Some attorneys have argued that SSRIs cause serious adverse events, capable of compelling defendants to engage in strikingly complex criminal behavior. On close examination, however, these phenomena may be clearly distinguished from criminal behavior.
The study by Yerevanian and Choi1 on the impact of psychotropic drugs on suicide and suicidal behaviors in bipolar disorders concludes that there is insufficient evidence that psychotropic medication has an adverse impact on suicide risk. The final advice regarding careful monitoring and assessment of patients at significant risk for suicide is not only prudent but also happens to be the standard of care. The enduring concern about psychotropics, particularly SSRI antidepressants, somehow “causing” suicide gives me the opportunity to discuss a bit further the problem of mistaking subsequence for consequence.
Consider a scenario in which the biopsychosocial antecedents of suicide culminate in a mental state of suffering, which then drives the individual to seek help. This help may include antidepressants, whose efficacy at the present time is controversial.2,3 At this point in the chain of events, one may have a depressed individual receiving inadequate treatment, who also has pre-existing and individual-specific suicide risk factors. Nevertheless, the fact that this individual began taking an antidepressant at some point before a suicide represents an all too tempting handle to grasp.
The confusion and misinformation about the putative hazards of SSRIs became so substantial over the past decade that physicians actually became afraid to prescribe antidepressants. Specifically, the “black box” warnings for antidepressants starting in 2003 promptly led to a steep decline in prescribing these drugs for children and adolescents, with a corresponding decrease in treatment of depression in both children and adults.4 Psychiatric researchers then began to quiet some of the hysteria, when they found that antidepressants were not associated with suicide and actually decreased suicidal thoughts and behavior.5,6 The controversy surrounding antidepressants and suicide risk in pediatric depression remains ongoing.7,8
The urge to attribute powerful mental influence to the relatively benign SSRIs is well known to forensic psychiatrists. Indeed, fluoxetine has been cited in more medication defense criminal cases in the United States than any other psychotropic.9 Some attorneys have discovered the potential value of scapegoating these widely used medications, arguing that SSRIs are capable of compelling defendants to engage in strikingly complex criminal behavior.
A case of “antidepressant-induced” bank robbery
The following vignette is based on an actual criminal case in the federal court system (even though the case is public record, some details have been altered to preserve confidentiality).
Ms A was a 24-year-old woman charged with aiding and abetting her boyfriend in the commission of a bank robbery. She had a history of treatment for dysthymic disorder, borderline personality disorder, and intermittent misuse of illegal substances. About 2 months before the offense, she began to feel more dissatisfied with her life circumstances and had moderate depressive symptoms. As a result, her psychiatrist prescribed 20 mg/d of paroxetine (Paxil). During the 2 months leading up to the robbery, there was no evidence that Ms A experienced adverse effects from Paxil, nor did she endorse symptoms of the serotonin syndrome. She did not experience any symptoms consistent with an antidepressant-induced mania, such as a decreased need for sleep, pressured speech, flight of ideas, inflated self-esteem, or psychomotor agitation. She reported not abusing any substances leading up to the offense.
Her boyfriend suggested, and she agreed to, robbing a bank so they could start a new life in a different country. Ms A remained in the getaway car as a lookout, and started the engine when she saw her boyfriend exit the bank, per his instructions. As they sped away, she sorted and counted all the stolen bills, placing them in the glove compartment. They checked into a motel using false names, and enjoyed each other’s company over drinks and dinner. Ms A made sure to place the money in a locked safe in the motel room and disposed of all the bill wrappers, which bore the bank’s logo. That evening, Ms A called her mother who became concerned about Ms A’s welfare. Ms A’s mother ultimately helped police locate her daughter, and Ms A and her boyfriend were arrested by police early the next morning.
The defense expert, well known for attributing criminal behavior to psychotropic medication, stated in his report that it was his opinion “well beyond a reasonable degree of medical certainty” that Ms A “would not have become involved with a bank robbery if she had not been exposed to Paxil.” The defense expert went on to describe Ms A as suffering from a host of maladies, including “involuntary intoxication” with Paxil, “severe central nervous system dysfunction,” acutely impaired judgment, serotonin syndrome, and antidepressant-induced mania . . . to name just a few. Ultimately, the court was not persuaded, and did not agree that Ms A’s use of Paxil caused her to be unable to appreciate the wrongfulness of aiding and abetting bank robbery.
SSRIs, crime, and violence
Despite the fact that “involuntary intoxication” is sometimes raised as a defense in crimes in which the defendant was taking an SSRI, there is no convincing scientific evidence that SSRIs play a role in causing criminal behavior of any type. In terms of violent criminal behavior, there is also no evidence of a relationship between antidepressant agents and violent behavior.10In a study using nationwide data from the Netherlands, the association between antidepressant prescriptions and lethal violence was analyzed over a 15-year period, from 1994 to 2008.11 The results showed a significant decrease in lethal violence (homicide and suicide) during a period in which exposure to antidepressants increased. These findings are consistent with other reviews concluding that no increased susceptibility to aggression or suicidality can be reliably connected with fluoxetine or any other SSRI, as well as other studies showing that SSRIs act to reduce irritability and aggression.12,13
A small proportion of patients treated with SSRIs may show increases in anxiety or experience akathisia in the initial phase of treatment. Reports of more serious adverse events, such as antidepressant-induced mania and the serotonin syndrome may confuse the lay public’s understanding about antidepressant effects on behavior. However, on close examination, these phenomena may be clearly distinguished from criminal behavior committed in the absence of signs or symptoms of these serious adverse reactions.
