Radical Psychology
2006, Volume Five


They Took My Depression and Then Medicated Me into Madness” [1]:
Co-Constructed Narratives of SSRI-Induced Suicidality


Rachel Liebert and Nicola Gavey


Abstract


Evidence that selective serotonin reuptake inhibitor (SSRI) ‘antidepressant’ use may elicit suicidal thoughts and behaviours in people of all ages has been circulating for nearly thirty years. Nonetheless, knowledge of the possibility and/or significance of these adverse effects appears to remain relatively absent from public, and at times professional, discourse regarding the use of these drugs. We present co-constructed narratives from two New Zealand women, Heather and Gail, who experienced intense suicidality associated with SSRI use. These counter-narratives destabilize risk-benefit arguments that might otherwise be used to adulterate claims of adverse effects. They thus form a poetics of resistance to those minimizing and pathologizing ‘expert’ discourses which continue to prevail in this area, and which often act to contain the adverse effects of these drugs within the unruly minds and bodies of those affected.


Introduction


Evidence that selective serotonin reuptake inhibitor (SSRI) ‘antidepressant’ [2] use may elicit suicidal [3] thoughts and behaviours in people of all ages has been circulating for nearly thirty years (see for example Breggin, 1993; Coulter, 1989; Glenmullen, 2000; Healy, 2004a; Healy and Aldred, 2005; Teicher, Glod, and Cole, 1990). However it was not until October 19 2004 that Medsafe [4], in line with other governmental regulatory bodies internationally(ADRAC, 2004; EMEA, 2005; FDA, 2004b, 2004c, 2005; Health Canada, 2004; MHRA, 2003), issued a warning to New Zealand health professionals that the risk of increased suicidality [5] generally outweighed the benefits of prescribing SSRIs for people under 18 years of age (Medsafe, 2004). Prozac was excluded from this New Zealand warning and a “favourable” risk-benefit ratio for the use of all SSRIs in people over the age of 18 was maintained. Moreover, the warning itself seemed largely driven by a concern with the risk of completed suicide (see also Ellis, 2002) and not attentive to arguably related non-fatal adverse effects, such as akathisia [6], aggression, violence, suicidal ideation and suicide attempts, each of which can have immediate and long-term negative consequences on a person’s quality of life (Healy, 2004a). Thus, although drug regulators have begun to act on evidence about the potential risks of suicidality associated with SSRIs, it would seem that only a partial and limited picture of these risks is on offer through such official bodies. In this article we seek to furnish a space for witnessing people’s complex experiences with the adverse effects of SSRIs and, in doing so, speak to and against what we suggest is an ongoing minimization of these risks7.


Background

        

Since the release of Prozac in 1986, evidence that SSRI use is associated with increased risk of suicidality has emerged from varying sources. This has included case reports from clinical use of the drugs (see for example American College of Neuropsychopharmacology, 1992; Fava and Rosenbaum, 1991; Healy, 2004a; King et al., 1991; Rothchild and Locke, 1991; Teicher, Glod, and Cole, 1990; Wirshing et al., 1992); meta-analyses, and particularly re-analyses [8], of clinical trial data from pharmaceutical companies (see for example Aursnes, Tvete, Gaasemyr, and Natvig, 2005; Fergusson et al., 2005; Gunnell, Saperia, and Ashby, 2005; Kraus, 2006); legal cases (see for example DeGrandpre, 2002; Glenmullen, 2000; Healy, 2004a; Healy, Herxheimer, and Menkes, 2006; Lucire, 2005); epidemiological studies (see for example Donovan, Kelleher, Lambourn, and Foster, 1999; Donovan et al., 2000; H. Jick, Kaye, and Jick, 2004; S. Jick, Dean, and Jick, 1995); analyses of data from governmental regulatory bodies (see for example Committee on Safety of Medicines, 2004; Healy, 2004a; Khan, Khan, Leventhal, and Brown, 2001; Khan, Warner, and Brown, 2000; Medawar, Herxheimer, Bell, and Jofre, 2002); and analyses of primary care databases (see for example Didham, McConnell, Blair, and Reith, 2005; Healy and Whitaker, 2003; Martinez et al., 2005).


Overall, evidence suggests that SSRIs double the risk of suicide (Healy and Aldred, 2005) during the initial weeks of either starting, changing the dose, or stopping the drugs (Healy, 2004a). Healy (2002) has suggested that, since the release of Prozac, SSRIs may have been responsible for an average of one death per day. Nonetheless, suggestions that SSRIs may cause suicidality remain highly contentious due to arguments regarding the validity of the above sources of evidence. Many of the investigations into evidence of the links have lead to exposés of pharmaceutical industry suppression of evidence of these adverse effects through their methodology within, and/or selective dissemination of, SSRI clinical trials (see particularly Healy, 2004a).


