Experts: Troubled patients may go off meds

Consequences, such as recent college campus shooting, can be horrific

NIU Shooter's Girlfriend Speaks Out

CHICAGO - Psychiatrists say it’s a common scenario — troubled patients stop taking their medicine, because of cost, side effects, the stigma, or delusions that they don’t need it. The consequences can be tragic, though rarely as horrific as the Valentine’s Day suicide-slaughter at Northern Illinois University.

No one knows what triggered Steven Kazmierczak’s campus rampage, yet one of the clues to an emerging psychiatric profile is this: His girlfriend says he recently stopped taking Prozac.

Prozac is a drug generally prescribed for major depression. It and similar antidepressants carry warning labels about risks for suicidal behavior in patients younger than Kazmierczak, who was 27.

Still, stopping these drugs can also lead to suicidal thoughts and behavior. And taking them may increase the risk for other violence if they’re mistakenly prescribed as the only treatment for patients in a depressive phase of bipolar disorder, psychiatrists say. In that case, the drugs may trigger a manic phase that could include aggressive behavior toward others.

In court cases, attorneys have sometimes tried to blame violent behavior on Prozac. However, scientific evidence to support that is lacking, and psychiatrists and the drug’s maker, Eli Lilly and Co., say the underlying mental illness is the most likely culprit.

Shooter stopped taking Prozac
Kazmierczak, a graduate student in social work at the University of Illinois, was a worrier with obsessive-compulsive tendencies, his girlfriend told CNN, but it is not known if he’d been diagnosed with depression or bipolar disorder. She said he’d stopped taking Prozac three weeks before last week’s tragedy.

Two days before the Feb. 14 shootings, a New York man who’d been treated for psychiatric problems and who had also stopped taking medication is accused of fatally stabbing a therapist.

“Can stopping medications be an important contributory factor to deterioration of behavior ... where violence ends up being committed? Yes, absolutely,” said Dr. Paul Ragan, an associate professor of psychiatry at Vanderbilt University.

Ragan said he has had patients attempt suicide after stopping antidepressants because their insurance ran out, although violence against others is rare in depression.

On or off medication, the vast majority of people with schizophrenia, depression and bipolar disorder “do not engage in violent behavior,” said Dr. David Fassler, a University of Vermont psychiatry professor.

Still, compliance with medication is a significant problem, he said.

“Research demonstrates that about 25 percent of patients stop taking antidepressant medication within three months. By six months, some studies suggest that the overall compliance rate is less than 50 percent,” Fassler said.

For about one-third of patients, side effects are the main reason they stop taking psychiatric drugs, Fassler said.

Dr. Lynne Tan, a psychiatrist at Montefiore Medical Center in New York, said many patients complain that antidepressants cause restlessness, agitation and racing thoughts. Sweating, sexual dysfunction and headaches are other common side effects. Sometimes they subside over time, and if not, patients can be switched to other medications, she said.

Stopping and restarting
Elizabeth, a 26-year-old graduate student in social work at the University of Chicago who asked that her last name not be used to protect her privacy, said she stopped and restarted antidepressants many times since being diagnosed with depression at age 16.

“Stigma does play a big part of it,” she said. “That’s why I was so eager to consider myself well and to go off of it.”

When she left college and was no longer covered by her parents’ insurance, cost also became an issue — $60 to $70 a month for a generic antidepressant. She declined to identify the drug.

But each time she stopped, debilitating depression including suicidal thoughts would return, she said.

“If I’ve learned anything from this journey, it’s that medication really works for me,” she said.

Greg Coughlin, 53, a health department employee for DuPage County west of Chicago, said several years ago he repeatedly stopped taking drugs for a type of schizophrenia because he was “in denial” about suffering from mental illness.

Coughlin said the last time he stopped, in the 1990s, he became extremely obnoxious and agitated, and ended up in a mental hospital.

Now he’s on three mood stabilizers that zap his energy and cause weight gain, but make him feel “more solid, more relaxed, more satisfied in life.”

Coughlin, a board member of the Illinois chapter of the National Alliance on Mental Illness, said he finally accepts that to function, he’ll need to be on drugs for life.

Elizabeth said she can live with the side effects — extreme sweating and a hand tremor — and credits psychotherapy, a support group and exercise with helping her cope.

