By Andrew J. Wakefield
At the Royal Free Hospital, London, in 1996 my gastroenterology colleagues and I were reliably informed by our attending child psychiatrist, that acts of extreme violence, such as the tragedy of Sandy Hook Elementary School, were perpetrated more commonly by those with Asperger’s syndrome (AS). Like so much that child psychiatry has had to offer - then and since - this assertion is misleading.
In support of his statement, the Royal Free’s child psychiatrist, Dr. Berelowitz, cited the example of Martin Bryant who had recently been imprisoned for committing 35 murders and causing 37 serious injuries in Tasmania in April 1996, in what became known as the Port Arthur Massacre. Bryant, according to Dr. Berelowitz and later, Wikipedia, had AS. Both sources turn out to be incorrect: the report of Paul E. Mullen, Professor of Forensic Psychiatry at Monash University, Melbourne, Australia, who examined Bryant in prison in May 1996, tells the story. In his criticism of an earlier diagnostic assessment by a Dr. Sale, Dr. Mullen wrote:
“Mr Bryant craves the attention of others. He desires relationships but fails to effectively communicate with others unlike the patients with Asperger's who are blandly indifferent to others. Mr Bryant also lacks, in my opinion, the central features of this condition, which are repetitive activities, unusual skills with all absorbing obsessive interests and problems with motor coordination. He also showed marked delay in the acquisition of language skills and required remedial therapy for this language deficit which is contrary to the picture found in those with Asperger's Syndrome.”
While my experience of 18 years suggests to me that many with AS are not blandly indifferent to others, Bryant’s speech delay precludes this diagnosis. In addition, Bryant had an IQ of 66 – well below the average or above average IQ that experts consider necessary for this diagnosis..
More recent reviews of the relevant medical literature do not support an association between an increased risk of violence and AS.. This fact is crucial, lest the wider community stigmatize a population of individuals that are already poorly served and badly misunderstood by many. This does not mean, however, that those with AS are not at increased risk of violence under certain circumstances, as discussed below.
A further Web-based review (see below) of acts of violent crime similar to those seen in Port Arthur, Colombine, and Connecticut reveals that the majority of cases are not associated with any evidence of an ASD diagnosis in the perpetrator at all. So what do these tragedies have in common?
A common denominator
As with all tragedies of this nature, many try to make sense of the “senseless.” In the case of Martin Bryant, Dr. Mullen failed. He concluded his expert psychiatric report with the following:
“The enormity of Mr Bryant's crimes call out for some explanation equally dramatic and extraordinary. It is not to be wondered at that the media have either attempted to portray Mr Bryant as afflicted by a dramatic mental illness, such as schizophrenia, or to be some kind of evil genius. In my opinion the origins of this terrible tragedy are not to be found in a single dramatic and sufficient cause, but in the interaction and combination of a range of influences and events. We may never know fully the intentions and state of mind which led to the killings, but a number of the contributions are apparent.”
But clues to the likely origins of this particular tragedy were there – as they always are – in the “patient’s” history; Mullen simply missed them. Bryant was taking tranquilizers for anxiety and sleep disturbances. From Mullen’s report, he was using these inconsistently, “on three or four occasions per week.” In a separate section of his report Dr. Mullen also documents that:
“During the 12 months prior to the offences [Bryant’s] alcohol consumption rapidly increased. He reports that in the six months prior to the tragedy he typically drank every day. He would have his first drink in the morning and then drink more heavily in the afternoon and evening.”
These factors – erratic compliance with tranquilizers and alcohol abuse – are related and crucial. The risk of adverse reactions to tranquilizers is greatly potentiated by alcohol due, in part, to shared metabolic pathways in the liver. The preferential metabolism of alcohol will lead to impaired metabolism of the tranquilizer. Adverse reactions to psychotropic drugs including tranquillizers are also more common in those with existing mental illness, and violence is a well-recognized adverse reaction.
