Saturday Morning Essay: finishing up on SSRI use and school shootings

Working my way out of this intellectual box canyon concerning SSRI use and school shootings, I would summarize as follows:  to an extent, the perception that an event such as that which occurred at Newtown indicates the end of civilization in America is the result of what statisticians would call emphasis bias.  For example, here is how Jim Kunstler appraised the meaning of the tragedy in his latest Clusterfuck blog post:

"Finally the USA has an act that perfectly expresses its true spirit as the horror show nation among nations: the random mass slaughter of little children by a maniac. Is it not so that the failure to protect little children from harm is the most shameful weakness an adult human can present?"

 I understand the reaction; however, calling America a "horror show" over and over does not really advance our understanding of the phenomenon of school shootings.  In a way, school massacres are sui generis, both in America and in the world at large.  They're very, very weird.  They also run counter to the general trend in violent crime in the United States.

In the past 20 years, for instance, the murder rate in the United States has dropped by almost half, from 9.8 per 100,000 people in 1991 to 5.0 in 2009. Meanwhile, robberies were down 10 percent in 2010 from the year before and 8 percent in 2009.  Christian Science Monitor.

That's a difficult statistic for a doomsayer like Mr. Kunstler to make sense of.  The country is becoming less violent, probably as the result of two social phenomena:  the graying of America (demographically, the United States has "matured out" of its prime crime-committing years); and the end or abatement of the cocaine craze of the 1980's, which introduced a lot of heavy-duty killing in connection with a drug which tended to make its users frigging nuts, and also brought into the USA a lot of badass dealers and soldiers of Colombian narco-gangs.

The solutions being proposed to the problem of school shootings seem to center around outlawing of assault weapons (a good idea) or a moralistic behavioral modification concerning violent video games (this is Wayne LaPierre's idea; this creepy, sepulchral figure from the NRA can be counted on to talk about everything except guns).  I honestly don't think video games are the problem; I think it's a poor way for children to expend their youthful energy, and I believe they would much better off playing in the real, as opposed to virtual, world, but if playing violent video games actually led to school massacres (all by itself), then not a child would be left standing in the American school system today. Kids (especially boys) play violent video games today with the same frequency and alacrity as we played "army" and cowboys & Indians when I was growing up.  Young males act out battle games, one way or another.

To understand the problem of school shootings would require a pretty serious multivariate regression analysis of sociological phenomena, but I would think that the known correlation between SSRI use and a certain irreducible occurrence of violent behavior as a "side" effect is worth exploring systematically.  What we can say is that databases show an astonishing co-occurrence between the rapid growth of anti-depressant use since the introduction of Prozac in 1987, and the rise in school massacres over the same time period.  To repeat: correlation is not causation. I realize that. However, we drug the hell out of kids today, to improve their "attention" (Ritalin) or elevate their moods (the full medicine cabinet of SSRI's and bipolar medications), and mainly to fatten the bottom line of powerful Big Pharma, while medical research (which Big Pharma tends to fund) and government (ditto) look the other way.  Most of these drugs do not perform better, over time, than placebos or simply waiting the problem out, but in a small percentage of people, they produce very sinister and murderous effects.

If there were some way to cull the rapid-firing assault weapons from America's armamentarium of 300 million firearms so that they were no longer available for illicit use, I suspect that the destruction in school shootings would drop precipitously.  That would be a very good thing, and it makes a lot more sense than training school teachers to pack heat.  But I doubt that it would put an end to school violence.  A kid with a six-gun can still take 5 fellow students with him before he inevitably turns the gun on himself in an SSRI-driven murder/suicide.  Lord knows that's a better outcome, but it's not a "solution."  For that, the truth would have to be aired out.

Mass Producing Maniacs in America

Prozac was introduced to the market by Eli Lilly in 1987.  It quickly gained favor among psychiatrists, or psychopharmacologists as they are often called these days, given their preference for treating all mental illness with psychotropic drugs, since it allowed the profession "to do something" about depression besides try to talk the patient into feeling better.  The mechanism of Prozac, generically called fluoxetine, was to "selectively" inhibit the re-uptake of the neurotransmitter serotonin in the brain's neurons.  Neurotransmitters do what their name suggests: they transfer energy from neuron to neuron across the synapses of brain cells.  Serotonin is essential to the maintenance of mood stability.

Since depressed patients taking Prozac began to "feel better" after an induction period on the drug, researchers (anxious to sell Prozac) backed into a diagnostic analysis: since readings of spinal fluid indicated that patients taking Prozac had increased levels of serotonin in the brain, the depression must have been caused by a "chemical imbalance" resulting in too little serotonin before administration of the drug.  This is similar to claiming, as Daniel Carlat notes in Unhinged - The Trouble With Psychiatry, that “By this same logic one could argue that the cause of all pain conditions is a deficiency of opiates, since narcotic pain medications activate opiate receptors in the brain.”

