Eighteen months after Toran Henry killed himself, his mother finally gets to have her say on whether an anti-depressant had an influence on his death. Chris Barton looks at the case that has raised questions about the drug's use
When Toran Tiavare Henry took his own life he was 17.
He left behind a grief-stricken mother, an absent father, devastated school friends and a string of questions.
The unfathomable why of it. Why one so young, so intelligent, with an active social life would take such a despairing, final step.
The question continues to haunt his mother and friends and even here, in the Auckland Coroner's Court, there is unlikely to be a satisfactory answer.
Inescapably with suicide, there are morbid questions of how? The method of death is explained to the court in matter-of-fact detail, but cannot be published because the Coroner's Act prohibits it - the rationale being such media reports may lead to copycat suicide attempts.
Talk is free, however, and Toran's friends, the staff and many students at Toran's school, Takapuna Grammar, all know how he did it and how he was found by his mother, Maria Bradshaw.
"There are no words to describe the shock of what I saw," his mother tells the court.
"It is a sight so shocking, so unnatural, that it is impossible for the brain to register what it is seeing."
Then there are questions about whether anything could have been done to stop such tragedy and who might be to blame. There are many "if only ... " possibilities.
His mother, in a frantic dash to get home to her son, arrives too late.
Several friends stop by just before he dies, but decide not to walk down the driveway to his house.
Teachers know Toran has been humiliated in a fight outside the school the day before his death, but no one contacts his mother.
A social worker, speaking by telephone to Toran just hours before he kills himself, notes an escalating situation: "He said that he was trying to reach out for help and his trust had been broken ... that this had been his last option and it hadn't worked out ... that he felt he had nowhere else to turn."
But the question that generates most debate in the inquest is what part, if any, his medication played in his death. Toran was taking Fluox, a generic form of the drug fluoxetine, better known as Prozac, for depression.
What's not commonly known about the drug is that it can have unwanted side effects, including suicidal thinking leading to suicide attempts. Could side effects have happened here?
The question is controversial. The consensus in New Zealand, and the advice from Medsafe, is there is "diminished but persisting increased risk of self-harm, hospitalisations, but not suicide, in patients prescribed a selective serotonin reuptake inhibitor (SSRI)" - the class of drugs which includes Prozac.
What can't be ignored, however, is special blood tests ordered after Toran's autopsy found fluoxetine at the low end of therapeutic levels. He also had a blood alcohol level of 148 milligrams per 100 millilitres.
Toran's mother is adamant Toran was caught in the grip of a medication induced "activation syndrome" - a cluster of symptoms including irritability, agitation, aggressiveness, impulsiveness and mood swings - that have been linked to an increased risk of suicide.
The health professionals involved in Toran's care are unconvinced - arguing that he didn't have side effects from the drug and other factors, such as depression, were more likely explanations for his death.
Expert witness Dr Sabina Dosani says the question of whether SSRIs are associated with an increase in suicidal events is still under debate in the academic and clinical psychiatric communities.
She refers to Dr David Healy, a professor in psychological medicine at Cardiff University who has published widely on the subject and who has for most of his career "held the view that fluoxetine (Prozac) and other SSRIs can lead to suicide".
Dr Dosani says the association between fluoxetine activation syndrome and suicide continues to be controversial. "No definitive conclusion yet exists. Against this backdrop, prescribing SSRI medication is standard practice and endorsed by the main regulatory and professional bodies."
Deborah Marshall, representing Waitemata District Health Board, asks Dr Dosani directly for her views.
Ms Marshall: Professor Healy has concluded that: "There is a compelling case that Prozac can trigger suicide in susceptible individuals." Would you agree with that statement?
Dr Dosani: I would not agree that there is a compelling case.
Ms Marshall: This next statement is: "There is little evidence that it is likely to be of benefit in patients in Toran Henry's age bracket." Would you agree with that?
Dr Dosani: No, I disagree with that.
Dr Healy, the author of more than 150 peer-reviewed articles and 20 books including Let Them Eat Prozac, and who has testified in 20 cases in which SSRI anti-depressants have been involved in cases of suicide or homicide, responds to Dr Dosani's evidence by a letter to the coroner.
He points to analysis of adult placebo controlled drug trials by the United States Food and Drug Administration (FDA) in 2006 which show a 2.3 fold increased rate of suicidal behaviours in people aged 18-24 years. Dr Healy refers also to drug trial data from Eli Lilly, the makers of Prozac.
"If we analyse the data as presented here it will be obvious to all members of the Court, even those without statistical or mathematical expertise, that the risk is significantly greater on Fluoxetine than on placebo. Infinitely greater."
By the time the inquest begins on November 9, some 19 months after his death on 20 March 2008, Toran's suicide has already been widely publicised in the press and on TV - primarily because Toran's mother speaks out.
Mrs Bradshaw ignores the Coroner's Act, which says no one can say a death is by suicide until the coroner says so. Even then, all that can normally be said is the name, address and occupation of the person and that the death was self-inflicted.
Media reports vary. Some are sensational. Some get the facts wrong. Some blatantly breach the act, announcing the death as suicide. Others use code words "tragic", "sudden" or "referred to the coroner".
Mrs Bradshaw doesn't stop speaking out. For several months after Toran's death, she is active on a website dedicated to her son.
Many of the posts on the site are outpourings of grief, but there is also detailed discussion about Toran's death and reactions from his friends.
The site serves also to organise a protest march up Queen St on May 13, 2008, the day Toran would have turned 18. In the face of a mother's grief, the Coroner's Act is impotent.
