Sunday, January 4, 2004 (SF Chronicle)
A Suicide Side Effect?/What parents aren't being told about their kids'
antidepressants
Rob Waters


   * Names and identifying details have been changed.

   For 16-year-old Angela Reich*, 2002 was a year of hell. First, the Palo
Alto teenager was diagnosed with a rare form of highly aggressive cancer.
Then she went through months of debilitating chemotherapy that made her
nauseous, caused her hair to fall out and kept her in bed for much of her
last year of high school. She handled it all with unflappable poise and
good humor until it seemed she was out of the woods. But the worst began
when she started taking the antidepressant Paxil.
   "Angela had been just pushing through and pushing through," says her
mother, Sara.* "She mustered all her strength and courage to face the
chemo and to be sick all the time." By the end of the summer, with the
most intense part of her treatment behind her, she was worn out and
discouraged. "She started to feel overwhelmed and depressed."
   She began seeing a therapist and talked openly about her feelings. But
after a few weeks her depression had not lifted, and Angela asked about
going on antidepressants.
   It took six weeks for the Reich's insurance company to approve a
psychiatrist, and by then Angela was in a deep funk. "She was not wanting
to get out of bed in the morning," Reich recalls. "She couldn't do her
homework. She said it felt terrible to live like this, but then she would
say, 'I don't want to die, I don't want to hurt myself.' I remember
sitting across from her at the kitchen table and tears pouring from her
eyes and her saying 'This is so hard.' "
   The psychiatrist prescribed Paxil, a selective serotonin reuptake
inhibitor (SSRI) similar to its famous predecessor, Prozac. On a dose of
5, then 10, then 15 milligrams a day, Angela soon started feeling better.
Five weeks after she began taking the medication, Angela and her mother
met with the psychiatrist, who suggested another boost in dosage. "He said
she's doing well now; she could be doing even better on 20 milligrams,"
Reich remembers. She was hesitant, but Angela wanted her old life back and
thought it made sense to try. The next day, she started on the higher
dose.

   Restless Legs, Sleepless Nights
   Within days, Reich says, her daughter was acting strangely. The first
change was Angela couldn't keep her leg still. "She'd be sitting in a
chair and her knee would be jerking up and down." She became irritable and
had more trouble sleeping. Her parents would ask about her restless,
jerking leg and she would snap at them to leave her alone.
   When Reich left on a business trip, Angela called her three or four times
a day and begged her to come home early. When she returned, Angela "burst
in my room and hugged me," Reich says. "She kept saying, 'Mommy, I'm so
glad you're home.' She was scared, like she couldn't cope. She said she
dreaded going to bed because she had so much trouble sleeping. She'd lay
there thinking and her thoughts got darker and became unbearable."
   That night, Reich shared her daughter's bed but Angela slept little and
was still wound up in the morning. When her mother tried to get her ready
for a piano lesson, she said she wasn't going. "She looked funny and had a
weird smile on her face," Reich remembers. "I knew something was wrong. I
looked around the room and saw some pill bottles. I asked if she took any
pills and she said 'Yes.' "
   Under questioning, Angela told her mother she had taken four tablets of
the sleeping pill Ativan. Then Angela ran to the bathroom, locked the
door, and started going through pill bottles. Her father, Jim, smashed the
door open and snatched a bottle of Benadryl from her hands. She ran to her
purse, seized a bottle of Tylenol and began shoving pills in her mouth.
Her mother grabbed her, pinned her arms, and marched her to the car, as
Angela's younger brother watched.
   Reich drove straight to a nearby hospital. One block from the house,
Angela turned to her mother. "She said 'Mom, I don't know why I did that.
It was like something took me over.' And I said 'I know, it wasn't like
you. But I will keep you safe.' "
   At the emergency room, the staff administered charcoal to absorb the
drugs, then transferred Angela to a psychiatric hospital. The next day,
the hospital psychiatrist called Reich. "He told me it was a drug-induced
suicide attempt," she said, related to the increased dosage of Paxil.
