Ambien, Delusions, and Violence: Is There a Link? Part 2

Last week I wrote about the recent arrest of Air Force veteran Derek Stransberry, who caused panic aboard Delta Airline Flight 273 when he told the crew he was carrying dynamite and traveling under a false passport. I also described the case of Mr. Abrams, who was charged with stabbing his wife to death. Prior to committing their respective offenses, both men had allegedly taken Ambien, a widely used sleep aid with rare but disturbing side effects.
I was hired by Mr. Abrams's attorney to conduct an evaluation of his mental state at the time of the offense. I was to determine whether he was insane, or "not responsible" for the crime. For months prior to his arrest he had been severely depressed. He had been taking antidepressant medications along with Ambien. When his depression did not lift he began a course of electroconvulsive therapy (ECT).
Mr. Abrams claimed to have no memory of killing his wife. Although I could not explain his amnesia, I believed his story. I concluded that he was depressed and psychotic at the time he killed his wife. I thought that a medical doctor's expertise would be essential in understanding this complex and puzzling case.
During the next few years, Mr. Abrams' mental state fluctuated. His depression returned and he was transferred to a forensic hospital for treatment on several occasions. During one hospitalization Mr. Abrams became acutely psychotic. The staff concluded that he was hearing voices and was delusional. He told them his parents were murdered and fluid had been removed from his brain. After a few days, for no apparent reason, his psychosis remitted.
The hospital records indicated that Mr. Abrams was not uniformly liked by the staff. Many described him as manipulative and demanding. Some seemed to conclude that he was malingering when he insisted he had no memory of killing his wife. Apparently they did not believe his amnesia was genuine. But I still did.
My colleague Dr. Siegel, a forensic psychiatrist, met with the defendant three and a half years after I did. Dr. Siegel concluded in his report, "While I cannot make a firm statement based upon firsthand information that Mr. Abrams lacked substantial capacity to know or appreciate the nature and consequence of his conduct or that his conduct was wrong, it is my professional opinion with a reasonable degree of psychiatric certainty that the balance of probabilities point in that direction."
The district attorney retained a forensic psychiatrist, and I was not surprised to learn that he came to a different opinion than that of Dr. Siegel and me. The prosecution-retained psychiatrist concluded that the defendant was responsible for killing his wife and that he had stabbed her because of "acute stresses" and his underlying personality features.
After submitting his report, Dr. Siegel continued to search the Internet for the latest research on the side effects of Ambien, and discovered a few articles that seemed to explain Mr. Abrams' amnesia. One article described 21 cases of psychotic symptoms associated with Ambien. Some patients even reported visual hallucinations (Huang, Chang, Hung & Lin, 2003). The second study described two patients who reported hallucinations and delusional thinking after taking Ambien. Neither patient had any history of psychosis (Markowtiz & Brewerton, 1996).
The district attorney offered Mr. Abrams a plea for manslaughter. Although Mr. Abrams was aware that most insanity defenses are unsuccessful, he chose to go to trial with a "not responsible" defense.
Dr. Siegel and I testified first. We told the jury about Mr. Abram's severe depression, his Ambien use, and the latest research on Ambien side effects. Then the prosecution-retained psychiatrist was called to the stand to testify about his opinion.
The jury was not out long. They deliberated only a few hours before returning with a verdict of guilty. The judge sentenced Mr. Abrams to 25 years to life.
I was not surprised by the verdict or the sentence, but I was disappointed that Dr. Siegel and I had not managed to convince the judge and jury that the Ambien could have caused or contributed to Mr. Abrams' amnesia, temporary psychosis and violence. Perhaps they weren't convinced because the side effects of Ambien were not well known. During recent years, however, the press has reported numerous stories of strange behaviors associated with Ambien use. In 2006, for example, Representative Patrick Kennedy claimed that he took Ambien and could not remember crashing his car.
I have recently seen more strongly worded warnings about the side effects of Ambien: "Sleepwalking, and eating or driving while not fully awake, with memory loss for the event, as well as abnormal behaviors such as being more outgoing or aggressive than normal, confusion, agitation, and hallucinations may occur. Don't take it with alcohol as it may increase these behaviors. In patients with depression, worsening of depression, including risk of suicide may occur." www.AMBIENCR.com
It has been a few years since Mr. Abrams' conviction, and I wonder if the verdict would have been different if he were tried today, especially if the jury heard testimony about Mr. Stransberry's bizarre behavior on Flight 273. It will be very interesting to follow Mr. Standsberry's legal case and see whether he uses a psychiatric defense at trial. A jury might believe his psychotic break was linked to the use of Ambien.