THE FORENSIC MEDICAL EXAMINATION

The association between antidepressants and violence has been known since the 80s but it drew public attention only after mass shootings in the United States.Just like medication that can disturb the chemical balance elsewhere in the body - like diarrhea caused by antibiotics - the same can happen at the level of the brain. Due to these disturbances, unwilled emotions and involuntary behaviors can occur. When they are severe, they can be considered as a delirium, a toxic psychosis induced by medication. Like all medication antidepressants and other psychotropic medication can cause side effects. One of the most feared adverse reactions is violence. In the extreme, this can take the form of suicide or homicide.

In 2001, 76-year old David Hawkins, known as a loving father and husband, strangled his 70-year old wife to whom he was married for 50 years. Judge O'Keefe referred to the "conditio sine qua non" in the following way in his ruling: "The killing was totally out of character for the prisoner, inconsistent with the loving, caring relationship which existed between him and his wife, and with their happy marriage of 50 years, I am satisfied that but for the Zoloft he had taken, he would not have strangled his wife."

It frequently occurs that physicians do not recognize aggression as a side effect of a drug and interpret the symptoms as an underlying psychiatric disease. Delirium caused by psychoactive medication represents a continuum, with, on one end, diffuse complaints of restlessness, and anxiety and on the other end, a condition of fully developed Akathasia (hyperactive form of delirium) with extreme violence, suicide, and homicide. 

Leading up to the offence, the medication prescribed to Mrs. Aiken consisted of: Ambien, Amitriptyline, Bupropion, Citalopram, Motrin, Lorazepam, Tizandine hydrochloride, Cyclobenzaprine, and Etonogentrel/ethinyl estroiol. It is unlikely the physician who prescribed this medication warned Mrs. Aiken and her family properly. Instead of weaning her off or at least consider her worsening condition as a side effect, the health care providers diagnose a Major Depression Disorder and prescribe even more psychotropic medication, basically jeapardizing her health even further and facilitating addiction and it becomes evident that leading up to the offense, Mrs. Aiken developed a toxic psychosis or akathasia. 

To gain a correct view of the influence of medication on the psychiatric symptoms, it is important to take the history into account. Mrs. Aiken has a limited psychiatric history, with problems that are part of daily life. She detoriated once she was put on antidepressants and was then prescribed more psychoactive medication. She went into full blown (toxic) psychotic episode, commits the offenses, stopped the antidepressants, deteriorated again. She then restarted the antidepressants, tapered them off, discontinued the co-medication, and improved. Mrs. Aiken has currently no sign of a psychiatric illness. The fact that after stopping the antidepressant without tapering off Mrs. Aiken deteriorated is a known phenomenon described in the DSM under code 995.29 "the Antidepressant Discontinuance Syndrome."  The importance of taking drug-drug and drug-gene interactions into account when prescribing medication cannot be over-stressed. If any other medication is added or she falls ill with an infection or suffers other health issues, she might very well start accumulating cyclobenzaprine, which has side effects that could mimic psychiatric symptoms. This could be interpreted as a relapse of a psychiatric disorder instead of an adverse drug reaction. I really think under no circumstances Mrs. Aiken should take any psychoactive medication, she [Mrs. Aiken] can not metabolize it. With writing this report, I have no intention of going over the trial again or to find any reason to criticize decisions made in the past. I simply want to inform health care providers about the developments in the field of pharmacogenetics, which can help them in weighing the risk whether or not Mrs. Aiken is still a danger to herself or the people around her. -S.J.M. Eikenlenboom-Schieveld, MD, Forensic Medical Examiner since 1999

the Expert Witnesses 

Dr. Keenan was hired by the prosecutor didn't interview family, friends, co-workers -- no one except, Anne's daughter months after her delusional state ended because she was no longer on the mind-altering Rx drugs. He concluded "she is sane and knows right from wrong today." 

Dr. Sugden researched Anne's daughter background to include interviewing family, friends, and co-workers. He concluded that Anne's daughter was completely out of her mind -- from the Rx drugs -- and had no way of knowing right from wrong at the time of the offense. The third doctor who testified at trial was the emergency room physician who attended to Anne's daughter a few hours after was and her two children were discovered unconscious by her husband. The E.R. doctor stated that Anne's daughter was delusional and clearly out of her mind. The judge concluded that the psychologist hired by the prosecutor drew the wrong conclusion about Anne's daughter.

THE SUPREME COURT OPINION

In one of the earliest cases on the topic (intoxication from prescribed medications), Perkins v. United States,14 the Supreme Court stated that if a defendant commits an offense while in a mental state amounting to insanity that was induced by a drug prescribed by a doctor, taken in good faith and in accordance with the prescription, then he is not guilty of the offense. In Perkins, a federal appellate court reversed a conviction of manslaughter when the defendant put forth evidence of delirium caused by chloral hydrate prescribed for nervousness.

In Minneapolis v. Altimus,12 a case cited as initiating the modern defense of involuntary intoxication, the defendant argued that he was not criminally responsible for driving under the influence of diazepam (Valium) because he was not aware of the side effects of intoxication. The Minnesota Supreme Court outlined three requirements for involuntary intoxication with prescribed medications: that the defendant did not know, or have reason to know, of the intoxicating effects of the medication; that the prescribed medication, not an alternate substance, caused the criminal behavior; and that the defendant can establish that insanity was induced by the medication (Ref. 12, p 857).

THE LAW

Involuntary Intoxication can excuse what normally would be regarded as a criminal act if;

My daughter met ALL three criteria but her public defender never motioned for Involuntary Intoxication. Why?

"As the stories unfold, let the facts be your guide and the truth be your compass."

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