Tiefer (2006) and Metzl (2003) argue that exposés regarding the actions of the pharmaceutical industry are best understood through an exploration of the sociocultural context in which they are embedded. This seems particularly applicable to the notion of SSRI-induced suicidality given the current omnipresence of depression [9] diagnostics (see for example Murray and Lopez, 1997; Oakley-Browne, Wells, and Scott, 2006; Ustun, Ayuso-Mateos, Chatterji, Mathers, and Murray, 2004; World Health Organisation, 2001) and notoriously high rates of SSRI prescriptions internationally (see IMS Health, 2005; McManus et al., 2000; Middleton, Gunnell, Whitley, Dorling, and Frankel, 2001; PHARMAC, 2005; Rihmer, 2001). These statistics on depression prevalence and SSRI use have been interrogated by critical scholars examining their function within broader social discourses and practices, including the medicalisation of unhappiness (see for example Gardner, 2003; Healy, 1997, 2004b; Krause, 2005; Kutchins and Kirk, 1997), cosmetic psychopharmacology [10] (see for example Fraser, 2001) and disease mongering (see for example Healy, 2004a; Moynihan and Cassels, 2005; PLoS Medicine, 2006).

         

Evidence linking SSRI use with increased risk of suicidality is thus embedded within a broader cultural and corporate praxis that constructs psychological distress as unwanted and SSRIs as an appropriate means of intervention; ‘good citizens’ use SSRIs (Gardner, 2003). This context potentially constrains the dissemination of knowledge about adverse effects from the drugs. Indeed people who use ‘antidepressants’ have been found to not be provided with accurate accounts of the state of knowledge about depression and ‘antidepressants’ (Gardner, 2003), including the fragile status of the serotonergic theory of depression (Lacasse and Leo, 2005; Moncrieff and Cohen, 2006) and the possibility and intensity of adverse effects from the drugs (Grime and Pollock, 2004). Knowledge of SSRI-induced suicidality likewise appears remarkably absent from public, and at times professional, discourse (Glenmullen, 2000; Healy, 2004a; Hodson, 2005).


In this article we present in-depth narratives from two women who experienced close encounters with SSRI-related suicidality – one personally, and one as experienced by her daughter. These narratives are crafted from their own words, in an explicit attempt to avoid what Michelle Fine (1994) describes as the tendency for reports of people’s personal experiences to be presented in such a way that “the articulate professional voice sound(s) legitimate against the noisy dialect of the Other” and “the rationality of the researcher/writer domesticate(s) the outrage of the Other” (p. 73). Rather, our method of co-construction seeks to provide insight into the way in which SSRIs can inhabit the rich context of people’s lived lives, without the diagnostic tools, quantitative checklists, medicalised theories and/or professional rationales that filter personal accounts of SSRI use in clinical research, and ‘expert’ discourse [11]. Thus, in presenting people’s stories, we have tried to use as many of their words as possible [12]. They are distinguished by the use of this font. Ours have also been used where necessary to add context, enhance flow or position each person’s extracts in relation to each other [13].


Heather


The first narrative is that of Heather’s, whose daughter Sophie experienced agitation and compulsive suicidality, leading to suicide, when taking Prozac. Like all participants talking about personal experiences, Heather contacted us directly to participate in an interview after she heard about this research through her networks. Unlike other informants however, Heather wrote to us via a letter marked “Confidential”. She asked us not to phone or interview her at home as her seeking acknowledgement, truth and justice around the circumstances of Sophie’s suicide caused her husband considerable distress. Indeed, in her community she could think of only two friends who supported her talking about the influence of Prozac on Sophie. For these reasons, Heather and I (RL) met in the basement of one of these friends’ houses for the first half of our four hour interview, and in her car in the car park outside for the second half. This is her (our) story.


In December 2000, Heather’s 22 year old daughter, Sophie, completed her Bachelor of Science majoring in mathematics but she actually loved science a lot. Sophie also loved music all sorts of music and she loved dancing. She was a quietly confident person with a Christian faith, she didn’t go to church or anything but she had a faith. At school Sophie was described as gracious, dignified, and hard-working as well as courteous, quietly spoken. She was a wonderful daughter. She didn’t use drugs, she didn’t smoke, she didn’t abuse alcohol, she was respectful of other people, cared about other people, sensitive to other people, especially people who were maybe on the fringes that other people might think were not acceptable members to society. So she was a real caring, compassionate person, an absolutely lovely girl.


After completing her degree, Sophie was preparing to shift from home (‘City A’) to another city (‘City B’) in a fortnight. She was moving to do this part-time work teaching science and maths and to start study towards a BA (Bachelor of Arts degree). She was so excited to have got the job because she thought she could be self-sufficient while she was studying. Prior to leaving for City B Sophie had no medical problems and no mental health problems except for migraine headaches and these were getting really quite bad, and so I said, “Go to the doctor and see what’s happening”.


