Odysseus was in his 70s. Coming up to the 50th anniversary of a very happy marriage. He had formerly been a respected professional, a longtime member of the bowling and social clubs – a pillar of the community.
He had had minor episodes of anxiety primarily since retirement but no diagnosis of nervous problems. He went to his primary care doctor and was given a sleeping pill for poor sleep but stopped it after the first pill knocked him out. A few weeks later he was brought back to the clinic by his wife and ended up on Cipramil (citalopram) for anxiety. In the following 9 days he had 3 nose-bleeds – an SSRI side effect not recognized by his doctor.
The medical records pointed to a deteriorating situation… but no risk was noted
He kept a diary while he was on Cipramil, which recorded that he was feeling worse and worse, and becoming concerned that he might be going mad. He returned to the doctor and complained about his antidepressant but was persuaded to continue the pills – “these drugs take several weeks to work”. No risk of suicide was noted. The medical notes record his concerns about the stress he was causing his wife.
The medical records, the later testimony of acquaintances and family members all point to a deteriorating situation. His anxieties about trivial matters were escalating rapidly. He began voicing doubts about his wife’s commitment to him. This was exacerbated by a new anxiety about driving that led him to ask her to drive him everywhere which she would not do. He described himself as a fly in a jam jar and his diary records a fear that he might be committed to an asylum.
His son found him pacing restlessly and scratching himself furiously – the 10th day since starting citalopram
He mentioned suicide to neighbors but said he would never have the nerve. A daughter thought of flying home. A son came to visit, and found his father pacing restlessly, scratching himself furiously and unable to hold a coherent conversation. His son left the following morning for a work engagement – the 10th day since his father started Cipramil.
Shortly afterwards, Odysseus got a blunt instrument, went into the bedroom where his wife was sleeping and battered her to death. The transcript of his interview with the police later that day – after calling them to tell them what had happened – shows a man who was incoherent. Several weeks later, after Cipramil was stopped, when interviewed in hospital he was quite different.
A clear cut case of SSRI induced violence
This was one of the most clear cut cases of SSRI induced violence that I’ve seen. His children were happy for him to come home to live with them if he were acquitted. I wrote a report supporting a not guilty by virtue of insanity case. In comparable cases elsewhere, such as David Hawkins in Sydney in 2001, people have walked out of Court effectively free (see Healy et al 2006).
Did Odysseus’s lawyers bottle it? Neither Odysseus nor his family saw my report. He was in prison, isolated from almost all contact and unable to test their view or intentions. He accepted their advice to plead guilty, which gave him 2 years in prison. No one it seemed had any incentive to help Odysseus get home. For the police, he kept their conviction rate up. For the lawyers, he was on legal aid and so they stood to make the same amount of money from a quiet day in the office. I wrote to the Judge but was blocked from sending the letter by advice that I would be in contempt of Court.
All of the biases outlined in these posts come into play when it comes to the issue of violence on prescription medication. We have no difficulty in believing that illegal drugs like cocaine or amphetamines, or over-the-counter drugs like alcohol can lead to violence, but extraordinary difficulties in believing that prescription drugs can do so.
The original insanity defense
Drugs formed the basis for the original insanity defense outlined by Chief Justice Matthew Hale in 1743 who stated that:
“if a person by the unskillfulness of his physician or the contrivance of his enemies, eat or drinketh such a thing as causeth such a temporary or permanent frenzy, as aconitum or nux vomica, this puts him into the same condition, in reference to crimes as any other frenzy, and equally excuseth him” .
The frenzy Hale refers to here means delirious states, stemming from physical or other disorders, and only secondarily to what later came to be termed not guilty by virtue of insanity or psychiatric illness. Delirium refers to states induced by a fever, or toxic metabolism, or by a toxic agent such as a drug. Delirious states as instanced by the disordered mental states accompanying a high fever or delirium tremens offer an absolute defense against murder and provide a basis for a not guilty verdict because the capacity to form intent to kill could not have been present.
But 260 years later we have much greater difficulties with these issues than Hale had. In the Pittman case in South Carolina, a 12 year old boy who had murdered his grandparents several days after starting Zoloft, Judge Pieper was much less clear than Hale before him:
“There is no case in South Carolina that addresses involuntary intoxication by prescription drugs… It seems to turn the whole medical system on its side if you can’t rely on the medication your doctor prescribes… It potentially forces you into a situation of lifetime commitment if that drug induces an effect of which you are unaware. There’s something disconcerting about that, albeit probably of a legal nature that is troubling me”.
The idea that a doctor might have poisoned a person is close to unconscionable
Treatment induced violence may be the most neglected treatment related problem in all of medicine, despite an abundance of the most convincing data. How could something be so Evidence in the 18th century and cause such problems now?
This is one of the two places where the tensions in prescription only arrangements become most acute (the other is pregnancy). No doctors intend harm, and certainly not harm to an innocent third party. The idea that a doctor might have poisoned a person is close to unconscionable. The idea that the most poisonous aspect of what happened was the doctor’s advice to continue taking the pills or double the dose leads many doctors and lawyers to something close to a psychotic breakdown when it comes to violence on prescription drugs.
Easier boycott Odysseus than Lundbeck’s drugs
And so in the face of mass school shootings where the great majority of the perpetrators are on antidepressants, we stay silent. Odysseus only got two years – a small price to pay many will think for ensuring the guilty don’t walk free.
But Odysseus didn’t just get two years. Back in Ithaca, his friends who had once been willing to testify on his behalf in the belief he was not guilty now refuse to have anything to do with a guilty man. The social club and bowling club turned down his applications to rejoin. For medical care he has to go back to the same doctor. The people he now has most contact with are the checkout girls at a supermarket some miles away.
Dare he risk an appeal? The judicial system might opt to re-imprison him.
And of course Penelope is dead. Who was responsible for her death? Lundbeck? Easier boycott Odysseus than Lundbeck’s drug. The gods seem more likely to listen and bring Odysseus home than Lundbeck.
 Hale M (1736/2003) Historia Placitorum Coronae. Vol 1 Lawbook Exchange. Clark New Jersey, Chapter 4, Concerning the Defect of idiocy, madness and lunacy, in reference to criminal offences and punishments. page 30