Continuing the Spotlight on the Suicides Series
I have largely avoided naming names and will continue to avoid putting names in the frame but Stephen’s family doctor’s name, Dr Brannigan, is already in the public domain, and I’ve made it clear that the coroner thought highly of him and the whole point behind these posts is to show how even a decent doctor can end up in a nightmare. These posts are about a rotten barrel not a rotten apple.
Dr Brannigan had his own lawyer present. The hospital had theirs.
He seemed a decent man. There was a longstanding relationship between him and the family. Stephen had been his patient for years and the two appeared to get on in a manly way.
He began nervously.
Prozac & CBT
Some years before, Dr Brannigan had spoken to Stephen when he was grieving after the death of a parent. This conversation led to a prescription for Prozac. The script was repeated once.
Prozac clearly didn’t work and Stephen may not have taken much of the first course. But like most of us, he took the second script from his doctor – finding it difficult to tell him he’d stopped taking the tablets.
How do I know this? We know 50% of people stop the SSRI they have been given within a month because it doesn’t suit them or they feel its not really needed. Stephen’s family mentioned he hadn’t thought it suited him and had stopped it. Dr Brannigan didn’t renew it after the second script, which he would have done had either he or Stephen thought it been working.
After the second script, Stephen according to Dr Brannigan was better and didn’t need any more. When pushed on whether he thought the drug had made him better, he declined to say it had helped.
There was no entry in the record saying it had or hadn’t helped. For lawyers who have no idea what giving an antidepressant means, however, the lack of an entry saying it hadn’t helped meant there was no evidence it hadn’t helped or caused problems in any way.
Some time later, when Stephen was out of sorts Dr Brannigan suggested a course of CBT – rather than more Prozac. Stephen agreed but again gave this up after a few sessions. He was a get on with life person rather than someone who liked to pick over things.
In early 2016, Stephen had a chest infection that didn’t respond to the first antibiotic he was given. One of Dr Brannigan’s colleagues gave him a prescription for a week’s doxycycline. The chest infection cleared but almost immediately afterwards Stephen complained of anxiety. The table here replicates last week’s table – Spotlight on the Coroner
The first point to note is Doxycycline is among other things an SSRI. Dr Brannigan was not to know this – very few doctors do. But you don’t need to know how a drug works to know what it’s doing. You just have to listen to and believe the people who have taken it when they tell you what’s happened to them since they took it.
Doxycycline is well known to cause suicide in people who have been given it for acne or malaria prophylaxis or for chest infections. Only marginally less likely to cause suicide than isotretinoin (Accutane) when given for acne.
Second, the comparison of the two doxycyline sets of figures in the Table above brings out how FDA reports can hide problems. In addition to reports of depression, there are reports for malaise, asthenia, depressed mood, anhedonia and mood swings, all of which added up make nearly 10% of the reports on doxycycline – even without adding in reports of emotional disturbance, emotional disorder or other events that could conceivably have been depressive.
There are similarly separate reports for anxiety, agitation, panic attack, nervousness, fear, restlessness and stress. All told over 25% of the reports on this drug are related to suicide or its antecedents.
If you apply the same logic to sertraline, quetiapine, mirtazapine and buspirone that featured in Appendix 1 in last weeks post – the one page of data the coroner decided not to admit as evidence – you can guess what the true profile of the effects of these drugs is likely to be.
In response to Stephen’s anxiety, with no sense it was caused by doxycycline, Dr Brannigan referred Stephen for counselling. Counselling, CBT, Mindfulness or whatever are only likely to make a problem like doxycycline induced anxiety worse – as the therapist tries to persuade someone their real problems stem from being bullied at school or whatever. Fortunately or unfortunately, the waiting list for therapy was long.
Another point to note is that this adverse response to a serotonin reuptake inhibitor fits the profile of a poor response to Prozac – another serotonin reuptake inhibitor and antibiotic as it turns out. In a situation like this, it can be expected that the next serotonin reuptake inhibitor will produce an even worse response.
While waiting for counselling, one day when Stephen came into the surgery, Dr Brannigan decided to give him sertraline. On the witness stand, he made out that Stephen seemed totally different to the usual Stephen and he Dr Brannigan figured this was more like a real depression than the rather minor nervousness that had led him to prescribe Prozac some years before.
At least this is what he said on the stand at the inquest. The medical record doesn’t bear this out.
This account is not accepted by Stephen’s family. Nor is it consistent with his activities at the time that show him continuing to do things such as play in concerts. They knew he was out of sorts but didn’t notice a dramatic change at this point in time.
Why sertraline? Well according to Dr Brannigan there is evidence that this is better for dealing with proper depression. There isn’t. The sertraline literature is comprehensively fake. Any hints that it is better for a severe depression is pure marketing copy.
More to the point, whatever change there might have been in Stephen that day paled in comparison to what came next. Up to the evening he took his first sertraline tablet, Stephen O’Neill was a man who had had no contact with the mental health services and neither he nor his family ever envisaged him having contact.
After he took his first pill, for the remaining 6 weeks of his life he was in constant contact with the services and pretty well every moment of contact made things worse.
Serotonin Pick-up Syndrome
After a catastrophic response to sertraline, Stephen ended up in hospital briefly. The medical notes are clear – he told people that sertraline had caused all his problems. This was noted but not heeded.
There he was given lorazepam in a low dose one evening just before discharge and found it tremendously helpful. His view that it had close to normalised him was recorded in the medical record.
When he returned to Dr Brannigan, the lorazepam was not continued and Quetiapine was introduced instead. This as a previous post has noted made things worse. But although Stephen reported being worse, the Quetiapine was not switched back to a benzodiazepine.
This is because pharmaceutical companies did an extraordinary hatchet job on the benzodiazepines in the 1990s as part of the marketing of sertraline, paroxetine and fluoxeting (Prozac). Most family doctors in the UK ended up quite literally thinking the benzodiazepines are more dangerous than opioids and that in comparison SSRIs are harmless. They still think this and dish out opioids more liberally than benzodiazepines.
This reputation continues to this day, when prescriptions for benzodiazepines are a fraction of the scripts for SSRIs – with over 10% of the population hooked to an antidepressant. This reputation persists even though within 3 years of its launch in the UK, there were more reports to the UK regulator of dependence on paroxetine alone than there been in the previous 20 years for all benzodiazepines combined.
This is the case even though when marketing SSRIs in the 1990s, the companies went around telling family docs that in the early phase of treatment with an SSRI there could be a serotonin pickup problem but not to worry this would pass and it could be managed by giving their patients diazepam or lorazepam to take during the first few days of treatment.
The point here is not that benzodiazepines are safe, although I, and I’d imagine most people working in the secondary mental health services, if given a choice between diazepam to take everyday for a year or fluoxetine or sertraline would take diazepam. The point is that Stephen was handing Dr Brannigan and everyone else who was in contact with him the diagnosis on a plate.
It could not have been more clear. And he could not have been more ignored. He was ignored by decent and even good people – in much the way that people abused by the clergy in the Catholic Church were ignored by decent and good bishops or other clergy.
This ignoring is a public health hazard. Inquests are supposed to be about trying to minimise risks to the public health.
Next Week: Spotlight on The Hospital Doctor