Pharmacosis: trigger algorithm

The first descriptions of a drug causing suicide came in 1955. A few years later in 1958 and again in 1959 the problem was described with imipramine. Treatment induced suicide became a prominent media issue in 1990 with a paper by Teicher and Cole. But it was not until 2004 that regulators and companies conceded that these drugs can cause a problem. There are now 38 drugs listed as causing suicide, including drugs for asthma, obesity and skin conditions in addition to antidepressants, anticonvulsants and antipsychotics.

The first descriptions of risk-taking behavior on l-dopa were described in 1981. Similar problems were described shortly afterward for dopamine agonists given for Parkinson’s disease. Dopamine agonists are now also given for minor conditions like restless leg syndrome. The problems were serious – judges and clergymen were arrested for gambling, prostitution and other risk seeking behaviors (see DBM Dopamine & Parkinson’s Disease). But it was not until 2008 that regulators finally conceded that these drugs given for Parkinson’s disease could cause these risk-taking behaviors.

The moral of the story is that it can be decades from the time that a problem is first described to the point your doctor gets to hear about it and even then he may not be likely to believe it. When it comes to side effects, most doctors are Flat-Earthers, partly because it’s not a cause for concern for them in the way that it is for those they put on treatment.

There are a number of steps we take you through at Rxisk.org to establish whether your drug is causing your problem – whether you are suffering from Pharmacosis or not. This will work for problems known to be caused by the drug but also for problems not yet linked to treatment. These are the steps that any expert would take you through before deciding there was a linkage. These are the steps pharmaceutical companies routinely work through, based on which they often decide their drug has caused a problem, while still denying in public that it does so.

These are the kinds of questions that need to be asked even when it is known that a drug does cause suicide, gambling, heart attacks or some other problem. Just because someone has begun to gamble or been violent and is on a drug that can cause violence or gambling does not mean the drug has caused the problem. A judgment is still needed as to whether the drug is likely to have played a part or not. Ideally this will be a team judgment – involving the person affected and as many others as possible.

Some of the steps outlined here can be found in other algorithms of which the most famous is the Naranjo algorithm but we ask more questions and score things differently.

Pharmacosis Trigger Algorithm

    1. When did you start the drug? When did the problem start?
    2. Did the problem start or get worse after a dose increase?
    3. If you lowered the dose, did the problem clear up?
    4. If you stopped the dose, did the problem clear?
    5. If you used any other treatment as an antidote, did the problem clear up?
    6. If you restarted the drug or increased the dose, did the problem reappear or get worse?
    7. Have you ever had this reaction before on another drug? Was it the same type of drug?
    8. Have you had other drugs of the same type as this? Did you have a similar effect on them?
    9. Have you ever had this happen to you before when not on a drug?
    10. Could anything else be causing this problem?
    11. Have you ever been told you are a poor metabolizer of drugs and need lower doses, or do you have a history of sensitivity to drugs?
    12. Could you have taken too high a dose?
    13. Has a doctor or a pharmacist reviewed your problem? Do they see a link?
    14. If a name has been put to your condition is it rare off drugs?
    15. Are there previous reports of this reaction in the Rxisk or FDA database or on Google?
 Rxisk Score:

9 +

points strongly to a link – bring to your doctor/pharmacist

5-8

points to a likely link – bring to your doctor/pharmacist

0-4

needs information or input from your doctor/pharmacist (Qs 13, 14, & 15 in particular)

 

Rxisk Team

No simple score can tell whether  a drug has caused a problem. It needs a team and research and judgment. The person on the drug is critical – no-one knows what is going on quite the way the person on the drug does (see Unbearable lightness of being), and as history shows people on the drugs often get it decades before the experts. But there are many side effects that need judgment calls from doctors or pharmacists or increasingly anyone armed with Google and prepared to research things (see Out of my mind).

Birth defects in general like the phocomelia caused by thalidomide cannot be tested by challenge, dechallenge or rechallenge. Babies had been born limbless and deformed like this before thalidomide but it suddenly became a lot more frequent.