Sophie went to the GP and while there had what they called an “anxiety attack” where she started hyperventilating and one of her wrists had a carpopedal spasm and she’d never had that before. So the doctor has written that she had an anxiety attack, that she’d had exam stress, that she was worried about flying to City B and that she’d also had an uncle who’d died in that year, so what he had thought was that she may have mild depressive illness and anxiety. So when I got home from work I said to her, “How did you get on at the doctor’s?” and she said, “Oh he thought I might have depression”, and I was actually quite shocked at that because there had been no signs and, I said, “Well do you think you’re depressed? Do you feel depressed?” and she said, “No” she said, “I think I’m just tired”. The doctor had given Sophie a sample pack of Aropax, prescribed her two weeks worth of a benzodiazepine, and told her to go back before her flight away to get more of the latter to help with her fear of flying. She didn’t take the Aropax ‘cause she said she didn’t want to, but she did take the benzodiazepine, and she did go back in a fortnight and get the extra prescription for the flight.


A few days after moving to City B, Sophie phoned Heather and said, “Oh Mum” she said, “I felt like I was having a nervous breakdown” she said, “I didn’t know where I was.” Heather and her husband went to City B to help Sophie settle in, and found that she was quite edgy and tearful, tired, she had made a very strange decision in the flat that she’d picked to move into. She was acting totally out of character and just could not make a decision. And it was totally unlike her, and it worried me to see the way she was ‘cause it wasn’t normal for her but I kind of just put it down to her being a little bit homesick. In retrospect, Heather realised that at this time Sophie had been experiencing withdrawal effects from the benzodiazepine that she had been taking for the past fortnight.


Only three days after Heather and her husband had returned home to City A, Heather received a phone call from Sophie and she said, “I don’t know what’s happening to me Mum” she said, “My legs and my arms are all going numb” she said, “I can’t breathe properly”. Heather asked Sophie’s flat mate to call an ambulance and she was taken off to the emergency department. Heather caught the first flight possible back to City B and arrived at Sophie’s flat the next day where she had to let myself into the flat and I was just absolutely shocked when I saw her. She was curled up in bed and her whole body looked distorted. She kept having muscle spasms, she was hyperventilating, she just had her head in the pillow, and she had bitten her fingernails down, her fingers were bleeding where she had bitten right down, those are all the effects of benzodiazepine withdrawal, and she said, “I took a single Aropax yesterday” she said, “I think that is what has caused it”.


Heather rang a local GP who came to the flat and prescribed Sophie the benzodiazepine clonazepam, and said, “What she’s got is true panic attacks”. So I thought, “Panic attacks, well what are they?” “Oh” he said, “It’s a long term illness”. Heather felt she had to trust him because you do trust your doctors ‘cause they know more than you and obviously at that point I knew absolutely nothing about withdrawal or anything. Sophie continued having panic attacks, developed agoraphobia, and soon her whole way of functioning was gone. She was scared of the phone and her whole behaviour was just so unusual for her. I had to ring her employer and I had to go and search for a flat, and those were things normally she would have done and wanted to do. I had to get all the equipment and stuff to furnish it without her even picking it. Heather had no idea what was going on I couldn’t understand why I couldn’t get through to her anymore, when we talked about things it was like going round in circles.


Soon after this Heather took Sophie to a GP in City B. He examined her while I waited in the waiting room and then he called me in and he said to me, “We have to look at anorexia being a problem”, and Sophie was sitting on the bed and she was so angry and she said, “Mum! Tell him I am not anorexic”. And I told him. I can see why he thought she was because she had lost an enormous amount of weight and she was a very slender person anyway and our entire family is. So I said to him, “She’s not anorexic”, that week from when we first went up there to when I went back she had lost weight. She’d lost her appetite. She couldn’t face food because she was feeling sick from the effects of the withdrawal and probably the Aropax as well.


After six weeks of staying with Sophie, Heather had to go back home to City A. Less than a week later, towards the end of March, Sophie had a real bad panic attack at work, and her employer had called a friend who was a counsellor, and I think the counsellor was also a friend of the doctor’s, and so they had discussed everything and the doctor had called in to see Sophie and he’d given her Prozac. He’s got written in his records Sophie did not want it because she believed that Aropax had caused the first panic attack in City B and that he wanted to refer her to psychiatric help immediately but because she didn’t want it he prescribed Prozac instead.


Despite not wanting to, Sophie started taking the Prozac. From then on we can really see Sophie’s behaviour change. Only a few days after he’d prescribed the Prozac she rang me early in the morning and, I’ll never forget that day either because I was still in my pyjamas reading the newspaper and it was about the suicide of a well-known young local football player, and Sophie rang and she said, “Mum I feel like I’m cracking up” and she said she was just feeling very strange. Heather went to City B for a few days until Sophie seemed better. A month later, in April, Heather and her husband returned to City B to visit and our son came up too and he was shocked at Sophie. He said, “Mum her face has got so little”, and she was always very pale. Her skin, which normally had been clear, had bad acne nearly the entire time. By then I think she was hyped up on Prozac because Sophie wanted us to take her out dancing, out to a night club even though when we went shopping she still didn’t want to come into the shops, and she put music on that night when we were at her flat and she was dancing around.