   Neither Angela, Sara nor her husband, Jim, an internal medicine doctor,
knew Paxil might carry a risk of triggering suicidal thoughts or actions.
Aside from a generic statement that depressed people are more likely to
attempt suicide, there is no mention of such a risk in Paxil's prescribing
information.

   England Acts, United States Follows
   The risk Paxil may pose to children and teenagers burst into the news
this
summer, when British regulators issued a warning urging doctors not to
prescribe the drug to children. They were acting on new data presented to
United States and British authorities showing that among 1,100 children
enrolled in clinical trials of Paxil, those taking the drug were nearly
three times as likely to consider or attempt suicide as children taking
placebos. "There is an increase in the rate of self-harm and potentially
suicidal behavior in this age group," said a statement from the British
Medicines and Healthcare Products Regulatory Agency (MHRA). "It has become
clear that the benefits (of Paxil) in children for the treatment of
depressive illness do not outweigh these risks."
   Nine days later, the FDA issued a similar warning and announced that it
would conduct a detailed review of pediatric trials of Paxil, a review
soon broadened to include seven other antidepressants, including top
sellers Prozac, Zoloft and Effexor. In August, Wyeth Pharmaceuticals
warned doctors that its drug, Effexor, triggered hostile behavior or
suicidal thinking in children at twice the rate as the sugar pills taken
as placebos.
   Then, last month, the MHRA announced that it was urging doctors to stop
prescribing a group of six antidepressants, including Paxil, Zoloft and
Effexor because they caused an increase in suicidal thoughts and actions.
"These products should not be prescribed as new therapy for patients under
18 years of age with depressive illness," wrote Gordon Duff, chairman of
the MHRA's Committee on Safety of Medicines, in a "Dear colleague" letter
to British physicians.
   Prozac, the only SSRI approved for use in depressed children, was not
included in the new warning. The British review did not find a significant
increase in the risk of suicide-related events among children taking the
drug.
   The British and American warnings were a stunning turnaround that left
thousands of parents whose children are using the drugs wondering whether
their children were at risk. But it was also long-sought vindication for a
small group of researchers, family members and lawyers who have been
arguing for years that antidepressants cause some people to become
violently unhinged. They say they've been frustrated in getting this word
out to the public, in large part because of the FDA's unwillingness to
confront and control the drugmakers.
   The FDA's warning about a possible suicide risk from Paxil left Sara and
Jim Reich feeling furious, betrayed, and ready to sue. "Had I known there
was a threefold increased risk of suicide among kids taking Paxil, I would
not have allowed my daughter to go on that drug," said Jim. In fact, Jim
has prescribed the drug himself and is outraged that the Physician's Desk
Reference, or PDR - the drug bible for doctors, based on FDA-approved
prescribing information - says nothing about Paxil's suicide risk.
   The British and American warnings also raised some troubling questions:
How did drugs that have been widely promoted as nearly risk-free, and that
are commonly prescribed by pediatricians and child psychiatrists, come to
be seen as potentially dangerous? What should parents whose children are
taking them do about it? And just how effective are these drugs that can
sometimes cause such serious problems?

   An Uncontrolled Experiment
   Since 1987, when Prozac became the first SSRI on the market, America's
love affair with antidepressants has worked its way down the age ladder.
Between 1987 and 1996, the use of antidepressants and other psychotropic
medications by children and adolescents tripled, with most of that
increase occurring after 1991, according to a recent study in the Archives
of Pediatric and Adolescent Medicine. By 1996, the study found, 6 percent
of American children and teenagers were taking psychotropic medications,
one-third of which were antidepressants.
   Biological solutions to behavioral problems were becoming increasingly
acceptable, even fashionable. "I think there's been a revolution in the
way people think about behavior," says Lawrence Diller, a behavioral
pediatrician in Walnut Creek. "The idea that children's behavior is the
product primarily of their genetics and biochemistry was promoted by
American psychiatry and hijacked by the drug industry. It's simply become
more acceptable to see behavior as a reflection of an imbalance in
chemistry rather than an imbalance in life."
