Patients may stop drugs for many reasons

CHICAGO -- Psychiatrists say it's a common scenario -- troubled patients stop taking their medicine, because of cost, side effects, the stigma or delusions that they don't need it. The consequences can be tragic, though rarely as horrific as the Valentine's Day shooting at Northern Illinois University.

No one knows what triggered Steven Kazmierczak's campus rampage, yet one of the clues to an emerging psychiatric profile is this: His girlfriend says he recently stopped taking Prozac.

Prozac is a drug generally prescribed for major depression. It and similar antidepressants carry warning labels about risks for suicidal behavior in patients younger than Kazmierczak, who was 27.

Still, stopping these drugs can also lead to suicidal thoughts and behavior. And taking them may increase the risk for other violence if they're mistakenly prescribed as the only treatment for patients in a depressive phase of bipolar disorder, psychiatrists say. In that case, the drugs may trigger a manic phase that could include aggressive behavior toward others.

In court cases, attorneys have sometimes tried to blame violent behavior on Prozac. However, scientific evidence to support that is lacking, and psychiatrists and the drug's maker, Eli Lilly and Co., say the underlying mental illness is the most likely culprit.

Kazmierczak, a graduate student in social work at the University of Illinois, was a worrier with obsessive-compulsive tendencies, his girlfriend told CNN, but it is not known if he'd been diagnosed with depression or bipolar disorder. She said he'd stopped taking Prozac three weeks before last week's tragedy.

Two days before the Feb. 14 shootings, a New York man who had been treated for psychiatric problems and who had also stopped taking medication was accused of fatally stabbing a therapist.

"Can stopping medications be an important contributory factor to deterioration of behavior ... where violence ends up being committed? Yes, absolutely," said Dr. Paul Ragan, an associate professor of psychiatry at Vanderbilt University.

Ragan said he has had patients attempt suicide after stopping antidepressants because their insurance ran out, although violence against others is rare in depression.

On or off medication, the vast majority of people with schizophrenia, depression and bipolar disorder "do not engage in violent behavior," said Dr. David Fassler, a University of Vermont psychiatry professor.

Still, compliance with medication is a significant problem, he said. For about one-third of patients, side effects are the main reason they stop taking psychiatric drugs, Fassler said.

Dr. Lynne Tan, a psychiatrist at Montefiore Medical Center in New York, said many patients complain that antidepressants cause restlessness, agitation and racing thoughts. Sweating, sexual dysfunction and headaches are other common side effects. Sometimes they subside over time, and if not, patients can be switched to other medications, she said.

Elizabeth, a 26-year-old graduate student in social work at the University of Chicago who asked that her last name not be used to protect her privacy, said she stopped and restarted antidepressants many times since being diagnosed with depression at age 16.

"Stigma does play a big part of it," she said. "That's why I was so eager to consider myself well and to go off of it."

When she left college and was no longer covered by her parents' insurance, cost also became an issue -- $60 to $70 a month for a generic antidepressant. She declined to identify the drug.

But each time she stopped, debilitating depression including suicidal thoughts would return, she said.

"If I've learned anything from this journey, it's that medication really works for me," she said.

Greg Coughlin, 53, a health department employee for DuPage County west of Chicago, said several years ago he repeatedly stopped taking drugs for a type of schizophrenia because he was "in denial" about suffering from mental illness.

Coughlin said the last time he stopped, in the 1990s, he became extremely obnoxious and agitated, and ended up in a mental hospital.

Now he's on three mood stabilizers that zap his energy and cause weight gain, but make him feel "more solid, more relaxed, more satisfied in life."

Coughlin, a board member of the Illinois chapter of the National Alliance on Mental Illness, said he finally accepts that to function, he'll need to be on drugs for life.

Elizabeth said she can live with the side effects -- extreme sweating and a hand tremor -- and credits psychotherapy, a support group and exercise with helping her cope.

While accounts from friends and professors suggest that at least on the surface, Kazmierczak was coping well, there were also signs of trouble.

He had a history of cutting himself, which is often a symptom of inner anger and a sense of feeling powerless, said psychologist Wendy Lader, who runs a suburban Chicago treatment center for self-cutters.

Self-cutting is thought to be more common among women, but women are also more likely than men to seek treatment for it, Lader said.

Kazmierczak also wore macabre shock-value tattoos covering both forearms -- an unusual and disturbing choice for someone pursuing a career in social work, Lader said.

Dr. Louis Kraus, a forensic psychologist with Rush University Medical Center in Chicago, said with no known criminal background or history of violence or anti-social behavior before the killings, Kazmierczak presents a bewildering psychiatric image.

"Obviously something very tragic is missing from this puzzle that we don't fully understand yet," Kraus said.