# Presentation: 239299

## Slide 1

## 1. Energizing Role of Antidepressants

-   “In ***no ***case was there evidence that strong pre-existing self-destructive urges were activated and energized by Prozac.  ***No*** patient was actively suicidal when Prozac treatment began.  These thoughts were uncharacteristic . . . and more intense, obsessive and violent than *anything* previously experienced.”

**Notes:**
Quotes from Drug Safety “Antidepressant Drugs and the Emergence of Suicidal Tendencies” by Martin H. Teicher, Carol A. Glod and Jonathan O. Cole, 8 (3):186-212, 1993.
“Prozac” has been substituted for “fluoxetine” throughout for clarification. 
This slide from page 194.

## 2. Paradoxical Worsening of Depression

-   “A small percentage. . . showed a . . . marked worsening of depression and *de novo* emergence of suicidal ideation.”

**Notes:**
Quote from page 188.

## 3. Akathisia

-   “Akathisia produces severe internal distress and has resulted in suicidal states. . .  Serious akathetic states . . . occur in patients receiving Prozac.”

**Notes:**
Quote from pages 190-191.

## 4. Panic-Anxiety

-   “Prozac can initially exacerbate panic symptoms in some patients.  Precipitation of panic attacks may enhance suicidal tendencies . . . and be a determinant of short term risk.”

**Notes:**
Quote from page 191.

## 5. Manic or Mixed Manic and Depressive States

-    “Great care should be employed in the . . . treatment of patients with *suspected* bipolar illness.  They should be *closely* monitored for the emergence of . . . reactions.  The emergence of mania can enhance violent aggressive behavior and a mixed state can augment suicide risk.”

**Notes:**
Quote from page 192.

## 6. Insomnia or Disturbances in Sleep Architecture

-   “Prozac appeared to produce a very dramatic increase in rapid eye movement, even during non-REM sleep stages, not observed with any other class of drugs.  They reported a significant reduction in delta sleep, causing emergence of day terrors or suicidal ideation, similar to unmedicated patients with a history of suicide attempts.”

**Notes:**
Quote from page 193.

## 7. Obsessive Suicidal Preoccupation

-    “Strong obsessive suicidal thoughts emerged after Prozac treatment.  Patients tried to conceal their suicidal impulses.  It was remarkable how violent they were.  The serotonin system enables us to dismiss normally fleeting and transient suicidal thoughts and prevents us from acting on aggressive impulses.  Excessive augmentation may render us unable to dismiss these thoughts, leading to uncharacteristic obsessions.”

**Notes:**
Quote from pages 194-196.

## 8. Borderline States or Hostility

-   “Patients who do *not* suffer from borderline disorder may have drug-induced borderline reactions that include emergence of uncharacteristic aggression, self-mutilation and suicide.  Depending on the basal state of serotonin release, Prozac may augment serotonin neurotransmission in some and diminish it in others.  *Furthermore these effects may change over time and may vary with dose.”*

**Notes:**
Quote from page 197.

## 9. Alterations in EEG Activity

-   “One study . . . reported a strong positive association between EEG disturbances, suicidal ideation and assaultive-destructive behavior.  EEG disturbance led to enhanced vulnerability to impairments in impulse control and ability to reject suicidal thoughts. Antidepressants ***can*** induce EEG disturbances, precipitate seizures, and may enhance suicidal tendencies.”

**Notes:**
Quote from pages 197-198.

## Recommendations for Warnings

- Include ***All*** SSRIs and SNRIs
- Refer to ***All*** Mechanisms
- Reduce Standard Dosing for New Patients
- Taper Off Slowly if Condition Worsens
- Administer Concomitant Sedative for       Adverse Reactions