Alarmingly absent from Mullen’s otherwise detailed report are the following: i. the name of the prescription “tranquillizers” that he was taking; were they “major” or “minor”? ii. any reference to the very real potential for interaction between such drugs and the large amount of alcohol that Bryant was consuming in the months prior to the attack, and iii. any mention of a violent psychotic reaction to these drugs - particularly in combination with alcohol - playing any role at all in his crime.
The combination of alcohol and ad hoc use of tranquillizers will have produced widely fluctuating drug levels. Fluctuations in drug levels put patients at particular risk of adverse reactions. This phenomenon is also well recognized for the second generation antidepressants, selective serotonin reuptake inhibitors (SSRIs) for which the Physician’s Desk Reference [PDR] states:
"Adverse reactions are most likely to occur when starting or discontinuing the drug, increasing or lowering the dose or when switching from one SSRI to another.”
The PDR goes on to list an array of established central nervous system reactions including: Mania, Hallucinations, Personality Disorder, Psychosis, Alcohol Abuse and/or Craving, Hostility, Paranoia, Delusions, and Impulsivity.
Taking any tranquillizers, as Bryant did on “3 or 4 occasions a week”, in combination with large amounts of alcohol, is a recipe for disaster. Had this been recognized, as it should have been, and had the role of prescription psychotropic drugs in such events been flagged at that time, future disasters might have been avoided.
This brings us back to the common denominator, the one and only consistent feature of successive killing sprees, psychotropic prescription medications.
Prescription meds and violence
In 2011 the Institute for Safe Medication Practices published in the journal PloS One an analysis of data from the FDA’s Adverse Event Reporting System. The article identified 31 drugs that are disproportionately linked with reports of violent behavior towards others.
The authors wrote:
“We identified 1527 cases of violence disproportionally reported for 31 drugs. Primary suspect drugs included varenicline (an aid to smoking cessation), 11 antidepressants, 6 sedative/hypnotics and 3 drugs for attention deficit hyperactivity disorder….
…Acts of violence towards others are a genuine and serious adverse drug event associated with a relatively small group of drugs. Varenicline, which increases the availability of dopamine, and antidepressants with serotonergic effects were the most strongly and consistently implicated drugs.”
The top ten offenders – all prescription drugs - include: the antidepressants Desvenlafaxine (Pristiq) (x 7.9 more likely to be associated with violence than other drugs), Venlafaxine (Effexor), a drug related to Pristiq. Both are also used to treat anxiety disorders (x 8.3), Fluvoxamine (Luvox) (x 8.4), Paroxetine (Paxil), an SSRI antidepressant (x 10.3), Fluoxetine (Prozac) (x 10.9), the tranquilizer Triazolam (Halcion), also used to treat insomnia (x 8.7), the attention deficit disorder drugs Atomoxetine (Strattera) (x 9), and Amphetamines: (Various, x 9.6). Also included are the antimalarial Mefoquine (Lariam) (x 9.5) and Varenicline (Chantix) the anti-smoking medication (x 18).
The heart of the matter: Big Pharma and Psychiatry - a liaison dangereuse
Aberrant behavior is at the heart of the current crisis. This behavior – not on the part of perpetrator however - is characterized in the following reports, just a few of many.
Johnson and Johnson
“Johnson and Johnson settles five Risperdal Suits”
“The former commissioner of the U.S. Food and Drug Administration, David Kessler, says Johnson & Johnson and its Janssen subsidiary broke the law in marketing the antipsychotic drug Risperdal for use in children and adolescents.”
“The promotion of non-approved uses in the most vulnerable children of powerful drugs is most concerning. Janssen's promotion of Risperdal, a powerful drug, for non-approved uses in the most vulnerable children is deeply troubling." 
(CBS/AP) LITTLE ROCK, Ark. - An Arkansas judge has fined Johnson & Johnson ( JNJ ) and a subsidiary more than $1.1 billion after a jury found the companies downplayed and hid risks associated with an antipsychotic drug.
