A Bitter Pill
Sydney
Morning Herald, June 19 2004
They
were lauded as the miracle drugs: a new generation of antidepressants that
promised to make us "better than well". But for Merrilee Bentley they did the
opposite: her spiral into darkness ended when she tried to kill herself and her
two daughters.
Richard Guilliatt reports.
The day Merrilee Bentley
tried to kill herself and her two daughters began like every other day she
endured last winter. Some time around 8am, Bentley awoke in a fog of fatigue and
listlessness, shuffling into the kitchen of the small bungalow she shared with
her husband, Mat, in the orchard country south of Perth. Her 10-year-old
daughter Ally was getting ready for school, two-year-old Lauren was awake, and
Mat was preparing to leave for his job at a local sawmill. Bentley tried to help
with breakfast, but felt overwhelmed by exhaustion. She thought about asking Mat
to stay home from work, but money was tight, so she let the idea pass. In the
kitchen, she made herself a cup of coffee and swallowed two tablets of Effexor,
the antidepressant
she'd been taking in ever-increasing doses for six months.
At 31, Bentley was in the grip of a fearsome depressive spiral. The previous
year she had tried to kill herself four times, twice by hanging. Each new day
now brought incessant thoughts of suicide, as if a malignant growth had taken
root in her mind. On this particular day, her social worker was unavailable and
she began to feel increasingly agitated. Almost as if she were fleeing her own
thoughts, Bentley grabbed the car keys and resolved to drive 220 kilometres
north-west to Perth. She put Lauren in the car, picked up Ally from school, and
was heading west to Bunbury when a familiar idea began gnawing at her.
"I was thinking, 'No one cares. No one's there. I'd be better off dead.'" A year
later, Bentley still cannot recall the events of that day without sobbing. "And
because my children were with me, they kind of came into the argument in my
head: should I just turn around and take them somewhere, or should they come
with me? And the argument in my head was, 'No, don't let them be without a
mother.' So I convinced myself to take them with me."
After driving into Bunbury,
Bentley hocked her wedding ring for some cash and bought a length of rubber
hose. At a Hungry Jack's restaurant, she sat watching her children in the
playground while she composed a letter to them, expressing her sorrow for what
she was about to do. Putting the girls back in the car, she drove north for
nearly an hour and pulled over at a wayside stop off the highway near Waroona.
She ran the hose from the exhaust pipe into the back window, telling the girls
it would warm the car, and sat in the back with them, listening to the radio.
But the hose was kinked, and nothing happened, so Bentley tried to shake herself
free of her death wish and drove on towards Perth.
"I stopped at a petrol station, and Ally asked for a bottle of Fanta. And I
looked at the bottle and thought, 'That'll fit on the exhaust pipe.' And all
these thoughts came back - just on and on and on and on. I bought some tape and
I bought scissors, and I cut the bottle and put it on the pipe. I found another
car park and I put the bottle on the exhaust and put the hose in the
window. I could smell the fumes a lot more.
"I really thought you just
fell asleep. We were sitting in the back seat, and after about 10 minutes Ally
said, 'It stinks.' I said, 'Just rest,' still convincing myself I had to do
this. Then my eyes started to sting a bit, and I was getting confused. And Ally
was starting to hold her nose and Lauren was starting to cry and get upset. Ally
said, 'It's horrible,' and I said, 'Well, get in the front.' So she got in the
front seat for about 30 seconds and I saw her going towards the door and I said,
'Just get out,' as she was opening the door.
"Then I got really angry with
myself, because although I knew what I was doing, I didn't actually want to
cause them any pain. I didn't want to hurt them. So I opened the back door, sat
Lauren on the back seat, and I went and got the hose and ripped it out and threw
it in the bush." In the weeks that followed these few hours, Bentley's life
disintegrated. Her fragile marriage collapsed, her children were taken away from
her, and she found herself huddling in a concrete police cell in Bunbury charged
with attempted murder, before being sent to Graylands psychiatric hospital. But
amid all this trauma, separated from everyone she knew, she also came to a
pivotal decision: on July 5, a week after her antidepressant dosage was
increased to 450mg a day, Bentley stopped taking Effexor. Within days, she began
to feel better. Her energy returned, the suicidal obsession ebbed away, her mind
cleared. By September, a psychiatrist pronounced her free of depressive
symptoms.
