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September 19 2017

On June 11th this year, 16-year-old schoolgirl Jordan Keates (left) was discovered hanged in the hallway of her foster family’s home in Lydd-on-Sea, in Kent.

At her inquest this week, a statement from a nurse at CAMHS who saw Jordan four days before her death was read out by coroner Katrina Hepburn. It said that there were times when she had stress from personal relationships. In February she had taken an overdose, but “in March and April she was still improving, she was more positive, her relationship was going well and she wanted to go to college to pursue art.”

Jordan’s foster mother Louise, with whom she had been for the past year, said: “She was a very funny girl. She was brilliant at her art and had a great future ahead of her. She was the first child we have ever fostered. Her death just came out of nowhere. We do feel let down by mental health services. We weren’t made aware of how many times she had been seen by mental health carers.”

In the various newspapers that reported on this story, there was no mention of any medication that Jordan may have been prescribed.

 

September 13 2017

On December 1st last year, 19-year-old student Rowan Sollitt (right) hanged himself at his hall of residence at Manchester Metropolitan University.

Yesterday’s inquest in Manchester heard that, in the days before his death, Rowan had “sought help” for depression from his GP, who prescribed antidepressants.

On November 30th, the day before he died, Rowan entered a walk-in clinic at the university. There he was given a form to complete. His answers confirmed that he ‘sometimes’ made plans to end his life, believed the world would be better if he were dead ‘most of the time’; and that he ‘often’ thought about hurting himself. Rowan, who was grieving the loss of his grandfather, scored a risk factor of 14 on the form. The court heard any score over six would show ‘risk’.

He then had an ‘assessment’ session lasting 10 minutes with counsellor Kathleen Matthews, during which he showed her scars on his arms from recent self-harming. Kathleen told the inquest that she was restricted to 10 minute sessions and hadn’t been trained to tot up scores on the forms. She said a ‘phenomenal number’ of students expressed similar feelings and that, once Rowan reassured her he didn’t intend to take his own life for fear of hurting his family, she didn’t feel he was in immediate danger. Rowan left after being placed on a waiting list for counselling.

Yvonne Harris, head of counselling, said that an efficient system had been in place at the time, but said that Rowan’s case should have been flagged to either herself or a mental health advisor. Yvonne also said that the ‘dearth’ of resources in Manchester’s mental health services meant that GPs were regularly referring students to university support services.

Rowan’s father Michael told the hearing: “We can’t change what has happened to Rowan, but maybe we can change things for future young people.” He described the university’s system as ‘broken’. He said he was ‘flabbergasted’ more hadn’t been done to help his son after what he had written on the form.

Michael added: “There are 50,000 students at this university. There needs to be sufficient funding to help with mental health and welfare services. It’s a traumatic transition from being at home to being by themselves.”

Describing Manchester’s mental health system as a ‘very disturbing merry-go-round’, coroner John Pollard (left) said that mental health services had been set up ‘with the best of intentions’ but that 10-minute sessions were ‘not enough’.

He added: “The answers given were those of a young man who was seeking help and really feeling quite bad. For whatever reason, his condition did not manifest itself, so that they felt he didn’t need immediate help from a psychiatrist, and that was not arranged.”

Mr Pollard said he would monitor the university’s services to ensure lessons were learned, and that he would take further action if they were not.

Perhaps the first lesson to be learned should be to carry out a risk assessment based not on a facile questionnaire, but on whether their patient is, like Rowan, suffering an adverse reaction to antidepressants prescribed recklessly and in contravention of NICE Guidelines.

 

September 3 2017

During the past two weeks, the Manchester Evening News has reported on the inquest of 14-year-old Charlotte Baron (right) from Rochdale, who died in February after hanging herself in her bedroom wardrobe.

The inquest was told that, in September 2015, Charlotte was hospitalised after taking an overdose of paracetamol. Following the incident, social services and mental health workers from Rochdale council and Pennine Care NHS Trust were assigned to her.

A psychiatric nurse who met with Charlotte on a number of occasions said that she considered her to be of high risk, but described her as a bright pupil who enjoyed school, loved her family had lots of good friends.

When asked by coroner Joanne Kearsley (left) if it would be correct to say Charlotte wasn’t suffering from a mental health condition, but was someone who was “very low in mood and unhappy”, the nurse agreed.

Delivering a verdict of death by misadventure, the jury concluded that: “The circumstances in which Charlotte met her death are due to documented issues impacting on Charlotte’s emotional well-being, which resulted in a high risk of self harm, inadequate assessment and action planning of this risk by multiple agencies and Charlotte’s unstructured home life.”

There was no mention in any the reports of any medication being prescribed to Charlotte.

 

August 28 2017

The problems caused by the over-prescribing of antidepressants are not limited to the UK and the USA.

After another increase in suicide figures in New Zealand, Chief Coroner Deborah Marshall (right) has called for a renewed focus on preventing self-inflicted deaths, and for more discussion about the need for everyone to recognise the risks in people they know.

Maria Bradshaw (left), chief researcher for Community Action on Suicide Prevention, Education and Research (CASPER), said that the increasing numbers showed that the Government’s approach was not working and needed to be rethought: “If we keep doing what we are currently doing, we can expect numbers to keep rising.”

The non-profit organisation released a report in June criticising the health-based approach to suicide as narrow and ineffective. Issues included reliance on medication, overlooking wider social issues and lack of data gathering.

