“The System is Not Listening”

“This drug is poisoning me. It’s giving me problems I never had before.”


On July 29th 2016, 48-year-old Stephen O’Neill (top) was found hanged at his home in the village of Brackaville in County Tyrone, Northern Ireland. Stephen was well-known as a musician and singer who appeared regularly at venues in the Coalisland area, and was described as kind, caring and “a delight to work with”. His family said that he had a great love of nature, and enjoyed walking in the woods by Coalisland Canal.

Stephen was single, a non-drinker and had never taken illicit drugs. He was close to his family, had no money worries and had been planning a trip to Zambia.

On the first day of his inquest this week in Omagh, the court heard concerns that an antidepressant he was prescribed may have triggered severe anxiety and depression.

In the months before he died, Stephen was prescribed Sertraline. After taking the medication, he began to suffer from insomnia, diarrhoea and restlessness.

The family noticed a dramatic and sudden worsening in his mental condition. His brother Patrick said: “Up until he took the tablets, Stephen was coping with life. In the short time since he took them he said, ‘The tablets have done something to my head’.”

Patrick said that Stephen “just didn’t know what was going on with himself.” He was nothing like the brother he had known. He felt anxious, agitated, and unable to sleep. He was not eating, lost half a stone in weight in two weeks and stopped going to the gym.

Patrick also spoke of a worrying incident which happened when Stephen was staying at a sister’s house: “He woke up at the bottom of the stairs with a rope in his hand. He didn’t know how he got there.” However, a medical professional had told him: “It couldn’t be the tablets“.

Consultant psychiatrist Dr Matthew Armstrong (left), who treated Stephen in Craigavon Area Hospital, said: “There did seem to be some sort of shift, which could be linked to consumption of Sertraline. I accept the last six weeks of his life represents a sea-change in the level of anxiety he had.”

On the second day of the inquest, world-renowned psychopharmacologist Professor David Healy (right) told the court: “I’m pinpointing Sertraline as the drug that produced the catastrophic reaction. When Mr O’Neill gets Sertraline he shifts states quantitatively.”

Dr Healy paraphrased Stephen’s attitude in the weeks leading up to his death: “He said, ‘This drug is poisoning me. It’s giving me problems I never had before’. He’s handing them the diagnosis on a plate, and the system is not listening.”

Dr Healy queried the safety of Sertraline, saying: “The evidence in SSRIs (the category of drugs to which Sertraline belongs) is that they cause more suicides than they prevent.” In support, he quoted the US Food and Drug Administration (FDA), which found more deaths among patients on SSRIs than among those on placebos.

Under cross-examination, Dr Healy robustly queried the response to Stephen’s distress: “The system, in Mr O’Neill’s case, did not know what it was doing and was flailing around.”

He emphasised that he was not blaming individual medical staff, saying: “I was impressed by his GP and nothing I’m going to say here impugns him.”

Consultant psychiatrist Dr Pat McMahon (left), who had never met with Stephen, gave evidence on behalf of the Southern Trust. He claimed that Stephen’s treatment was within the guidelines at all times. He also repeated Pharma’s unsubstantiated mantra that the benefits of the medication outweighed the risk.

He denied that the Trust was putting people at risk, but agreed that Sertraline was a factor in Stephen’s death, saying: “There was a clear adverse reaction to the medication, and that was recognised.”

Coroner Patrick McGurgan (right) adjourned the inquest to consider a report written by Dr Healy, before returning for a third and final day to deliver his verdict.

Mr McGurgan said that all medical witnesses at the three-day inquest acknowledged that Stephen had suffered a catastrophic reaction to Sertaline, but  quoted the evidence of psychiatrist Dr Pat McMahon that Sertaline alone was not responsible for Stephen’s death. “It possibly contributed, along with other identified stressors,” the coroner told the inquest.

Mr McGurgan noted that Stephen had sought help from his GP on a previous occasion. In 2011, after the death of his father, he had suffered a bad reaction to Fluoxetine, an SSRI similar to Sertaline. He discarded the medication and, subsequently, he was successfully treated with Cognitive Behavioural Therapy.

In April 2016, Stephen’s anxiety flared up again, but he was not depressed.

In June, he returned to his GP, who gave him a prescription for Sertaline. Within two days, Stephen became very emotional and tearful. He was staying with a sister, who revealed that he said “if she was going out he might kill himself.” He reported the bad reaction to a local pharmacist and stopped taking Sertaline. Other medication was prescribed, but was ineffective.

In the subsequent weeks, Stephen was twice admitted to the psychiatric unit at Craigavon Area Hospital.

There, consultant psychiatrist Dr Matthew Armstrong examined him. “That the deceased would take his own life was not on (Dr Armstrong’s) radar,” the coroner said. On one occasion, Stephen had said: “Life is worth living, but I’m struggling.”

At various stages during a 6-week period, Stephen was prescribed the antidepressant Mirtazapine, as well as Quetiapine (anti-psychotic), Buspirone (anxiolytic), Diazepam, Propranolol and Zopiclone.  A cocktail of drugs, each one just seeming to exacerbate the original symptoms.

For whatever reason, Mr McGurgan decided to omit to mention the prescribed medication, which the manufacturers accept can induce suicidal ideation, in his final verdict.

Instead, the coroner ruled (using an anachronistic phrase not often heard nowadays) that Stephen “took his own life while the balance of his mind was disturbed.”

Coroners are part of the System. And the System is not listening.



