Winging it: Antidepressants and Plane Crashes

David Healy, MD
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The crash last week of the Germanwings plane has shocked many.  In view of the apparent mental health record of the co-pilot Andreas Lubitz, questions have been asked about the screening policies of airlines.  The focus has generally been on the conditions pilots may have or the arguments they might be having with partners or other situational factors that might make them unstable.

Even when the issue of the medication a pilot may be taking is raised, as an article by Erica Goode in the New York Times makes clear, it is in the context of policies that permit pilots to continue on drugs like antidepressants to ensure any underlying conditions are effectively treated.


Side-Effective 

Clearly if a drug is effective in clearing up an underlying condition, its use should make the pilot – or driver of a coach carrying 50 or more passengers – safer.  But fewer treatments in medicine are effective in this sense than people might think and even when effective they come with effects that need to be balanced against the likely effects of the underlying condition.

Doxycyline, for instance, a widely used medicine for acne and for malaria prophylaxis, can be very effective for acne.  But doxycycline can also make someone depressed, suicidal and homicidal, while acne doesn’t do this.

Other antibiotics like Levaquin and Cipro can cause a range of serious and enduring problems including psychosis but are ordinarily given for problems that are unlikely to compromise a pilot’s ability to fly and keep her passengers safe.

Antidepressant Effects

So what about depression?  The risks of suicide or homicide from mild to moderate depression or anxiety are almost nil.  Think of it this way – what we call depression today in nine cases out of ten was called anxiety 30 years ago before the development of the SSRIs and anxiety was not thought of as a significant risk factor for suicide or homicide.

Difficulties with a partner or at work can lead to precipitate action including suicide or homicide.  They can also lead to anxiety or depression but the anxiety or depression linked to these events don’t for the most part cause problems except in so far as sleeplessness on the one side or a sedative drug on the other might cause an accident.

Whatever the risks of suicide or homicide linked to such anxiety or depressive states might be, in clinical trials antidepressants close to double them – and not just in younger adults. They do so by causing psychosis, or by producing an agitation laced with suicidal or homicidal thoughts, or by producing an almost lobotomized state in which people will do things they would ordinarily never do, or by increasing blood alcohol levels if the person has had a drink.

GSK data suggest these drugs appear to make someone more likely rather than less likely to “act out” if they have just had a partner break up with them.  See Kraus – Clinical features of patients with treatment-emergent suicidal behavior following Paroxetine.

All of this has been relatively well known for decades.  We could have made things much safer by discussing the changes treatment can trigger openly much earlier and permitting patients and doctors to identify problems and find solutions – such as switching to a drug of a different class.  Doctors and patients have been left flying by the seat of their pants.

The Debate

There are likely to be a number of features to the current debate.

First an impression will be created that we know more about these drugs than we in fact do.

We know almost nothing about what antidepressants actually do – we still don’t know what they do to serotonin.

Rather than being effective like an antibiotic, these drugs have effects – as alcohol does. Their primary effect is to emotionally numb. Patients on them walk a tightrope as to whether this emotional effect is going to be beneficial or disastrous.

We know even less about other drugs Lubitz might have been on such as mood-stabilizers.  These too can produce suicidality and homicidality but they have a different signature to that of antidepressants.  The trouble is that, unlike the case of the SSRIs, no doctor giving any patient a mood-stabilizer can tell them what to watch out for or what the timeframe of problems is likely to be.

Lubitz has been widely reported as having vision problems – see  Mail on Sunday. Antidepressants cause visual problems – see RxISK.  But there is little known about these problems.

Second there are a lot of powerful interests at stake.

Some of these will think nothing of playing the personality card in the case of Lubitz to create the impression this was all about his instability rather than an instability in him created by treatment.

Third these powerful interests employ the best public relations on the planet.

These companies will in a variety of ways play the card that anyone suggesting treatment may have been part of what went wrong are just conspiracy theorists.

Fourth efforts to manage the problem will be portrayed as effective.

We will hear that the Federal Aviation Authority in the US only permits pilots to fly on a selected number of antidepressants when they have been stable on treatment for six months.  Sounds good.  But no mention of the problems that happen on withdrawal – which are as great as those that happen on starting.  See Antidepressant Withdrawal: A Prozac Story – on RxISK.  Prozac is one of the selected antidepressants.

