Seroxat - Crisis expert says Paxil may have been factor in suicide

Crisis expert says Paxil may have been factor in suicide. Sara Carlin Supplied photo Related Stories •Sara Carlin inquest begins


A second expert witness called by the Coroner's Counsel, Wednesday, has said Paxil use may have been a contributing factor in the death of Sara Carlin.


The 18-year-old Oakville woman and graduate of St. Ignatius of Loyola had been taking the anti-depressant about a year when she hanged herself in the basement of her family home on Sunday, May 6, 2007.

A coroner's inquest into her death is being held to examine the circumstances surrounding that death and determine if Paxil played a role in it. Health Canada has issued advisories warning Paxil can increase the risk of suicidal events in people under 18, had.

Dr. Nathan Scharf was qualified by the Coroner's Counsel Michael Blain as an expert in the area of selective serotonin reuptake inhibitor (SSRI) use in children and adolescents because of his work as director of crisis services at the Youthdale Treatment Centre in Toronto.

The centre provides emergency crisis intervention for children and adolescents found to be at risk.

Blain said Scharf works with young people at the centre as a psychiatrist.

When asked by Blain to comment on Sara's case, Scharf initially said Paxil was probably not a major contributor to her death because she had been taking the Paxil since February of 2006 and most suicidal thoughts and adverse effects take place in the first few weeks if they are going to take place at all.

As Sara had been quite far along in her Paxil treatment, Scharf said it was more likely her suicide was a result of other things going on in her life.

This opinion was also shared by the Coroner's Counsel's previous expert witness, Dr. David Juurlink.

On cross-examination, however, Carlin's lawyer Gary Will pointed out that Scharf had very little information on Sara's case. He had received only a page and a half summary from the Coroner's Office.

This summary included no medical records from Sara's doctors or statements from her parents about how they feel she changed when she began taking Paxil. Her parents have testified she changed from an academically and athletically focused young woman to an apathetic person who abused drugs and alcohol.

Will listed a number of incidents in which Sara's Paxil dose increase was followed shortly by some adverse behaviour on her part.

This included the Palm Springs incident, which occurred a few weeks after Sara began taking Paxil.

The Carlins have testified that Sara spent most of the time in bed with the blinds pulled down during a family trip to Palm Springs. They considered is very out of character for her.

When the Paxil dosage was moved from 10 mgs to 20 mgs, Will said Sara suddenly quite her part-time job at an optometrist's office.

Steve Schenke, who is representing three doctors associated with treating Sara, contested this statement. He said employment records indicate Sara left this job in June.

Will said soon after the Paxil level was moved from 20 mgs to 30 mgs in September, Sara wrote a letter to herself that some have characterized as being close to a suicide note.

Another dose increase from 30 mgs to 40 mgs in October was followed a week later by Sara being taken to a London emergency room after mixing sleeping pills, cocaine and alcohol.

Scharf said he was not aware of any of these incidents or their proximity to the Paxil dose increases.

When asked if he believed Paxil could cause suicide, Scharf said he did not believe there was a 'suicide button' within a person that Paxil could switch on, but said Paxil can cause agitation, sleep disturbances and increased anxiety, which in turn can lead to suicidal ideation.

Will next talked about Sara's Paxil prescription going missing for two to three days in early May during the last days of her life.

He asked Scharf about SSRI Discontinuation Syndrome and if side effects of a Paxil withdrawal could include suicidal ideation.

"I haven't experienced that in my practice. I have seen literature that would suggest that as a possibility," said Scharf.

"I accept that."

Will said that when Sara's Paxil prescription was refilled she may have taken as much as 120 mgs in a 36-hour period to make up the doses she missed.

Will asked Scharf if such a scenario could have played a role in her suicide.

"Certainly, it may have played a role. I cannot say it did not play a role," said Scharf. "It was perhaps one factor among others."

When cross-examined by Schenke, Scharf agreed it was more likely the large amount of alcohol Sara ingested the night before her death was a greater contributing factor to her suicide than Paxil, but stopped short of saying it was completely responsible for her death.

In addition to speaking about Sara's case, Scharf also talked about the process he goes through before putting someone on an SSRI at his practice.

Scharf said a physical evaluation takes place to ensure there is no underlying medical condition that could be contributing to or masquerading as a psychiatric condition.

Laboratory investigations are also conducted so Scharf can make sure the person is not anemic, that they have a properly functioning liver and kidneys, that they are not diabetic or pregnant.

Scharf said he typically works with a parent or guardian to work out when the medication would be introduced, who is going to monitor the child, how the medication will be dispensed, how issues of missed medication will be dealt with and how long the course of treatment will be.

Although Sara was 17 years and seven months old at the time she was prescribed Paxil and entitled to confidentiality, Scharf said he would have urged her to involve her family for the purpose of monitoring the drug.

He said it was appropriate for family practitioners to inform patients and their families about the side effects of the drug, especially if the side effects can lead to suicidal thoughts or even suicide.

Earlier this week, the inquiry heard testimony from Dr. Tom Stanton, Sara's family doctor, who said the appointment Sara was put on Paxil lasted for about 30 minutes.

He said he did not tell Sara about the risk of suicidal events associated with Paxil because patients are less likely to actually take the drug when told this.

During her cross-examination, Teresa Walsh, lawyer for Paxil manufacturer GlaxoSmithKline, pointed out that a family doctor, who has looked after a patient for a number of years, would already know much of the information sought in Scharf’s extensive examinations.

Stanton also testified the Carlin family was not provided information about Sara starting Paxil because Sara wanted her medical information kept confidential and that he had told Sara that if the medication made her feel worse she should come back.

It was also pointed out that Scharf's work at a crisis centre is very different than the work that goes on at a family doctor's office with Scharf seeing far fewer patients than a family doctor.

GlaxoSmithKline, the manufacturer of Paxil, has previously stated that patients should not stop taking Paxil without first consulting their doctor.

Any concerns with the use of Paxil, should be discussed with the patient’s health-care professional
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