The organisation concluded that there needed to be more caution about prescribing antidepressants.

 

July 21 2017

Just after 8 pm on October 21st 2015, 41-year-old Richard Davies (right) was shot dead by a police officer at his home in St Neots, Cambridgeshire.

An inquest, which concluded today, heard that earlier in the evening Richard tied up his three children and threatened them with a kitchen knife. He placed duct tape over their mouths and ordered them to stay on their beds.

The children managed to escape by jumping from the bedroom windows. They phoned 999, and sent their mother Samantha a text which read: “Call the police. Get them to come to our house. Dad’s going to kill himself. He’s tied us up. I’m not joking.”

When the police arrived at about 7:45, Richard shouted at the armed officers out of the living room window. He goaded them, shouting, “Come on, shoot me.”

Richard, who was an engineer, used a home-made gun, firing three shots from the downstairs living room window and another two from the bedroom upstairs before he was shot by a police officer.

The inquest had been told that Richard and Samantha had agreed that he would leave the family home at the end of the month.

A statement from a local GP said that Richard attended the surgery on September 24th. He presented with low mood said that he had violent thoughts about a colleague at work. The doctor signed him off work, prescribed antidepressants and referred him to the mental health team.

On October 13th, eight days before his death, Richard had an assessment at the surgery where he told a mental health nurse that he had already increased his medication and was going to run out. She recommended to his GP that his prescription of antidepressants be increased in dose.

The jury at the inquest concluded that Richard had been lawfully killed.

 

July 17 2017

An article in yesterday’s copy of Brisbane newspaper The Courier-Mail revealed that the family of 14-year-old Angel Cowie (right) are taking four Queensland doctors to court for prescribing her increasing doses of the powerful anti-depressant Endep, marketed in the UK and other countries as Amitriptyline.

Angel’s mother Renea said rather than the drug helping Angel get through her depression, it became a means to kill herself. Now, three years after her daughter took her own life with an overdose, Renea just wants justice for Angel’s death and to warn other parents of the dangers.

Angel didn’t like taking medication. She didn’t want to be a pill popper. But she did it for me,’’ said Renea.

I just wanted her to get better. As a parent I thought I was doing the right thing. Some of these medications prescribed to our children are very dangerous. I want parents to do the research and not just let their children take what the doctor says.’’

The family’s lawyers are now suing the four GPs for negligence and breach of duty of care and breach of contract. Their claim alleges that Endep, as a tricyclic anti-depressant, was inappropriate for treating major depressive disorders in adolescents.

Renea (left) said that Angel suffered depression from the age of 12 and, after recognising the signs, she took her to a central Queensland medical centre in February, 2012. After being told Angel had been self-harming for two months, the doctor prescribed 10 milligrams a day of Endep.

A month later, the same GP was told that Angel had begun to have problems with sleep and behaviour. His response was to increase the dosage to 25mg a day.

Angel stopped taking Endep three months later and in November 2012, after she self-harmed, she was referred to a youth mental health service, but refused to go.

Between June 2013 and February 2014, when she died, Angel was prescribed increasing amounts of Endep by three other doctors at the same medical centre. The daily dosages increased from 10mg to 25mg to 50mg and finally 75mg. 16 days after that final prescription, Angel took an overdose of Endep and died.

Angel’s father Michael said: “Angel was a beautiful, talented girl who loved to draw, who loved her music and loved her family. My message to parents is ask questions, do whatever it takes to protect your children.’’

 

July 12 2017

On September 20th last year, 14-year-old Sofia Legg (right) was found hanged at her home in Cheddar, Somerset.

Yesterday, her mother Sandy told the inquest in Taunton that Sofia was “failed by the system” and that no parent should have to beg for professional help.

Sandy had taken Sofia to her GP in March 2015 after becoming worried about her low mood and teachers reporting signs of self-harm. The doctor referred her to Child and Adolescent Mental Health services (CAMHS), but they decided that she did not meet the criteria for specialist support.

In February 2016, Sandy noticed patches on Sofia’s head and suspected she was self-harming by pulling her own hair out. Four months later, Sofia’s GP made an “urgent referral” to CAMHS after the teenager said that she had been having suicidal thoughts.

She was seen twice in July by care co-ordinator Camal Dhillon who told Mrs Legg that there was a six-month waiting list for cognitive behaviour therapy.

The day before Sofia’s death, Camal had a meeting with Sofia, who told her that she had put an item that could have been used for self-harm under her bed.

Camal told me we needed to secretly take away (the item) from the bed in her room and that I needed to watch her and keep a close eye on her,” Mrs Legg said. “Camal gave us a crisis plan, which included things like talking. There were instructions for Kevin (Sandy’s husband) and I to check on her regularly.

No follow up appointment was made during this meeting but Camal said she would speak to a psychiatrist and review the case to see whether medication was a good option and that she would contact me as soon as she had an answer.”

Whether Camal meant by this statement that she was thinking about commencing, stopping or changing Sofia’s medication was not reported.

Sandy told the inquest that, following her daughter’s death, she had read investigation reports stating that she had been told by Camal to supervise her daughter at all times.

I was angry with this because this is different from the words used by Camal to me personally which was to watch her and keep a close eye on her,” Mrs Legg said. “This is also different from the crisis plan which says we were to ‘check in regularly’ on her. If constant supervision was necessary then this should have been stated directly to me before I left with Sofia.