Today, Bentley is convinced
that Effexor drove her to the brink of murder, and last month the Chief Justice
of Western Australia came to much the same conclusion. The implications of that
carry far beyond Bentley's life, because her case is simply the latest in a
succession of tragedies that have raised persistent and disturbing questions
about the "miracle" of modern antidepressants.
In the history of drug-induced euphoria, there has never been anything quite
like the Prozac phenomenon. Launched by Eli Lilly in 1988, this tiny pill came
to embody the seductive promise that science had found the key to human
happiness. Prozac regulated the brain's serotonin levels and thus, it was
claimed, made people "better than well". It became a cultural touchstone -
dissected on talk shows, emblazoned on countless magazine covers, name-checked
in pop songs and movie titles, extolled in
countless best-selling books. It spawned its own buzz-phrases - Prozac Nation,
Listening to Prozac - and reaped billions of dollars for the pharmaceutical
industry, which quickly launched a range of copycat drugs like Zoloft, Aropax,
Paxil and Luvox.
These drugs, the selective serotonin reuptake inhibitors (SSRIs), were said to
be non-addictive, came in a one-size-fits-all dose and were virtually impossible
to overdose on.
But from the very beginning,
the effusive testimonies of people who had experienced the "Prozac miracle" were
shadowed by other stories from people who underwent bizarre transformations,
becoming agitated, aggressive, emotionally blunted and suicidal.
A series of violent murders
and suicides linked to the drugs sparked alarm in the early 1990s, but the drug
companies successfully fought off lawsuits, and the US Food and Drug
Administration (FDA) reviewed the evidence and pronounced them safe. By the late
1990s, however, several drug companies had been forced to hand over their
internal records to personal injury lawyers, and it became clear they had
suppressed damaging data. In 2001, a Wisconsin jury ruled that the SSRI drug
Paxil had caused 60-year-old Donald Schell to kill his wife, daughter,
granddaughter and himself in a shooting frenzy. Three weeks earlier, a NSW
Supreme Court judge ruled that an overdose of Zoloft had caused 76-year-old
David Hawkins to strangle his wife. Drug companies have settled dozens of
lawsuits. Meanwhile, British health officials last year banned the use of all
SSRIs
except Prozac for treating under-18-year-olds, revealing that clinical trial
data on Paxil - which the drug company GlaxoSmithKline had suppressed - showed
an increased risk of suicidal behaviour for minors.
According to the Los Angeles Times, an unreleased report last year by the FDA
came to very similar conclusions, in particular about Paxil and Effexor. US
health authorities are now reviewing all data on SSRIs, and many drug experts
are now acknowledging there may be a dark underside to the SSRI phenomenon.
Prominent among them is Dr David Healy, a clinical researcher from the UK. Healy
has worked as a consultant to many of the major drug companies and written
several books on the history of psychiatric medicine. He remains a firm advocate
of drug treatment for depression and thinks SSRIs work well for many people. But
he has become the drug industry's worst nightmare: an authoritative expert who
believes SSRIs are also killing thousands of people every year.
