Prozac Timeline

Below is the timeline presented to the jury in the Forsyth v. Eli Lilly Trial. It was presented during closing arguments by the plaintiffs. It lists Lilly’s internal documents. The plaintiffs allege that it shows that Lilly knew about Prozac-induced suicidality and violence (even before Prozac was approved for marketing in the United States) and that this was withheld from the public.

• Aug. 1978 – Team Meeting Minutes – “There have been a fairly large
  number of reports of adverse reactions . . . Another depressed patient developed
  psychosis . . . Akathisia and restlessness were reported in some patients.”
  Exhibit 30 (2nd page, end of 2nd paragraph)

• May 1984 – BGA Comments – “During the treatment with the preparation
  (Prozac) 16 suicide attempts were made, 2 of these with success. As patients
  with a risk of suicide were excluded from the studies, it is probable that this high proportion can be attributed to an action of the preparation
  (Prozac) . . .” Exhibit 42 (page 3, 6th paragraph)

• Jan. 1985 – Lilly receives reasons why the BGA will reject Lilly registration,
  one of which was because of “SUICIDAL RISK.” With instructions
  for “IMMEDIATE FOLLOW-UP ON ALL KEY OPINION LEADERS ON THE BGA COMMISSION
  FOR SELECTED VISITATION NEXT WEEK.” Exhibit 53

• March 29, 1985 – “Benefit/Risk Considerations” – “The
  incidence rate (suicide) under fluoxetine (Prozac) therefore purely mathematically
  is 5.6 times higher than under the other active medication imipramine.”
  . . . “The benefits vs. risks considerations for fluoxetine (Prozac)
  currently does not fall clearly in favor of the benefits. Therefore, it
  is of the greatest importance that it be determined whether there is a particular
  subgroup of patients who respond better to fluoxetine (Prozac) than to imipramine, so that the higher incidence of suicide attempts may be tolerable.
  Exhibit 58 (pages 18 & 22)

• June 1986 – Draft of Proposed PRECAUTIONS and ADVERSE REACTIONS Sections
  of the Prozac Package Insert – “Mania and psychosis may be precipitated
  in susceptible patients by antidepressant therapy.” Exhibit 5 (1st
  page) (never included in actual inserts)

• Aug. 1989 – Additional Feedback Regarding the Fluoxetine (Prozac) Review
  by the Commission A (Germany) – “3. The counterindication because of
  acute suicidality should become a warning whereby the physicians should
  be advised that in the absence of sedation, the risk of higher suicidality
  should be taken into account.” Exhibit 88

• Nov. 17, 1989 – Letter to sales representatives on article about Prozac-induced
  akathisia authored by Dr. Lipinski and others. “In the article the
  authors voice their suspicion that ‘the triad of symptoms’ (anxiety,
  nervousness, and insomnia) reflects the syndrome of akathisia, ‘which,
  in their view is apparently related to fluoxetine (Prozac) therapy.”
  But the sales people are warned: “Use of this information in product
  discussions may violate federal law.” Exhibit 91 (1st page, 2nd paragraph
  and 2nd page, last sentence)

• Jan. 1990 – PROZAC and SELF-DIRECTED VIOLENCE – “We have just received
  a pre-print of an article (not a letter to ed.) Which we understand is to
  appear in the February 1990 AMERICAN JOURNAL OF PSYCHIATRY suggesting that
  Prozac can induce severe, intense, obsessional suicidal ideation.”
  . . .” Exhibit 94

• Jan. 30, 1990 – Letter to sales representatives giving the sales people
  a “heads-up” on the forthcoming Teicher article regarding Prozac
  and Suicide and instructing them as follows: “Because these issues
  (suicide) are not part of our current marketing plan, you should not initiate
  discussions on these articles. … “Again, because these issues
  are not part of our current marketing plan, discussions should not be initiated
  by you.” Exhibit 15 (bottom of second page)