In addition I am angry as I feel Sofia’s school should have been informed this was necessary too so they could provide supervision at all times while Sofia was away from home

After delivering a verdict of suicide, coroner Tony Williams said that he would be submitting a PFD report, raising his concerns about the Trust that he had heard in evidence.

 

July 1 2017

On October 2nd last year, shortly before 11:30 pm, Berkshire Police received a call from 55-year-old Michael Rough (left). He told them, “I have just stabbed my girlfriend.”

The operator asked if she was breathing and he replied, “No, she’s dead.”

Michael confirmed that he was in the bedroom with her and told the operator that he was going to stab himself.

When emergency services arrived at Michael’s home in Crowthorne, they found 53-year-old psychiatrist Jackie Pattenden (right) laid in a pool of blood on the bedroom floor with a stab wound to her chest.

Michael was rushed to hospital with a number of stab wounds before being charged with murder.

Earlier this week, Michael went on trial at Reading Crown Court. He had previously admitted to manslaughter on the grounds of diminished responsibility, a plea that was accepted

The court heard that Michael was struggling with his finances after he lost a major contract for his business as a tree surgeon. He then visited his GP and was prescribed antidepressants and sleeping pills, two weeks before the incident.

Psychiatrists who interviewed Michael while he was in custody concluded he had moderate depression and his condition was not severe.

The judge sentenced him to fourteen years in prison.

An inspecting officer commented: “Michael Rough and Jackie had been involved in a relationship since the beginning of the year which appeared to those who knew them to be happy with no suggestion of violence or arguments between them. However, after reporting feeling depressed and stressed over work, Rough stabbed and killed his partner Jackie. I hope today’s sentencing will enable those who knew and loved Jackie to have a sense of closure and be able to move on from this utterly tragic time in their lives.”

 

June 18 2017

In an article for the Guardian, published on their website today, journalist Sarah Marsh (left) revealed that tens of thousands of young people in England, including children as young as six, are being prescribed antidepressants by their doctors. The figures have prompted concerns that medics may be overprescribing strong medication because of stretched and underfunded mental health services.

Data obtained by the Guardian shows that 166,510 under-18s, including 10,595 seven-to-12-year-olds and 537 aged six or younger, were given medication typically used to treat depression and anxiety between April 2015 and June 2016.

Dr Antonis Kousoulis (right), a clinician and assistant director at the Mental Health Foundation, said the figures show that: “We are failing to provide a choice of age-appropriate psychological treatments at the point of the need.” He added: “GPs overprescribe antidepressants often because of the long waiting lists for specialist services, but the evidence that these medicines are effective in children is not as comprehensive as is it for‎ drugs for other conditions.”

In her article, Sarah pointed out that guidance from NICE says that Fluoxetine should be given only to teenagers and children with moderate or severe depression, when psychotherapy has failed. It also advises that such medication should be taken in concert with other support, such as counselling. According to NICE, Fluoxetine should be “cautiously considered” for those aged five to 11, but notes that the evidence for its effectiveness in the age group is not established.

On the other hand, David Taylor (left), who is the Royal Pharmaceutical Society’s spokesman on mental health medicines, and who has financial links to several of the companies that make antidepressants, claimed that: “Antidepressants are only used in children in circumstances where there is clear support from robust clinical trials. Adolescents with anxiety, obsessive compulsive disorder and post-traumatic stress disorder may be prescribed antidepressants, and Fluoxetine is used in depression.”

A major study, published in The Lancet last year, concluded that the majority of antidepressants do not work on children and teenagers, and that prescribing them could do more harm than good.

The new data is released as concerns grow about a lack of funding for mental health services. Norman Lamb (right), the Liberal Democrats’ health spokesman, said: “There is no doubt a significant link between the growing use of antidepressants and the immense pressure children’s mental health services are under. Children’s mental health services are in desperate need of more resources…Money isn’t getting through to the frontline, and now we are seeing the consequences of this neglect.”

 

June 12 2017

In August 2014, police officers in Chevely, Maryland, took 24-year-old Sonya Spoon (left) to hospital for an emergency mental health evaluation after she had threatened to kill herself and her children.

Four days later, doctors said that she had been treated and prescribed antidepressants and was ready for release from the hospital. Sonya’s mother Pavi pleaded with doctors to keep her daughter, but to no avail.

36 hours after returning home, Sonya suffocated her 3-year-old daughter Kayla and son Ayden (1), then tried to take her own life. She was arrested and charged with murder.

At a hearing held last week, Sonya pleaded guilty and apologised, saying: “I don’t know exactly what’s wrong with me. What I did was horribly wrong. I wasn’t well and couldn’t see clearly what was going on.”

Sonya’s lawyer, Mirriam Seddiq (right), said that Sonya’s case “represents a failing of the mental health and criminal justice systems.” She added, “We have a crisis of not being able to handle mental health issues in this country.”

Nevertheless, the judge decided that while he believed Sonya was remorseful and endured unfortunate circumstances, she still was responsible for her actions. He sentenced her to 45 years in prison, but gave her the option of serving her sentence at the Patuxent Institution, a prison that offers inmates mental health services.

Today’s Washington Post commented: “No question, as her attorney argued, the mental-health system failed her. The hospital that judged her ready for release with a prescription for antidepressants needs to do some soul-searching over how it handled this case. Families that are struggling to deal with the mental health problems of loved ones need more support.”

