Akathisia suicidality

Hamilton, M., Opler, L. (1992). Akathisia, suicidality, and fluoxetine. Journal of Clinical Psychiatry, 53, 401-406. 

Breggin, Peter R., How Glaxosmithkline Suppressed Data on Paxil-Induced Akathisia Implications for Suicidality and Violence , Ethical Human Psychology and Psychiatry An International Journal of Critical Inquiry 8, no. 2 (2006) 91-100... 

In addition to parkinsonism, another extrapyramidal side effect is the so-called acute dystonic reaction in which muscles (usually of the face or neck) go into an acute spasm. A dystonic reaction is painful and unpleasant, usually occurs early in treatment, and sometimes occurs after the very first dose of an antipsychotic. Another extrapyramidal symptom is akathisia, a restless inability to relax and sit still. Akathisia can range from a mild restlessness to extreme agitation. Rarely, patients have been known to attempt suicide during severe episodes of akathisia. It is easy to overlook akathisia, because it can easily be mistaken for a worsening of psychosis or anxiety. 

In addition to the somatic side-effects of neuroleptics, there are a number of important psychiatric side-effects, such as demotivation or indifference (a direct effect of most drugs, actually part of the definition of the neuroleptic effect). This may mimic the negative features of the illness and may lead to prescriptions of an antidepressant when a reduction in dose or change of antipsychotic may be more appropriate. A second key problem is anxious activation or akathisia. This dose-dependent dysphoric state may lead to an apparent worsening in the clinical picture and accordingly an increase in antipsychotic dose rather than decrease and may be so intolerable as to lead on to suicide. 

Wirshing W, Van Putten T, Rosenberg J, et al. Fluoxetine, akathisia and suicidality is there a causal connection [Letter] Arch Gen Psychiatry 1992 49 580-581. 

Rothschild, A. J. Locke, C. A. 1991, Reexposure to fluoxetine after serious suicide attempts by three patients the role of akathisia, J.Clin.Psychiatry, vol. 52, no. 12, pp. 491-493. 

Patients suffering from akathisia often use electrical metaphors or descriptions such as electricity going through my veins or shocks in my head. Words like excruciating, torture, and indescribable are commonly used. Patients often say that they would rather die than live with akathisia, and the disorder can cause suicidality. Unlike patients suffering from anxiety, these individuals seem to be describing physical phenomena as if they are being tortured from the inside out. 

In the legal arena, patients who commit violence may be able to use akathisia as an exculpatory or mitigating factor. In cases of suicide and violence, product liability suits may be brought against drug manufacturers who fail to warn that their products cause akathisia and that akathisia is associated with potentially disastrous consequences. The existence of akathisia in the absence of external movements can be a critical diagnostic issue. 

The consequences of akathisia can be devastating in terms of individual suffering and the potential for violence and suicide. Under Associated Features and Disorders, the DSM-IV-TR warns that the... 

Akathisia can literally drive a person crazy. Barnes (1992) pointed to studies indicating that akathisia can induce psychosis. He cited literature confirming that it can cause aggression and violence or suicide (see also Breggin et al., 1994a, for discussion of akathisia and suicide). Van Putten and Marder (1987) reviewed the literature and concluded that akathisia in the extreme case, can drive people to suicide or to homicide. Too often, doctors are likely to mistake the akathisia for the patient s mental disorder and increase the medication, creating a vicious cycle. 

Unfortunately, some of these painful and mentally disabling neurological reactions, including dystonia and akathisia, can also be caused by the newer antidepressants such as Paxil, Prozac, Zoloft, and Celexa. These distressing adverse drug reactions sometimes contribute to or cause violent and suicidal behavior (chapters 6 and 7). 

It takes no great imagination to grasp the suffering of a patient condemned to even a relatively mild tardive akathisia for a lifetime. I have seen cases of this kind that were previously mistaken for severe anxiety or agitated depression. Chapter 3 reviewed research indicating that acute akathisia can drive a patient into psychosis and to violence and/or suicide. Considering the millions of patients subjected to this torment, the problem takes on epidemic proportions. 

Her hospital and clinic charts disclosed that 2 years earlier, she had been treated for approximately 6 months with neuroleptics. The sensation she was describing had first been noted while she was taking the medication. I concluded that she probably had tardive akathisia, a subtle case that did not force her to move about. However, because she did not show external signs of the disorder, other physicians were reluctant to make the diagnosis. The patient felt driven to distraction and even to suicide, but after my diagnosis, she felt somewhat relieved. At last, a physician was taking her seriously and talking honestly to her. 

The experience of constant pain from dystonia or inner torture from akathisia can drive a person to suicidal despair. The physical disabilities associated with disorders can also become very depressing to patients. 