In his latest book, Let Them Eat Prozac, Healy uses drug company research data
and his own expertise to argue that SSRIs may induce suicidal thoughts in as
many as 1 per cent of patients. (If that sounds like fairly small odds, consider
that 50 million prescriptions for these drugs have been written in Australia
since Prozac came on the market.) What's more, Healy says, the pharmaceutical
industry knew this from the beginning but hid the problem by sanitising the
data. And, in doing so, they enlisted the help of many scientists who accepted
industry money to conduct research, or attached their names to ghost-written
research papers. A case in point is Effexor, the drug Merrilee Bentley was
taking when she tried to kill her children. Healy recalls that several years
ago, he was invited to a luxury convention centre on the Californian coast where
Wyeth
Pharmaceuticals, Effexor's manufacturer, was sponsoring a conference on
depression. As part of the deal, Wyeth had paid ghost writers to draft a "David
Healy" paper which he could present on the difficulties of achieving "full
remission" of depression - a phrase which happily coincided with Wyeth's
marketing campaign for Effexor. Healy declined the offer, but the article
subsequently appeared in the Journal of Psychiatry and Neuroscience, under
another researcher's name. Healy's outspokenness has incurred the full wrath of
mainstream psychiatry. At a recent symposium on antidepressants in Sydney, one
psychiatrist, Dr. Olav Nielssen, dismissed Healy's work in a few sentences and
said "there's a word in Yiddish I could use to describe him". Professor Ian
Hickie, director of the Brain and Mind Research Institute at the University of
Sydney, says Healy is a "hired gun" who uses selective research to help people
sue drug companies. Hickie points out that the suicide rate among older
Australians, who are prescribed the lion's share of antidepressants, has fallen
since the advent of SSRI drugs. Furthermore, he says, doctors are extensively
educated on the side effects of these drugs and appropriate warnings for
patients. That wasn't the case, however, for Merrilee Bentley. In all her years
seeking treatment for depression, Bentley cannot remember a doctor ever warning
her that antidepressants might worsen suicidal impulses. She was first diagnosed
with depression as a child, after her mother left home on Christmas Day 1978,
leaving her father, Philip Wright, with four daughters under the age of 13.
Wright remarried and his new wife, Avril, developed a strong bond with the
girls. But Merrilee was the youngest and most emotionally vulnerable of the
sisters, and fear of rejection became a recurring motif in her life.
At 16, she left home, eventually moving in with her biological mother in Bunbury,
180 kilometres south of Perth. It was a fraught relationship, however, and the
events of 1978 were never really resolved. By 22, she had a son, Carl, and a
daughter, Ally, with her then boyfriend, Daniel. But Daniel became violent and
she moved 50 kilometres inland to Collie, struggling to cope with life as a
single mother. "I'd say that's when it started," she recalls, sitting in the
lounge room of her father and stepmother's home in bushland near Collie, on a
late May afternoon. "Being a single mum, being lonely, meeting guys who just
wanted to have sex with you." She sighs. "Just longing to be loved. In 1995, I
tried Prozac, which really didn't agree with me - it made me a bit aggressive, a
bit angry." It's almost a year since Bentley tried to kill herself and her
children, and for all the tears and sorrow that punctuate her conversation, it's
clear she has undergone a remarkable transformation. A year ago, she weighed 76
kilograms and was "a walking vegetable". Today, she is 20 kilos lighter and has
been drug-free since September. The dark circles under her eyes hint at the
difficulties she is till grappling with: her children have been in the care of
various relatives since June 2003 and she is not allowed to see them without
supervision; she has separated from her husband and lives in a small bungalow
near her father's house; she has pleaded guilty to four counts of attempted
murder (two for each child) and is scheduled to be sentenced by the WA Chief
Justice the day after our interview. But despite it all, she talks with resolute
candour about the calamitous events of the past year.
Like so many people suffering depression and stress, Bentley turned to her local
doctor for help and was handed a packet of pills. After Prozac she tried Zoloft,
but it made her nauseous. In August 1996, she met her current husband, Mat
Bentley, who was six years her junior, but the relationship was stressed from
the beginning by the disapproval of his family. Acutely sensitive to the
smallest rejection, Bentley first had suicidal thoughts after an argument with
Mat in early 1998, around the time she was first prescribed Aropax. Whether the
suicidal thoughts followed the Aropax, or vice versa, is unclear.
It's this very issue that
sparks the fiercest arguments in the antidepressant debate. Depressed people
often feel suicidal, so drug companies have long argued that the illness, not
the drugs, is the problem. Critics like David Healy, on the other hand, say
SSRIs can trigger the very symptoms they're supposed to treat, which makes
detecting their side effects a nightmare. It's a circular argument which is
almost impossible to resolve.
What's indisputable about Merrilee Bentley's case is that she attempted suicide
only after she was prescribed the drugs, and her condition worsened as her
dosage increased. In February 2000, as Bentley became stressed by the family
squabbles surrounding her impending marriage to her boyfriend, her GP put her
back on Aropax. Five weeks later she became suicidal and was hospitalised.
