once again. It’s elementary My Dear Watson. For an ADR you need A Dr.

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  1. as soon as i heard about the shooting i said to people i bet this kid was on an anti d – wouldnt suprise me if it was zoloft.

  2. I mentioned this in a previous comment but some elaboration may better illustrate the issue. I am often asked for consultation with respect to patients being treated by other physicians/psychiatrists/neurologists. A couple of years ago, I saw a young man, 18 at the time, who had been using street drugs. He was in the adolescent psychiatry unit of a local hospital, the attending being a young, inexperienced psychiatrist. To cut a long story short, against my recommendation, this young fellow was treated with an endless variety of ECT, antidepressants, antipsychotics and benzodiazepines, among them lorazepam described as being used for “sedation of aggressive patients”. Every time he was given the lorazepam, which is fast-acting, he became violent, combative and ended up in five point restraints much of the time. He was aware of this effect and begged not to be given it. Tragically, he later committed suicide when on olanzapine.
    While this was happening, his best friend from school, who had also been into street drugs as well as prescription drugs, came to the same hospital with his mother, pleading to be admitted. He was told that there were no beds and just go and “talk to his doctor”. He was taking large amounts of lorazepam among other meds. That afternoon, he stabbed his mother, killing her, then tried to throw himself under a truck as he staggered, naked down the street. He ended up in the room next to his friend – in the bed that hadn’t been available that morning. I managed to persuade his lawyer that the drugs, particularly the lorazepam, played a large part in this horrific story, perhaps because of the fact that he was a) male and b) in the age group identified in the black box warnings on antidepressants, arguing that hormonal issues in this group probably produce unwarranted and often paradoxical effects. The judge accepted my argument so that the charge became involuntary manslaughter instead of murder.
    But his mother is still dead and so is his best friend.

  3. Teri Byrne says:

    We need to try and stop the reality of pharmageddon…how can a whole world turn a blind eye to the reality and ongoing pharmageddon to so many…why not try to stop it instead of just exposing it…Governments, Justice Departments included do not want to know…why?

  4. Until last Thursday, one other popular explanation for this tragedy was the “failure of our mental health system.” The assumption was that lack of mental-health services – or the stigma against their use – had allowed James Holmes to go as terribly off the rails as he had. If only we had been able to get him some help!

    Well, there is a genuine tragedy in a country where so many people with serious illnesses can’t get treatment even if they want it – where the largest psychiatric facilities are the jails and prisons. But I was skeptical from the start that this was James Holmes’ tragedy. Here was a young man living and working in the very bosom of the mental health establishment. So, now we know that he was getting help … in fact, what most Americans would consider “Cadillac medical care.” High-class university doctors, who do actual research! We should all be so lucky. (Or should we?)

    The level of secrecy surrounding this case so far has been extraordinary. A coalition of about twenty media groups, including the Denver Post, the New York Times and NPR have challenged the blanket suppression of all court documents by the judge. The university has been even more tight-lipped, and has reportedly forbidden faculty or students to talk to the media. I’m afraid this hasn’t a great deal to do with defending Holmes’ right to a fair trial, or even protecting Dr. Fenton. More likely, they are protecting the university itself – and, very likely, the drug or drugs Holmes was prescribed there.

    Dr. Fenton’s CV disappeared from the Web for a few days, I guess, but it is back. Her current research involves Abilify vs. Risperdal, and a bright shiny fMRI:,%20Lynne.aspx

    My guess would be he was taking an SSRI plus Abilify – but who knows. And who knows if the drugs themselves led him to this horror, or simply failed to prevent it. Even if it’s only the latter, I hope it leads some people in the psychiatric establishment to take a look in the mirror. If all those faculty mentors failed to see there was anything wrong – or indulged in denial because the young man was so bright – what does that say about them as a profession? A collection of tin ears, or tin hearts, or both. Maybe we would have had more advance warning if the poor guy had worked waiting tables at Applebee’s – instead of at a graduate school of neuroscience, surrounded by top researchers on “the biological basis of psychiatric disorders.”

  5. Behind most suicides/atrocities is a psychiatrist/doctor.
    Behind lurks the psychiatrist/doctor innocently handing out prescription drugs like smarties.
    Behind, almost invisibly and with a deft hand, egocentric experts unconsciously perform an operation, so successful, so professional, that any chance of the drug being involved in atrocities is out.