Update: February 2nd 2020

Stephen’s family have recently created a page on Facebook entitled “Stephen’s Voice”. Last week, they published an article in which they told the story of the last few weeks of Stephen’s life, imagining how he would have expressed himself had he been able to do so:

My name is Stephen O’Neill; I was a singer and musician, lived a healthy lifestyle, never had touched a drop of drink in my life, smoked or took drugs. I was in to fitness, ran marathons and loved to raise money for local charities. I lived for my family. I had no money worries, I was comfortable in life.

However in 2016 I was having trouble sleeping and switching off at night, I decided to go to the doctors and on 16th June 2016 I was prescribed 50mg of Sertraline for “mild anxiety” and “sleep disturbance”.

My brother in law picked me up from the doctors that day and we went on a few deliveries. I told him I had just been prescribed anti-depressants and that I had been having trouble sleeping. We had a good chat and then I went to pick up the tablets. I told the pharmacist that I didn’t want to go down the medication route, I had responded well before to CBT after the death of my parents but there was a wait list for the talk therapy so I thought I’ll try what the doctor prescribed. I was feeling my usual upbeat self, what harm could they do?

In the early hours of 18th June, after taking the tablets for just 24hours, everything changed. I experienced the scariest night of my life. My heart was racing; I felt feelings of agitation so strong that I could not sit still. Thoughts were running through my head a million miles a second, my mind was in over drive with scary thoughts I had never had before. I don’t know why, but I put a belt around my neck. At about 2am I ran a cold shower to try snap out of this feeling, it didn’t work. I went for a walk at about 3am to try and get rid of the restless feeling in my legs and clear my head, it didn’t work. I came back home and took the Sacred Heart picture off the wall and held it, praying for the sun to come up.

As soon as morning came I went to my sister’s next door and told her I needed to see the doctor ASAP. She didn’t understand what was happening but as it was a Saturday said I should go see the pharmacist. Without even getting freshened up, I went down the town. I know the pharmacist was shocked at the change in my appearance. I told her it was the tablets; they had done something to my head. She rang the out of hours doctors and they told me to stop the tablets immediately and gave me diazepam.

I went home but still couldn’t shake the feeling. I rang my other sister and she picked me up. I told her everything; I was having dark thoughts that were never there before the tablets. We rang the out of hours doctors again and they sent out a crisis team. I told the crisis team the same thing I had told my sisters and the pharmacist, the tablets had done something to my head.

I was so scared and desperately wanted to get better so I voluntarily went into a local psychiatric unit. I told anyone who would listen that there was something wrong with the medication, I felt like it was poisoning me. They noted that I wasn’t clinically depressed and that I had an adverse reaction to Sertraline but they didn’t really seem to take on board what I was telling them.

Over the next six weeks, instead of just taking me off medication, the doctors kept prescribing me tablets. In that short space of time I admitted myself to the unit twice more and I was given Quetiapine (antipsychotic drug) and Mirtazapine (serotonergic drug), Buspirone (anti-anxiety) as well as other drugs such as Diazepam, Propranolol and Zopiclone. A cocktail of drugs, each one just seeming to exacerbate the symptoms.

The feelings were unbearable, I had to phone and cancel all my music bookings. All I wanted to do was walk. I must have walked for miles trying to shake the feelings of restlessness and agitation. If i couldn’t go for a walk I would just pace round and round the house. I just couldn’t settle. All my thoughts were multiplied by 1000. I couldn’t sleep, I felt so nauseated I would even retch but nothing was coming up because I couldn’t eat. I had no appetite. I lost about a stone and half in weight. My hands were shakey and my legs were twitchy. Sometimes I felt like I had mice crawling up my legs and that the hair was standing on my head, tingling. Everything seemed louder too; a slight bang would have me jumping. I had this overwhelming feeling of fear. I was twitchy, jittery, tearful, exhausted.

But I was determined to fight this feeling; I was determined to get better. Because the doctors kept telling me that it couldn’t be the tablets I began to think of what else could be causing this. I had lost the sight in my eye when I was younger after an accident so I even went for an eye test in case something would show up behind the eye and I was also looking into booking private for a brain scan. I even tried a spiritual healer in my desperation. I just didn’t know what was happening to me. They just kept telling me and my family I would not act on my thoughts, that my physical body would not be harmed.

We called the crisis team again on 27th July as I collapsed in front of my sister. She even told them I had woke up in the hallway with a rope around my neck; I had snapped out of trance and didn’t know how I got there. I was scared. But I was told not to come down to the unit; I was told again it would take a few more weeks for the tablets to work.

But it was too late, on 29th July 2016 I was dead, six weeks after I first took medication.

The family concluded the article with this statement: “Stephen dedicated his life to helping others. He will continue to help others through his story. We are not anti-medication, we are pro-informed choice. If only we knew then what we know now…If this post can help at least one family from avoiding the absolute carnage that our family has suffered then we can take some comfort in knowing Stephen’s Voice lives on.”

Update: February 8th 2021

Stephen’s niece Colleen recounted the last six week’s of Stephen’s life, and the ordeal of his inquest, on the website of my friend Bob Fiddaman. At the end of her account, Colleen asks: “How many more times do we have to hear families who have been torn apart by medication-induced suicide say ‘If only we knew then what we know now’?”


Related Articles:

In the Court of the Coroner

No Prior Intention

When is a Suicide not a Suicide?

Citalopram: Ten Years of Denial

Murdered by Sertraline?



6 Replies to ““The System is Not Listening””

  1. Such a heartbreaking story, Stephen sounds like such an amazing person. Hopefully telling his story might help someone else in the future. May he Rest in Peace.

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