Just like phocomelia on thalidomide, conditions that looked like tardive dyskinesia happened before the antipsychotics, but were a lot more common after the antipsychotics were introduced. In this case though the tardive dyskinesia that appeared on the drug cleared up if the dose of the drug was increased – could this be caused by the drug? Scoring on the Rxisk Trigger algorithm might not point to a link but scoring on the Rxisk Terminator algorithm in the next post might have helped to bring out the link.

Ultimately the more reports shared among the greatest number of people the more likely we all are to find an answer (see Unbearable lightness of being).

Rxisk.org has gone live in Beta for feedback as of today June 18th.

19 COMMENTS

  1. I’m not saying anything in this article is wrong. But it needs more citations. Because I can’t prove anything said in this article is true, either. Please. We need to make our case strong. We need to provide solid evidence. Anything proven without evidence can be disproven without evidence. It’s just opinion, without citation, and useless.

  2. David Healy answers questions on his blog at davidhealy.org, where this article was originally published.

    You might pick up his book Pharmageddon for citations.

    Gathering credible, detailed adverse events reports on RxISK.org would further the cause of patient safety tremendously.

    • Yeah right because ‘gathering credible, detailed adverse events reports’, is surely something that should be done anonymously online, as easy as leaving this comment was. Good luck with that accuracy.

      And I thought with drug an adverse event was a bodily reaction to the drug, not a magical co-opting of free will leading to a human decision that nobody is a fan of, say, a well planned successful suicide.

      You’ve gotta love this, he covered all his bases.

      “If you stopped the dose, did the problem clear?”

      “If you restarted the drug or increased the dose, did the problem reappear or get worse?”

      So if you plan a suicide on the drug, or off the drug, the drug is to blame.

      This guy gets paid to stand up in court and blame drugs for complex human choices. I didn’t know there was a molecule in a drug that could destroy human free will. Did you? News to me.

      This guy gets worse every time I read one of his quack articles. He’s got a hobby horse and a lucrative one at that.

        • It all depends on whether you think every choice an individual makes while on a drug is a drug caused event.

          Or just the choices you disagree with, like the choice to hang oneself.

          If I was on a drug, would typing this comment be considered a drug caused event?

          What if I was typing this comment WHILE tying a noose on the rafter above my computer and standing on a stool?

          What if I chose to sing a song while doing so, would the comment typing, and the song, not be labeled an ‘adverse event’, but the kicking of the stool and hanging myself be labeled an ‘adverse event’?

          No one on this planet should be standing up and saying a drug caused any human action more complicated than a seizure, when they do, they embarrass themselves and look ridiculous.

          • If you don’t care to report an effect as adverse, don’t report it.

            If you’re so concerned that a patient-authored adverse event report might be false, figure out a way to improve upon the reporting process.

            Your insistence that psychiatric drugs do not have adverse effects other than observable physical phenomena has only nuisance value.

          • Anonymous,

            Perhaps another way of considering an adverse event that would clearly increase risk for violent acting out is to ponder a very perplexing aspect of akathisia. I describe it this way:

            “In outer space, no one can hear you scream”.

            I find it particularly cruel to subject anyone to a state of inner torment from which they cannot articulate their need for help.

            In 1987 , as the coordinator of a hot line in a crisis referral center, I organized a suicide prevention networking workshop. One of the presenters talked about correlations between suicide methods and personal traits of people who attempted and completed suicide. He said that suicidal people who had great difficulty expressing their feelings, needs, etc were likely to hang themselves; direct violent harm to the part of themselves they most hated; choking off the damaged part of themselves. This was 25 years ago. I haven’t attempted to validate this psychologist’s assessment, but it has stuck with me.

            So, the fact that many of the adverse event suicide statistics linked to SSRIs involve hanging as the violent means used and occur in a group who were not considered high risk for suicide is a very chilling bit of news for me to grapple with.