The following year, the British National Formulary, a joint publication of the British Medical Association and Royal Pharmaceutical Society of Great Britain (1991), listed suicidal ideation and violent behavior as fluoxetine side effects. Also in 1991,1 published Toxic Psychiatry, in which I observed for the first time that Prozac was producing a continuum of overstimulation that included akathisia, agitation, anxiety, insomnia, depression and mania, and, in the extreme, suicide and violence. I drew on previously sequestered FDA premarketing data on Prozac, the scientific literature, and my own clinical and forensic cases. 

This chapter has already mentioned cases in which SSRI-induced akathisia played a role in the worsening of the patient s condition and suicidality. Akathisia is a painful inner agitation that manifests as the inability to sit still or stop moving. The hyperactivity may manifest itself subtly as a feeling of jitteriness or grossly as frantic pacing or repeatedly sitting up and down. 

Akathisia was first described in association with neuroleptic drugs. The inner agitation associated with akathisia can become extremely uncomfortable, causing the individual to feel tortured from within (see vivid descriptions in Van Putten, 1974, 1975a b Breggin, 1997a), leading to extreme irritability and suicide or violence. 

Although akathisia by definition usually involves a hyperactive movement component, clinical experience indicates that it may be accompanied with a feeling of jitteriness without actual physical movement that is, the same jittery, agitated subjective experience, accompanied by irritability, violence, or suicidal feelings, can occur without the specific component of feeling driven to move about. Indeed, on earlier occasions, the individual may have experienced the associated compulsion toward hyperactivity. Healy (1994) made similar observations. 

The gravest consequence of akathisia is its reported association with suicide. The patient population receiving antidepressants for affective illness are [sic] at high risk for suicide, and the additive effect of untreated akathisia could be tragic. 

Wirshing et al. (1992) reported on five cases of a fluoxetine-induced syndrome consisting of akathisia and suicidality. In all five cases, the akathisia and the suicidality remitted when the drug was stopped or reduced in dosage. In one case, a rechallenge with an increased dose of fluoxetine again produced the syndrome. They concluded, Our cases appear to confirm that certain subjects experience akathisia while taking fluoxetine and... 

Masand et al. (1991) reported on two cases of suicidality in association with fluoxetine. One of the patients suffered from akathisia. In both cases, the suicidal feelings subsided shortly after stopping the medication. Neither patient had prior suicidal ideation. Both developed violent fantasies (hanging and jumping out a window). 

A number of clinical reports have described a syndrome of obsessive SSRI-induced suicidality and aggression that seems particular to these drugs, starting with Teicher et al. (1990). These cases bear some similarity to akathisia-driven suicidality, but compulsion toward self-harm is not accompanied by the specific symptoms of akathisia. They summarized, Six depressed patients free of recent serious suicidal ideation developed intense, violent suicidal preoccupation after 2-7 weeks of fluoxetine treatment (p. 207). Additional cases and potential mechanisms of action were analyzed by Teicher et al. (1993). 

The capacity for SSRIs to induce akathisia—and for akathisia to cause suicidality, aggression, and a worsening mental condition—is also recognized in the DSM-IV and the DSM-IV-TR in the section dealing with neuroleptic-induced akathisia. The DSM-IV-TR observes, Akathisia may be associated with dysphoria, irritability, aggression, or suicide attempts. It also mentions worsening of psychotic symptoms or behavioral dyscontrol. It then states, Serotonin-specific reuptake inhibitor antidepressant medications may produce akathisia that appears identical in phenomenology and treatment response to Neuroleptic-Induced Acute Akathisia (p. 801). 

In summary, there is incontrovertible evidence that antidepressants cause suicidality, irritability, violence, and mania as well as a wide range of other psychiatric adverse drug reactions often related to overstimulation, such as insomnia, anxiety, agitation, emotional instability, and akathisia. They can also cause apathy and emotional indifference. There is also strong evidence that they cause lasting abnormalities in brain function and even brain anatomy, including abnormal brain cell proliferation, death of brain cells, and shrinkage of brain tissue. 

Reynaldo quickly developed akathisia—agitation accompanied by a compulsive need to move—as well as other maniclike symptoms of irritability and anxiety. As described in chapters 6 and 7, antidepressant-induced akathisia can cause violence, suicide, psychosis, and an overall worsening of the patient s mental condition. 

Breggin, P. (2006c). How GlaxoSmithKline suppressed data on Paxil-induced akathisia Implications for suicide and violence. Ethical Human Psychology and Psychiatry, 8, 91-100. 

Wirshing, W., Van Putten, T., Rosenberg, J., Marder, S., Ames, D., Hicks-Gray, T. (1992). Fluoxetine, akathisia, and suicidality Is there a connection Archives of General Psychiatry, 49, 580-581. 

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