Medication-Induced Violence | Do Psychiatric Drugs Play a Role in Mass Shootings?

Mass shootings, particularly school shootings, have tragically become a topic of everyday conversation in America and, invariably, questions are asked about the mental state of the perpetrator. What sort of derangement can produce such senseless acts of violence? What are the causes of school and other mass shootings? It is unlikely there is only one cause in any situation—it is multifactorial—however, is there a straw that consistently breaks the camel’s back?

Media reports are increasingly focusing on one factor that has been found to be associated with dozens of mass shootings in America: the psychiatric medications the attacker may have been taking. Were they taking these medications or, similarly dangerous, withdrawing from them, around the time of the shootings? How long had they been taking the drugs? Could those drugs have produced or contributed to a state of mind that led to the assaults?

Our firm is currently investigating the relationship between certain prescription drugs and medication-induced violence. We would like to hear from anyone who has been injured, or whose loved ones have been killed or injured, at school shootings or other mass shootings involving psychiatric medications. For more than 30 years, we have litigated personal injury, wrongful death and consumer fraud cases against major pharmaceutical companies. We believe an investigation into the link between psychiatric drugs and mass shootings is an essential step toward understanding the escalating violence we are witnessing in America.

Psychiatric Medications and Violence

There is no question that many people use psychiatric medications, or give them to their children, and find them helpful. It is also true that children and adults experience extremely debilitating psychological states and need help.

There are, however, two very good reasons to examine the issue of medication-induced violence.

First, a large body of research has shown that psychiatric drugs can make people manic, psychotic, aggressive, suicidal, and homicidal. These are proven drug reactions, not symptoms of a mental illness. Unlike symptoms of a disorder, these reactions often disappear when the drug is withdrawn, or the dose lowered, and reappear when the drug is resumed.

In healthy volunteer studies, where patients taking the drugs have no psychiatric disorder, volunteers frequently experience drug-induced reactions, ranging from suicidal thinking and aggressive thoughts, to episodes of violence. A third line of evidence comes from research on medications that affect the brain in ways similar to psychiatric drugs, but are prescribed for non-psychiatric disorders. They often create the symptoms of psychiatric disorders in people whose mental health is not in question.

These destabilizing effects are caused by several different classes of medications, including antidepressants, antipsychotics, opioids, sedatives, and drugs for attention deficit hyperactivity disorder (ADHD).

A second reason to look further into the issue of medication-induced violence is that a great many school or mass shooters were taking or withdrawing from psychiatric mediations at the time of their assaults. In other cases, the shooters had a long history of taking these medications, and appeared to worsen over time, but it is unclear whether they were under the direct influence of the drugs when they committed their crimes. The privacy of medical records is often a barrier to uncovering the role psychiatric drugs played in the violence.

Both of these factors—the ability of psychiatric medications to induce violence and aggression and the fact that so many perpetrators of mass shootings took these drugs—demand that we investigate the possibility that these events were influenced by prescription medications.

How Do Psychiatric Drugs Affect the Brain?

For decades, we have been told that psychiatric drugs work by correcting or regulating abnormal brain function. So, it stands to reason that individuals receiving drug treatment should be less likely to commit violent acts.

Today, however, the “chemical imbalance” theory has been discredited.. According to Ronald Pies, former editor-in-chief of Psychiatric Times and a professor of psychiatry at Syracuse and Tufts Universities, “In truth, the ‘chemical imbalance notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” Dr. Wayne Goodman, Professor and Chair of Psychiatry at the University of Florida, McKnight Brain Institute, argues claims that antidepressants “work by normalizing serotonin levels are not based on scientific evidence and should be prohibited.”

“Telling people, as I was told by my doctor, that depression is caused by a problem in your brain is, firstly, untrue and it is also really problematic because it cuts people off from finding the real causes of their depression and anxiety. We’ve been telling ourselves this chemical story for 35 years and every year depression and anxiety gets worse.”
Johann Hari, “Lost Connections” author.