Once treated with a drug, a pilot is never the same again.  Even if the underlying condition clears, he may not be able to stop.  The risks are not eliminated.  The only way to manage these risks is to have a close relationship between the pilot and her doctor in which the doctor is fully informed as to what the risks are – a doctor who acts like a pilot in the sense that she doesn’t take risks that will bring her down along with her pilot–patient.

Let them Burn

In lectures for several years  – see Professional Suicide — I have compared the roles of doctors and pilots saying that we are all safer flying than we are in the hands of our doctors because the pilot knows if the system isn’t safe and you die, she will also, whereas doctors can always and routinely do blame your condition or your circumstances.

This idea has now crashed into Andreas Lubitz and his doctors.  We are all wondering about Lubitz and what motivated him.  What about the doctors who may have unintentionally primed him?

At the moment it is difficult to see Lubitz as a victim but he may be.  His doctors may also be victims.  They may have joined a string of doctors who agonize over horrific events they are party to.

Treatment may not have precipitated what happened in this case but there are many people in the pharmaceutical industry who have known for a long time that something like this can happen on their medication and they have done nothing to put in place systems to manage these risks or to dismantle the system that gives rise to risks like this at a much greater rate than we should have to tolerate.

That corporations might do this is not a conspiracy theory. In the famous Ford Pinto case, a Ford executive made aware of risks that their car would lead to a regular number of drivers and passengers being incinerated each year – a problem that could have been inexpensively put right – famously wrote

“It’s cheaper to let them burn.”

The powers that be have been winging it for decades.

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18 COMMENTS

  1. Thank you for your analysis of this situation, Dr. Healey.

    The first thought I had when I heard about this crash being caused by a suicidal pilot was, “I wonder if he was on anti-depressants?” When I heard about the vision problems I just knew what had happened.

    When my son started on SSRIs he developed so many problems that I didn’t even link his sudden vision problems to the SSRIs. After much reading and studying I am beginning to understand how terribly damaging these drugs can be for some people. For him there were so many changes and he has never recovered even though he only took SSRIs for three months over seven years ago.

    I thank you for all the work you are doing to expose these people and their monstrous lies.

  2. When I first saw the mental health/depression angle being broached in relation to the crash I didn’t think in terms of antidepressants as a cause — I was more anticipating a pogrom against depressed people who are “untreated”; i.e. not yet on drugs. This turns it around a little. If this event could be used to put a spotlight on the horrors of psychiatric drugs perhaps it would be a little bit less of a total loss for everyone.

  3. I knew yesterday, based on the news, that it was a drug induced plane crash. I told a friend exactly that. But I was also grateful last week that my 16 year old lovely daughter traveling in Germany at the time was not on that plane.

    Thank you, David, for all your research and honesty. I’m very grateful for all you do. I am so very sorry you are being persecuted for being an ethical an honest doctor who speaks the truth. Truly, you will be seen in history as in the right. And I am personally so very grateful for all you are doing.

  4. Thought provoking article Dr. Healy. I was wondering, can you direct me to the references that support this paragraph, specifically the doubling of risk for suicide and homicide?

    “Whatever the risks of suicide or homicide linked to such anxiety or depressive states might be, in clinical trials antidepressants close to double them – and not just in younger adults. They do so by causing psychosis, or by producing an agitation laced with suicidal or homicidal thoughts, or by producing an almost lobotomized state in which people will do things they would ordinarily never do”

    I’m eager to alert friends to these issues, but some people require extra convincing…

  5. It seems like you have very important facts and arguments to present here; however I could not get to the end of the story due to the quality of writing. I don’t mean that as a criticism. I am passionate about these issues too, but as both a journalist and a mental health consumer, I know how important it is to write such pieces succinctly and cogently – in order to gain a wider audience. I highly encourage you to seek an editor in the future.

      • “Passive-aggressive” is someone who doesn’t have the guts to put his real name on his MIA registration, “oldhead.”

        I stated my point respectively, unlike you. If I have to read multiple, run-on sentences many times over, to make any sense of an article – then very important ideas like the above are never going to see the light of day. If it didn’t take hours to decipher the article I would have shared it via social media with my network of friends and colleagues – who include prominent journalists.

        If you don’t know what the “consumer movement,” “self help movement,” “ex-patients'” movement etc are — then it seems you are just spouting opinions rather than doing the research necessary to inform the wider public – in a way that will make people actually listen – on what is so screwed up about how we treat, view and “diagnose” the “mentally ill” today.

