|A Bitter Pill|
A Bitter Pill
by Richard Guilliatt, Sydney Morning Herald
Originally published: June 19, 2004
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 still 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."
© 2004 Alex Chernavsky firstname.lastname@example.org