 

May 22 2017

An article in today’s Telegraph, by science and heath correspondent Henry Bodkin, reveals that depression is being significantly over-diagnosed and over-medicated because GPs are too reliant on a basic questionnaire.

The PHQ-9 Patient Health Questionnaire is an easy-to-use, nine-question form, which sets the threshold for the condition extremely low and results in patients being wrongly diagnosed, medicated, and thereby put at risk.

The PHQ-9 asks patients questions such as the extent to which they have had poor appetite, low energy, sleep and concentration levels, as well as feelings of low self-worth over the past two weeks.

Each answer, such as “on several days” or “nearly every day”, is awarded a score. The points are then added up and matched against a depression severity scale, ranging from not depressed to severely depressed.

Patients whose symptoms may be the result of unusually stressful or traumatic episodes in their lives are being mistakenly labelled as clinically depressed, because GPs are not taking the time to conduct proper psychiatric interviews.

It hardly comes as a surprise to discover that this simplistic quiz was developed by the pharmaceutical company Pfizer, who originally owned the intellectual property and distribution rights. Pfizer also manufacture Venlafaxine and Sertraline, two of the most commonly prescribed antidepressants in the UK.

Pfizer, who manufacture the benzo Xanax in the USA, are also responsible for the GAD-7 Generalised Anxiety Disorder Assessment, which works in a similarly flawed way to diagnose anxiety.

Dr James Davies (left), researcher at the University of Roehampton and co-founder of the Council for Evidence-Based Psychiatry, said: “GPs are very busy and they often don’t have time to do a full interview. It’s about getting people in and out of the door in 10 minutes. These forms have a very low criteria for anxiety and depression. Millions of people have filled them and in and got medication, but did they know they were developed by Pfizer?”

 

May 10 2017

One morning last July, 17-year-old Solly Betts (right) was found hanged at home in Exmouth, Devon.

Solly was planning on joining the army and had been studying at a nearby military academy.

At this week’s inquest in Exeter, Solly’s instructor described him as: “A good student, one of our leaders,” but added that Solly was ‘too hard on himself’.”

Solly had been to his GP to get “help”, which we can probably assume was given in the form of antidepressants. He was referred to CAMHS, but two clinicians deemed that his was a routine case and he died before he received an appointment.

Before he died, Solly spent a good part of the night playing online with a gaming friend. He spoke to his friend about suicide and said to him, “Should I do it? I don’t know whether to do it.”

His friend told Solly that he “was not a loser and was a good friend,” but police investigators said there was “no real conclusion to that conversation.”

Coroner Lydia Brown (left) said Solly was a “young man of such promise.” She recorded an open conclusion because she could not be certain the teenager intended to kill himself. She said: “Solly took his own life by hanging. His intent was unclear. He was clearly contemplating matters but it was not a particular cry for help.”

 

May 3 2017

22-year-old Oliver Hare (right) was a university graduate who was fluent in French, Spanish and German. He had secured a job teaching English at a school in Shanghai and, earlier this year, he took time off to visit Dubai to join his mother Ann, who was working there.

He returned to the UK from Dubai on February 8th and was met in Sussex by his father, Chris.

Oliver was unhappy with his life in Shanghai and, on a previous trip home, had been to the local surgery where he was diagnosed with depression and was prescribed the antidepressant Citalopram. He didn’t start taking these tablets until he returned to England this year.

On the morning of February 14th, Oliver was discovered hanging from a window at home in Worthing.

At this week’s inquest, his father said: “Because his mood didn’t seem to have improved, he tried taking the tablets. He only took four days’ worth.”

Chris said that his son was anxious about returning to Shanghai and had booked a doctors’ appointment for 5.30pm on the day he killed himself.

He said he would be in a lot of trouble if he didn’t return,” Chris continued. “I said: ‘You’ve been diagnosed with depression, nobody’s going to make you return to work, we’ll go to the doctors tomorrow and get you signed off from work’. He was making the situation about returning to China into a huge event in his head.”

Delivering a verdict of suicide, coroner Elisabeth Bussey-Jones (right) said: “There’s no evidence to suggest that anyone else had any involvement. In light of the mood of the deceased that has been described and the manner by which his body was found I am satisfied that he intended to take his own life.”

The coroner made no reference to the possible part played by Citalopram in Oliver’s death.

 

April 12 2017

On October 27th last year, 45-year-old Leanne Edwards (left) took her life at her home in Rowner, Hampshire.

A recent inquest in Portsmouth heard that Leanne’s depression started after she lodged a complaint about her manager at Tesco.

Leanne’s husband Darren told the inquest that, as he left for work that morning, Leanne had seemed “more upbeat”, but that there had been a period of about two months where she had been “emotionless”. She had taken an overdose of medication two weeks beforehand, and had received initial care at Parklands Hospital in Basingstoke, which Darren praised.

However, problems started when she was transferred to Elmleigh in Havant. Darren (right) said: “No-one listened to Leanne or myself when she said the medication was not working, despite our begging and pleading. They had a ‘we know better’ attitude.”

He said that her care had been lacking in understanding, care, planning and general competence. Staff did not tell him that Leanne had been diagnosed with bipolar disorder, and they did not call him for at least two hours when she left the unit one day without permission.

Darren continued: “I put my faith in the professionals. They should have seen the signs. I hold them solely responsible for Leanne taking her own life…They failed in their procedures and systems and most importantly they failed Leanne.”