“Judge Tim Fox found nearly 240,000 violations under Arkansas' Medicaid-fraud law over Risperdal. Each violation came with a $5,000 fine, setting the total penalty at more than $1.1 billion.”
“Jurors returned a quick verdict Tuesday in favor of the state, which had argued that Janssen Pharmaceuticals Inc. lied about the potentially life-threatening side effects of Risperdal.”
“Glaxo Agrees to Pay $3 Billion in Fraud Settlement
In the largest settlement involving a pharmaceutical company, the British drugmaker GlaxoSmithKline agreed to plead guilty to criminal charges and pay $3 billion in fines for promoting its best-selling antidepressants for unapproved uses and failing to report safety data about a top diabetes drug, federal prosecutors announced Monday. The agreement also includes civil penalties for improper marketing of a half-dozen other drugs.”
“The three criminal charges involved [psychotropic drugs] Paxil, Wellbutrin and Avandia and included a criminal fine of $1 billion.”
Inducements and Fraud
“Prosecutors said the company had tried to win over doctors by paying for trips to Jamaica and Bermuda, as well as spa treatments and hunting excursions. In the case of Paxil, prosecutors claim GlaxoSmithKline employed several tactics aimed at promoting the use of the drug in children, including helping to publish a medical journal article that misreported data from a clinical trial.”
Lack of individual accountability
“No individuals have been charged in any of the cases. …critics argue that even large fines are not enough to deter drug companies from unlawful behavior. Only when prosecutors single out individual executives for punishment, they say, will practices begin to change.”
“What we’re learning is that money doesn’t deter corporate malfeasance,” said Eliot Spitzer, who, as New York’s attorney general, sued GlaxoSmithKline in 2004 over similar accusations involving Paxil. “The only thing that will work in my view is C.E.O.’s and officials being forced to resign and individual culpability being enforced.”
Fines - The “cost of doing business”
Despite the large amount, $3 billion [fine] represents only a portion of what Glaxo made on the drugs. Avandia, for example, racked up $10.4 billion in sales, Paxil brought in $11.6 billion, and Wellbutrin sales were $5.9 billion during the years covered by the settlement, according to IMS Health, a data group that consults for drugmakers.”
“So a $3 billion settlement for half a dozen drugs over 10 years can be rationalized as the cost of doing business,” Mr. Burns said. Mr. Burns and others have said that to institute real change, executives must be prosecuted criminally or barred from participating in the Medicare and Medicaid programs, an action known as “exclusion.”
Abbott Labs to Pay $1.5 Billion to Resolve Criminal & Civil Investigations of Off-label Promotion of Depakote
“[The] Company Maintained Specialized Sales Force to Market Drug for Off Label Purposes…”.
“Abbott has pleaded guilty to a criminal misdemeanor for misbranding Depakote in violation of the FDCA.”
Side effects “downplayed”
“Not only did Abbott engage in off-label promotion, but it targeted elderly dementia patients and downplayed the risks apparent from its own clinical studies,” said Acting Associate Attorney General Tony West. “As this criminal and civil resolution demonstrates, those who put profits ahead of patients will pay a hefty price.”
A “Catcher in the Rye”
For President Obama to become a “Catcher in the Rye” – a savior in this relentless tragedy – he must take the Pharmaceutical Industry head on. Through the Department of Justice, he has made a start. However, fines should be a multiple of Pharma’s revenues and not some nominal settlement that does little to discourage their insatiable greed. Individuals within offending companies need to be held accountable and face criminal prosecution.
Obama must meet the autism tragedy head on and deal with the proximate cause of the epidemic – unsafe and untested vaccination practices. The treatment of autism spectrum disorders must start with an understanding of these disorders as primarily medical conditions with toxicological, immunological, gastrointestinal, and nutritional issues front and center. Through the Interagency Autism Coordinating Committee and the CDC his administration has been a dismal failure.
And for those at risk – young people receiving off-license mind-bending drugs, an urgent overview of individual indication, efficacy, compliance, and adverse effects must be undertaken, funded by the relevant players in the pharmaceutical industry and conducted independently of any other input from them.