But if the drugs are not correcting a chemical imbalance, what are they doing? In truth, no one really knows. Psychiatric drug labels will either state that the drug’s “mechanism of action” is unknown or they will explain what is “presumed to be,” “believed to be,” or “hypothesized to be,” behind the drug’s effects.

One of the best explanations of how psychiatric medications affect the brain was offered by two prominent psychiatrists and neuroscientists, Steven Hyman and Eric Nestler, in a paper published in the American Journal of Psychiatry in 1996. At the time, Hyman was director of the National Institute of Mental Health (NIMH) and Nestler was Director of the Division of Molecular Psychiatry at Yale.

“Chronic administration of psychotropic drugs” they wrote, causes “substantial and long-lasting alterations in neural function…” These alterations in brain function, “likely exceed the strength or time course of almost any natural stimulus.” As a result, the brain operates “qualitatively as well as quantitatively different from the normal state.”

Of course, to tie mental disorders to abnormal brain functioning would require a biological test that can distinguish a state of mental illness from a state of mental health. Currently, no such test exists. In 2013, former NIMH director Thomas Insel admitted that psychiatric diagnoses are not based on “any objective laboratory measure.”

“We’ve been telling patients for several decades that we are waiting for biomarkers [for psychiatric disorders]. We’re still waiting.”

  • David Kupfer, MD, 2013. Kupfer was chair of the task force that produced the current psychiatric diagnostic manual, DSM-5. Biomarkers are signs in the body that are objectively measurable and indicate an abnormal or diseased state. E.g., a high white blood cell count is a biomarker for an infection.

FDA Reports Also Link Psychiatric Medication to Homicidal Tendencies

It would appear, then, that most individuals who are prescribed psychiatric medications have never been found, through objective medical testing, to have abnormal brain chemistry or function. But, according to Hyman and Nestler, chronic use of psychiatric medications, far from normalizing brain function, causes the brain to operate abnormally. They suggest that these changes are responsible for the drugs’ therapeutic effects. But there is evidence that those changes may also explain the acts of violence that are, in so many cases, associated with psychiatric medications.

In 2010, Thomas Moore, a senior scientist at the Institute for Safe Medical Practice (ISMP) and Joseph Glenmullen, a Clinical Instructor in Psychiatry at Harvard Medical School and author of two books on antidepressants, published a study on prescription medication-induced violence in PLoS One.

Moore and Glenmullen extracted serious adverse event reports from the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System, searching for any drugs with 200 or more case reports received from 2004 through September 2009. They selected any reports that indicated homicide, homicidal ideation, physical assault, physical abuse or violence-related symptoms and then used mathematical and statistical methods to identify drugs that were significantly more associated with those reports compared to other drugs.

Out of 484 medications they evaluated, 31 (6%) were significantly more associated with violence. Those 31 drugs accounted for nearly 80% of the violence case reports (384 homicides, 404 physical assaults, 27 physical abuse reports, 896 homicidal ideation reports, 223 cases described as violence-related symptoms). All but seven of the drugs were psychiatric drugs.

Prescription Drugs Associated With Violence

Drug PRR* Usage
Chantix (varenicline) 18 smoking cessation
Prozac (fluoxetine) 10.9 antidepressant
Paxil (paroxetine) 10.3 antidepressant
amphetamines (includes Adderall; Dexedrine) 9.6 ADHD drug
Larium (mefloquine) 9.5 prevents or treats malaria
Strattera (atomoxetine) 9 ADHD drug
Halcion (triazolam) 8.7 sedative
Luvox (fluvoxamine) 8.4 antidepressant
Effexor (venlafaxine) 8.3 antidepressant
Pristiq (desvenlafaxine) 7.9 antidepressant
Singulair (montelukast) 7 anti-inflammatory
Zoloft (sertraline) 6.7 antidepressant
Ambien (zolpidem) 6.7 sedative
Lexapro (escitalopram) 5 antidepressant
Xyrem (sodium oxybate) 4.9 treatment of narcolepsy
Celexa (citalopram 4.3 antidepressant
Abilify (aripiprazole) 4.2 antipsychotic
Oxycontin (oxycodone) 4.1 narcotic, [opioid]
Wellbutrin (bupropion) 3.9 antidepressant
Geodon (ziprasidone) 3.8 antipsychotic; used in bipolar disorder
Ritalin, Concerta (methylphenidate) 3.6 ADHD drug
Remeron (mirtazapine) 3.4 antidepressant
Neurontin (gabapentin) 3.3 anti-seizure
Keppra (levetiracetam) 3.3 anti-seizure
Valium (diazepam) 3.1 sedative
Xanax (alprazolam) 3 sedative
Cymbalta (duloxetine) 2.8 antidepressant
Klonopin (clonazepam) 2.8 anti-seizure; treatment of panic disorder, anxiety disorders
Multiferon (interferon alfa) 2.7 treatment of cancer, hepatitis
Risperdal (risperidone) 2.2 antipsychotic
Seroquel (quetiapine) 2 antipsychotic

