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drug mixing; "Prozac causes suicide" rumor

Posted by Elizabeth on June 23, 1999, at 23:44:37

In reply to Re: BEWARE/COMMENT S-EFFECTS-DRINK,PROZAC,XANAX,ZOLOFT, posted by saintjames on June 23, 1999, at 12:21:29

I agree with what others have already said about Xanax + alcohol being a dangerous combination. Some people who abuse Xanax use it in combination with alcohol to get just these effects - i.e., extreme disinhibition. And yes, they tend to do stupid things while they're so intoxicated.

For myself, I've taken both Prozac and Zoloft. I've never found that drinking in *true moderation* was a problem for me while on these medications. If you are unable to keep your alcohol consumption moderate, this may be a sign that you have a "drinking problem" and should abstain from alcohol altogether.

I have *not* mixed alcohol and benzodiazepines (Xanax, Klonopin, Valium, Ativan, etc.), as I know what this combination can do to a person.

Now, about this rumor that Prozac causes violent behavior. America is a litigious society; anybody can sue a drug company, and many people are perfectly willing to stoop to burdening our judicial system with frivolous lawsuits. The fact that these suits have been brought means nothing whatsoever.

There have been a few such lawsuits. I can't recall a single case in which any wrongdoing was found on the part of the drug company or the prescribing doctor. Generally what seems to happen is, the family of the individual who committed suicide or became violent makes the claim that the individual had no history of such behavior prior to taking the drug, but then it comes out during the trial that there was a history of violent or suicidal behavior.

Studies have consistently failed to find any increase in suicidal behavior (I'm not sure if they've looked at violent/homicidal behavior) with SSRI use.

Leon AC, et al. Prospective study of fluoxetine treatment and suicidal behavior in affectively ill subjects. Am J Psychiatry. 1999 Feb;156(2):195-201.

Wernicke JF, et al. Fluoxetine and concomitant centrally acting medication use during clinical trials of depression: the absence of an effect related to agitation and suicidal behavior. Depress Anxiety. 1997;6(1):31-9.

Warshaw MG, et al. The relationship between fluoxetine use and suicidal behavior in 654 subjects with anxiety disorders. J Clin Psychiatry. 1996 Apr;57(4):158-66.

Tollefson GD, et al. Absence of a relationship between adverse events and suicidality during pharmacotherapy for depression. J Clin Psychopharmacol. 1994 Jun;14(3):163-9.

Tollefson GD, et al. Evaluation of suicidality during pharmacologic treatment of mood and nonmood disorders. Ann Clin Psychiatry. 1993 Dec;5(4):209-24.

Goldstein DJ, et al. Analyses of suicidality in double-blind, placebo-controlled trials of pharmacotherapy for weight reduction. J Clin Psychiatry. 1993 Aug;54(8):309-16.

Crundwell JK. Fluoxetine and suicidal ideation--a review of the literature. Int J Neurosci. 1993 Jan;68(1-2):73-84.

Wheadon DE, et al. Lack of association between fluoxetine and suicidality in bulimia nervosa. J Clin Psychiatry. 1992 Jul;53(7):235-41.

Beasley CM Jr, et al. Fluoxetine: no association with suicidality in obsessive-compulsive disorder. J Affect Disord. 1992 Jan;24(1):1-10.

Jick H, et al. Comparison of frequencies of suicidal tendencies among patients receiving fluoxetine, lofepramine, mianserin, or trazodone. Pharmacotherapy. 1992;12(6):451-4.

Baldwin D, et al. 5-HT reuptake inhibitors, tricyclic antidepressants and suicidal behaviour. Int Clin Psychopharmacol. 1991 Dec;6 Suppl 3:49-55; discussion 55-6.

Beasley CM Jr, et al. Fluoxetine and suicide: a meta-analysis of controlled trials of treatment for depression. BMJ. 1991 Sep 21;303(6804):685-92.

Fava M, Rosenbaum JF. Suicidality and fluoxetine: is there a relationship? J Clin Psychiatry. 1991 Mar;52(3):108-11.

What we get out of this is that the risk of suicidal ideation emerging on antidepressants is no greater than it would be if you treated the depression with only a placebo.

Also of note is the fact that SSRIs have been shown to decrease aggression. There may be a paradoxical effect in a few people, but if so, it is quite rare.

Teicher and colleagues published a paper in 1993, three years after their initial report of cases of treatment-emergent suicidal behavior on fluoxetine. It's pretty good reading, and they offer a number of hypotheses. (BTW, be assured that the authors do still prescribe SSRIs and consider them good antidepressants.) Some speculations have been made that these events are the result of akathisia, hypomania, or "activation syndrome" induced by the antidepressant; that it's worse to take an antidepressant and not respond to it than to take no antidepressant; or that people who've recently started on antidepressants get increased energy before their mood improves, so that they finally are able to "go through with it."

I should note that even in the cases presented by Teicher et al., confounding factors were present. You can read more about this in the appendix to _Listening to Prozac_ (Kramer, 1993, pp. 304-5). Kramer also discusses some of the outstanding issues.

It's been suggested that patients with histories of impulsive aggression may have an increased risk.

One recommendation in regard to reducing the risk has been to start at the lowest possible dose and increase it gradually as tolerated (Rothschild AJ, et al. Reexposure to fluoxetine after serious suicide attempts by three patients: the role of akathisia. J Clin Psychiatry. 1991 Dec;52(12):491-3).




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