Tilburg University
Instrumental violence in relation to a selective serotonin reuptake inhibitor
Brouwers, R.C.; Groenewoud van Nielen, E.M.C.; Loonen, A.J.M.; Oei, T.I.
Published in:Violence in clinical psychiatry
Publication date: 2011
Document Version Peer reviewed version
Link to publication in Tilburg University Research Portal
Citation for published version (APA):
Brouwers, R. C., Groenewoud van Nielen, E. M. C., Loonen, A. J. M., & Oei, T. I. (2011). Instrumental violence in relation to a selective serotonin reuptake inhibitor. In I. Needham, H. Nijman, T. Palmstierna, R. Almvik, & N. Oud (Eds.), Violence in clinical psychiatry: Proceedings of the 7th European Congress (pp. 73-75). Uitgeverij Kavanah.
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7TH European Congress on Violence in Clinical Psychiatry, October 2011, Prague – Czech Republic
Instrumental violence in relation to a selective serotonin reuptake inhibitor
Ethical and legal aspects of violence, paper.
R. C. Brouwers, E. M. C. Groenewoud‐van Nielen, A. J. M. Loonen and T. I. Oei Correspondence: rbrouwers@trajectum.info
Keywords: instrumental violence, legal aspects, ssri, classification. Introduction
Sometimes more than one expert advises the court and different opinions are reported about the case they examined. For the court to be able to get an overall impression, it must at least be aware of the methods of the various expert witnesses and actors (public prosecutor, accused and behavioural expert, medical specialist) in order to arrive at a meaningful integration. In the determination of accountability the following questions come up: 1 Was there a pathological disorder at the time the punishable offence was committed, 2 If yes, is the causal relationship between the disorder and the punishable offence adequately plausible, 3 If yes, what assessment should be given to accountability –in the light of the first two questions and all circumstances of the case? A disorder contributes to recidivism in this point of view, whereas in the pattern of questions of the behavioural expert, the question of recidivism is only asked after the question about a relevant disorder. In criminal court cases it is important to examine whether the crime is or is not premeditated since premeditated crimes are punished more severely. If a person’s (instrumental) violent behavior can be associated with a mental disorder the court may pronounce a verdict involving diminished responsibility and possibly court supervision (Mobbs, et. al., 2007).
In this case we like to discuss the relation between use of the anti depressive drug paroxetine, a selective serotonin reuptake inhibitor, and a fatal tragedy as a result of instrumental violence in a family where the mother was suspect to kill her husband and daughter a few days after use of the selective serotonin reuptake inhibitor. After that she tried to kill herself but survived the crash with her car.
Description of the case
She sat on her settee and was caught by the overwhelming feeling that she did not want to live any more. At the same time she felt that she could not cause the grief about her suicide on her husband and daughter and she decided to take them with her in death. She then made fairly extensive preparations of her farewell and subsequently went looking in the home for a means to kill them with: she found an axe in the garage. She struck her husband in the head several times and then thought: “two more to go”, meaning herself and her daughter. After having killed her daughter as well, she tried to commit suicide by running her car into a tree. She had by then already called he emergency number (4.59 am) and announced that she had committed murder. She got wounded in the collision with the tree and was taken to hospital. At 9.05 am blood samples were taken, which were later analysed by the NFI (Dutch Forensic Institute). In the blood traces (< 10 ng/ml whole blood) of paroxetine were found. According to the verdict the locum GP had prescribed once again paroxetine to the woman in a dose of once daily 20 milligram’s (1 tablet), but that she did not fill the prescription. This was confirmed by the fact that the prescription was recovered in the woman’s home, and also by the pharmacy’s records which showed that no medication had been delivered to the woman between 17 December 2007 and 3 September 2008. In the consultation with her own GP on 3 September 2008 the dose was augmented, because she (the GP) indicated that she had supposed the 20 milligram’s had not been effective. Had the woman started her medication on 6 August, she would have been taking one tablet daily of the drug for 4 weeks, and there would not have been any improvement after 4 weeks’ medication. According to the standard GP guideline doubling the dose was then indicated. The woman later testified that she had taken three tablets of paroxetine on 3 September and two more on 4 September. The toxicological analysis by the Dutch Forensic Institute (NFI) showed traces of paroxetine in her blood and the conclusion of the NFI was that the concentration was so low that it could not have influenced her behaviour. But later, during the trial pharmacological experts agree that the conclusion is wrong in several respects. On the basis of one single measuring of whole blood and quite some time after the drug has been ingested, it cannot be determined how high the concentration was quite soon after taking the drug. Furthermore, in the use of serotonin reuptake inhibitors (occasional) cases are known where normal shortterm use was followed by an outburst of violence.