   The phenomenal growth in antidepressants prescribed to children leaves
many doctors and therapists uneasy. Diller, who has written about his
misgivings in two books ("Running on Ritalin" and "Should I Medicate My
Child?"), cautiously prescribes antidepressants to some children, but says
the new data about a possible link to suicide is making both him and some
parents think twice. "It hasn't caused me to stop using SSRIs,
particularly in teenagers, but I think it's another reminder that our
information is incomplete."
   To understand how we got here, it's important to know a bit about the
drug- approval process. When a drug company applies to the FDA for
approval to sell a medication, it must demonstrate that the drug is safe
and effective for a particular population, such as adults, and a specific
condition, such as depression. Once the drug has been cleared by the FDA
and is on the market, doctors are free to prescribe it to anyone for any
reason. "Off-label" prescribing, is quite common; the only real
restriction is that drug companies cannot market drugs to unapproved
groups. From 1987, when Prozac was first approved for adults, until early
last year, when Prozac became the first SSRI approved for use in depressed
children 7 and older, all antidepressants used by depressed children were
prescribed off-label.
   The widespread use of antidepressants by children, critics say, amounts
to
an uncontrolled national experiment. The prescribing physicians are often
pediatricians or family doctors with little or no training in
psychopharmacology. The drugs are frequently given in the absence of
therapy or other interventions. The subjects of the experiment - children
- are too young to give meaningful consent. There is little understanding
of the long- term effect these medications have on the architecture of
children's developing brains. And the evidence that the drugs are
effective is less than impressive.
   When Prozac was approved for depressed children last year, it was on the
strength of two controlled trials. One, published in 1997 in the Archives
of General Psychiatry, found that after eight weeks, 56 percent of kids
taking Prozac showed some improvement, according to the clinicians who
evaluated them, compared with 33 percent of the kids in the placebo group.
But 69 percent of the kids taking Prozac still had significant symptoms of
depression. Clinical trials of Paxil, Zoloft and Effexor found those drugs
to be no more effective than placebos in treating depressed children.
   Perhaps the most notable finding from clinical trials of antidepressants
is how many children respond well to placebos - as many as 59 percent in
some studies. This high placebo response rate is a common finding in
pediatric drug trials, in which children are generally seen once or twice
a week by clinicians, says David Healy, an internationally known
psychopharmacologist from the University of Wales College of Medicine who
has emerged as a prominent critic of drug company practices. "This
suggests that simple support can help children in many cases," Healy says.

   SSRIs: Cleaner and Safer?
   In the years since 1987, SSRIs have developed a reputation for being
largely free of serious side effects, vastly improved over the older
generation of so-called tricyclic antidepressants. In some respects, this
is true: Distressed patients who attempt to kill themselves by overdosing
are unlikely to succeed; they can usually tolerate the pills. And patients
taking tricyclics are more likely to suffer from constipation, urinary
retention, blurred vision and dry mouth.
   But SSRIs cause sexual problems at fairly high rates, as well as
insominia, nausea, dizziness and other side effects. Studies also have not
found them to be more effective than the older pills at relieving symptoms
of depression. "The SSRIs have sold themselves very heavily as safe and
clean drugs compared to the old antidepressants," says Healy. "Well, it's
not clear that they're safer, and it's not clear that they cause fewer
side effects."
   One side effect of SSRIs, recognized for at least 15 years, is a
sensation
called akathisia, a restless agitation that ranges from jitteriness to a
sensation described by some people as "jumping out of their skin." Healy
believes akathisia is the principal trigger for impulsive violence in some
people taking SSRIs. "They became anxious, agitated, terrified, unable to
sleep at night and restless," he says - the symptoms that plagued Angela
Reich.
