"I Didn't Just Cross a Line I Tripped Over an Edge": Experiences of Serious Adverse Effects with Selective Serotonin Reuptake Inhibitor Use

New Zealand Journal of Psychology, Mar 2008 by Liebert, Rachel, Gavey, Nicola

Evidence that selective serotonin reuptake inhibitors (SSRIs) may elicit suicidal and/or aggressive thoughts and behaviours has been circulating for nearly thirty years. Despite a growing body of knowledge around these serious adverse effects, however, they continue to be surrounded by controversy. In particular they are subject to (arguable) counter-arguments that any risks from using the drugs are outweighed by benefits and/or more attributable to a person's 'underlying disease'. Moreover assessments of risks often use rates of completed suicides as the ultimate measure. In this paper we draw on people's own accounts of their experiences of serious adverse effects associated with SSRI use. In depth semi-structured interviews were undertaken with nine people who had either used SSRIs themselves or had witnessed the use of SSRIs by a close family member. We present four themes identified across the interviews relating to adverse effects from SSRIs: experiences of akathisia, aggression and suicidality; 'out of character' behaviour; harm to relationships; and accounts of responses from the medical profession. Participants reported that the experience of adverse effects had marked impacts on general wellbeing, identities and relationships. These accounts cast doubt on notions that serious adverse effects associated with SSRI use may stem from an underlying condition and/or be outweighed by benefits from SSRI use. In addition they offer a persuasive and poignant plea to further consider non-fatal adverse effects and their consequences in assessing the risks of these drugs.

Selective serotonin reuptake inhibitor (SSRI) antidepressants have become the subject of considerable controversy in recent years. Not only have serious questions been raised about the efficacy of these drugs (e.g., Moncrieff & Kirsch, 2005) but evidence has long been mounting of an association between SSRIs and suicide. This evidence which has arisen from a range of sources including case reports (e.g., Teicher, Glod, & Cole, 1990), meta- and reanalyses of clinical trials (e.g., Kraus, 2006), legal cases (e.g., Healy, 2004a), epidemiological studies (e.g., Donovan et al., 2000) and primary care databases (e.g., Martinez et al., 2005) - has lead critics to urge far greater caution around the use of these drugs, particularly at the point of starting, stopping or changing dose (Healy, 2004a). According to Healy (2006) the current "best estimate for the likely risk of suicide on SSRIs over placebo is 2.6" (p. 93). Links between SSRIs and a number of other serious adverse (and withdrawal) effects - such as aggression, akathisia, mania and the wider realm of suicidality - have also been postulated (e.g., Breggin, 2003; Glenmullen, 2000; Healy, 2004a; Medawar, Herxheimer, Bell & Jofre, 2002; Whitaker, 2005), although the research evidence is less well established (see for instance Healy, Herxheimer, & Menkes, 2006, regarding the links between SSRIs and violence).

Although pharmaceutical regulatory bodies in the United States, the United Kingdom, Europe, Canada, Australia and New Zealand have responded to this evidence of serious potential adverse effects by issuing warnings about the risks associated with SSRIs (e.g., ADRAC, 2004; EMEA, 2005; FDA, 2005; Health Canada, 2004; Medsafe, 2004; MHRA, 2003), proponents of the drugs nevertheless continue to argue that their benefits outweigh the risks. For instance, it has been claimed that SSRIs are associated with a decrease in the rate of suicide at the population level (e.g., Khan, Khan, Leventhal, & Brown, 2001), although more recently others have countered that there is no evidence for any causal relationship between increasing use of SSRIs and declining rates of suicide (e.g., Safer & Zito, 2007). As well as this debate about whether SSRIs On balance' may help more people than they hurt, the currency in which such cost-benefit analyses are calculated is often restricted to measures of completed suicide. This can give a distorted view of the suicidal effects of these drugs because nonfatal experiences (including suicidal ideation, suicide attempts, akathisia and aggression) tend to be overlooked, or their seriousness minimised, by proponents (liebert & Gavey, submitted for publication). For example, although one study reported a decreased risk of completed suicide with antidepressant use, it also reported a marked increase in the risk of attempted suicide (Tiihonen, Lonnqvist, & Wahlbeck, 2006), yet such findings are rarely emphasised. In addition proponents have been found to employ constructions of depression that allow SSRI adverse effects to be attributed to an 'underlying disease', thereby further minimising the drugs' significance in causing harm and instead suggesting people's experiences derive from pre-existing suicidal tendencies (Liebert & Gavey, submitted for publication)1.

Given these complexities, the debate on SSRIs is threatening paralysis, with many agreeing that we cannot 'really' know, in a traditional scientific sense, whether or not SSRIs cause suicidality (e.g., Simon, 2006). Nonetheless, as Simon (2006) has pointed out, "even if randomised trials and large observational studies find no effect [of SSRIs] on average rates of suicide attempt or suicide death, average effects may not apply to all individuals" (p. 1861). In light of this obvious point, it is arguably important to move beyond the broader debate about population level risks and benefits to explore more fully what these adverse drug effects are like for those people who do experience them. Beyond reports of clinical observations (e.g., Healy, 2004a) and an analysis of people's web-based reporting of SSRI problems (Medawar, Herxheimer, Bell, & Jofre, 2002), there is little detailed documentation in the literature of the nature and impact of such effects, particularly from those who have experienced them personally. In this article, we enter the debate about the risks of SSRIs through suggesting the need to look beyond medicalised assumptions that arguably limit the scope of concern to the relative risk of completed suicide. Instead, through engaging with people's own descriptions of their experiences with these drugs, we aim to provide more in depth understandings of the phenomenology and consequences of a wider range of serious adverse effects from SSRIs, including those that fall short of death. In doing so, we hope to highlight and illuminate the potential human cost of SSRI use for some people (see also Liebert & Gavey, 2006).