aware of this, then ingesting the dose can be seen as own culpability and intent can be assumed. The discussion during the trial will then probably be whether or not the side effect is a rare one. If the side effect hardly ever occurs with users of the drug, it is reasonable for the defence to plead that own culpability is out of the question. When the concentration in the blood is of no importance and she never had a similar reaction in previous treatments, taking three tablets instead of the prescribed two cannot be held against her in relation to the violence against her daughter and her husband.
In trying to establish a relation between the violence and the use of paroxetine the experts disagree on several topics. Was it a violent subtype of depression or the overdose of paroxetine the second day after starting the drug? Was it a delusion the thought she had that the only way to protect her husband and daughter from the experience that she wanted to end her life was to kill them. Or was it a state of depersonalization caused by heavy stress, sleep deprivation. Was it the side effect acathisia with dysphor feelings? Was it a sub‐arachnoid haemorrhage made her more susceptible to an undesired effect of paroxetine? The woman had the time and the opportunity to reflect on and to account for the consequences of her intended actions. It is remarkable that obviously in the period that she was preparing her actions the horrible nature of her intentions did not make her correct herself. Apparently she was convinced that her actions would spare more grief. The question is whether she did not experience the appalling nature of her intended actions as such because of the effect of the paroxetine on certain areas of the brain that usually have a correcting effect. Antidepressants have effect on certain psychological functions short after intake. Harmer and colleagues (2006) found antidepressant drug treatment modifies the neural processing of non conscious threat cues. Volunteers receiving citalopram showed decreased amygdale responses to masked presentations of threat. Paroxetine single acute administration diminished brain activity induced by motivation in healthy subjects (Marutani et. al., 2011)
To sum up: depending on the advice the experts, a wide range of possibilities is presented which only enter the picture when a disorder is suspected and when that disorder is linked to the facts the accused is charged with. In conclusion, when paroxetine has an unknown, recorded, direct effect (distortions of perception, cognitive distortions, depersonalisation, acathisia) but is not dose‐dependent; the woman could have been acquitted because intent is lacking. But if the effect turns out to be dose‐ dependent and she was aware or could have been aware of this, culpability, culpa in causa, enters the picture: an unintended or unpursued effect but nevertheless the result of an initial overdose. If, as an element of the affliction, a temporary delusion exists (caused by the drug) then complete unaccountability can be put forward, resulting in criminal disposition. If that is not the case and only the affliction depression contributes to the action, she can only be held partly accountable. Should the chance of re‐offending be deemed small, detention in a mental hospital as a possible court decision is to be deserted and ordinary punishment remains.
There are many models of violence and aggression and according to Weinschenker and Siegel (2002, 237-250) many of these models can be brought back to the bimodal classification with instrumental (predatory attacks) and impulsive (affective defense) components. In this case the type of violence was instrumental, it was planned and careful executed. There are more cases like this for instance the case of Joseph Wesbecker who shot several people in the morning of 14 September 1989.
More attention must be paid to the mental disabilitating influence of medication on certain
psychological functions shortly after intake. Although a monocausal relation is a necessity for a clear judgment we believe that is never the case. How to judge the accountability in this case depends on the position the expert takes and the reader can ask himself what would I advise the court when a woman in her sixties, with no history of violence, killed her husband and daughter a few days after taking paroxetine in a state of depression.
References
Weinschenker, J. & Siegel, A., Bimodal classification of aggression: affective defense and predatory attack. Aggression and Violent Behavior, 2002, 7 (3), pp. 237-250.
Praag, H. M. van, 5-HT-related, anxiety- and/or aggression-driven depression, International Clinical
Psychopharmacology, 1994, 9 (supplement 1), pp. 5-6.
Sierra, M., Depersonalization, a new look at a neglected syndrome, Cambridge: University Press, 2010.
Did prozac make him do it? The case of Joseph Wesbecker, in: Time, 1994.
Harmer, C.J., Mackay, C.E., Reid, C.B., Cowen, P.J. & Goodwin, G.M., Antidepressant drug
treatment modifies the neural processing of non conscious threat cues, Biological Psychiatry, 2006, 9, pp. 816-820.