During April, Sophie’s benzodiazepine dosage was reduced. However, toward the end of the month she was having periods of feeling depressed, and so her GP had upped the dose of Prozac to 30mg. Then, around the 22nd May, Sophie rang and she said she was feeling really low, and I said to her, “Do you want me to come up?” and she said, “No I’ll be all right” she said, “It’s just that time of the month” she said, “It’s probably just that”. But two days after, on 24th of May, Sophie’s counsellor had gone to Sophie’s flat for a counselling session and Sophie had slashed her wrist. Not deeply, the damage that she had done was not going to actually cause her to bleed to death, it was self-mutilation behaviour although in Sophie’s mind she was attempting suicide and it’s written in her records that that is what she was doing.


Sophie’s counsellor rang Heather and her husband to tell them of Sophie’s suicide attempt. Heather was out, but when she arrived home, my husband was just standing there and I knew something was wrong and he said, “Our baby’s tried to kill herself” and so we just packed up our gear and went straight up to City B. We got up there I think about 11 o’clock at night. It was such a shock to see her locked in a psychiatric unit and locked in the bedroom as well. Sophie, Heather and her husband met with the psychiatrist who actually said Prozac can cause a person to be aggressive to themselves. So that kind of gave me a shock, but, what she did was up the dose. She put it up then to 40mgs which is what Sophie remained on for the rest of the treatment.


Heather’s husband went back home but Heather stayed with Sophie in City B, where she was scared to let her out of my sight. Heather would get up early in the morning, have my shower with the door open so that I could hear what Sophie was doing. If I had washing to hang out I would rush down early before she got up hang it out and rush back up. Sophie would get irritated and she said to me, “You don’t have to do that follow me around and be scared”.


After five days Sophie made another suicide attempt. That day Sophie hadn’t gone to work, she’d gone to this park and started slashing both wrists this time, um, multiple cuts to them. I was sitting at her table in the flat, and I saw a police car pull up and I thought, “Please don’t let him be coming here” and he knocked on the door and he said, “Your daughter has attempted suicide”. And it was like, “He’s come a week too late”. The other suicide attempt had just happened the week before, and it just was so hard to actually take in. So he took me to her at the hospital, she was in A and E when I got there, with a policeman standing at the end of her bed. I went in to see Sophie and the nurse pulled the curtains round, and Sophie was totally upset she had mud all over her skirt and both her arms were bandaged up and all dirty. She was just dirty and just terrified, just so sad looking.


Sophie was discharged and moved back home to City A with Heather and her husband. Around this time, Heather explained to a psychiatrist during an appointment with Sophie that, “Sophie is different to what she used to be”. And Sophie is sitting right here beside me. And the psychiatrist said, “Well what do you mean she’s different?” and I said, “Well, in the beginning, when she’d rung and she was in that acute state and I was back home in City A she said to me then, “Mum” she said, “I will never commit suicide because I know it would break your heart”. I know it was the Prozac because that’s when the suicidal behaviour started, after it was prescribed. So I said to the psychiatrist, “She was not suicidal at the beginning”. I said, “She told me it would break my heart” and I cried in front of Sophie, I said, “You know it’s like she doesn’t even care”. And it was. I could feel this Sophie separating from us and particularly from me because, she always called me her best friend and we used to talk for ages on the phone. We just had a wonderful mother and daughter relationship as well as a friendship and I couldn’t understand why it had changed. She used to say to me, before she was treated with drugs, if she was worried about anything, she would say, “You know just what to say to make everything right”.


Then, in June, we’d only had her home a month and she had made her third suicide attempt, that was slashing again. The fourth suicide attempt she actually tried to hang herself. From reading back on her records, Heather now realises that Sophie had developed a suicidal obsession it was like she wasn’t aware of what her actions were like. After she’d attempted suicide she would just bounce back. It was as though she thought, “I hadn’t done anything out of the ordinary. I’ve just been down to the shops to get groceries or something”. She couldn’t see the impact of it and yet she was a very insightful person. None of the behaviour, particularly from May was like her and I couldn’t understand it. She couldn’t understand it herself. One time when she had her wrists bandaged up, she said, “I must be going crazy”, she said, “Who would do this? Only if they’re crazy”. Sophie just cried and cried because she couldn’t understand what was happening to her. Her behaviour was not a choice. It’s like a real, compulsion.


On 31st August, still living in City A, Sophie made her fifth attempt. She rang me, she’d had been admitted to the psychiatric unit, she’d gone there voluntarily, she’d called the crisis team again, she’d slashed her wrists again. No-one rang that night. Sophie rang herself the next morning and I went out there, went to a room where she was on like 15 minutes observation. At this time Heather was told she was responsible for some of Sophie’s suicidal behaviour, it was just a terrible terrible time where you have got professionals thinking that you have done these things to your child. It was terrible because, we had nurtured Sophie, protected her, taught her right from wrong. She couldn’t understand the effects of her behaviour, and professionals thought we had actually done it to her.


