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.