Mrs Bradshaw levels accusations at others involved in her son's care - Takapuna Grammar and the Marinoto North Child and Adolescent Mental Health Service of the Waitemata District Health Board.
The publicity appears to have some effect.
The school decides to conduct an independent inquiry headed by Sir Ian Barker. The Education Review Office investigates student safety at the school and Marinoto commissions an external review of Toran's engagement with the service.
Both the school and Marinoto make public the findings of their respective investigations.
Technically both have also breached the Coroner's Act, a point not lost on coroner Murray Jamieson: "I am confronted by some evidence that the Takapuna Grammar School and Waitemata District Health Board have engaged with the media in respect of matters which pertain to the proceedings before this court."
Mrs Bradshaw continues her crusade. In November 2008 she is a guest speaker at an exhibition organised by the Citizens Commission on Human Rights (CCHR) founded by the Church of Scientology.
She tells the audience: "I've breached the Coroner's Act so many times I don't care. There is nothing I have to lose any more and nothing I won't do to have the truth told about my child."
In March 2009, unhappy with results of the school's inquiry and still critical of Marinoto, Mrs Bradshaw releases her own report - Lessons Learned From The Death Of Toran Tiavare Henry - a 161-page, footnoted document with appendices.
Shortly after its release the coroner issues an order prohibiting making public any evidence or submissions about Toran's death. Even then, days before the inquest, he has to remind media organisations of the suppression order.
The reminder comes following postings on the Trade Me message board about the inquest and a news report in which Bradshaw confirms she wants to file a private manslaughter prosecution against a psychiatrist who treated Toran.
The coroner is not impressed: "The materials appear to contain statements or postings from an interested person in respect of the forthcoming inquest."
The net result of Mrs Bradshaw's actions is a swarm of lawyers - for the school, the Waitemata District Health Board, the police, plus two barristers representing two psychiatrists involved in Toran's care - bristling with evidence to counter her allegations.
The inquest, one of the longest on record, lasts 18 days.
Mrs Bradshaw is on the stand for four days, including two and a half days of robust cross examination. When her lawyer, Moira Macnab, raises concerns about the type of questioning the coroner points out it is happening, in part, because of suggestions by Mrs Bradshaw that she "intends to pursue individuals giving evidence at this inquest in venues other than this".
Senior Constable Paul Herman is the first to give evidence about the possible influence of fluoxetine. "Some of the friends would notice a difference when he was on the medication and then when he was not on the medication ... When he was on the medication it was a different type of behaviour that showed up." Mrs Bradshaw maintains her son suffered side effects including extreme fatigue and aggressiveness.
Those involved with his care point out there were other explanations for the tiredness, that it can also result from depression, and that Toran had exhibited aggressive and self-harming behaviour when he wasn't on medication.
Experts also point out that depression and anxiety can manifest as agitation and irritability in adolescents, as can substance abuse which, in Toran's case, mainly involved binge drinking. In the period of care leading up to his death, Marinoto staff maintain they were not told about Toran's increasing anger and aggression.
Medsafe group manager Dr Stewart Jessamine tells the court that because fluoxetine is not approved for major depressive disorder treatment in children and adolescents in New Zealand, the only way it can be given to that age group is by what's known as "off label" prescribing.
"This means informed consent must be obtained from the patient," he says.
Marinoto staff prescribing fluoxetine for Toran, in the two periods in 2007 and 2008 he was under their care, say informed consent was sought and, in the second instance, Toran asked to go back on the medication.
Both Toran and his mother were given information pamphlets which included information about side effects. Staff also say they discussed with Toran and his mother that the drug was not approved for those under 18 and that it carried a "Black Box" warning in the United States.
Mrs Bradshaw disagrees: "I learned that the medication was not approved for people under the age of 18 some months after Toran's death and was absolutely shocked."
In the United States the FDA require a "Black Box" warning to be displayed on all packets of fluoxetine. The warning explicitly states that "anti-depressants increased the risk compared to placebo of suicidal thinking and behaviour in children, adolescents, and young adults in short-term studies of major depressive disorder and other psychiatric disorders".
The coroner asks Dr Jessamine why Medsafe doesn't require such a warning here. He says the Medicines Act doesn't allow for such a requirement and new legislation would be necessary to make it compulsory. Medsafe does, however, make consumer information about the drug available on its website.
After each expert witness testimony, the lawyer assisting the coroner asks three questions.
"Do you have any experience of suicidal thinking in such patients whilst you are treating them on fluoxetine?" All the experts say they have.
"Do you have any experience of suicide attempts in such patients?" Two of the experts say they have and one also has experience of a completed suicide.
"Can you give the coroner your view on how information about fluoxetine ought to be best provided to adolescent patients with depression and their parents, guardians and GPs?" Answers vary, but most indicate discussion followed by standardised written material would be desirable.
All experts also point out that while the drug can have side effects there is strong evidence that fluoxetine has benefits in the treatment of depression.
One of the psychiatrists who prescribed the drug for Toran is asked directly whether it was a mistake: "When prescribing fluoxetine to Toran I did not mean to harm him, which is part of our oath, and I prescribed him with my best intentions, as we prescribe to many other young people in New Zealand, and I do honestly not believe that by doing so I caused any harm to Toran whatsoever."
On the last day of the inquest the coroner makes an oral ruling: "On the evidence presented to me I am satisfied that the death was intentional and self-inflicted. No other persons were directly involved and I now adjourn this inquest for my written finding."