Heather also found that all the doctors at some stage blamed Sophie’s behaviour and suicide on alcohol. However her alcohol use was because benzodiazepines and also Prozac trigger the increased use of other substances as a means to self-medicate drug-induced akathisia. Indeed prior to being prescribed these drugs Sophie had no history of alcohol abuse. She was not an abuser at all. She never binged on it or anything but as her health deteriorated she did start drinking particularly after Prozac was introduced. After her fifth suicide attempt Sophie had by that time, realised that she was using alcohol more than she’d ever used in her life. During that day while she was still in the unit, I had gone back to her flat ‘cause she’d left her kitten inside, and her light was still on and everything, so I’d gone back there and she’d left us a note saying, “I can’t control the drinking, and I can’t control the anxiety.” So it was like constant anxiety induced by the drugs and this use of a substance to try and get rid of this anxiety it was so bad.


By this stage, through her cumulative interactions with GPs and psychiatrists in City A and City B, Sophie’s behaviours had received diagnoses of ‘anxiety disorder’, ‘depression’, ‘PMDD’ (‘premenstrual dysphoric disorder’), ‘anorexia’, ‘personality disorder’, ‘alcohol abuse’, and ‘social phobia’. One time, following a meeting with a psychiatrist where it had been implied Sophie was an alcoholic, Sophie acknowledged that she had begun self-medicating with alcohol and wanted to change but said to Heather “Mum I’ve had, how many times of what I thought would be turning points.” So, she couldn’t understand why she kept harming herself and attempting to take her life. In the first week of September Sophie agreed to go with Heather to an anxiety support group meeting, where Sophie just came out with it like it was ordinary she said, “Oh last week I tried to commit suicide”. It was like you know, it’s just kind of bizarre to actually explain, sometimes she was just so seriously depressed, and then sometimes she didn’t care about anything and was completely detached, “It doesn’t matter”, “What’s the big deal?”.


On the 8th of September, Sophie had another appointment with a psychiatrist. The medical records show that Sophie said again in this appointment (as she had to many mental health workers many times before), “I don’t think this medication’s helping me”. She’d also told the counsellor, “I think the problem is just stress, its stress management that I need”. The day after the appointment with the psychiatrist, Sophie took twelve Paracetamol. She rang the crisis team, they said she would have to go into the mental health unit at the hospital, I think, and she said, “Oh no” that she hadn’t taken any Paracetamol, so they rang the doctor and he said that, “Yes Sophie did admit to taking twelve Paracetamol” but he said that she would be okay and that he had no grave concerns about it. It turned out that that weekend Sophie had actually made six different phone calls to try and get help; the GP, the hospital, the crisis team, the GP at his home, and the GP in City B and, Lifeline. However, none of those people told Heather and her husband about that weekend.


Three days later she was dead. I had been getting all sorts of information for Sophie to read, and that morning Heather and her husband only had one car and I had to take my husband to work so that I could get the car because I was going later to photocopy this information for Sophie, so my husband and I drove round the corner, saw these police cars there outside Sophie’s flat, so that told me straight away Sophie’s dead, and I was just so, I didn’t cry, my husband did, but it was like I just felt dead myself. She hung herself.


No-one listened to her. No-one, had involved us in anything. No-one informed Sophie or us about the effects of the drugs, so we didn’t know what we were facing. We don’t even have an exact date of death. We’re saying September the 12th 2001.


Gail


Our second narrative is that of Gail’s, who experienced suicidal obsession when taking Aropax. After hearing about our research, Gail contacted us saying that she had “very strong views” about the link between SSRIs, suicidality and aggression. Knowing nothing more than this, we arranged to meet her in the Central Business District of a large New Zealand city, where she worked in a demanding professional role. As requested, we arrived at Gail’s work for the interview, but were wary of confidentiality as to what we might say if one of her colleagues asked why we were there. This unease lifted as we saw how Gail had noted our appointment on a whiteboard calendar in the reception area: ‘10am, Rachel Liebert, Meds and Madness’. We fell immediately for the title, and the three of us walked to a local café and sat outside for two hours as Gail told her story.


In 1999 Gail, who was 39 years old at the time, was working as a senior manager in a central government agency. A recovering alcoholic, she relapsed after many years clean. One of the things that happens to me when I stop drinking is that I get very very stressed and this time she also got very very depressed and had some muddle in my life that I kind of wasn’t attending to very well. Gail had gone back to work on something like the 6th of January and all I could picture was myself under my desk slashing at my wrists, and that wasn’t normal for me and I thought, “Oh maybe you’re not being a drama queen maybe you should go to a doctor”. So she did, and was told to be off work for six weeks. Gail felt like everyone was overreacting a bit ‘cause I kind of just had that soldier on thing going on. But I think it was a sense of relief as well that things were being taken care of. In addition she got prescribed paroxetine (Aropax). I also got given benzos for the first time in my life.