            In my mind, the adverse effect, akathisia, is torture. I suppose you could call me ridiculous for a whole new set of reasons after this disclosure, but it hardly matters. Would you agree that marketing torture in the guise of treatment merits public outrage?

            We would be hard pressed to find a means to communicate this *risk* much less address it without the leadership David Heal has provided.

            In the vacuum created by PHARMA’s choke hold on the truth, the raw data of all RCTs in their closet, no one has been able to hear our screams…

          • “In my mind, the adverse effect, akathisia, is torture.”

            Akathisia is a vague term describing inner restlessness.

            It’s too vague to blame for murder, rape and suicide.

  3. Actually, as far as my experience goes, this article makes a lot of sense. The sad thing though is that when my son reported to the psychiatrists the side effects he had on olanzapine and which drove him to try to kill himself, the doctors totally ignored what he was saying and said they had never heard of such a thing. Had they googled olanzapine side effects and withdrawal effects on the internets where people were crying out for help, they would have quickly found out that there were hords of people reporting exactly the same problems as my son. We actually asked the psychiatrists to do just that. The answer we got was that they only read scientific papers and didn’t listen to personal stories- that says it all and shows clearly why psychiatrists in thei ivory tower havent got a clue. I am only too happy to see that there are psychiatrists trying to spread the word themselves.

    • Of course it seemingly makes sense to people. Blaming every frowned upon human choice on a drug ‘side effect’ is a Russian doll that can be made to sound plausible on the internet, just like a horoscope.

      Just as blaming every frowned upon human behavior on a fake brain disease can be made to sound plausible.

      With so many people, it’s either a strong belief in a brain disease causing a bad decision to be made, or a drug causing a bad decision to be made, both believers simply believe this because it sounds plausible. Neither believer can detail just exactly how a non demonstrated brain disease, or a drug, hijacked somebody’s free will. We are expected to just take the leap of faith that they have taken.

        • Oh really!

          Can you show me a rape, suicide, or murder case, where the defendant was on SSRIs, that drug blaming psychiatrist ‘critics’ would not accept money to be an expert witness in the case?

          It is open slather with these people.

          You throw reductio ad absurdum at me, but I throw back at you the FACT, that there are an endless army of grieving parents ready to latch onto Healy’s views and blame drugs for the kid’s suicide, SIMPLY because that is the most comforting explanation for them, NO ONE is prepared to detail to me how a chemical compound drives someone to become a killer or self-killer.

          Believe me, if there was such a compound, the army would be using it.

          • Anonymous,

            There is no comfort for parents whose children proceed them in death. No matter the cause. Seeking justice is not a comfort measure, it is a duty. Dr. Healy is a medical expert due solely to his personal decision to pursue a courageous investigation into numerous cases that were alarming only a few psychiatrists. He became an expert at considerable loss of standing and respect within his profession. ALL medical expert witnesses are financially compensated. Of the three experts on this issue that I know of; Dr. Glenmullen, Dr. Breggin and Dr. Healy, I beleive their work and sacrifice are above reproach.

            You have often written in striking candor of your own personal experiences that leave no doubt as to your having survived many agonizing ordeals as an unwilling *patient* of inhumane and unjust psychiatric treatment. I find it difficult to reconcile in my own mind how it is that you can express such hostility and insensitivity towards SSRI induced akathisia that many have described form their own personal experience as *torture*.

            Although they proffer eloquent discourse when propagating that SSRIs are safe for for children and adolescents– for everything from social anxiety to OCD and loosely defined depression, I fear the leading professors of psychiatry at Harvard Medical School are no better informed than you are, regarding the undeniable evidence of suicide and violent acts caused by SSRIs. Some people, for whatever motives, seem to avoid study that can lead to truth. I know why Biederman, Wilens and spencer are threatened by the truth, but I can’t figure out why you would be.

          • Sinead.

            Show me the chimpanzees in the lab the kill themselves on prozac.

            I don’t take the same leaps of faith you take, so we will have to agree to disagree.