• Feb 1990 – Teicher article published “Emergence of Intense Suicidal
  Preoccupation During Fluoxetine (PROZAC) Treatment” – “The purpose
  of this report is to suggest the surprising possibility that fluoxetine
  (Prozac) may induce suicidal ideation in some patients.” . . . “In
  our experience, this side effect has occurred in 3.5% of patients receiving
  fluoxetine (Prozac) . . .” Exhibit 95

• February 7, 1990 – Leigh Thompson Memo – “Anything that happens in
  the UK (England) can threaten this drug (Prozac) in the US and worldwide.
  We are now expending enormous efforts fending off attacks because of (1)
  relationship to murder and (2) inducing suicidal ideation.” Exhibit
  97

• February 7, 1990 – Leigh Thompson Memo – “I am concerned about reports
  I get re UK attitude toward Prozac safety. Leber (FDA) suggested a few minute
  ago we using CSM database to compare Prozac aggression and suicidal ideation
  with other antidepressants in UK. Although he is a fan of Prozac and believes
  a lot of this is garbage, he is clearly a political creature and will have
  to respond to pressures. I hope Patrick realizes that Lilly can go down
  the tubes if we lose Prozac and just one event in the UK can cost us that.”
  Exhibit 98

• June 1990 – Letter to Lilly by concerned doctor – “I am writing to
  inform Eli Lilly Company that a disturbing number of suicides or suicide
  attempts associated with Prozac has come to my attention over the last several
  months.” I am concerned that the association with Prozac may be more
  than coincidental.” . . . “There appears to be growing concern
  that Prozac may somehow trigger a suicidal preoccupation in a small subset
  of patients and that their families should be warned of this potential risk.
  It is certainly possible that some of the cases reported are “coincidence”
  in that the depressed person may have attempted suicide independently of
  Prozac. However, some of these cases appear to be in patients taking Prozac
  for reasons other than depression.” Exhibit 102 (2nd page)

• July 18, 1990 – Memo regarding call from Paul Leber at the FDA. “Paul
  Leber called yesterday; I contacted him at 6:15 am this morning and half-hour
  conversation, very, very pleasant . . .” “The call was about suicide.”
  . . . “He asked that we FAX nothing to him unless he has agreed before
  hand.” “Paul (Leber) is taking a position in talking with outside
  folks today that Lilly and FDA working together on the suicide issue and
  following closely the postmarketing events, but that there are no denominators
  and the best that can be done is to put a ‘cap’ on the number of events.”
  Exhibit 104 (top of 1st page and bottom of 2nd page)

• August 3, 1990 – Letter to sales representatives regarding reports of suicidal
  ideation/behavior possibly associated with PROZAC therapy. “This
  information is not intended to replace our current promotional strategy
  but is being provided to enable you to respond to physicians when appropriate.
  You should not initiate discussion on these issues nor use this letter in
  detailing. However, if asked to comment on these issues by a health
  care professional, you should: 1. Reassure the health care professional
  that no casual relationship has been established between suicidal ideation
  and PROZAC therapy.” Exhibit 17 (bottom of 1st page and top of 2nd
  page)

• August 31, 1990 – “Dear Doctor” letter assuring them that there
  is no “causal relationship between Prozac and suicidality (ideation
  or acts).” Exhibit 22

• September 12, 1990 – Lilly memo between Max Talbot and Leigh Thompson- Talbot
  says “One possible strategy if FDA presses for an additional labeling
  change vis-a-vis suicide is a class-wide (i.e. ALL antidepressants) cautionary
  note; however we should take this position only as a last resort.”
  Thompson replies: “that report MUST move swiftly through approval and
  to Dr. Leber’s (FDA) hands – – he is our defender.” Exhibit
  109

• September 14, 1990 – Lilly memo between John Heiligenstein (Lilly) and Leigh
  Thompson – Heiligenstein says: “We feel caution should be exercised
  in a statement that “suicidality and hostile acts in patients taking
  Prozac reflect the patient’s disorder and not a causal relationship to Prozac
  – – – – Postmarketing reports are increasingly fuzzy and we have assigned
  ‘Yes, reasonably related’ on several reports.”. . . “You
  may want to note that trials were not intended to address issue of suicidality.”
  Exhibit 110