        • “Passive-aggressive” is someone who doesn’t have the guts to put his real name on his MIA registration, “oldhead.”

          Sorry, but I think the term you’re looking for is “paranoid.”

          I understood the article quite readily. If you’re so into the appropriate use of language I suggest you consider the semantic absurdity of a notion such as “mental health,” especially before you “consume” it.

          Btw my comment was not intended as hostile; I call ’em like I see ’em.

        • jeaneneharlick

          Excuse me, anyone who is forced to consume a product is no consumer. When you have no choice about whether you use a product or not, you are not a consumer. People caught in the so-called “mental health system” are not consumers in any way, shape, or form. This is just another example of how the drug companies, psychiatrists, and the “mental health system” play word games to get the billions in dollars of profit that they make off the toxic drugs.

          • Good point. We are no more “consumers” of psychiatry than prisoners in Guantanamo are “consumers” of torture.

            If Orwell was really rolling in his grave every time they spit out this nonsense could probably be serving as a turbine by now powering half of London.

          • I’m curious to understand this viewpoint. The vast majority of those in the ‘mental health system’ come of their own volition seeking a service, isn’t that right?

            I do understand the point that is being made about involuntary ‘treatment’ AND I understand the viewpoint that most here hold that the ‘treatment’ is not helpful.

  6. I can understand why the 9/11 terrorists killed thousands of strangers. They held the incredible belief that killing infidels would guarantee them an eternal place in heaven with 72 virgins. But why would a suicidal man want to take 150 strangers with him?

    Then I recalled the late Loren Mosher saying, “Every time I read of what seems like a random multi-person shooting, I always presume that that person had just started an SSRI or just stopped.” (You can see a video of Loren talking about this at http://www.yoism.org/?q=node/234#lm — fast forward to 5:08 for this part of the discussion where he responds to anecdotal evidence that a large number of psychiatrists and psychologists take or have taken SSRIs.)

    So after some painful contemplation of this tragedy, like many here at MIA, I conjectured that the copilot was taking (or recently stopped taking) an antidepressant. This was prior to reports that he had been treated for depression and actual antidepressants had been found.

    I tried to leave a comment suggesting this possible explanation on an article at The New York Times. The Times has reviewed and posted numerous comments I have made in the past. This one never appeared.

    David Healy wrote, “These companies will in a variety of ways play the card that anyone suggesting treatment may have been part of what went wrong are just conspiracy theorists.” I assume that their propaganda has also influenced folks like the moderator of comments at The Times so that my comment was seen as coming from such a conspiracy theorist. They wouldn’t even post a comment that raised the question of a possible link to psychiatric medication. In mainstream forums, we can’t even bring up the notion for consideration.

  7. I decided to comment on 1boringoldman today, where a few psychiatrists consistently respond to his posts– the comment I am sharing below, shut down the *discussion* on Dr. Nardo’s posting a link and a quote from David Healy’s post “Winging it…”