Source: Thomas J. Moore, Joseph Glenmullen, Curt D. Furberg, “Prescription Drugs Associated with Reports of Violence Towards Others,” PLoS One, 5(12): e15337.

*PRR – Proportional Reporting Ratio, a statistic representing the frequency of reporting of adverse events for a drug compared to the frequency of reporting for that event for all other drugs. The higher the number, the more that drug is associated with that adverse event compared to other drugs.

The drug most associated with violence was the smoking-cessation drug Chantix (varenicline), which had been found to be linked to thoughts and acts of violence and aggression in another study by Moore and Glenmullen.

As the table shows, antidepressants were the worst class of drugs for potentially causing medication-induced violence. Amphetamines, which are used in the treatment of ADHD, and another ADHD drug, Strattera, were also high on the list. Two other types of ADHD medication, Ritalin and Concerta, also appear.

Mood stabilizers, used in the treatment of bipolar disorder, as well as many antipsychotics, had relatively low associations with violence. While this might seem odd, it also suggests Moore’s findings were not the result of mental disorders in those taking the drugs. The fact that the smoking cessation drug Chantix, which is used by a predominantly non-psychiatric population, was linked to violence more than any other drug, also supports this view.

An update of the Moore/Glenmullen study by extended their analysis through December 2014 and added data from Health Canada. The results essentially confirmed the original findings, though the rankings were somewhat different. ADHD medications and antidepressants still ranked high on the list, and, with a broader definition of violence that included suicide, Ritalin moved much higher in the RxISK rankings.

A 2015 study by researchers in Finland further corroborates Moore’s findings. The Finnish researchers collected data on all homicides investigated by police in Finland from 2003 to 2011. They found antidepressants increase the risk of homicide by 30% and benzodiazepenes (anti-anxiety drugs such as  Valium, Xanax, Halcion, and Klonopin) more than double the homicide risk.

According to the non-profit parent rights organization AbleChild, there were nearly 15,000 reports to the FDA’s MedWatch system on violent psychiatric drug side effects between 2004 and 2012. This included “more than fifteen hundred cases of homicidal ideation/homicide, 3,287 cases of mania and more than eight thousand cases of aggression.”

ADHD Medication and Violence

In 2006, the FDA’s ADHD psychiatric review team called for stronger warnings on ADHD drugs after a safety review found almost 1,000 case reports of psychosis (including hallucinations) or mania related to Adderall, Concerta, Ritalin and Strattera submitted to the agency by drug makers between January 1, 2000 and June 30, 2005. These symptoms came in children with “no identifiable risk factors, at usual doses of any of the drugs used to treat ADHD.”

There was a “complete absence” of these ADHD medication side effects in children treated with dummy pills during clinical trials and in many children the symptoms stopped when the drugs were withdrawn and resumed when they were restarted. In addition to the case reports submitted by manufacturers, there were 560 reports of psychosis or mania submitted to the FDA via its MedWatch reporting system. It is estimated that only about 1% of adverse side effects are reported to the FDA. This suggests that over 100,000 children diagnosed with ADHD may have become psychotic or manic while taking ADHD drugs during this five- and-a-half year period.