Coroner Lincoln Brookes (left) delivered a short narrative finding in which he reflected on Leanne’s mental health conditions, medication and care.

A representative from Southern Health NHS Trust admitted that they had failed Leanne, saying: “She was let down by the level of care that she received.”

 

April 3 2017

In June last year, 16-year-old Britney Mazzoncini (right) attended an appointment with her GP, where she said that she was suffering from depression and anxiety. The GP prescribed a month’s supply of Propranolol and, 16 days later, Britney took a fatal overdose of the tablets at her home in Glasgow.

In January this year, Britney’s mother Annette McKenzie presented a petition to the Scottish Parliament (scroll down to Jan 21). She told the committee that she wants the law to be changed so that children should no longer be prescribed medication to treat mental health issues without parental consent.

Yesterday’s Sunday Post reported that Annette (left) has been left “devastated”, after an inquiry into Britney’s death by the General Medical Council ruled that no action will be taken against the unnamed GP who prescribed Britney the powerful beta-blockers. Annette had complained that the doctor failed to recognise that Britney was suffering from depression, failed to properly advise her, or make a referral to mental health services, or to initiate proper safeguarding procedures. She alleged that the GP’s treatment was reckless, and directly contributed to the death of her daughter.

The “independent expert” commissioned by the GMC said that Britney should have been referred to the Children and Adolescent Mental Health Services (CAMHS) for specialist help and that failure to consider such a referral resulted in Britney’s treatment falling “seriously below the standard expected”.

The inexperienced GP at the centre of the case countered these claims, saying that it was not clear that Britney was suffering from depression and that, as a 16-year-old, she had the full capacity to make her own decisions and there was no reason to suspect that capacity was impaired.

The GMC found that there was “compelling evidence” that doctors of greater experience would have acted in the same way. They ruled that a tribunal “would be unlikely to find her fitness to practise is currently impaired” and said that the case “should be closed with no action”.

Annette is now planning to appeal the GMC’s decision and is being backed by her MP Chris Stephens, who has supported the family through their ordeal.

 

April 2 2017

An article in today’s Mail on Sunday reports that Lundbeck’s Citalopram, linked to more suicides in the UK than any other antidepressant medication, “could be a weapon in the war on obesity”, as it “could help people with compulsive eating habits choose healthy food”.

This theory is being promoted by Ivo Vlaev (right), professor of behavioural science at Warwick Business School, who said: “We found that Citalopram increased the number of choices for healthy foods made by people when compared to a placebo. Our trials suggest that after taking the drug, people are more likely to make decisions based on health rather than taste.”

Three months ago, Medical News Today published an article entitled “Could a narcolepsy drug help combat food addiction? Again, the research was led by the aforementioned Prof Vlaev, who found that “Modafinil was found to have an effect on impulsivity in healthy individuals and so would be able to have an even bigger effect on food addicts, who are lacking in certain types of dopamine.”

Modafinil was originally manufactured by Cephalon, but is now marketed by Lundbeck in several parts of the world under the brand-name Provigil, and in Mexico as Modiodal.

In the USA, Provigil is classified as a schedule IV controlled substance and is restricted in availability and usage, due to concerns about possible addiction potential. In 2007, the FDA issued a warning that “there have been reports of hallucinations, anxiety and suicidal thoughts linked to the use of Provigil”.

 

March 26 2017

Today’s online edition of the Daily Mail reported that, on January 22nd this year, 14-year-old Naika Venant (right) hanged herself in the bathroom of her foster home in Miami, Florida. She live-streamed the end of her life on Facebook.

From the age of six, Naika had lived in 14 different foster homes. A report published after her death found that Naika had suffered years of sexual abuse, and had been beaten and rejected by her mother.

In the 18 months prior to her death, Naika was prescribed medication for ADHD as well as Zoloft, known as Sertraline in the UK This is an SSRI antidepressant which authorities in both countries do not permit to be prescribed to children, due to a heightened risk of suicide.

In December last year, a month before Naika died, a doctor decided to double the dosage of Zoloft.

Florida state officials said that Naika’s constant relocation to different foster homes placed her in situations where adult guardians were unable to monitor her consistently for any danger signs while she was on psychiatric medication.

 

March 23 2017

Yesterday, assistant Gloucestershire coroner Caroline Saunders delivered a verdict of suicide after the inquest of 18-year-old Courtney Davis at Gloucester Coroner’s Court (right).

On April 22nd last year, Courtney was found hanged in her bedroom after writing “to die would be an awfully big adventure” on the wall. The court was told that “she had support from a number of agencies”, although she did not always attend appointments.

In August 2015, Courtney was referred by her GP, Dr Christopher Morton, to the mental health services, mainly due to eating problems.

By November, clinical psychologist Dr Chloe Constable (left) had assessed that she was suffering from severe depression, although a psychiatrist who saw her two days later did not consider her suicidal. Neither did her GP when he saw her on April 6th last year, just two weeks before she took her life.

A post-mortem on Courtney found that she had been taking the medication prescribed to her. This included the sedative Zopiclone and the opioid Tramadol, as well as two SSRI antidepressants – Citalopram and Sertraline.