Tragically, predictably, there will be more events like that at Sandy Hook Elementary. The vast number of individuals with developmental disorders presages such events. This is not because of their diagnosis, per se, but rather I would suggest, because they may be at increased risk for adverse reactions (due to pre-existing conditions) and are being inappropriately medicated with drugs for which violence is a recognized adverse reaction. These drugs are being prescribed by a “mainstream” medical system that, through clinical neglect, has run dry on alternative treatments for autism spectrum disorders while enjoying Parma’s inducements way too much to look for any.
My opinion is neither mine alone, nor is it new. In attempting to make sense of the “senseless” it offers both tangible reasons and approaches to prevention. It is not enough that our hearts break for those affected; we are compelled to act. Perhaps inevitably, I am left with a mental image of Pharma lobbyists scaling Capitol Hill like an army of Orcs closing on Helm’s Deep. It’s a hideous sight.
Red Lake, Minnesota – March 2005: 16-year-old Jeff Weise, on Prozac, shot and killed his grandparents, then went to his school on the Red Lake Indian Reservation where he shot dead 7 students and a teacher, and wounded 7 before killing himself.
El Cajon, California – March 22, 2001: 18-year-old Jason Hoffman, on the antidepressants Celexa and Effexor, opened fire on his classmates, wounding three students and two teachers at Granite Hills High School. He had been seeing a psychiatrist before the shooting.
Eric Harris, one of the killers at Columbine High School, was on the antidepressant drug Luvox. Court records show that the prescription for Harris had been filled ten times between April 1998 and March 1999.Three and one half months before the shooting, the dosage had been increased. The Physician’s Desk Reference records show that during controlled clinical trials of Luvox, manic reactions developed in 4 percent of the children given the drug.
Thomas Solomon, a fifteen-year-old at Heritage High School in Conyers, Georgia, shot and wounded six classmates. He was on Ritalin at the time.
Kip Kinkel, a fifteen-year-old at Thurston High School in Springfield, Oregon, killed his parents and two classmates and wounded twenty-two other students while on Ritalin and Prozac.
Notus, Idaho – April 16, 1999: 15-year-old Shawn Cooper fired two shotgun rounds in his school, narrowly missing students. He was taking a prescribed SSRI antidepressant and Ritalin.
In 1989, less than one month after taking his first dose of Prozac, Joseph Wesbecker massacred eight coworkers with an AK-47 before turning the weapon on himself.
Michael McDermott, convicted of killing seven co-workers, tripled his dosage of Prozac before the shootings. On the witness stand he said he believed that he killed Nazis and not his co-workers. He said an archangel appeared to him before the massacre, telling him that he could prevent the Holocaust if he traveled back in time to 1940 to kill Adolf Hitler and six German generals.
Brynn Hartman, wife of comedian Phil Hartman, shot and killed her husband and herself while on Zoloft.
Andrea Yates in Houston, Texas, drowned her five children while on Effexor and Remeron.
Christopher Pittman shot and killed his grandparents when he was age twelve. He claimed that a voice inside his head told him to kill his grandparents on November 28, 2001. Christopher had recently started to take Zoloft to treat mild depression.
Columbine, Colorado – April 20, 1999: 18-year-old Eric Harris and his accomplice, Dylan Klebold, killed 12 students and a teacher and wounded 26 others before killing themselves. Harris was on the antidepressant Luvox. Klebold’s medical records remain sealed. Both shooters had been in anger-management classes and had undergone counseling. Harris had been seeing a psychiatrist before the shooting.
Jeff Weise, age 16, had been prescribed 60 mg/day of Prozac (three times the average starting dose for adults!) when he shot his grandfather, his grandfather’s girlfriend and many fellow students at Red Lake, Minnesota. He then shot himself. 10 dead, 12 wounded.