This review of marketed experience with amphetamine/dextroamphetamine [Adderall], atomoxetine [Strattera], methylphenidate [Ritalin, Concerta], and modafinil [Provigil], presents compelling evidence for a likely causal association between each of these four drugs and treatment emergent onset of signs and/or symptoms of psychosis or mania, notably hallucinations, in some patients. Post in larger font

  • Food and Drug Administration, Center for Drug Evaluation and Research, “Psychiatric Adverse Events Associated with Drug Treatment of ADHD: Review of Postmarketing Safety Data,” 2006

The same safety review reported “numerous postmarketing reports of aggression or violent behavior during drug therapy of ADHD.” In approximately 20% of the cases the behavior was considered life-threatening or required hospitalization. The majority of the reports of ADHD violent behavior were for children and adolescents, most of whom had “no specific risk factors for aggression or violent behavior.” According to the report, “a striking majority (80 to 90% overall) of patients … had no prior history of similar events.” Drug makers submitted over 1,400 reports of ADHD aggression or violent behavior, with over 700 additional cases reported to MedWatch.

The FDA report establishes an unmistakable tie between ADHD medication and violence.

Given the scientific evidence linking the drugs to violence, the labels are inadequate—they fail to provide adequate warnings to doctors and patients about the risk of drug-induced violence, including homicidal tendencies.

Antidepressants and Violence

As the Moore/Glenmullen ISMP study demonstrates, antidepressants and violence are closely linked. In-depth analyses of data collected in antidepressant clinical trials (studies involving human participants) adds further weight to the study. Recent history also provides evidence of a tie between antidepressants and school shootings (see School Shootings in America below).

A large 2016 study by the highly regarded Nordic Cochrane Center, found that the risk of aggression more than doubled in children and adolescents taking antidepressants. The study also showed a doubling in the rate of akathisia, which is one of the known side effects of antidepressants that creates a state of extreme agitation and restlessness and is closely associated with violent behavior. The study was based on 70 clinical trials for antidepressants (Cymbalta, Prozac, Paxil, Zoloft, Effexor) involving 18,526 patients.

A second study by the Nordic Cochrane Center focused on clinical trials in which healthy volunteers were given antidepressants. The researchers found, “Antidepressants double the occurrence of events in adult healthy volunteers that can lead to suicide and violence.”

The authors wrote that their results were “consistent with the increased incidence of hostility” reported by the European Medicines and Healthcare Products Regulatory Agency, the European equivalent of the FDA. The study also reported that tranquilizers and sleep aids were used in many trials, which could have lowered aggression-related antidepressant side effects, making the true risk of antidepressant medication-induced violence even higher.

Antipsychotics and Violence

Three antipsychotics—Abilify, Geodon and Risperdal — appear on the list compiled by Moore and Glenmullen tracking potential medication-induced violence. These drugs are called second generation antipsychotics, or atypical antipsychotics, to distinguish them from first generation antipsychotics that appeared in the 1950s, drugs like Thorazine, Stelazine and Haldol. Each of these atypical antipsychotics has been tied to incidents of aggression. This may be because akathisia is one of the principal adverse antipsychotic side effects.

In the clinical trials that led to Abilify receiving FDA approval to be used as an adjunct treatment for depression, 25% of the patients taking Abilify suffered from akathisia, versus 4% of those on placebo. 12% on Abilify experienced restlessness, vs. 2% on placebo. By the end of the six-week study, the akathisia had resolved for only half the patients.

In 2013, researchers in Japan and Canada conducted a systematic search of Abilify studies. They found that Abilify was causally related to increases in psychotic symptoms, agitation and aggression. The findings were published in the journal Psychopharmacology.

In one of the most important and well-known studies of the effects of antipsychotics, the 2005 Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, Geodon produced moderate to severe akathisia in 9% of patients, Risperdal in 7%. Medication was discontinued for 74% of CATIE’s 1,432 patients due to “inefficacy or intolerable side effects or for other reasons.”