   There have long been signs that SSRIs sometimes cause these reactions,
which drug manufacturers have tried mightily, and largely successfully, to
keep out of the public eye and off the labels. This issue first arose a
couple years after Prozac went on the market, amid a raft of media reports
about grisly acts of murder and suicide. The most notorious event took
place in 1989, when Joseph Wesbecker went on a shooting frenzy, killing
nine fellow workers of a Louisville, Ky., printing plant before turning
his gun on himself. Wesbecker, who had a history of mental problems, was
taking Prozac. No one could prove Prozac caused his rampage, but by early
1991, some 350 suicides of Prozac patients had been reported to the FDA,
according to one former FDA official. Those reports, which occurred
outside the context of scientific clinical trials, were dismissed as
anecdotal and sensational by company officials.
   Harder to dismiss, though, was a study published by Harvard researcher
Martin Teicher and two colleagues in the American Journal of Psychiatry in
1990 about six patients who developed "violent suicidal preoccupation"
after taking Prozac for two to seven weeks. "It was also remarkable how
violent these thoughts were," the authors reported. "Two patients
fantasized, for the first time, about killing themselves with a gun," they
wrote, while one placed a loaded gun to her head, another had to be
restrained to prevent self- mutilation, and another fantasized about
killing himself in a gas explosion. None of the patients was suicidal when
they started taking Prozac, the researchers reported, and their fixation
with violence and death abated when they stopped.
   Similar symptoms were noted the next year in a paper in the American
Journal of Child and Adolescent Psychiatry about six children ages 10 to
17 who developed "intense self-injurious ideation or behavior" while
taking Prozac. After three weeks on the drug, one 14-year-old girl, who
had been depressed but never suicidal, began cutting and otherwise
injuring herself. She told hospital staff, "I'm just waiting for the
opportunity to kill myself, " and chanted, "Kill, kill, kill; die, die
die; pain, pain, pain," according to the paper. The Yale University
authors noted the complexity of reaching any conclusion about the cause of
these events since the children all had lengthy histories of psychiatric
difficulties that put them at risk for suicide. They also noted that many
children taking Prozac become agitated, restless, and disinhibited and
developed insomnia to boot.
   A 1998 paper by Roger Lane, a scientist at Pfizer, the maker of Zoloft,
stated that "all SSRIs have the rare potential to cause akathisia." In its
most extreme form, Lane wrote, patients may feel that "death is a welcome
result."
   Lane also warned that akathisia can sometimes be mistaken for worsening
depression, prompting some doctors to increase the dosage - and the
danger. Healy agrees. "[Doctors] have been educated to think that SSRIs
take four, five, six weeks to work," he says. "But they can cause problems
long before that."
   In response to the Teicher paper and the growing media furor connecting
Prozac to acts of violence and suicide, the FDA in September 1991 convened
an extraordinary special hearing of its Psychopharmacological Drugs
Advisory Committee. Speakers told of family members who committed suicide
or homicide while on Prozac and begged agency officials to ban or restrict
the drug. But representatives of Eli Lilly, maker of the blockbuster drug,
backed by FDA and academic researchers, argued that suicide is an inherent
risk among depressed patients. The Lilly officials presented figures from
the company's clinical trials database suggesting that people on Prozac
were at no greater risk of suicide than people taking placebos.
   Committee members voted unanimously in Lilly's favor, and Prozac remained
on the market. No warning that the drug might induce violent or suicidal
urges in some people was added to its label.

   'Cooking the Books'
   The Prozac suicide controversy, and the huge number of suicide reports
that were streaming into the agency, reverberated inside the FDA, where
two other SSRIs, Paxil and Zoloft, were being considered for approval. The
FDA medical officer charged with reviewing Paxil's safety and efficacy
data was Martin Brecher, now an executive with the British pharmaceutical
company Astra Zeneca. "The reports of successful suicide were coming in in
bunches," he said in a recent deposition. "It was extraordinary,
especially in comparison to other annual reports where, you know, you had
20 reports of a cold and maybe two reports of some liver enzyme elevations
and here you are with 20 deaths in a report."