In one of the least justifiable comments by a coroner that I have ever seen reported, Mrs Saunders said: “I am satisfied neither medication nor alcohol contributed to her death.” The acknowledged risk of suicidal ideation that occurs when either  Citalopram or Sertraline are prescribed is so serious that NICE does not countenance the use of either drug for anybody under the age of 18, or just a few months younger than Courtney was when she died. The prescription of both of these drugs to Courtney, alongside Tramadol and Zopiclone, proved to be a lethal combination.

 

March 20 2017

Last week, a landmark court case began in Chicago. The plaintiff, Wendy Dolin (right), alleges that the death of her husband Stewart in 2010 was induced by a generic version of GSK’s SSRI antidepressant Paroxetine, marketed as Paxil in the USA and Seroxat in the UK.

At the time of his death, Stewart Dolin was 57, an extremely successful and popular corporate lawyer, and senior partner with the prestigious firm Reed Smith in Chicago.

Stewart (left) consulted his physician about some work-based anxiety, and was prescribed a generic version of Paroxetine. After 6 days, during which akathisia began to set in, Stewart walked from his office to a nearby railway station, where he stepped in front of a train. The lawsuit claims that GSK failed to warn prescribers of the increased risk of suicidal behaviour in adults.

Although GSK’s opening argument maintained that “Paxil does not cause suicide”, testimony heard during the first week of the case showed conclusively that not only is that premise fallacious but that, for many years before Stewart’s death, GSK were well aware that they were peddling a lie.

The case is expected to continue for another few weeks. For those interested in its progress, UK patient advocate Bob Fiddaman will be publishing regular updates on his website.

 

March 1 2017

54-year-old Alison Sharp (right) lived in the village of Tattenhall in Cheshire, and worked as business manager for a nearby estate.

Alison had been in an abusive marriage, and was first treated for depression by her GP, Dr Emma Taylor, in May 2000.

Alison’s brother James told her inquest last week that Alison had filed for divorce from her husband in 2016 and moved from the family home “for her own safety.” Following that, her mental health deteriorated, and she went to see her GP.

Dr Taylor told the court: “She was struggling with the feelings of guilt and the trouble this would cause her family.” And when she returned to the surgery the week before her death, Dr Taylor said that she appeared very different, had lost weight, was tearful and kept apologising.

Dr Taylor doubled the dosage of her prescription for Fluoxetine and arranged for Alison to see mental health nurse David Millard the following week.

Mr Millard told the inquest that Alison did not display any risks of self-harm, but maintained good eye contact and did not appear significantly depressed.

On September 28th last year, the day after her appointment, Alison’s family found her hanging in the stables of her former home.

Neither Dr Taylor, nor Mr Millard, nor even coroner Jean Harkin made any mention of the heightened risk of suicidal ideation associated with a sudden change in the dosage of antidepressants.

Instead, as she delivered a verdict of suicide, the coroner described Alison as “an intelligent woman who fooled healthcare professionals into believing that she was not an immediate risk.”

 

February 21 2017

In 2012, 67-year-old Carolyn Brock (left) complained to her GP about stress after her retirement, and was given medication “to help with her depression.” Later that year, she stabbed herself with a kitchen knife.

In 2014, her son took his life, and it affected her mental wellbeing.

Last July, Carolyn was admitted into A&E in Southmead Hospital (right) after taking an overdose, and in August the crisis team took over her care. By this time Carolyn was taking drugs for anxiety and blood pressure as well as for depression.

She remained as a voluntary patient in Southmead (right) where, on August 21st , she told staff she was going out for a walk. However, she took a lift to the fifth floor, climbed the railings and jumped to her death in the hospital’s atrium.

During this week’s inquest, psychiatrist Jacek Kolsut told the inquest that: “There was a plan in place to keep her going.” He had rated her as being at “medium risk”, but added: “Some medication can cause unpleasant side effects.”

Delivering a verdict of suicide, coroner Maria Voisin (left) said that Mrs Brock was “a patient whose risk had increased, and required accompanied leave” and that there had been “a failure to communicate this to staff caring for her”.

She concluded: “This failure led to her inappropriately leaving on unaccompanied leave which results in her having an opportunity to take her own life.”

 

February 20 2017

A major BBC TV documentary, exploring the link between SSRI antidepressants and violence, is now in progress, and will feature stories from all over the world.

If you have ever become violent or had violent thoughts while on SSRIs, and would be willing to share your story, please contact film maker Katinka Blackford Newman (right) at katinka.newman@gmail.com, 07885 153049 or via her website www.katinkanewman.com.

Katinka says: “Filming will take place in next few weeks; we will come to you.”

 

February 19 2017

Today, the UK Government’s Judiciary website published a Prevention of Future Deaths (PFD) report which had been submitted by Berkshire coroner Peter Bedford (left).

At an inquest held in Reading last month, Mr Bedford delivered a verdict of suicide after 76-year-old Charles Rendell was found hanged in his garage in September last year.

Five days earlier, Mr Rendell had undergone a prostate biopsy and was subsequently prescribed the anti-biotic drug Ciprofloxacin. He had no history of depression or mental health problems.

