ZOLOFT
34 Zoloft is the trade or brand name of an antidepressant medication, the essential chemical in which is sertraline. Whilst the recommended initial dose is 50 milligrams, the medical evidence suggests that 25 milligrams is a safer initial dose, particularly for elderly people. The effective drug in Zoloft is capable of causing sleeplessness, agitation, confusion, hallucination and psychosis. Furthermore, because responses to antidepressants can be idiosyncratic the effect of a given dose on one particular individual may be more profound than on another or even on a statistically "average" person.
35 The Australian Department of Health and Aged Care (the Department) maintains an Adverse Drug Reaction System. In it the Department records instances of adverse reactions reported to it in relation to particular drugs. There is no obligation on medical practitioners, pharmacists or suppliers to advise the Department of adverse reactions. As a consequence the numbers recorded in the Adverse Drug Reaction System do not represent the totality of the cases of adverse reaction which occur in Australia. However, the numbers are useful and such as to raise a warning of particular adverse effects that may be experienced.
36 In the Department's Adverse Drug Reaction System, sertraline has been recorded as the sole drug implicated in:
· 20 cases of aggression
· 319 cases of agitation
· 63 cases of confusion
· 8 cases of delirium
· 5 cases of delusion
· 43 cases of hallucination
· 34 cases of manic reaction
· 18 cases of psychosis.
37 Although these numbers may be regarded as a source of concern, it should be remembered that Zoloft is widely and commonly prescribed in Australia and elsewhere in the world. However, the amount of Zoloft taken by the prisoner, namely 250 milligrams, is not a fatal dose. Indeed people who have taken up to 6 grams of Zoloft have recovered from such an overdose. Moreover, the usual therapy with Zoloft is to commence with a lower dose and gradually increase it by weekly or other increments up to 200 milligrams. A dose of this size is only administered after the patient has been on the lower doses for a period, during which the body becomes accustomed to the drug and a degree of tolerance is built up.
38 The figures in the Department's Adverse Drug Reaction System are consonant with the views expressed by Dr David Healy of the University of Wales College of Medicine. In his report Dr Healy confirms that Zoloft can cause agitation and a certain amount of disinhibition so that some individuals engage in aggressive or dangerous behaviours without due regard for the consequences and in a manner that is out of character for them. Behaviour of such a kind is sometimes described in terms "that suggest manic or psychotic reactions". Zoloft can also lead to suicide. In this regard it should be noted that when medically examined shortly after his arrest the prisoner was found to be "acutely suicidal".
39 The manifestations of aggression, agitation, confusion and hallucination experienced by the prisoner are thus readily able to be explained by reference to the Zoloft which he had ingested in the early hours of 1 August, 1999.
40 The psychiatric condition of the prisoner at the time of the killing has been variously described by the medical practitioners whose reports have been tendered and who have given evidence.
41 Dr Jonathan Carne, a Consultant Forensic Psychiatrist, describes the condition of the prisoner at the time he attacked his wife as a state which was formerly described as "toxic delirium". He was of opinion that the factors affecting the prisoner at the time he killed his wife were agitated depression, exacerbated by akathisia and delirium or psychosis which involved, amongst other things, his hallucinating. These disorders were a consequence of an underlying condition of depression and the effects on the prisoner of the dose of Zoloft which he had taken to relieve his symptoms of sleeplessness, agitation and depression.
42 Dr William Lucas, a Forensic Psychiatrist who specialises in criminal cases, expressed the view that the prisoner was suffering from "a major depressive episode "which amounted to an abnormality of mind" at the time he killed his wife and that this "impaired his capacity to understand events … and he was unable to control himself". His opinion was that in view of the dose of Zoloft taken by the prisoner:
"… there is a probability that his anxiety and agitation was exacerbated by a drug known to produce this side effect. Any exacerbation of the already severe symptoms of agitation and anxiety would probably reduce his capacity to control his actions."
43 Dr David Healy was of the opinion that because of the antecedent history of the prisoner there had to be "some unusual factor operative in his case." He described that factor in the following terms:
"The unusual factor in my opinion was the fact that he was taking Zoloft at the time and this produced a strange and unusual state of mind in him involving akathisia and possibly also emotional blunting and psychotic decompensation and this led directly to his behaviour on … August 1st 1999. In my opinion had he not been taking Zoloft the events of that night would not have happened. The temporal association between his intake of Zoloft and these events and the congruence of this time frame with the time frame reported in the literature argue strongly for an SSRI (Selective Serotonin Re-uptake Inhibitor) induced problem."
