Paragraph 14 reads: "It's rare for patients who are stopping antidepressants to report severe psychological effects, but such reports do exist. Last month, doctors from Stanford University published a case study of a woman who began having symptoms of delusion within days of halting her Prozac therapy. The patient imagined hearing her son's voice even though he wasn't there, had uncontrollable crying spells and at one point said, 'I am Jesus.'

Paragraph 9 reads: "For some people, stopping antidepressants abruptly may leave them briefly worse off than they were before they took the medication. That's because of the effect that Prozac and similar drugs have on serotonin, a chemical messenger in the brain that plays a key role in depression, obsessive-compulsive disorder and other psychological conditions."

http://www.chicagotribune.com/news/chi-prozac_19feb19,0,6167104.story

The NIU shootings

Doctors: Prozac, violence rarely linked

Experts doubtful that halting medication led directly to shooting at NIU

By Jeremy Manier | TRIBUNE REPORTER

February 19, 2008

In the wake of Steven Kazmierczak's murderous shooting spree at Northern Illinois University, law-enforcement officials noted he had begun to behave erratically after he recently stopped taking psychiatric medication.

That fact might seem to offer a tidy explanation for his rampage, or at least some insight into his troubled mind. But psychiatrists say suspending a patient's use of antidepressants -- Prozac, in Kazmierczak's case -- is rarely linked to violence toward others.

When used under a therapist's supervision, they stress, such medication can help people overcome depression and other mental ailments. And while the source of Kazmierczak's state of mind remains a mystery, experts said it's unlikely that halting his Prozac therapy would have led directly to his shooting plot.

At the same time, psychiatrists say, his case may help reinforce a key lesson: Stopping antidepressant therapy suddenly can be risky if patients do not follow a doctor's instructions and don't report any negative effects.

About one-fifth of people who halt a course of Prozac-like drugs report symptoms associated with a condition known as discontinuation syndrome, which can include abdominal pain, dizziness, crying spells, irritability and even a sensation similar to an electrical shock in the patient's arms or legs.

Kazmierczak's former girlfriend, Jessica Baty, told CNN on Sunday that he had stopped taking Prozac because "he said it made him feel like a zombie." One crucial detail left unanswered is whether Kazmierczak stopped the medication under the advice of a doctor or if he did it on his own.

Several experts said that because of discontinuation syndrome, they advise patients who stop to do so gradually and to call if they experience worrisome symptoms. With most patients, that's enough to forestall any serious adverse effects.

"Your body has to adjust to being off the medication," said Dr. Joan Anzia, an associate professor of psychiatry at Northwestern University's Feinberg School of Medicine. "Some people are more sensitive to it than others."

For some people, stopping antidepressants abruptly may leave them briefly worse off than they were before they took the medication. That's because of the effect that Prozac and similar drugs have on serotonin, a chemical messenger in the brain that plays a key role in depression, obsessive-compulsive disorder and other psychological conditions.

Serotonin carries signals among brain cells that affect mood, appetite and sexuality, among other brain functions. Although the biological roots of depression are a source of controversy, some research suggests it may stem in part from low levels of serotonin.

The Prozac class of antidepressants -- also called SSRIs -- works by producing a surplus of serotonin in the brain. The excess serotonin can ease anxiety, curb unwanted impulses and relieve depression. It can also lead to diverse side effects, including the "zombie"-like lack of motivation that Kazmierczak's former girlfriend described. But other patients experience virtually the opposite problem in the form of akathisia, a state of extreme restlessness.

The added serotonin may also change how some brain cells function, by decreasing their normal response to the chemical. That may worsen the effects of low serotonin levels when patients abruptly stop taking antidepressants.

"The issue is how fast you reduce the serotonin activity," said Dr. William Scheftner, chair of psychiatry at Rush University Medical Center. "If the drug dosage is lowered gradually you have the opportunity to make adjustments."

It's rare for patients who are stopping antidepressants to report severe psychological effects, but such reports do exist. Last month, doctors from Stanford University published a case study of a woman who began having symptoms of delusion within days of halting her Prozac therapy. The patient imagined hearing her son's voice even though he wasn't there, had uncontrollable crying spells and at one point said, "I am Jesus."

In one other case of multiple homicides, the Columbine school shootings, assailant Eric Harris had been taking the antidepressant Luvox before the murders. Harris claimed on a videotaped message that he stopped taking the pills in order to let his anger grow without the restraint of the medication.

It's true that antidepressants such as Prozac can reduce impulsive aggression in patients who are prone to such problems, said Dr. Emil Coccaro, chair of psychiatry at the University of Chicago Medical Center. For such patients, going off the drug may lead to loss of impulse control and more aggressiveness, he said.

Yet Coccaro noted that the NIU murders did not appear to be a case of impulsive killings. Kazmierczak planned the spree in advance, and apparently sent goodbye messages and phone calls the night before the murders.

"That looks like premeditated behavior," Coccaro said. "He didn't just snap."

In addition, unlike Zoloft and other similar medications that disperse from the body rapidly once patients stop taking them, Prozac persists in the body for weeks. That can cushion the sudden effects of going off the drug, experts said.

Patients who take Prozac in low doses -- about 25 milligrams per day or less -- tend to have the fewest side effects when stopping the drug, said Anzia of Northwestern. Kazmierczak's dosage level is unclear.

The idea that Prozac itself leads patients to violence has gained little scientific support. In 2004, the U.S. Food and Drug Administration required drug companies to put a warning label on antidepressants such as Prozac, stating that the drugs may provoke suicidal thoughts in young adults. That move was controversial, and a study last year by University of Illinois at Chicago researcher Robert Gibbons showed that suicide rates among young adults have increased as antidepressant use declined.

Many experts point to such studies as evidence that whatever the risks of antidepressants, they are outweighed by the drugs' effectiveness at preventing suicide by treating patients' depression.

For now, the public information about Kazmierczak's psychological history remains incomplete, making it nearly impossible to guess what mental problems may have affected his behavior.

But experts said it may be significant that Kazmierczak's former girlfriend said he cut himself as a teenager. Cutting can be a sign of serious psychological problems, Coccaro said, and that history of trouble is at least as important as the medication that Kazmierczak took.

"It's hard to believe this just appeared from nowhere," Coccaro said.

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jmanier@tribune.com

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