The FDA approved Geodon drug label lists agitation, hostility, confusion, hyperkinesia (hyperactivity), amnesia, and delirium among the frequent “treatment emergent” adverse reactions reported in the clinical trials that preceded FDA approval of the antipsychotic drug. Frequent means that particular antipsychotic drug side effects were seen in at least one out of every 100 patients. Treatment emergent means the effect occurred for the first time or worsened after the patient began taking the antipsychotic drugs following an initial evaluation. Reactions that are considered to be part of the illness being treated or unlikely to be drug-related are not included.

“First generation” antipsychotics are also associated with extreme akathisia and violence. In a case report published in the American Journal of Forensic Psychiatry in 1985, the authors described five cases in which Haldol was associated with akathisia, homicide and suicide.

In Washington State, a 2007 Tacoma News Tribune investigation into increasing violence at Western State Hospital, a psychiatric facility, tied the increase to a change in prescribing that favored newer antidepressants and atypical antipsychotics. Abilify, Geodon and Risperdal were the three medications on the antipsychotics drugs list cited as contributing to the problem and being “more likely than others in their class to cause agitating side effects such as restlessness, anxiety and insomnia [emphasis added].” Harvard-trained psychiatrist Stephan Kruszewski, quoted in the story, said, “There is a significant relationship between restlessness and agitation induced by medicine and the propensity for violence.”

Opioids and Violence

While prescription opioids like Vicodin and OxyContin are not psychiatric drugs, they deserve mention here. Prescription opioid and analgesic use has reached epidemic levels in America. Aggressive marketing by the pharmaceutical industry has resulted in skyrocketing abuse of opioid prescription drugs. The U.S. Department of Health and Human Services reported that 2.1 million people misused opioid drugs for the first time in 2016.

The tragic results for those who become addicted to these analgesics include severe psychological reactions. Abuse of the opioid hydrocodone has been linked with hallucinations, paranoia, irritability, aggression and violent behavior. Addiction websites warn of mood and behavior changes as one of the opioid side effects of hydrocodone use.

A 2015 study by researchers in Finland, published in the journal World Psychiatry, found that current use of opioid analgesics “was associated with significantly increased risk of offending.”

A 2014 study by University of Michigan researchers, published in the journal Addictive Behaviors, reported that prescription opioids and sedatives were the substances most likely to have been used prior to dating violence among a group of 575 teenagers and young adults.

School Shootings in America

The list of school shooters under the influence of psychiatric drugs at the time of their rampage is a long one. Among them are:

Columbine High School Shooting, Littleton, Colorado

On April 20, 1999, two senior students, Eric Harris and Dylan Klebold, drove to Columbine High School, parked their cars, and carried two propane bombs into the cafeteria. A bomb summary by the Jefferson County Sheriff stated that 488 students in the cafeteria would have been killed or seriously injured if the bombs had detonated. When Harris and Klebold realized the bombs had failed, they began shooting, ultimately murdering 12 students and one teacher before killing themselves.

Harris had been prescribed the antidepressant drug Luvox. The family of one of Harris’ victims filed an antidepressant lawsuit against the maker of Luvox, Solway pharmaceuticals, and hired psychiatrist Peter Breggin as a medical expert, giving him access to key records in the case. According to Breggin, the school shooter “took Luvox on the day that he did the shootings, or perhaps the night before, because he had a normal, effective level of Luvox in his blood on autopsy. I have seen the data.”

Breggin reviewed the scientific research linking Luvox and other antidepressants to mania, psychosis, and aggressive behavior in two papers, one published in the International Journal of Risk and Safety in Medicine in 2001 and a second published in the same journal in 2004.

Northern Illinois University Campus Shooting, Dekalb, Illinois

On February 14, 2008, Steven Kazmierczak opened fire with three pistols and a shotgun on the campus of Northern Illinois University, killing 5 students and wounding 17 others before killing himself. He had been taking three psychiatric drugs, the antidepressant Prozac, Xanax, a drug used to treat anxiety, and Ambien, a sleep aid. All three drugs have been linked to acts of violence and homicide. Kazmierczak’s girlfriend of two years said she had never seen him behave violently.