Within two weeks Gail was taken off the benzodiazepines, however the Aropax was continued and sometime over the next four weeks she got uncharacteristically suicidal, in the sense that for the first time in her life I was actually taking steps and moving towards acting on it. But I didn’t know that, which is kind of the place where it’s a bit mad. But you can be in one half of your brain making plans, and in another part of your brain not recognise it. It’s just you know, like being a wonderfully shut down person. Gail had a number of suicide attempts over the next number of months. I had repeat admissions to an acute ward before she ended up in the public system, and was put on really really high doses of paroxetine. Now I don’t remember what size pills they are whether they’re a 10 or a 20 milligram was standard, say it was a 20 then I was put on 60 milligrams a day.


From there life got kind of messier. Gail ended up moving house and oh a whole lot of shit happened, weird stuff that just normally would never happen. You know I took up with a new girl which I just would not do in the middle of this so weird, and a girl I would never ever take up with normally. In particular though, Gail found herself all the more uncontrollably suicidal. Life just got completely chaotic with repeat admissions to hospital for suicide attempts. I was mostly attempting suicide with drug overdoses, took massive doses of paracetamol, actually so big, because I knew you could kill yourself with paracetamol but I didn’t know how, and nobody would tell me, and I was washing them down with, one night it was pure gin, and actually I was taking so much that I would just start throwing up, which actually kind of saved me. But it would piss me off ‘cause she felt like, “Fuck me I’m not going to die”. It was like “Fuck so now I have to go to hospital, fuck” you know I was so angry about that. Gail kept being really suicidal and I couldn’t work out how I had turned.


Gail also became capital D for difficult. There was a lot of kind of bad behaviour stuff, you know, really stupid squabbles with family members. One family member in particular was being really supportive and I made his life fairly difficult. Gail found herself with a complete self obsession where you expect everybody to dance on the end of a very short string that you’re tugging on. She was completely oblivious to how you’re perceived in the world or what you’re coming across like. But at the same time you’re also you know kind of intensely focused on getting well or doing better but completely incapable of doing it. Gail ended up homeless. I was living out of my car, I was kind of roaming around the countryside a bit, but mostly living out of my car oh and stayed at a camping ground once but, it was chaotic.


There were huge chunks of what was happening with Gail that we couldn’t reconcile because before these changes I was working as a senior advisor in one of the most central agencies of government, you know managing big complex projects. It’s like, “How the fuck did I end up being this kind of moron?” I couldn’t work it out. I couldn’t work it out. Did I even want to be dead? There was an incompetence about the suicide attempts that drove people nuts ‘cause it meant I kept trying and failing. Not that they wanted me to succeed but you know, it was like, “For God sakes you’re not any good at this stop doing it.”


In October of that year Gail was still very very intent on killing myself, and another friend who’d also been failing at suicide and I met up. It must have been the most macabre conversation for other people to listen in on. We’d sat out at a cafe talking about suicide methods and how to get them right, given what we sort of mostly preferred to do. Anyway three weeks later she was dead. She got it right, and I found out on my 40th birthday which was kind of a marker day it was like. “Fuck I’ve got to be clean, you know, got to get clean I’m 40”. Gail had this sense of being incredibly old and my life being completely over, of being, you know, entirely having missed the boat on having a good relationship with somebody and, oh you know in the chaos I’d sold my home and I’d spend most of the money and, ohhhhh, it was just like, “Fuck my life’s, you know, crap”. It was like if you clean up there is a chance you’ll get it right. Gail decided that what I needed to do was, clean up off alcohol and addictive drugs, and then see if I could get some clarity through that, see what is left over, see if there was any kind of mental illness, you know, ‘cause it was all just such a bloody mess.


Gail considered herself lucky, so lucky compared to so many people I knew to have had past experience of cleaning up, getting into a 12-step programme for recovery from alcohol addiction that had lead to significantly improved quality of life, as it meant she therefore decided to go down the same route for coming off the Aropax. At the end of October she went to Narcotics Anonymous to take myself off to rehab, to get clean, get some clarity. However after a couple of months being clean Gail felt that the depression persisted so went back on the Aropax. After doing so she had another suicide attempt so decided to stay off paroxetine and that she wasn’t going to use these drugs anymore. Eventually I stopped taking the paroxetine. Once off the Aropax, Gail had her one and only suicide attempt not on the drug when life got really bad. She felt that basically it had just become this kind of almost reflex thing that I feel like shit, get your hands on whatever pills you can take far too many of them pray that this one works.