Wahluke, Washington – April 10, 2001: Sixteen-year-old Cory Baadsgaard took a rifle to his high school and held 23 classmates and a teacher hostage. He had been taking the antidepressant Effexor. Paxil (which caused him to have hallucinations)
Thirteen-year-old Chris Fetters killed his favorite aunt while taking Prozac.
Twelve-year-old Christopher Pittman murdered both his grandparents while taking Zoloft.
Thirteen-year-old Mathew Miller hung himself in his bedroom closet after taking Zoloft for 6 days.
Fifteen-year-old Jarred Viktor stabbed his grandmother 61 times after 5 days on Paxil.
Springfield, Oregon – May 21, 1998: 15-year-old Kip Kinkel murdered his parents and then proceeded to school where he opened fire on students in the cafeteria, killing two and wounding 25. Kinkel had been taking the antidepressant Prozac. Kinkel had been attending “anger control classes” and was under the care of a psychologist.
Luke Woodham age 16 (Prozac) killed his mother and then killed two students, wounding six others.
In 1998 A Pocatello had a Zoloft-induced seizure that caused an armed stand off at his school.
Michael Carneal (Ritalin) a 14-year-old opened fire on students at a high school prayer meeting in West Paducah, Kentucky.
Andrew Golden, age 11, (Ritalin) and Mitchell Johnson, aged 14, (Ritalin) shot 15 people, killing four students, one teacher, and wounding 10 others.
Conyers, Georgia – May 20, 1999: 15-year-old T.J. Solomon was being treated with the stimulant Ritalin when he opened fire on and wounded six of his classmates.
Rod Mathews, age 14, (Ritalin) beat a classmate to death with a bat.
James Wilson, age 19, (various psychiatric drugs) from Breenwood, South Carolina, took a .22 caliber revolver into an elementary school killing two young girls, and wounding seven other children and two teachers.
Elizabeth Bush, age 13, (Paxil) was responsible for a school shooting in Pennsylvania Jason Hoffman (Effexor and Celexa) – school shooting in El Cajon, California
Jarred Viktor, age 15, (Paxil), after five days on Paxil he stabbed his grandmother 61 times.
Chris Shanahan, age 15 (Paxil) in Rigby, ID, who out of the blue killed a woman.
Jeff Franklin (Prozac and Ritalin), Huntsville, AL, killed his parents as they came home from work using a sledge hammer, hatchet, butcher knife and mechanic's file, then attacked his younger brothers and sister.
Neal Furrow (Prozac) in LA Jewish school shooting reported to have been court-ordered to be on Prozac along with several other medications. Kevin Rider, age 14, was withdrawing from Prozac when he died from a gunshot wound to his head. Initially it was ruled a suicide, but two years later, the investigation into his death was opened as a possible homicide. The prime suspect, also age 14, had been taking Zoloft and other SSRI antidepressants.
Alex Kim, age 13, hung himself soon after his prescription of Lexapro had been doubled.
Diane Routhier was prescribed Wellbutrin for gallstone problems. Six days later, after suffering many adverse effects of the drug, she shot herself.
Billy Willkomm, an accomplished wrestler and a University of Florida student, was prescribed Prozac at the age of 17. His family found him dead of suicide – hanging from a tall ladder at the family's Gulf Shore Boulevard home in July 2002.
Kara Jaye Anne Fuller-Otter, age 12, was on Paxil when she hung herself from a hook in her closet. Kara’s parents said ".... the damn doctor wouldn't take her off it and I asked him to when we went in on the second visit. I told him I thought she was having some sort of reaction to Paxil…")
Gareth Christian, Vancouver, age 18, was on Paxil when he committed suicide in 2002. (Gareth’s father could not accept his son’s death and killed himself)
Julie Woodward, age 17, was on Zoloft when she hung herself in her family’s detached garage.
Matthew Miller was 13 saw a psychiatrist because he was having difficulty and school. The psychiatrist recommended Zoloft for him. Seven days after beginning the Zoloft samples, his mother found him dead… hanging by a belt from a laundry hook in his closet.