   Because Paxil and Zoloft were members of the same chemical class as
Prozac, the FDA asked officials at SmithKline Beecham (the predecessor to
GlaxoSmithKline) and Pfizer, Zoloft's maker, to submit reviews on the
drugs' effect on suicidal behavior of patients. Brecher called Thomas
Donnelly, a SmithKline Beecham executive, and asked him to prepare such a
report. In an internal company memo uncovered in a lawsuit, Donnelly
described his conversation with Brecher, noting that the FDA "does not see
it as a real issue but rather as a public relations problem."
   What happened next is controversial. Critics charge that the company
manipulated data to diminish the apparent suicide risk among Paxil users
and submitted it to the agency. One of the harshest critics is an unlikely
plaintiff's attorney in San Rafael, a self described conservative
Republican and retired Navy officer named Don Farber.
   Farber, who has spent the better part of the past five years suing Glaxo-
SmithKline and other drug companies, is one of a handful of lawyers
handling such cases. His first case involved a San Jose man, Reynaldo
Lacuzong, who, in 1996, drowned his two children and himself in a bathtub
three days after he began taking Paxil. After the suit was filed,
GlaxoSmithKline and the surviving Lacuzong family resolved the case with
an undisclosed settlement.
   The same thing has happened in dozens of other cases of alleged SSRI-
induced suicide or violence; few cases ever go to jury. In June 2001,
however, a case did. Three years earlier, Donald Schell, a 60-year-old
Wyoming man, killed his wife, daughter and granddaughter three hours after
taking two tablets of Paxil given to him as samples by his internist.
Surviving family members sued GlaxoSmithKline, and the jury awarded them
$6.4 million for the wrongful deaths of their relatives.
   "[The company] knew there was a small group at risk and Don Schell was
one
of those vulnerable people," the family's attorney, Andy Vickery told the
jury. Farber makes the same argument: Drug companies have an obligation to
warn doctors and patients that these drugs can pose a threat to some
people.
   "If there was a warning that said 'Caution: this drug may cause suicide
in
some people,' then doctors are going to know about it," Farber says.
   Instead of warning people, Farber charges, Glaxo-SmithKline tried to hide
the true numbers. "They cooked the books," says Farber during a recent
interview. "They cheated on the results. And the FDA is part of this."
   Farber says the company manipulated the figures. Documents obtained by
The
Chronicle show that in its initial application to the FDA, the company
reported that out of 2,963 adults taking Paxil during clinical trials in
the United States or other countries, seven patients killed themselves and
42 attempted suicide. But in a review submitted in April 1991, in response
to Brecher's request, the seven suicides had dropped to five and the 42
attempts had gone down to 40.
   At the same time, the number of attempted suicides by patients taking
placebos doubled from three to six in the later review. The 1991 review
also acknowledges that two suicides and two suicide attempts charged to
placebo occurred during a one-week "washout" period that came before the
start of the study. During that period, subjects were taken off any drugs
they had been using to get the drugs out of their system. Experts say it
is inappropriate to count events during the run-in period as placebo
events.
   Company officials admit there were errors made in reports filed with the
FDA, but deny any attempt to mislead. "There were unfortunately some
inconsistencies in how the data on suicide attempts was presented to FDA,"
says GSK spokeswoman Mary Anne Rhyne. "When we became aware of this, we
went back and looked at the clinical trial data again. GSK did not
intentionally submit any erroneous or misleading information to FDA. The
suicide data submitted to FDA explicitly identified when events occurred
during the placebo run-in period. FDA had all this information right from
the beginning."
   Farber contends that these small shifts in numbers make a big difference
in suicide rates. He claims that a close look at the data reveals that
only one placebo patient out of 554 attempted suicide, while 49 patients
out of 2,963 taking the drug committed or attempted suicide - a ninefold
difference.
   Rhyne disputes this analysis. "The randomized, placebo-controlled data
shows no statistically significant differences in suicides or suicide
attempts between Paxil and placebo," she says.

   Drug Firms and the FDA: Too Close?