In his PFD report, Mr Bedford listed his concerns:

  1. Apart from the fact that Mr Rendell had undergone a diagnostic biopsy to test for the possibility of Prostate Cancer, the only change in his daily routine was the prescription of Ciprofloxacin medication.
  2. Ciprofloxacin carries warnings / precautions that, in rare cases, depression or psychosis can progress to suicidal ideations / thoughts culminating in attempted suicide or completed suicide. However, it is unclear how clearly this is made known to Ciprofloxacin users.
  3. The literature suggests that this type of side effect can occur even soon after commencing Ciprofloxacin at a comparatively low dose. As it is an antibiotic, there is no compelling reason why patients should expect to have this effect unless this fact, and potential symptoms, are brought clearly to their attention by prescribing clinicians.
  4. One of Mr Rendell’s family members is a general practitioner in New Zealand. At the Inquest, she advised that she had no knowledge of the potential effect of Ciprofloxacin and, in conversation with her colleagues, nor did they. I am therefore concerned that this potential risk has not been given sufficient emphasis and that consideration should be given to prescribing clinicians highlighting the symptoms and suggesting to patients that they are alert of the possibility and react appropriately.

Mr Bedford addressed the report to Bayer, the manufacturers of Ciprofloxacin.

 

February 18 2017

Today I received my copy of The Sedated Society: The Causes and Harms of our Psychiatric Prescribing Epidemic. The book is edited by James Davies, and is comprised of chapters written by some of the world’s greatest experts in the subject, including Peter Gøtzsche, Robert Whitaker, Peter Breggin, Joanna Moncrieff, Peter Kinderman and Sami Timimi.

 

The book also includes a chapter written by Luke Montagu (right), who tells how he suffered crippling withdrawal symptoms from medication that he should never have been prescribed in the first place.

Over 15% of the adult population in the UK takes a psychiatric medication on any given day, and the numbers are only set to increase. When these figures are set against data exposing the poor outcomes and harms that these medications often cause, it becomes apparent that their commercial success is not due to their therapeutic efficacy.

The book reveals how pharmaceutical sponsorship and marketing, diagnostic inflation, the manipulation and burying of negative clinical trials, lax medication regulation, and neo-liberal public health policies have all been implicated in ever-rising psychopharmaceutical consumption. As increasing sedation of society may be leading to a more disabled society, this book closes by calling for total reform.

The Sedated Society is available from Amazon and other retailers, at a price of approximately £20-£25.

 

February 10 2017

On September 2nd last year, the body of Gareth Llewellyn, a 33-year-old student, was found at the foot of the Runcorn-Widnes Bridge (left).

This week’s inquest in Warrington heard from Gareth’s mother Lorna, who said that Gareth had acted “out of character” in the week prior to his death. She said: “He had randomly jumped off a train he was on with his dad at Birkenhead Park Station the day before his death and ran away, only returning home late.”

The next day she called the doctors to make an appointment for him, but found that Gareth was not home.

She called him at around 8:30am. He told her he was out, and then Gareth spoke to his sister some minutes later. At about 9:30am, Gareth was seen to fall “in a single immediate motion” over the barrier on the bridge.

At his inquest, a toxicology report stated that a “low amount of antidepressants used therapeutically” was found in his system which “has no bearing on his death.”

Coroner Alan Moore (right) did not think to question why the toxicologist should be so convinced that drugs with an acknowledged link to suicide should be exonerated on this particular occasion, but concluded that: “Gareth showed some unusual behaviour, but I cannot give a result of suicide as I am not sure he meant to take his own life…Therefore I must return an open conclusion.”

 

February 1 2017

Yesterday, an inquest in Midleton, Co. Cork, heard that 53-year-old Michael Greaney fatally stabbed his wife Valerie (left). He then wounded his 23-year-old daughter Michelle, before taking his life with the same knife.

The only motive offered at the inquest was that Michael was depressed and in debt. A garda officer surmised: “Michael Greaney was feeling like life wasn’t worth living. He didn’t want the family to suffer pain.”

The tragedy happened at the family’s house in Cobh on December 28th 2014. What was not reported was evidence provided by friends after the incident, who told a journalist that Michael had gone home from a friend’s house where he had drunk a glass of wine. His friends “expressed fears that the glass of wine may have reacted with his medication to drastically alter his mood.”

 

January 21 2017

In June last year, 16-year-old Britney Mazzoncini (right) attended an appointment with her GP, where she said that she was suffering from depression and anxiety.

The GP prescribed a month’s supply of Propranolol and, 16 days later, Britney took a fatal overdose of the tablets at her home in Glasgow.

Britney’s mother Annette McKenzie decided to initiate a petition and, on Thursday, introduced “Britney’s Plea” to the Public Petitions Committee at the Scottish Parliament. She said that she had been completely unaware of the prescription, and had mistaken side-effects such as tiredness as her daughter being lazy.

At present, GPs do not need to seek parental consent to prescribe medication as long as the young person is deemed to be able to understand the nature of the treatment and potential consequences of the treatment.

Annette (lefttold the committee that she wants the law to be changed so that under-18s cannot be prescribed medication to treat mental health issues without parental consent.

My daughter didn’t understand at 16 years old the severity and strength of the medication she was given,” she said. “She went to the doctor that day to ask for help; she didn’t go expecting to be given pills.”

Annette said that the strength and effect of some mental health medications make it important that parents and guardians are “fully involved and aware of the circumstances, allowing them to support treatment” and safeguard their children by taking control of pills of dispensing them as required.

We’re not just talking about my daughter being 16 here, we are talking about there being no age of consent,” she said. “If they deem you to be wise enough, they will send you away with medication.”

The committee agreed to contact the Scottish Government, the Scottish Association for Mental Health, the General Medical Council and a range of other relevant organisations.