            A few subjective reports, and a couple of books by a psychiatrist who offers nothing but statistics, has not proven there is a drug that makes people murderers or self murderers.

            Throw the vague term ‘akasthisia’ at me all you like.

            I don’t agree that people that stand up and make excuses in court for money, are above reproach.

            No further interaction on the topic of Healy from me will be entered into.

            You’re a fan of his, I’m not. Leave it at that.

            You know, I blame SSRIs for making me buy a blue car instead of a red one, too.

  4. OK– anonymous, as you wish. But I shall continue to ponder the elusive paradoxical enigma that you sometimes appear to be—

    I am a tough audience by the way— and ruthless in my pursuit of understanding what it is that casts the shadow — what exactly has created this paradox?

    The blue car will get you a cheaper auto insurance rate, but there is an error in judgement regarding which color suits you better… Stop the SSRI and see if RED feels more like the you I know!
    🙂
    Sinead

    • You might think it is a paradox that I don’t like these two things, I don’t agree.

      1. I don’t like simplistic, faith based explanations of behavior as ‘brain diseases’ no one’s ever been able to demonstrate exist.

      2. I don’t like simplistic, faith based explanations of behavior as ‘drug effects’ no one’s ever been able to demonstrate via anything other than vague self reports and faith based claims about magical drugs that rob people of free will.

      I also don’t like the intellectual dishonesty of using two types of explanations for the behaviors that are approved of, and ones that are disapproved of.

      In the drug blaming world of Healy fans, people choose a menu item at dinner because they want to, but they kill themselves not because they want to, but because ‘drugs made them do it’.

      I find the biological claims of general ‘mental illness’ infantile, as do I find the biological drug blaming claims of drug blamers infantile.

      There is no paradox. Drug blaming is as mindless as brain blaming. When neither the drug blamers nor the brain blamers can prove their claims, their creation stories for the behaviors they seek to ‘explain’.

      • Anonymous,

        I can’t see the connection in your argument. There is no scientific evidence for biochemical imbalance within the brain as a cause for symptoms of mental or emotional anguish. Those who believe in a biochemical brain disease model are, as you say faith-based, not science-based in their beliefs. Dr. Healy does not propagate the biochemical imbalance myth. My personal distaste of this model goes well beyond lack of scientific evidence- to viewing it as “willful deceit that has caused harm” and should be dealt with as a criminal offense. Drugs are a different story. There is scientific evidence showing how drugs change the brain, or rather create disease- both mental and physical. Psych drugs are toxic chemicals. In many cases, they are lethal poison.

        I assume that drugs alter the brain in ways that are completely outside of the realm of what naturally occurs in any of us. I assume that, for instance, akathisia that does not occur in the absence of a toxic chemical, can produce the perfect internal storm that prefaces violent behavior- even suicide. I have seen this adverse effect and listened to those who suffered through it, so I personally have no doubt.

        Your argument does not address the action required to stop the indiscriminate use of these toxic drugs. Which is where I find you to be out of character. Your approach is to simply remove the myth of biochemical causes across the board, BUT that in and of itself is inadequate, because the *faith based* believers would still consider the drugs as the lesser of two evils–to treat with *hope*, rather than to suffer through mental, emotional anguish. THIS is the reason that it is absolutely critical to expose the dangers of the drugs– about which more is known than the etiology of mental, emotional anguish.

        Ultimately, there will be advancement in true understanding of of the human side of suffering through many of the humanistic movements now underway. these movements gain strength through ALL exposures of the sham of biomedical psychiatry. For NOW, exposing the dangers of psych drugs is both urgent–to protect people from them- and an important first step to holding psychiatrists accountable.

        One more thing. I believe the litigation for *wrongful death* is a criminal, not a civil matter. I do not believe any amount of money soothes the pain of losing a child. I believe that parents engaged in the only current means for brining these issues to the legal arena and public attention is also a first KEY step for criminal indictment.

        So, Anonymous, perhaps I am only suggesting that you NOT look a gift horse in the mouth!

        xo’
        Sinead

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