Antidepressant-induced mania (sometimes called “switching”) occurs at a very low rate and will be distinguished by the characteristic signs of a manic episode.14,15 The serotonin syndrome is a cluster of signs and symptoms caused by the toxicity of various drugs, including antidepressants, which induce activity of the neurotransmitter serotonin.16 The syndrome is characterized by a rapid onset of the following triad of (1) mental status changes (confusion, delirium); (2) autonomic hyperactivity (high blood pressure, rapid heart rate, dilated pupils); and (3) neuromuscular abnormalities (increased reflexes, tremor, incoordination).17 The prevalence of serotonin syndrome is not well known. However, one review of the literature reported that serotonin syndrome developed in only 14% to 16% of individuals who overdosed on SSRIs.18 The range of severity is broad, and most patients develop symptoms 6 to 24 hours after ingestion.19
Obviously, both antidepressant-induced mania and serotonin syndrome will result in characteristic mental and physical signs and symptoms that should be carefully elicited. Both require medical intervention and observation, and should be relatively easily distinguishable from a mere criminal act committed in the absence of these rare phenomena.
1. Yerevanian BI, Choi YM. Impact of psychotropic drugs on suicide and suicidal behaviors. Bipolar Disord. 2013;15:594-621.
2. Penn E, Tracy DK. The drugs don’t work? antidepressants and the current and future pharmacological management of depression. Ther Adv Psychopharmacol. 2012;2:179-188.
3. Preskorn SH. What do the terms “drug-specific response/remission rate” and “placebo” really mean? J Psychiatr Pract. 2011;17:420-424.
4. Libby AM, Orton HD, Valuck RJ. Persisting decline in depression treatment after FDA warnings. Arch Gen Psychiatry. 2009;66:633-639.
5. Garlow SJ, Kinkead B, Thase ME, et al. Fluoxetine increases suicide ideation less than placebo during treatment of adults with minor depressive disorder. J Psychiatr Res. 2013;47:1199-1203.
6. Gibbons RD, Brown CH, Hur K, et al. Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine. Arch Gen Psychiatry. 2012;69:580-587.
7. Adegbite-Adeniyi C, Gron B, Rowles BM, et al. An update on antidepressant use and suicidality in pediatric depression. Expert Opin Pharmacother. 2012;13:2119-2130.
8. Barbui C, Esposito E, Cipriani A. Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. CMAJ. 2009;180:291-297.
9. Mason SE. Prozac and crime: who is the victim? Am J Orthopsychiatry. 2002;72:445-455.
10. Myers WC, Vondruska MA. Murder, minors, selective serotonin reuptake inhibitors, and the involuntary intoxication defense. J Am Acad Psychiatry Law. 1998;26:487-496.
11. Bouvy PF, Liem M. Antidepressants and lethal violence in the Netherlands 1994-2008. Psychopharmacology (Berl). 2012;222:499-506.
12. Walsh MT, Dinan TG. Selective serotonin reuptake inhibitors and violence: a review of the available evidence. Acta Psychiatr Scand. 2001;104:84-91.
13. George DT, Phillips MJ, Lifshitz M, et al. Fluoxetine treatment of alcoholic perpetrators of domestic violence: a 12-week, double-blind, randomized, placebo-controlled intervention study. J Clin Psychiatry. 2011;72:60-65.
14. Tondo L, VÃ¡zquez G, Baldessarini RJ. Mania associated with antidepressant treatment: comprehensive meta-analytic review. Acta Psychiatr Scand. 2010;121:404-414.
15. VÃ¡zquez G, Tondo L, Baldessarini RJ. Comparison of antidepressant responses in patients with bipolar vs. unipolar depression: a meta-analytic review. Pharmacopsychiatry. 2011;44:21-26.
16. Sternbach H. The serotonin syndrome. Am J Psychiatry. 1991;148:705-713.
17. Boyer EW, Shannon M. The serotonin syndrome [published corrections appear in N Engl J Med. 2007;356:2437; N Engl J Med. 2009;361:1714]. N Engl J Med. 2005;352:1112-1120.
18. Isbister GK, Bowe SJ, Dawson A, Whyte IM. Relative toxicity of selective serotonin reuptake inhibitors (SSRIs) in overdose. J Toxicol Clin Toxicol. 2004;42:277-285.
19. Ables AZ, Nagubilli R. Prevention, recognition, and management of serotonin syndrome. Am Family Physician. 2010;81:1139-1142.