Sometime early in year 2000 Gail’s psychiatrist indicated that she had been put on too high a dose of Aropax. When I was back at the psychiatrist, I was at a visit, and I remember him explicitly saying, “Yeah no don’t take that kind of dose we had you on too much”, or that, “Those levels are way too much”. They then had me down to one a day instead of three or four a day and I remember that always stuck in my head. However, this was the closest thing to an acknowledgement that the Aropax may have been implicated in Gail’s behaviour. Nobody ever said it was the meds. There was that clue the psychiatrist gave me about, “No that was too much Aropax”, but no it was, you know, “You were depressed”, “It was the substance abuse”. In addition Gail had picked up a diagnosis of ‘bipolar disorder’, which I always felt a little uncertain about. She also remembers sitting in a Case Manager’s office and her talking to me about people who have a ‘single episode of psychosis’, and sitting there thinking, “I don’t know why you’re telling me this”. It seemed like it had nothing to do with me; I had no idea I was being diagnosed. Gail didn’t end up finding out she’d been diagnosed as psychotic ’til I think it was eight months later, I was at my GP over something ordinary, and on her computer screen you could see the list of previous information that had come through from the hospital, and psychosis was on the list.


Gail continued to be perplexed by what had been happening to her over that year. I could never figure out why did I go from being this, slightly eccentric but you know, largely competent, reasonably functional person, to this other kind of thing. She started to put together the relationship between her behaviour and the Aropax. The thread I could never figure out was, “I’ve had periods of bad depression before, I’ve had periods of you know abusing alcohol and drugs before, but how did I turn into that particular version of a moron?” One three week period I had three admissions for suicide attempts. You know, how did I turn into somebody who kept making suicide attempts in such an incompetent way but so driven, and also so oblivious to what I was doing at the same time? I could never understand that. That was the bit that kind of confounded me about it all.


It wasn’t ‘til much later, a couple of years later in 2002, that somebody put me onto this Canadian magazine called Adbusters [14]. They did an issue back then on SSRIs and madness, and I liked a lot of their take on it. Gail started to read the magazine and thought, “Oh my goodness” you know, and I wasn’t absolutely certain that my story fitted there but there was just so many bits of it that rang true. In particular this was the way in which Gail didn’t just cross a line I tripped over an edge. I went into an abyss that I’d never gone into before. I’d had periods of being very bleak in my past as a consequence of addiction and depression and the way they feed each other. I had had periods of being really bleak and wishing I was dead, but wishing I was dead is very very different from this kind of chronic obsessive or just that hugely impulsive acting on it. Really really different. They are two very really different places and lots of people get to the bleak and wish I was dead, but relatively fewer of us go into that other kind of lunacy. And so that kind of made me think, and then the more I’ve read the more I’ve thought, “Yeah. There is a connection”. They took my depression and then medicated me into madness. You know, and I think you could medicate me into madness within a week, any day, just by using those drugs.


After coming off the Aropax Gail has had some periods of quite bad depression, since, and I just won’t take any meds. But I’ve also found some ways to live with it, excellent ways. She has had no more suicide attempts.


Poetics of Resistance


Heather’s and Gail’s experiences offer counter-narratives that destabilize a number of arguments that might otherwise be used to downplay or refute claims of SSRI-induced suicidality. One of the dominant lines of rhetoric deployed to minimize attention to adverse effects from SSRIs is the contention that the benefits of using the drugs outweigh their risks (Liebert, 2006). Such claims discursively operate at the level of the individual, by constructing adverse effects from SSRIs as ‘worth it’ for subsequent therapeutic effects, and at the level of the population, through constructions that any potential harm to the individual is justified by the drugs’ contribution to a ‘greater good’. Sophie and Gail did not benefit from SSRIs. More poignantly, however, their lives were deeply ruptured by the drugs. The cost for Sophie was death. But the harm associated with SSRIs is not fully encapsulated by measures of completed suicide alone. Gail’s job, relationships, identity and general wellbeing, were (are) intensely impacted upon. Heather’s and Gail’s narratives bring to life the silence(d) cost for those people who are conceptually sacrificed in arguments utilizing risk-benefit ratios.


Healy (2004a) described how two women who became suicidal and/or aggressive on Zoloft in his ‘healthy volunteer’ study remained “disturbed” by this behaviour even several months later. They questioned the “stability” of their “personalities”: “(t)heir view of themselves had been shaken. We had had at least a medium impact on their self-esteem” (Healy, 2004a, p. 187). Yet SSRIs, apparently, are a “pill for self-esteem” (Hewitt, Fraser, and Berger, 2000, p. 167). This paradox, this tension between what a pill is supposed to do and what it can do, arguably makes the impact of these adverse effects all the more powerful. Indeed Grime and Pollock (2004) found that people taking SSRIs experienced “confusion” about their still experiencing “episodes of severe depression” and wide variations in mood despite taking a drug that was supposed to alleviate these experiences (p. 364). Healy suggested that this reflection is especially significant in regards to SSRI-related suicidality and/or aggression due to the potential to attribute these adverse effects to something ‘wrong’ with the person:


The risk from these side effects, as opposed to the traditional side effects of the older antidepressants (such as dry mouth or difficulties passing water), was that they could be misattributed by the individual to personal failings or to a worsening of the illness. A misattribution like this might lead someone to spiral down (Healy, 2004a, p. 49).