   For its review of all pediatric trials of antidepressants, the FDA is
reanalyzing the data to determine whether reports of suicidal ideation
among children were categorized properly. Critics are concerned that this
reanalysis may minimize the apparent suicide risk to the benefit of drug
companies, and contend that the agency has a long history of protecting
the industry. They point to company memos, uncovered through legal
actions, that reveal a sense of confidence within the companies that the
FDA was on their side. Memos from Eli Lilly executives described one FDA
official, Paul Leber, as "our defender" and cautioned that faxes should
not be sent to him unless he knew they were coming so he could receive
them personally.
   Other memos suggest Lilly officials went to great lengths to conceal any
hints that Prozac might trigger suicide. Consider this line from a 1990
memo to Lilly executive Leigh Thompson written by Claude Bouchy, a Lilly
official in Germany, in response to a request to change the description of
an event from "suicidal ideation" to "depression." Bouchy writes: "Hans [a
fellow Lilly employee] has medical problems with these directions and I
have great concerns about it. I do not think I could explain to the BGA
[the German FDA], a judge, to a reporter, or even to my family why we
would do this, especially on the sensitive issue of suicide and suicidal
ideation."
   Critics charge that the pro-industry stance of FDA officials prevented a
more thorough examination of the role antidepressants may play in
triggering suicide and violence in some users. They also charge that many
American psychiatric researchers have been compromised in their ability to
look objectively at this issue because they are so dependent on funding
from pharmaceutical companies.
   The FDA's Thomas Laughren rejects the notion that his agency is
protecting
drugmakers. "The goal here is to get to the truth," he says. For the
review of pediatric trials of antidepressants now under way, the agency is
bringing in a panel of experts as judges. "We're taking all the cases and
having them reclassified blindly," he says. "They'll be looking at all the
information that is relative to the question of suicidality and they will
not know the drug assignment."
   As the agency reviews the data, experts will debate a core question: how
to reconcile reports of antidepressants triggering suicidal behavior with
other studies that suggest that these drugs reduce suicide rates. A paper
published in the October Archives of General Psychiatry found that regions
of the country where the use of antidepressants by children increased the
most also tended to have the greatest drop in suicide rates.
   Could antidepressants lower the suicide risk in some people while raising
it in others? "It's entirely possible that both things are true," says
Mark Olfson, a professor of clinical psychiatry at Columbia University and
lead author of the Archives paper.
   David Healy says the drugs simply have different effects on different
people. "My hunch is that, just as with adults, there is a group of
children who are suited to the pills and do very well on them and an
equally large group of kids who are not." Among those who don't do well,
Healy says, are some who get much worse.
   One thing most experts seem to agree on is that patients, especially
children, should be monitored closely for side effects from the day they
start taking the drugs. "They may be more anxious or have unusual thoughts
they've never had before," Healy says. "They may think about harming
others or themselves." Healy also suggests asking children if they've had
strange dreams, nightmares or thoughts since they started taking the drug.
"The other thing to look out for," he says, "is the opposite effect: Kids
who become absolutely fearless, they just don't feel anxious at all."

   Tragedy Strikes
   On Feb. 2, nearly 13 years after the 1991 Prozac hearings, an FDA
advisory
committee will once again hold a hearing about the risk of suicide by
people taking antidepressants, this time focusing on the risk to children
and teenagers. The meeting will come too late to help 17-year old Julie
Woodward of North Wales, Pa.
   In July, Julie began attending a two-week group therapy program at nearby
Horsham Clinic. A break-up with a boyfriend and conflicts with her parents
had left her feeling withdrawn and in a struggle to maintain good grades.
One condition of attending the program was taking antidepressants, Tom
Woodward says. He and his wife didn't really like the idea, but were told
they were "essential to treatment" and "very benign."
   On day three of the program, Julie began taking 50 milligrams of Zoloft,
and that night came the first signs of unusual behavior. Julie and her
mother had a small dispute, and Julie roughly shoved her mother, an
out-of-character act, Woodward says.
   During the next few days, Julie became more edgy and withdrawn. On the
evening of day six, she told her parents she wanted to stay home alone.