44 Akathisia (or turmoil) is a state of agitation which, when drug induced, is marked, may be associated with panic and an awareness of strange and unusual impulses that the affected individual does not ordinarily have.
45 Dr Healy's views as to the effects of Zoloft have particular weight since his doctoral thesis was based on research on the serotonin transporter system and the role of serotonin in depression and suicide. In this regard it should be noted that Zoloft is a serotonin re-uptake inhibiter. His interest in serotonin re-uptake inhibitors has been on-going. Furthermore, he has carried out research and clinical work on existing and novel psycho-pharmacological drugs and is an author in the field of psycho-pharmacology. His opinion is also supported by an assessment of suicidal acts of patients on sertraline prepared in response to an inquiry from the Irish Medicines' Board in 1999, and by a study in healthy volunteers conducted in the College of Medicine in the University of Wales using a dose of only 50 mgs of Zoloft. Two subjects with no prior history of mental or psychiatric problems and no current problems became suicidal and aggressive on such a dose of Zoloft. This was said by Dr Healy to be:
"significant in that it demonstrates that such problems can occur in an entirely normal individual."
46 In addition, he analysed the results of the clinical and company trials conducted in relation to serotonin re-uptake inhibiters, which include Zoloft. He said that "the results show a consistent pattern of drug-induced conditions variously described as agitation - anxiety - nervousness - hyper kinesis - tremor". Those results are supportive of his conclusion that "suicidality/homicidality can arise as a consequence of the drug …". Regrettably very few of the studies have been published so the attention of the wider academic community has been effectively diverted from the problem.
47 Dr Rosalie Wilcox, who is a General and Forensic Psychiatrist, assessed the prisoner shortly after his confinement at Long Bay Correctional Centre where he was housed in the Psychiatric Hospital. She assessed him thereafter on a regular basis and has treated him, successfully it would appear, so as to come to terms with what he had done and in relation to his depression. She endeavoured to understand and provide some explanation for the actions of the prisoner in strangling his wife. This act she described as "totally unpredictable and totally out of character". Her assessment of him in her report of 15 November, 1999 was that he was suffering from:
"major depression with melancholic features, obsessive compulsive disorder (mild) in association with a personality characterised by high trait anxiety and obsessional traits".
48 Because of what Dr Wilcox described as "the bizarre nature of his offence" he was closely observed. However, there was no indication that he had been or was psychotic. Furthermore, at no time did he express or exhibit that he had experienced any delusions.
49 With treatment over time his depression eased, his panic attacks settled and his presentation reflected his grieving for his wife and former life, rather than disease of the mind.
50 Dr Wilcox's opinion in relation to the state of the prisoner at the time he killed his wife was that he was "in a highly aroused state", that he "may have had a brief period of dissociation" and that he was suffering from "an abnormality of the mind, specifically a depressive illness".
51 In her oral testimony Dr Wilcox said that the personality of the prisoner was "compliant and perfectionistic" and that "he is not a rule breaker". She was questioned about the "highly aroused state" referred to in her report :
"Q … Accepting that he took 250 milligrams of this drug, do you accept that the ingestion of the drug probably materially contributed to the hallucination he described of seeing his own face?
A. I would say that that could be a high probability, yes.
Q. When you say his level of arousal may have increased, is that said upon the premise that you know that that drug may increase agitation, and if one accepts that he took five tablets it is likely that it did?
A. Yes, it could be likely."
52 The Crown caused the prisoner to be examined by Dr Olav Nielssen, Forensic Psychiatrist. He diagnosed the prisoner as being subject to a major depressive illness and expressed the opinion that "his impairment is at the more severe end of the scale and I believe he would easily meet the test for the defence (of diminished responsibility)." He recognised the effects of the amount of Zoloft ingested by the prisoner as being a factor which operated in combination with the effects of a severe depressive illness and his underlying personality to produce an abnormal state of mind with substantial effect on his judgment and his capacity for self control.
53 From the foregoing it can be seen that the medical evidence strongly supports a conclusion that, but for the effects of the 250 milligrams of Zoloft he had taken, it is wholly unlikely that the prisoner would have committed the crime to which he has pleaded guilty. Furthermore, it is common ground that his having done such an act is quite foreign to his former life history, his personality and psychological make up. It was also wholly inconsistent with his love for his marriage partner of nearly fifty years.