         

The potential for such intense self-doubt and, possibly, increased risk of later suicide attempts are all the more problematic given that currently (mis)attributing experiences of suicidality and/or aggression associated with SSRI use to something wrong with the individual is the dominant interpretation offered to people by clinical experts (see Liebert and Gavey, submitted for publication). Both Heather’s (Sophie’s) and Gail’s experiences of SSRI-induced suicidality were commandeered by a medical lens; diagnosed as being attributable to an underlying condition and further medicated. In this way, these women were effectively ‘seduced and abandoned’ by medical expert opinion (Chesler, 1972).


Nonetheless, the above counter-narratives enable the discourses used to suppress people’s experiences to (at least begin to) be “rendered strange” (Parker, Georgaca, Harper, McLaughlin, and Stowell-Smith, 1995, p. 5). As people tried to free themselves from the constraints of a supposed serotonin imbalance, experiencing these serious adverse effects tightened the grip of these conceptual neurotransmitters; claims of enablement or even enhancement from SSRI use became a reality of ‘disenablement’ (Fraser, 2001). Narratives of such disenablement offer up a poetics of resistance to those minimizing and pathologizing expert discourses which continue to prevail in this area, and which often act problematically to contain the adverse effects of these drugs within the unruly minds and bodies of those affected.


Acknowledgements


First and foremost we would like to acknowledge Heather and Gail for offering their stories to this article. We would also like to thank all of the other participants who contributed to the broader research project from which this article stemmed. Also to Janet Moody for transcribing interviews, and The University of Auckland Research Committee and Health Research Council of New Zealand for grants contributing to this research.

 

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Notes

         

[1] Gail, a woman speaking about her personal experiences in this article (not her real name).


[2] We have chosen to write ‘antidepressant’ to destabilize taken-for-granted assumptions around the prescription and efficacy of these drugs.


[3] The potential for SSRI-induced aggression has also been gaining attention of late (see for example Breggin, 2003; Healy, Herxheimer, and Menkes, 2006), however it is not addressed in this article.


[4] The New Zealand Medicines and Medical Devices Safety Authority.


[5] Suicidality is an umbrella term commonly used to denote all thoughts and behaviours associated with suicide.


[6] Akathisia (from the Greek a = not, and kathisia = sitting) is a neurologically driven agitation and restlessness associated with suicidality and aggression from SSRI use (Breggin, 2003; Glenmullen, 2000; Healy, 2004a).


[7] This paper is part of a broader study that sought to theorize, explore and interrupt if, how and why the dissemination of knowledges about SSRI-induced suicidality and/or aggression may have been suppressed in the New Zealand context (Liebert, 2006). Semi-structured interviews were undertaken with 24 key informants who had either professional or personal views and/or experiences relating to SSRIs, depression, suicidality and/or aggression. For more information on the methodology please see Liebert and Gavey (submitted for publication).


[8] See Healy and Whitaker (2003).


[9] In using the term ‘depression’ we do not wish to perpetuate an assumption that it is not problematic. Indeed, given the present circulation of arguments around the medicalisation of unhappiness due to in part to the role of the pharmaceutical industry in disease mongering (Healy, 2004a; Moynihan and Cassels, 2005) and the invalidity, unreliability and sociopolitics of clinical diagnostics (Kutchins and Kirk, 1997), it is arguably anything but. Thus, rather than depicting depression as an unswerving, objective entity, we understand the term to be embedded within a plurality of constructed meanings, social functions and diverse experiences.


[10] Kramer (1993) coined the term ‘cosmetic pharmacology’ to encapsulate the notion that SSRIs could be used to sculpt personalities and social ideals in an otherwise ‘healthy’ person.


[11] The potential for personal accounts to make a significant contribution to acknowledging and understanding experiences of increased suicidality from SSRI use has been noted elsewhere (Breggin, 1993; Glenmullen, 2000; Healy, 2004; Medawar, Herxheimer, Bell, and Jofre, 2002).


[12] All stutters, repetitions, “ums” (etc.) and minimal encouragers from the interviewer(s) (eg. “mm”), have been removed.


[13] Prior to their inclusion in this article, Heather and Gail were invited to make changes to their respective narratives.


[14] Adbusters (2002).


Biographical Notes:

Rachel Liebert recent completed her Masters degree in the Department of Psychology at The University of Auckland and for the past two years has also been a Project Worker for a social action campaign to promote human rights for people who use mental health services, rachel.liebert@gmail.com


Nicola Gavey is an Associate Professor in the Department of Psychology at The University of Auckland, Private Bag 92019, Auckland, Aotearoa / New Zealand, n.gavey@auckland.ac.nz


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