While accounts from friends and professors suggest that at least on the surface, Kazmierczak was coping well, there were also signs of trouble.

He had a history of cutting himself, which is often a symptom of inner anger and a sense of feeling powerless, said psychologist Wendy Lader, who runs a suburban Chicago treatment center for self-cutters.

Self-cutting is thought to be more common among women, but women are also more likely than men to seek treatment for it, Lader said.

Kazmierczak also wore macabre shock-value tattoos covering both forearms — an unusual and disturbing choice for someone pursuing a career in social work, Lader said.

Dr. Louis Kraus, a forensic psychologist with Rush University Medical Center in Chicago, said with no known criminal background or history of violence or anti-social behavior before the killings, Kazmierczak presents a bewildering psychiatric image.

“Obviously something very tragic is missing from this puzzle that we don’t fully understand yet,” Kraus said.

URL: http://www.msnbc.msn.com/id/23243677/

Antidepressants may not help many patients

Researchers find placebos work just as well, except in severe cases

Antidepressant medications appear to help only very severely depressed people and the drugs work no better than placebos in many patients, British researchers said Tuesday.

Their findings raise questions about the use of antidepressants, the most commonly prescribed drugs in the U.S. The study, led by Irving Kirsch of the University of Hull, concludes that less severely depressed patients might benefit just as much from therapy, exercise or other non-medical interventions.

"There is little reason to prescribe new-generation antidepressant medications to any but the most severely depressed patients unless alternative treatments have been ineffective," wrote researchers in the latest issue of the public Library of Science Medicine.

Researchers reviewed published and unpublished U.S. Food and Drug Administration studies of the four of the most commonly prescribed new generation antidepressants to learn whether patients' response depended on how depressed they were to begin with.

The studied drugs included Prozac, Effexor, Paxil and Serzone, which are all so-called selective serotonin reuptake inhibitors, or SSRIs. About 118 million antidepressant prescriptions were issued in 2005 in the U.S., according to the National Center for Health Statistics.

The researchers found that compared with placebo, the antidepressant medications did not yield clinically significant improvements in depression in patients who initially had moderate or even very severe depression. The study found that significant benefits occurred only in the most severely depressed patients.

"Although patients get better when they take antidepressants, they also get better when they take a placebo, and the difference in improvement is not very great. This means that depressed people can improve without chemical treatments," Kirsch said in a statement.

Placebo effect common in depression
The placebo effect long has been recognized in people with depression, said David Barlow, founder and director emeritus for the Center for Anxiety and Related Disorders at Boston University.

But he said the study provides valuable insight to researchers, patients and, most important, primary care doctors who prescribe most of the antidepressants.

"The take-home message is there are probably too many people on medications who might not need to be on these medications," Barlow said.

Patients taking the drugs should not stop without consulting a doctor, Barlow cautioned, but they might consider non-medical therapies before beginning or continuing the medication.

Mary Ann Rhyne, a spokeswoman for Paxil maker GlaxoSmithKline, said the study only looked at data submitted prior to the drug's U.S. approval.

"The authors have failed to acknowledge the very positive benefit these treatments have provided to patients and their families who are dealing with depression and they are at odds with what has been seen in actual clinical practice," Rhyne said.

"This analysis has only examined a small subset of the total data available, while regulatory bodies around the world have conducted extensive reviews and evaluations of all of the data available," she said.

Antidepressants likely are over-prescribed, mostly because of the hurried nature of care in the U.S. health system, Barlow noted. In busy primary care practices, there's considerable pressure to do something, anything, for patients suffering from mild to severe depression.

"A placebo can make people feel better as well," he said.

JoNel Aleccia and Reuters contributed to this report.

URL: http://www.msnbc.msn.com/id/23348068/

   As a health care worker in a psychiatric hospital, I understand the tenuous relationship between mental illness and medication. For some patients the side effects from taking certain medications is worse than their depression. Any one taking psychiatric medication needs constant monitoring, in my opinion. A medicine at a certain dose may work for a while and then something changes in the patients metabolism and now it doesn't work.  Psychiatrists must closely monitor their outpatients as much as humanly possible, for the patient's good and society's good. (Don't underestimate the power of placebos, Doc!)

tags: steve kazmierczak  prozac  mental illness  depression  help  science  police  

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