But when they looked for her later that night, they couldn't find her. The
next day, her father found her body hanging in the garage. One week after
starting on Zoloft, she had taken her life.
   When the FDA hearing comes, Tom and Kathy Woodward plan to testify, as do
Jennifer Tierney and her daughter, Jame, of Kernerville, N.C. The
Tierneys' story exemplifies another part of the antidepressant story:
withdrawal.
   All SSRIs have been reported to cause withdrawal problems in some
patients
who stop taking them. Paxil and Effexor, however, seem especially likely
to trigger withdrawal symptoms, probably because they exit a user's body
more rapidly. "Paxil has been linked to more reports of withdrawal
symptoms than any other drug in clinical history," says Karen Barth, an
attorney with Baum- Hedlund, a Los Angeles firm that is representing some
3,000 people who have suffered withdrawal problems on Paxil.
   Jame Tierney was 14 when she was prescribed Effexor to ease migraines
she'd been suffering from for years. She started with Effexor and other
drugs, but gradually went off the others. She enjoyed eight good months of
reduced headache pain. Then the migraines worsened and her neurologist
doubled the dose. Within two weeks, her personality began to change. "She
became the most angry, combative, raging child you've ever seen," says her
mother. "I'd never seen her like this and I had no idea why."
   Jame was also unhappy and depressed. "I was hopeless, and I thought
suicide was the only way out," she recalls. "I had violent thoughts and
tendencies that I'd never felt before." She contemplated killing herself
and made one attempt to cut her wrists.
   She remained on 150 milligrams and in a raging misery for a full year,
functioning at school but isolating herself in her room. Then her mother
learned Effexor wasn't a headache drug but an antidepressant, unapproved
for children, which can sometimes cause serious side effects. Over the
objections of the neurologist, Jame tried to taper off the drug. Her
personality quickly returned to normal, but she suffered terrible
withdrawal symptoms - constant vomiting, headaches, muscle aches and
disequilibrium that kept her out of school for months. Finally, on advice
from a California doctor, she began taking vitamin and enzyme supplements.
After six months, the withdrawal symptoms ended and her headaches are now
a rare event. Her bout with depression, which she experienced only on
Effexor, also came to an end.
   While Jame was weaning herself from Effexor, Angela Reich was trying to
get off Paxil. Her dose was cut to 15 milligrams a day while she got
through the next round of chemo. She lowered her dosage - to 12.5 mgs,
then 10, then 7.5, 5, and 2.5 over four weeks. Finally, on Jan. 24, she
took no Paxil. That's when the side effects began.
   "She couldn't sit up, she had trouble walking, and she was dizzy," Sara
recalls. "She couldn't walk straight, and she had this zapping, this
electrical feeling in her arms."
   The restless akathisia was gone, but Angela was uncomfortable, depressed,
and irritable - "really irritable," her mother says. One night, Angela
nearly flipped out. She ran into the living room, screaming, and started
grabbing books off the shelves and heaving them. "She tore them up and
said she hated them, she hated us and she hated the people around her,"
Sara says. "Then she grabbed for some knives." Her father restrained her
and held her until she calmed down. But the whole family was shaken. "I
started to feel like 'Oh my God, my kid has gone insane,' " Sara says.
   Somehow Angela and her family got through the next month, and she
gradually started to feel normal. She went off to college in September and
is doing well, her parents say. Best of all, as this article was going to
press, she got another negative biopsy report on her cancer.
   Angela didn't want to talk about her Paxil experiences with a reporter -
"It's just too painful," her mother explained. But she did want to join
the lawsuit that Baum-Hedlund is pursuing against GlaxoSmithKline. "She
wants to prevent anyone else from going through this kind of nightmare.
She wants to save other people from suffering like she suffered."

   Berkeley-based writer Rob Waters' articles have appeared in Health,
Parenting, and the Los Angeles Times. He is the co-author of "From Boys to
Men: A Woman's Guide to the Health of Husbands, Partners, Sons, Fathers,
and Brothers," which will be released in April.
----------------------------------------------------------------------
Copyright 2004 SF Chronicle