    How many of us in the uk wonder why David Kelly, weapons inspector, took his life with blades and an overdose. The results of enquiries have been locked away for seventy years to prevent distress to his family. Why?

    I remember reading David Kelly was on anti-ds; he was stressed, terrified and made into a scapegoat for our country and the man was not a man that I would accede to take his life without drug interference.

  6. Some of the gag orders re Holmes may be to allow investigation of Dr Fenton’s notes. If he told her during a session what he was planning, as he apparently did in the notebook that arrived late, she would be obliged, under Tarasoff, to report him to the police.
    I find that most people are under the impression that a physician/psychiatrist’s notes are as confidential as the confessional. Not true. They can be subpoenaed at any time. Some judges will allow parts to be redacted, others will not. This is the reason I never audiotape sessions. These can be subpoenaed as well. My notes have been subpoenaed several times. Of course, very often, not even I can read them. I have been asked by counsel to rewrite or type them and I refuse. They asked for my notes and that’s what they got. In Dr Fenton’s case, I am sure they are being scrutinized very closely indeed.

  7. George Annas in Doctors, Patients, and Lawyers — Two Centuries of Health Law (NEJM August 2012) tells the story of the Coffee Quack that has resonance today. The Coffee Quack came to Beverly, Massachusetts, in 1807 and announced himself as a physician with “the ability to cure all fevers.” He used several concoctions, including drugs he called “coffee,” “well-my-gristle,” and “ram-cats.” He administered these drugs to a patient who had employed him to cure a severe cold. The patient vomited frequently, became exhausted, and within days suffered a series of convul- sions from which he died. He was charged with murder. The judge summed up his instructions to the jury:
    “It is to be exceedingly lamented, that people are so easily persuaded to put confidence in these itinerant quacks . . . If this astonishing infatuation should continue, there seems to be no adequate remedy by a criminal prosecution, without the interference of the legislature, if the quack . . . should prescribe, with honest intentions and expectations of relieving his patients.”
    The jury accordingly found the defendant not guilty

  8. paul pezzack says:

    There is no doubt at all that SSRIs cause violent thoughts and actions.
    i suffered the most terrible thoughts of using knives, scissors and screwdrivers to kill my mother and other family members whilst trying to get off prozac.
    it was utter mental torture beyond anything i could ever imagine.
    i dont drink ,take drugs ,have a criminal record or have a history of violence and yet i had these incredibly extreme thoughts.
    these drugs should be banned.but they wont be because they make so much money.there are so many suicides and murders now because of these drugs.
    but nobody will listen because they are told by their doctor/psychiatrist who want to promote these drugs that they are safe.just like i was told.
    there is plenty of proof of the dangers from the drug trial data obtained from Eli Lilly and GSK by Dr.Breggin on his site.
    it is incredible how they are still prescribed.i have suffered for 5 years with these evil drugs and havnt received any help.
    it is a massive joke.

  9. Hey, Paul, it would help if more like you and me and countless others made a comment or contact
    It is like coming out of the closet; humilating, embarrassing, frightening, intimidating, but once you get over those few emotions, it becomes easier to talk and reveal.

    It is a blog, nothing to be frightened of. Haven’t we all been frightened enough?