Florida State University Shooting, Tallahassee, Florida

Myron Deshawn May, a former Florida State honor student and successful attorney, shot three people at Florida State University before being killed by police on November 20, 2014. He had been prescribed the antidepressant Wellbutrin and Vyvanse, an amphetamine prescribed for attention deficit hyperactivity disorder (ADHD). May’s autopsy blood test found amphetamine levels indicating he was using amphetamines.

May’s descent into madness under the influence of psychiatric drugs was the subject of the documentary Speed Demons: Dying for Attention.

Did Medication Play a Role in the Marjory Stoneman Douglas School Shooting?

Nineteen-year-old Nikolas Cruz has been accused of carrying a semiautomatic AR-15 rifle into Marjory Stoneman Douglas High School on the afternoon of February 14, 2018, and opening fire, killing 14 students and 3 staff members. As is often the case in school shootings, details of the shooter’s mental health history and the exact medications taken are not clear, but it has been reported that Cruz was treated for ADHD and possibly depression. It also appears Cruz has been in the mental health system for many years and consistently taking his prescription medications.

The New York Times reported that Florida’s Department of Children and Families (DCF) investigated Cruz in September 2016, shortly after he turned 18. A DCF report stated that Cruz was autistic, had depression and attention deficit hyperactivity disorder (ADHD). He was regularly taking medication for ADHD.

A Naples Daily News story noted that a counselor with Henderson Behavioral Health in Broward County told DCF that Cruz was “compliant with taking his medications and keeps all of his appointments.”

A report in the Florida Sun Sentinel said the DCF report noted Cruz was being treated for depression, but it was unclear if that included medication.

The Washington Post reported that Cruz was a behavioral challenge at Westglades Middle School beginning in the 6th grade. His behavior was so disruptive that some teachers banned Cruz from their classrooms and at least one did not want to be alone with him in the classroom.

In 2013, Broward County stopped referring students to police for incidents of bullying, harassment and assault. Instead, they were referred to community social services agencies. School arrests fell 63% and Broward’s system of discipline received national recognition.

Mass Shootings in America

There seems to be an epidemic of mass shootings in America. Mass shootings are, of course, not confined to schools and multiple examples in the list of mass shootings provide evidence of an apparent link to medication.

It is often said that untreated or inadequately treated mental illness is the cause of mass shootings or other cases of extreme violence. Given the perpetrators in a majority of these cases were being treated, that argument rings hollow.

Navy Yard Shooting, Washington, D.C.

On September 16, 2013, Aaron Alexis fatally shot 12 people and wounded three others in a mass shooting at the Washington Navy Yard. Mr. Alexis was prescribed trazodone, a medication used to treat depression and insomnia that has a mechanism of action similar to SSRI antidepressants like Prozac and Paxil. Trazodone can cause mania and violent behavior.

Movie Theater Shooting, Aurora, Colorado

One of the most horrifying mass shootings in American history was the attack that took place at Century movie theater in Aurora, Colorado. On July 20, 2012, 25-year-old James Holmes opened fire in the theater, killing 12 and wounding 70.

Holmes had been prescribed the antidepressant Zoloft (sertraline). David Healy, a psychiatrist and international authority on antidepressants, was hired as an expert witness in the SSRI shooting case. In his opinion, the killings would not have happened had it not been for the medication James Holmes had been prescribed.

The Public’s Right to Know About Medication-Induced Violence

Parents and the public have a right to know what psychiatric drugs do in the brain, the side effects of taking and withdrawing from these medications, and the medical basis—or lack thereof—behind the skyrocketing number of children being prescribed these drugs. This is basic medical ethics and the foundation of informed consent. Failure to warn the public of the dangers of medication-induced violence, and to ensure patients taking the drugs are closely monitored for signs of adverse drug reactions can have disastrous consequences. People have the right to know.

If you or a loved one has been injured in an incident of mass violence that may have been caused by prescription medications, please contact the attorneys at Baum, Hedlund, Aristei & Goldman for a free consultation.