In fact, there is practically no scientific evidence for the "chemical imbalance" theory of depression.  All three books reviewed in an excellent piece by Marcia Angell in the New York Times Review of Books (http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/?pagination=false) make this point: psychopharmacology needed a theory which would fit the action of the drug, so the industry made one up.  Depression is caused by too little "natural" serotonin.  It certainly was a profitable way of thinking about the problem.  Prozac was followed by Paxil, Zoloft, Serzone, Celexa and similar anti-depressants, and we're now at the point where 10% (or about 30 million people) over the age of 6 years old in America are taking anti-depressants.

As Robert Whitaker notes most forcefully among the three writers, the problem with Prozac and its ilk is that messing around with the brain's delicate chemical transmission mechanisms has nasty effects, which Eli Lilly and the rest of Big Pharma of course call "side effects," although there is nothing incidental about them.  Artificially pumping up the level of serotonin in the brain (above the preexisting baseline which was, as noted, probably completely normal) naturally produces a "high" or euphoria, and depending on the metabolic idiosyncrasies of a given patient (can they metabolize all this serotonin flooding the synapse because of the presence of the drug), the patient may go all the way into depression's opposite pole, mania.  In other words, Prozac and other drugs acting on serotonin can produce maniacs.

It's worse than that, however, because the effects of anti-depressants (and other psychotropic drugs acting on other neurotransmitters, such as dopamine and norepinephrine) tend to continue even when the patient attempts to withdraw from the drug.  Marcia Angell summarizes this effect very neatly:

Getting off the drugs is exceedingly difficult, according to Whitaker, because when they are withdrawn the compensatory mechanisms are left unopposed. When Celexa is withdrawn, serotonin levels fall precipitously because the presynaptic neurons are not releasing normal amounts and the postsynaptic neurons no longer have enough receptors for it. Similarly, when an antipsychotic is withdrawn, dopamine levels may skyrocket. The symptoms produced by withdrawing psychoactive drugs are often confused with relapses of the original disorder, which can lead psychiatrists to resume drug treatment, perhaps at higher doses.

The brain cells, in other words, having adapted to the presence of a synthetic chemical which was interrupting natural function (re-uptake of serotonin), remain "stuck" in an up-regulated or down-regulated condition.  Thus, while conditions such as depression used to be, in the great majority of cases, self-limiting and brief in duration, we have, through the miracle of psychopharmacology, created an epidemic of people who are bummed out for good.

Or: become suicidal or totally psychotic, maybe even violently so.  Correlation is not causation, but it is highly suggestive, to say the least, that prevalence of anti-depressant use tracks more or less exactly the rise in school and public place massacres.  More soon.

We interrupt this Eli Lilly commercial to suggest a more plausible reason behind school massacres in America

I hate to ruin a good story line and distance myself from the renewed movement toward gun control in the United States.  It's the panacea du jour:  let's ban assault weapons and other rapid-firing firearms from widespread availability in the United States and all will be well.  This epidemic of school shootings will abate and we can feel safe again when our kids are in school.

Just one thing - there is something deeply illogical about that formulation of the problem.  Granted, once a killer (usually a "troubled" youth) flips, the easy access to military-style, rapid-firing weapons greatly enhances his destructive power.  That part is logical.  However:  in a sense there is an unspoken premise that in some way the assault weapon itself caused the massacre.  There the analysis breaks down.  That doesn't make any sense.  Nor does simply saying that the killer was "evil" or a "psychopath." 

A better question is to ask:  where are these evil, psychopathic killers coming from, do they have anything in common, and why are the patterns so similar?  To wit, the killer often seems to begin his rampage at home by killing family members, then proceeds to a school or other public place and kills multiple victims, then turns the weapon on himself and commits suicide.  Most of the massacres involve a mass murder-suicide sequence,  consistent with a decision to take a lot of people (often peers who shunned or excluded him) with him when his overwhelming emotional pain propelled him to suicide.

I generally find these days that if you want to understand a broad social phenomenon in the United States, the best place to look is somewhere that most people are not talking about.  The domination of Big Business (and corporate ownership of Congress and the Media) are such that you cannot rely on public discourse to identify the real source of problems.  As a good example, take the fixation on cholesterol levels as the key to understanding heart disease in the United States, and the related (and false) nutrional advice from doctors to stay away from saturated fat.  The commercial function of this advice is to sell Lipitor and related cholesterol-lowering drugs.  It has little or nothing to do with overall health.  Similarly, the "balanced diet" which has led to an epidemic of obesity in the United States is designed with subsidies to the monocultures of grain and corn farming in mind; nutritionally, it makes no sense whatsoever.  As a final example, the fixation on the "war on terror" is part of a propaganda campaign to justify the existence of a hugely oversized military establishment designed to fight this war "conventionally."  It has almost nothing to do with American safety, although one might want to keep in mind that the Predator drone strikes that are a salient part of this "war" have undoubtedly killed far more children of Newtown age than have ever died in American school shootings.  It's just that these children are mostly Pakistani and Aghani and are thus not within the consciousness (or conscience) of an American public which listens with rapt attention as the President comforts the good people of that small Connecticut town.