Things stabilised after she
fell pregnant with her third child, Lauren, but in mid-2002 her condition again
nosedived. Her son Carl had to move to his paternal grandparents' home in
Bunbury for schooling reasons; money was so tight the Bentleys had been forced
to rent out their house in Collie and move into the bungalow on Philip Wright's
property with the two girls; and
Bentley had become overweight from a thyroid problem.
In May 2002, she attempted an overdose of Aropax, a futile act which suggests
how little she had been told about the drug (death by SSRI overdose is virtually
impossible). In response, doctors doubled her dosage. Some months later, she
tried to hang herself in her father's shed after an argument with Mat, only to
be discovered by a friend. There was a pattern to these incidents, one of
extreme overreaction to normal life stresses. In the latter half of 2002,
Bentley's grandmother died and Lauren was burned by a scalding cup of coffee
which the toddler tipped off a bench. In November, Bentley again attempted an
overdose and was rushed to Collie Hospital by her father. Absconding from the
hospital, she wandered around Collie barefoot before calling the police and
being taken to the psychiatric ward of Bentley Hospital in Perth. There she took
the cord out of her pants and tried to hang herself in her room.
"I was in there for ... I don't know how long, perhaps a week," she recalls.
"Don't remember. And during that time they changed me from Aropax to Effexor." A
psychiatrist's report - remarkably, Bentley says this was the first time she was
referred to a psychiatrist - noted an improvement under Effexor, so the dosage
was doubled from 75mg to 150mg after she was released from hospital. By January
last year she was at home and on 300mg a day. Mat Bentley recalls watching his
wife get worse with each increase in dose.
"It never improved," he says. "She was more on edge, doing less around the
house. Some days I would get home from work and she was still in bed."
On Effexor, Merrilee Bentley recalls, the suicidal thoughts that had previously
been intermittent surged in strength and frequency. Each increase in dosage
induced a zombie-like state for a week, followed by overwhelming lethargy. "A
lot of it's a blur, but one thing I really remember is just sleeping. Feeling so
tired, and thinking at the end of the day that I was nothing. Nothing would
cheer me up. I'd get agitated easily, fly off the handle easily, at other times
be curled up in a ball crying for nothing major. My mental fixation at the time
was death, and that's all I thought about." Inside her head, she says, was a
battle between her rational self and an irrational other who promised that
suicide would bring relief.
"I went to my GP in March and told him, 'I think about suicide all day, every
day - even on a good day.' I really think he should have known something was
wrong then. But he let me walk out the door." (The doctor's notes record her
condition as "going okay, mildly suicidal thoughts".)
It took another three months before Bentley finally succumbed, in that car park
on the highway north of Bunbury on June 17, to her obsessional impulse to kill
herself. In the distorted thinking of that moment, she argued that by taking her
children with her, they would be spared the pain of living without a mother.
Bentley waited until the following morning to confess to her husband what she
had done. She made full admissions to a social worker, was briefly hospitalised,
and on June 24 her daughters were taken away by welfare officers. On a Saturday
afternoon 10 days later, police met her at her mother's house in Collie and told
her she was to be charged with four counts of attempted murder. After driving
her north to the scene of her crime and asking her to re-enact the events for a
video camera, they took her to Bunbury lock-up to be strip-searched and put on
suicide watch in a cell. "Then I crashed. I was sitting on the floor, rocking,
and I called them and said if they didn't get me to a doctor I was going to kill
myself." It was only then, when Bentley realised she had nothing left to lose,
that she resolved to try to wrest back control of her life.
A week earlier, a psychiatrist had upped her dosage of Effexor to 450mg - twice
the recommended maximum for mild depression. But only a few days after that,
she'd read an article in The West Australian newspaper that revealed something
no one had ever told her - that antidepressants can sometimes trigger mood
disorders. On the day she was arrested, Bentley had taken only one Effexor
instead of three. By the following day, when police transferred her to the
psychiatric ward of Graylands Hospital, she'd stopped taking Effexor completely.