    Katie Tierney Higgins RN April 1, 2015 | 12:27 PM

    Throughout my 20 year career as a psychiatric nurse, I encountered an obstacle to patient care and safety that could not be surmounted. The great divide, I call it. The superior, authoritarian demeanor of most psychiatrists — which persists even after the evidence for their having claimed authority without evidence has been quite thoroughly documented. It is crucial to witness the responses to the evidence, as it highlights what I see as the greatest evidence of the downfall of psychiatry ;
    Is it possible, to engage in discussion about the serious, life threatening risks of *psychiatric prescriptions* for * poorly substantiated psychiatric diagnosis*?
    A very few psychiatrists have engaged in the process of dialogue on the issues that most clearly speak to the harm done by propagation of bad science and participation in clearly proven marketing schemes with pharma. David Healy stands out as the only psychiatrist who dared to broach the topics that someone like me, a nurse, find the most relevant to psychiatry. IS it a medical specialty, comprised of professionals who are both courageous in their pursuit of alleviating suffering AND concerned about their patients? As a nurse, I found this NOT to be the case. I am not surprised that the criticisms are now rampant from all sectors of society, and simply furious that even now, when the threats to the public welfare are again, called to our attention, there is a prevailing tendency to protect psychiatry as a *noble profession*.
    I encourage all of the commenting psychiatrists here to reflect on– what behavior demonstrates one is both noble and professional? I am providing a link here to a radio interview taped last April, in which Dr. Healy demonstrates that there are, without a doubt, serious issues that must be addressed by his colleagues, and that the process of discussion will not become easier as the evidence for corruption and sheer indifference to it are mounting at an exponential rate.
    Hey check this out: https://www.corbettreport.com/interview-858-dr-david-healy-on-ssris-and-violent-behaviour/
    It never ceased to confound me, as a nurse, that doctors could deny what was right in front of their faces– the patients complaining, getting worse, losing hope. Similarly it was disturbing to be completely discounted as one who cared for and became closely connected to young patients and their families– AND to be disciplined for offering academic, scientific literature to the discussion (until 2010 at a prominent Harvard affiliated children’s hospital and 2014 in a small, corporate owned hospital) was beyond the pale. I fear for the unwitting public that is now encountering psychiatric *treatment* at a very alarming rate.
    I applaud Johann, Altostrata, Martijn and AA for doing their homework and speaking with clarity and compassion. I appreciate Dr. Nardo’s open and ruthlessly seeking mind. The simple truth is that people are suffering from a myriad of maladies– but none seem quite as pernicious or intractable as the condition that causes doctors to lose contact with the purpose of their profession, and seek only to preserve their status as superior authorities.
    If ever there was a case for a DSM label– Axis II– thy name is……but since we have it on psychiatrist based authority that these *disorders* are treatment resistant– well, the only recourse I can support is legal/criminal action. There really is no sane excuse for allowing fraud, causing harm where the benefit is clearly financial profit to be called, a *medical specialty*.
    IF psychiatry were a valid medical specialty, the discussion proposed by Dr. Healy over a decade ago would be the only focus of this *profession*.

    **Sorry, the comment form is closed at this time.** (per the site host, Dr. Nardo)

    I am rather used to being *shut down* by psychiatrists– this recent example points to another reason I am determined to speak out — People who read here and have a vested interest in protecting the public from *psychiatry* need to know that there is no forum within the ranks of psychiatry for the most crucial matters affecting our safety–. those who dare to broach the topics raised here– no matter what level, or professional standing they hold on an inpatient unit (an elsewhere in the *mental health* field, I assure you), they will be marginalized, demeaned via disciplinary action and in many cases simply *fired* — via new subversive management methodology.

    It is NOT the mainstream forum censure that bears need of the most scrutiny. One has to become aware of the extent to which psychiatry is invested in suppressing the evidence of their *crimes*.

  8. Katie,

    I was quite surprised and disappointed that after your post on the 1Boring Old Man Discussion on the plane crash that Dr. Nardo shut down discussion since it was still reasonably civil at that point. Obviously, it is his blog and he can do whatever he wants but still, I found the situation very disappointing.

  9. Dr. Healy make some interesting points here, but the logical flow of the argument fails in several spots due to misinterpretation and/or highly selective quotation of the literature.

    The claim that the risk of suicide from mild depression is nil is taken from Healy’s own paper, and is in conflict with other, better designed studies. The conclusions of the Healy paper are confounded by the fact that his study was performed on an English population, using psychiatric prevalence rates from the United States, a country with a suicide rate that is double that of the United Kingdom.

    The article further states that the GSK study found that ” these drugs appear to make someone more likely rather than less likely to “act out” if they have just had a partner break up with them.”. What the GSK paper actually says is that people taking antidepressants are more likely to act out in a stressful situation than in the absence of such a situation. Its a very different statement than the one presented above.

    Finally, the article takes it as a given that Lubitz was somehow overcome by the antidepressant that he took, and forced to fly his plane into the ground. There is no evidence for this. According to and FDA meta analysis, NNH for suicidal behavior in this age group was 333, with a relative risk of 2. By comparison, according to UN statistics, as a German male Lubitz represented a risk 5.5-fold greater than a British female. If the pharmaceutical industry has “to put in place systems to manage these risks or to dismantle the system that gives rise to risks like this at a much greater rate than we should have to tolerate.”, then surely the airlines are much to be blamed for subjecting us to the irrational and unpredictable behavior of Continental male pilots.

    Truth comes when we treat the data with respect and an open mind. When we approach it looking only for confirmation of what we already believe, we miss the opportunity for understanding.