Which sounds, of course, like a radical analysis of American politics, but by now (equally of course) it's not.  Noam Chomsky's notion of "manufactured consent" and corporate control of the "national conversation" (the range of policy options which are allowed into the discourse) sounded very radical when he first proposed it, but by now it's conventional wisdom.  It's the way things work.

 So back to the question: what is setting these killers off?  One distinct possibility is that the killers are suffering from statistically-inevitable "side effects" of the psychotropic drugs known as SSRI's, such as Prozac, Zoloft, Effexor, and numerous other spin-offs of fluoxetine (which was first used as a pain medication and was then discovered to have mood "regulating" effects).  It's possible that these are the most dangerous drugs ever devised by the alchemists of Big Pharma, that they do vastly more harm than good, and that their persistent use owes to a willful decision of the FDA and political establishment (read: Congress) not to notice (or study systematically) their massive downsides.

One of those downsides is to trip a fraction of the patients into patterns of "extreme violence" and "hostility."  A British study from 2006 on a limited class of SSRI's (selective serotonin re-uptake inhibitors) found a consistent link between anti-depressant use and violent ideation or hostile acting-out.  http://www.news-medical.net/news/2006/09/12/20073.aspx  It was on the order of 1/2 of 1%, but let's think about the math of this situation.  As prominent as the school shootings loom in the public mind, they still remain relatively "rare" compared to the sheer number of schools and American children of school-going age.  Meanwhile, SSRI's are prescribed with the nonchalant alacrity of a neighbor throwing M&M's into the Halloween bags of trick-or-treaters.  Thus, the "cohort" or statistical "sample" is created by our drug-happy legions of SSRI-prescribing psychiatrists (although increasing numbers of them wonder if the routine use of Prozac and its affiliates is a good idea - see Robert Whitaker's book, The Anatomy of an Epidemic, which analyzes the roughly four-fold increase in mental illness rates in the United States which has occurred since the widespread use of SSRI's and similar mood-regulation drugs were introduced about 30 to 40 years ago).  A tiny fraction of the millions of kids or young adults on SSRI regimes will thus predictably become both violent (homicidal) and self-destructive (suicidal). The drugs cause this reaction. The connection between suicide and Prozac and Zoloft (in particular) has been apparent for a long time. Among these new crazy people, a certain small fraction will have access to powerful firearms, as Adam Lanza in Newtown easily did, or they will use their ingenuity to acquire one of the 300 million firearms floating around the American landscape.

There you have a plausible causation sequence.  It makes more sense to me than blaming it all on "video games" or the Devil.  Shouldn't someone look into it systematically? This isn't conjecture: a substantial majority of the school-killers have in fact been SSRI users (such as the leader of the Columbine massacre, pictured above).  This again follows naturally from the American way of dealing with the issue.  A young person has "emotional" problems = visit to a psychiatrist = prescription of powerful mood-regulating drugs = statistical inevitability of tragedy.  (Notice that the killers, from Columbine to Newtown, are often from nice, white, relatively affluent backgrounds, the kinds of places where the parents are most likely to seek immediate drug intervention if little Johnny has a problem with "concentration" in school or seems "withdrawn" for a couple of hours.)  The problem has not been systematically studied the way it should be, and I don't think it's paranoid to suggest that there are reasons Big Pharma would prefer we not look at the problem too closely. 

So Dianne Feinstein, Senator from California and reliable spokesperson for the military-industrial complex, tells us we've already figured out the answer, based on no analysis whatsoever that I can see.  The school-killers have access to high-powered weaponry, and they get up one day and decide to kill as many people as they can.  We can settle on that answer without interfering greatly with America's lively export business of guns, grains and obesity.  No need to rock the boat - Big Pharma is one of the keys to Obamacare, after all, and the pharmaceutical companies have a stranglehold on Congressional financing (on some of the necks that Wall Street and the defense contractors aren't already clutching).

Now, I will concede that society does in fact produce psychopaths capable of random violence, quite apart from any influence of psychotropic drugs.  But common sense ought to tell us that something else is going on here.  We're producing way too many "troubled youth" with a sudden propensity to blow away everyone they know.  You can reduce their range of available weaponry (and we ought to do so), but you will not really solve the problem of hostility reactions to psychotropic drugs.  And we won't get at that problem until someone starts talking out loud about the connection.