Appearing in Bunbury courthouse to face her charges 24 hours later, Bentley was
a shivering mess, convulsed by nausea as her body went cold turkey. To ease the
symptoms, she began taking a low dose, and by Thursday she was in her room at
Graylands experiencing an "almost indescribable" change. "I have energy and can
think more clearly and the suicidal thoughts that plagued me on a daily basis
have now been replaced by the ability to think more objectively and positively,"
she wrote in a notebook. "It is truly an amazing feeling." Suddenly it seemed
clear that the force which had
pulled her inexorably towards suicide was not her depression, but the drugs - a
realisation that triggered an understandable anger. "I feel," she wrote, "that
the doctors, psychiatrists and other medical and mental health 'professionals'
that I have spoken to since my first suicide attempt have completely failed me."
Last year, 10.1 million antidepressant prescriptions were handed out in
Australia, according to the Health Insurance Commission, nearly double the
amount in 1996. To mainstream psychiatrists, this is a heartening sign that the
depressed are finally getting treatment and the stigma of the illness is
lifting. But an increasing number of doctors are concerned: SSRI drugs are
now routinely prescribed for conditions such as hyperactivity, anorexia and
stress. A quarter of a million prescriptions last year went to children and
adolescents, at a time when the safety of these drugs for minors is under a
cloud. Dr Jon Jureidini, head of the department of psychological medicine at the
Women's and Children's Hospital in Adelaide, has voiced concern about
the over-prescription of these drugs and their possible links with suicidal
behaviour. And Dr Yolande Lucire, a Sydney forensic psychiatrist, told a recent
meeting of forensic scientists that she has observed significant numbers of
people entering hospital with SSRI-induced mania and psychosis.
On a chilly Wednesday morning at the Supreme Court in Perth last month, Merrilee
Bentley appeared in the dock before Chief Justice David Malcolm to learn whether
she would go to jail for the events of June 17 last year. Six weeks earlier,
Bentley had pleaded guilty to attempted murder, largely to spare her children
the trauma of testifying. The prosecution had enlisted a
psychiatrist, Dr Adam Brett, who said it was unlikely Effexor played a
significant part in her illness; another psychiatrist, Dr David Lord, said
Effexor may well have been "unhelpful", but he was not aware of any scientific
research linking antidepressants to a heightened risk of suicide.
Towards the end of his long summary of the case, Justice Malcolm uttered a
19-word sentence that few in the court had been expecting. "My finding," he
said, "is that on the balance of probability, the medication substantially
contributed to the commission of the offences." Effexor, the judge ruled, had
"gravely impaired" Merrilee Bentley's capacity for rational thought and action.
He imposed a two-year suspended jail sentence and told her she was free to go
home.
The decision was immediately attacked by mental health experts, who said it
would deter depressed people from seeking treatment. Professor Ian Hickie said
defence lawyers had recently devised a "cute trick" of pleading guilty but
blaming antidepressants. But later that night, as Bentley sat alone at her
kitchen table in the bungalow next to her father's house, she was not
celebrating. "So, I'm off drugs and I feel good, but I've got no children," she
said, taking stock of the ironies of her case. "And I've got a libido again, but
I've got no husband." She laughed bitterly. "It's like you have to lose
everything."
Since late last year, Bentley
has been seeing a counsellor, who has finally helped her recognise the warping
effects that losing her mother exerted on her personality. She believes the
malign influence of antidepressants twisted that into a delusion that it was
better to kill her children than to have them suffer the same abandonment. All
of which leads to the cruellest irony of all: welfare authorities are already
preparing to launch court proceedings to have her three children separated from
her permanently and placed in foster care.
So Bentley is facing more stress, another court battle, all of it while under
the cloud of a suspended jail term which can be enacted if she puts a foot
wrong. There will be bad days, when the spectre of depression hovers. She says
she's strong enough to get through it without drugs. But her court supervision
order stipulates that she must comply with any treatment her
psychiatrist suggests.
"I would be really afraid if someone said to me, 'You have to take this
medication,'" she says. "Throughout all this, there was never an offer from a
psychiatrist to work with me on the issues I was dealing with. It seems all I
was ever offered was medication. And to me, medication is too easy."
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