I have always been a big fan of the documentary program The Passionate Eye on CBC, Canada’s public broadcaster. Until now. On January 6, 2018, they aired “A Prescription for Murder?“, which was originally shown on the BBC. The program focused on James Holmes, the young man who shot and killed 12 people and injured 70 in a movie theatre in the United States in 2012. The central argument is that the SSRI (selective serotonin reuptake inhibitor) class of antidepressants can, in rare cases, cause people to become psychotic, violent, and homicidal.
The lead-up to a mass shooting
According to the documentary, Holmes first started seeing a psychiatrist at his university’s student wellness centre 17 weeks before he committed the murders. He reported social anxiety and intrusive thoughts of killing people; these thoughts were not new, but it was the first that he had disclosed them. After the killings, he told a psychiatrist that he had experienced thoughts of killing people since his teens as a sort of social avoidance strategy. The psychiatrist at the wellness centre started him on the SSRI sertraline, at a dose of 50mg per day.
Not long after, he described a theory he referred to as “human capital” that involved intentions to kill people. The dose was increased over the next 4 weeks to 150mg per day, as his intrusive thoughts were increasing. A little under 3 months after starting sertraline, he had made the decision to drop out of school, and declined his psychiatrist’s offer to continue treatment and start him on an antipsychotic.
It is not clear when he stopped taking the sertraline, but his last prescription would have run out 3 weeks before the shootings. The journalist argues that because of the timing it is likely that Holmes’ homicidal behaviour was triggered by the sertraline. Various psychiatrists are interviewed for the film, with several expressing the belief that the sertraline had triggered psychosis, which led to the killings. One went so far as to suggest that if Holmes hadn’t been put on sertraline the murders might not have happened.
Do SSRIs cause mass murder?
The documentary bothered me on multiple levels. If someone wants to make a film arguing that SSRIs can trigger psychosis and people should be aware of that, okay, so be it. But the choice of title is clearly intended to be sensational, as is the tagline “Is it possible that a pill prescribed by your doctor can turn you into a killer?”.
On the Canadian broadcast that I viewed, on multiple occasions a banner ran across the top of the screen warning that people should not stop taking their medication without first seeking medical advice. It seemed utterly absurd to be including this message for a film arguing that SSRIs turn people into mass murderers. If one pays enough attention, the more nuanced argument being made is that SSRIs can cause psychosis and this can precipitate homicidal behaviour; however, what’s missing is the key piece of information that the probability of a psychotic person committing homicide is extremely low. That is a very different can of worms than simply connecting SSRIs and homicide.
Temporal correlation does not prove causation
Another flaw in the argument that is never acknowledged is that temporal correlation, i.e. things being related in terms of timing, does not necessarily imply causation. I’ll talk more about this in an upcoming post about research literacy, but it is flawed logic to think that because Mr. Holmes took sertraline shortly before he committed a mass shooting, the only or best explanation is that the sertraline caused it. The documentary does not even touch on alternate explanations, the most obvious (at least to me) being that he was started on the medication because he was getting sick, it didn’t work, he got sicker, and he became psychotic, which triggered him to act on thoughts he admitted he’d been having for years.
Potential consequences of this messaging
I worry that some poor person with mental illness is going to watch this and think oh, I don’t want to be on a medication that’s going to make me a killer. And maybe that person will stop the SSRI they are already taking, or avoid going to see a doctor to seek help for distressing psychiatric symptoms. Maybe that will mean they get sicker. And maybe, just maybe, that could have disastrous consequences like suicide.
I have no hesitation whatsoever in saying that the risk of suicide from a depressed person not taking an antidepressant is higher than the risk of someone taking an SSRI and committing mass murder. There is no indication that the filmmaker has given any thought to these sorts of outcomes that could snowball in response to the messaging that antidepressants can turn people into murderers.
There also seems to be no consideration given as to how this documentary might affect public attitudes toward mental illness in general and psychiatric medication in particular. There is already more than enough stigma around this, and I for one do not want some random idiot thinking that I might fly into a homicidal rage because of my antidepressants. Someone who hasn’t lived with mental illness might think this concern is overblown, but the stigma around taking psychiatric medication is very real, as is the potential of this stigma to cause harm. By choosing to air this documentary, the BBC and CBC have chosen to move backwards in terms of stigma, exactly the opposite of where those of us blogging about mental health are trying to go.
I’m sickened by how irresponsible the BBC and CBC are for broadcasting this documentary. The same issue could potentially have been explored in a way that utilized much safer messaging. Being cynical, I’m guessing that this particular approach was chosen in order to generate buzz and viewership. I can only hope that it won’t do as much damage as I think it has the potential to.
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