 

January 18 2017

On September 12th last year, the body of 30-year-old Ravi Ghowry (right) was discovered on scaffolding at Reading Hockey Club. Ravi, who lived in a flat at the ground, had played for the club and acted as the club’s official photographer.

Yesterday’s inquest heard that Ravi had sought help for depression by attending 31 weekly private counselling sessions between December 2015 and August 2016. He had been advised to take Sertraline, but wanted to avoid it because his mother Rita was concerned that it may make him feel suicidal.

Consultant psychiatrist Dr Wais Ravi said that Ravi had “promised” to consider taking medication but wanted to be sure there was nothing else that would help before beginning a course of antidepressants. A few weeks before his death Ravi agreed to start taking Sertraline.

Asking Dr Ravi about his treatment, Rita asked if Mirtazapine would have been a more suitable option. However, Dr Ravi said that Sertraline was the recommended medication in guidelines from the Royal College of Psychiatrists, as “it is a much milder antidepressant.”

When he concluded the inquest, I presume that coroner Peter Bedford (left) chose not to question this dubious statement by the psychiatrist. He certainly chose to ignore the acknowledged link between Sertraline and suicide, of which Ravi’s mother was well aware, when he stated that he believed Ravi “did act with the intention of ending his own life, but did so while suffering from depression.” He added that he did not believe that Ravi had been neglected by medical professionals.

 

January 17 2017

Sophy Stott (right) had an exceptional academic ability and was a talented musician and writer. The 20-year-old woman had been transitioning to become male, and preferred to be known as Sebastian. Sophy took her life at her home in Belfast on March 19th 2015.

When she was 16, Sophy told her mother that she had been raped. Sophy first received mental health treatment after starting university in England in 2013. She returned home to Belfast in July 2014 and, after attempting suicide on several occasions, Sophy was referred to psychiatrist Dr Iain McDougall, at the request of her mother Elizabeth.

Elizabeth (left) told last week’s inquest that: “After she met with Dr McDougall she said she was annoyed at him, as she felt he was focusing on matters she did not think were important.” She did not want to take part in the group therapy sessions suggested by the doctor, asking for one-on-one treatment instead, a service unavailable at the time.

On March 3rd, 16 days before her death, the doctor changed Sophy’s antidepressant prescription from Citalopram to Sertraline.

Some time after she started taking Sertraline, Elizabeth said that there was a “definite change” in her daughter’s mood. “Between March 10th and 16th she tried to take her life three times, but I was in the house each time and stopped her,” she said.

On March 16th, Sophy met with Dr McDougall for the last time. She did not reveal her recent suicide attempts, but discussed how the new antidepressants made her mood low.

On the day of Sophy’s death, her mother had left the house briefly to buy food. She returned home from the shop to find Sophy hanging on the stairs.

Coroner Joe McCrisken (right) said that it was possible that Sophy had not been aware her mother had left, and could not say that she definitely intended to take her own life. He told Elizabeth that, following Sophy’s death, a report recommended that health trusts implement the one-on-one service that she had wanted. He said he was pleased to inform Elizabeth that this had been accepted by the Belfast Trust and was now available for patients.

Speaking afterwards, Elizabeth said that, although not all her questions were answered, she was “pleased” at the change to mental health services. “That was really part of what I was hoping for from the inquest, that lessons are learnt and other lives may be saved,” she said, “It’s important the causes are addressed and not just the symptoms of mental health issues.”

 

January 12 2017

In December 2013, Michael Mazzetti (left) contacted the police, and admitted three unreported offences that he had committed while working as a carer in County Durham.

He went on trial in April 2014, and was given a sentence of 8 years in prison.

On September 1st 2014, the 45-year-old was found hanged in his cell at Northumberland Prison.

At this week’s inquest, the jury heard that Michael’s feelings of guilt had continued to haunt him in prison. He was, however, determined to address these feelings, along with his low self-esteem.

A psychiatric nurse who worked with Michael said that: “He was experiencing low mood and anxiety.” When asked whether Michael should have been on an Assessment Care in Custody and Teamwork programme (ACCT), which sees those at risk of self-harm receive additional help and hourly cell checks overnight, the nurse said that “this was not considered necessary while the prisoner continued to engage with the mental health team.”

In his summary, coroner Tony Brown referred to a report given by Michael’s GP: “Michael Mazzetti had told her he did not think life was worth living but that he wasn’t planning on doing anything about it. She continued a prescription of antidepressants and increased the dosage. She found he was in a low mood but her judgement was he did not need to be on an ACCT.”

The jury delivered a verdict of suicide, and the coroner concluded that: “There was insufficient evidence to suggest health care omissions and a failure to open an…ACCT…contributed to Mazzetti’s death.”

The coroner was, presumably, unaware of the advice of the prescribers’ handbook, the British National Formulary (BNF). This states that “the use of antidepressants has been linked with suicidal thoughts and behaviour. Where necessary patients should be monitored for suicidal behaviour, self-harm or hostility, particularly at the beginning of treatment or if the dose is changed”.

It would surely be prudent to initiate an ACCT each time any prisoner is prescribed antidepressants, or whenever the dosage is changed.

 

News File: Aug-Dec 2013

News File: Jan-June 2014

News File: July-Dec 2014

News File: Jan-June 2015

News File: July-Dec 2015

News File: Jan-June 2016

News File: July-Dec 2016