  10. Very interesting, and thank you for writing about this.

  11. I am so very tired this evening. I will read more of the article tomorrow. What little bit I read I can comment that from my experience psych drugs could quite possibly lead to violent outcomes because of the physical and mental derailment that takes place in certain individuals for whatever reason. All the SSRIs I was given for depression had mental or physical manifestations that would have caused me to either end my life just to stop the unpleasant feeling, or to cut myself so that I could, in fact, “FEEL” something remotely resembling my customary human emotions Prozac was the worse with self injury for me. I actually held a box cutter and ran it down my leg just to see if I could bleed I guess. I felt so unreal on Prozac. Paxil, I could have witnessed the Holocaust and not give a hoot. No empathy. Just numb. No point to living; just like watching a dead pan movie. Zoloft…oh…Zoloft. That one I was on for a very short time. In house for depression and some new doc thought he’d give it a try. Well, on the 3rd day, when he came to the room, I told him, “I AM going to hurt myself–or Somebody if I continue this drug.” He had the good sense to listen. I would say it was probably the worse drug I ever swallowed in my lifetime (even more so than the Klonopin with its disastrous results). Zoloft did something to me, both physically and mentally that is difficult to describe. All revved up and trapped like feeling. Like a bee in a glass jar. It was worse than anything I’ve taken. This was in the 90s, so I don’t believe it had been on the market very long. The effect was almost immediate and was worsening each day I took it. I had heard some time after my experience that some man was on it and he killed a child in a restroom for no apparent reason. Really acted crazy and everybody was like, oh, he’s faking. Murder is inexcusable. I would hope we all can prevent ourselves from stepping over that line, but, I will say that I understood the defense. Three days I was on that Zoloft. Three days and I knew and judging by how fast that doctor took me off that drug, he must have known also when I looked into his eyes that I spoke the truth when I said it was doing me harm. It is inexcusable that these drugs are the epidemic blight to society that they are under the guise of “medicine.” Perhaps for some people they are helpful. I wouldn’t know a thing about that from my experience with them though. People are all different. Thanks for caring.

  12. Some people will try almost anything when in the throes of major depression. I know this. I have experienced Major Depression myself. However, there are also negative side effects concerning some alternative treatments such as ECT and again, I think it may be wise to consider the consequences of all therapies and the history of the patient before treatments begins, rather than dealing with the aftermath side effects. In a way, it seems that focusing on the pitfalls of one type of treatment (meds), in reality, capitalizes the alleged ‘acceptability’ of some alternative treatments (such as ECT, for instance). ((Art therapy is the exception here because we can all naturally draw.)) Depression for me is not as objectionable as some of the treatments I’ve read about lately. Do professionals ever consider that some people are just naturally melancholy by nature or is that thought process unacceptable now days? I believe I am one of these people of a melancholic nature. I may have romanticized depression in my poetic youth, but today, I would not consider “suicide” a viable option because I have reached the understanding that life is not mine to take. My moods fluctuate. I have not seen a psychiatrist in 7 years, and I’m much better mentally than I was 20 years on cockamamie treatments. Sadness, resurfaces, yes, but I know it will pass and I like me so much better now. It is ‘shocking’ to find out some treatments even still exist. Has anyone thought to open more artistic centers for people to express themselves instead of always medicating our ‘feelings’ away which are a normal part of life? I think we can do so much better for patients than the current menu of treatments. Mr. Healy doesn’t appear to be a sinister person, but I regard his profession with caution because of my own experiences with doctors in general (dating back to my youth). They seem highly positioned to institute broader changes regarding mental health issues than what I am seeing addressed. ART THERAPY (self taught, even casual ‘doodling’) has benefitted me more greatly than all my previous therapy combined. And I say that as a multi-attempt survivor. Best wishes to you and most of all, all of us who endure the labeling the industry has bestowed upon us./

  13. To clarify: I mean “My Life is not mine” to take. I did not ask for it; I do not recall petitioning anyone to come here to this place to be born, so, how could it be mine. My life is not mine to take – nor that of any other soul . We are all temporary residents of something greater than ourselves. I am not a religious person, but whatever that ‘greater than myself” thing is, perhaps it guided me to this realization and finally broke the cycle of suicidal ideation. Before I go, Dr. Healy, try wearing some brighter clothes once in a while. It couldn’t hurt your patient’s moods any…. Good night and Best Wishes

  14. You know, I have forgotten the worst of my depression because I am no longer on meds that were contributing to the condition itself (been off Rx 7yrs now). But today I could remember the actual depression itself without getting caught up in “feeling” it again. I misspoke earlier. My depression was severe enough that I probably would have submitted to ECT rather than Rx drugs during pregnancy. I would never want to risk a child enduring what I have been through because of drugs. There were careless decisions with prescriptions giving to my mother shortly after I was born (and quite possibly prior to my birth I’m wondering). I wasn’t a planned or wanted child. I’ve always fought depression, since a little girl. If I were in the situation of being “severely depressed and pregnant,” yes, Dr. Healy, I would possibly submit to ECT rather than take Rx meds if there were no other viable choices that worked for me. I am very sorry to have misspoken earlier about this issue. Sometimes I speak before understanding~~or, in this case, “remembering” what it was like to be severely depressed. Thank you for offering options. Choices are necessary to be truly free. Good night.

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