Kurt Danysh, age 18 and on Prozac, killed his father with a shotgun. He is now behind prison bars, and writes letters, trying to warn the world that SSRI drugs can kill.
Woody ____, age 37, committed suicide while in his 5th week of taking Zoloft. Shortly before his death his physician suggested doubling the dose of the drug. He had seen his physician only for insomnia. He had never been depressed, nor did he have any history of any mental illness symptoms.
A ten-year-old boy from Houston shot and killed his father after his Prozac dosage was increased.
Huntsville, Alabama – February 5, 2010: 15-year-old Hammad Memon shot and killed another Discover Middle School student Todd Brown. Memon had a history for being treated for ADHD and depression. He was taking the antidepressant Zoloft and “other drugs for the conditions.” He had been seeing a psychiatrist and psychologist.
Kauhajoki, Finland – September 23, 2008: 22-year-old culinary student Matti Saari shot and killed 9 students and a teacher, and wounded another student, before killing himself. Saari was taking an SSRI and a benzodiazapine. He was also seeing a psychologist.
Dekalb, Illinois – February 14, 2008: 27-year-old Steven Kazmierczak shot and killed five people and wounded 21 others before killing himself in a Northern Illinois University auditorium. According to his girlfriend, he had recently been taking Prozac, Xanax and Ambien. Toxicology results showed that he still had trace amount of Xanax in his system. He had been seeing a psychiatrist.
Jokela, Finland – November 7, 2007: 18-year-old Finnish gunman Pekka-Eric Auvinen had been taking antidepressants before he killed eight people and wounded a dozen more at Jokela High School in southern Finland, then committed suicide.
Cleveland, Ohio – October 10, 2007: 14-year-old Asa Coon stormed through his school with a gun in each hand, shooting and wounding four before taking his own life. Court records show Coon had been placed on the antidepressant Trazodone.
Greenbush, New York – February 2004: 16-year-old Jon Romano strolled into his high school in east Greenbush and opened fire with a shotgun. Special education teacher Michael Bennett was hit in the leg. Romano had been taking “medication for depression”. He had previously seen a psychiatrist.
 Newman SS and Ghaziuddin M. Violent Crime in Asperger Syndrome: The Role of Psychiatric
Comorbidity J Autism Dev Disord 2008;38:1848–1852
Ghaziuddin M, Tsai L, Ghaziuddin N. Brief Report: Violence in Asperger Syndrome, A Critique. Journal of Autism and Developmental Disorders, 1991;21:349-354
 See, Appendix 1
 Moore TJ, Glenmullen J, Furberg CD (2010) Prescription Drugs Associated with Reports of Violence Towards Others. PLoS ONE 5(12): e15337. doi:10.1371/journal.pone.0015337
 October 06, 2012|By David Sell, Inquirer Staff Writer. http://articles.philly.com/2012-10-06/business/34280657_1_risperdal-suits-j-j-antipsychotic-drug
 There are more than 400 individual Risperdal lawsuits pending around the country, with more than 80 filed in Philadelphia. Thursday's settlement might lead to settlements in some of those. J&J, based in New Brunswick, N.J., with divisions in the Philadelphia region, is in litigation on several levels. Though appeals are pending, it has lost cases in Louisiana ($258 million), South Carolina ($327 million), and Arkansas ($1.2 billion) in which the company was alleged to have promoted Risperdal inappropriately through taxpayer-funded Medicaid systems. J&J won its Pennsylvania case. After six days of trial testimony, it paid $158 million to settle in Texas. The company also is negotiating with the federal government on a case, with reports suggesting that J&J might pay more than $2 billion. Previously, the company agreed to pay $181 million to settle similar litigation with 36 states.
 By Katie Thomas and Michael S. Schmidt. New York Times. July 2, 2012
 Spokesman for the whistleblower advocacy group Taxpayers Against Fraud
 The Catcher in the Rye. J.D. Salinger
 See http://www.youtube.com/watch?v=5lTGrAkW8hU