• September 25, 1990 – Minutes of Lilly Meeting with FDA – discuss doing an
  in-hospital rechallenge of patients who met predefined criteria for suicidal
  acts and ideation and agrees to “analyze international data relating
  to suicide.” Exhibit 112

• October 2, 1990 – Memo to Lilly employee Leigh Thompson to Lilly employee
  Robert Zerbe regarding an upcoming Prozac symposium in which the issue of
  suicidality is discussed. “Then the question is what to do with the
  ‘big’ numbers on suicidality. If the report numbers are shown next
  to those for nausea, they seem small.” Exhibit 113 (2nd page.)

• November 7, 1990 – Leigh Thompson memo – “I’d suggest that priorities
  are: (1) protect Prozac” . . . Exhibit 116

• November 13, 1990 – Memo from Claude Bouchy (Lilly Germany) to Leigh Thompson
  Re: Adverse Drug Event Reporting – Suicide Fluoxetine – In response to Lilly’s
  request that he (Bouchy) change the event “suicidal ideation”
  to “depression,” Bouchy writes: “Hans (another Lilly employee
  in Germany) has medical problems with these directions and I have great
  concerns about it. I do not think I could explain to the BGA, a judge, to
  a reporter or even to my family why we would do this especially on the sensitive
  issue of suicide and suicidal ideation.” Exhibit 117

• November 14, 1990 – Second memo from Claude Bouchy (Lilly Germany) to Leigh
  Thompson Re: Adverse Drug Event Reporting – Suicide Fluoxetine in which
  he states: “I personally wonder whether we are really helping the credibility
  of an excellent ADE system by calling overdose what a physician reports
  as suicide attempt and by calling depression what a physician is reporting
  as suicide ideation.” Exhibit 118

• April 15, 1991 – Memo to Leigh Thompson called “Upcoming TV appearance”
  Section I. “MESSAGE GOALS – Whatever questions you are asked or direction
  the interview take, the three points we want to establish are: 2. ‘It’s
  in the disease, not the drug.’; Section III ‘If pressed, or as a postscript
  to the above, then make the point that absolutely no evidence indicates
  that PROZAC as a cause of such behavior (violence and suicide).’, and ‘Prozac
  defense . . . There is simply no medical or scientific merit to the argument.”
  Exhibit 123

• April 23, 1991 – Leigh Thompson Memo re 20/20 Show in which he admits that
  on the issue of suicidality “I did NOT share the European data AT ALL.”
  and “She attacked on us hiding data by dividing up reports by many
  COSTART terms. She had numbers for suicide, overdose, intentional overdose,
  unintentional overdose and said they came to 1200 (or 1400) total suicides
  – – so we went around on OD not necessarily being suicide and COSTART, etc.”
  Exhibit 124 (bottom of 1st page and 4th paragraph of 2nd page)

• May 15, 1991 – FDA Meeting to Discuss Fluoxetine Rechallenge Protocol –
  “we agreed to have the rechallenge protocol ready to go by September
  1, 1991 Exhibit 125

• August 1991 – Dr. David Healy’s Article “Antidepressant Induced Suicidal
  Ideation” – “These two cases suggest that the emergence of suicidal
  ideation on antidepressants cannot always be attributed to a lifting of
  psychomotor retardation but rather that the ideas may in some instances
  be produced by antidepressants.” Exhibit 126

• October 29, 1991 – Lilly prepared draft for Dr. Beasley entitled “Suggested
  Reply Points to Oswald, Healy & Creaney” in which he acknowledges
  that item 3 of the HAMD is an insensitive measure of suicidality and states:”There
  was no specific rating scale for akathisia included in the trial designs
  for the studies reported, so the only source of data would be adverse event
  reports. Akathisia is a subjective phenomenon and hence would rely on patients
  volunteering information.” Exhibit 130 (2nd page)

• December 1991 – Dr. Rothschild’s Article “Re-exposure to Fluoxetine
  After Serious Suicide Attempts by Three Patients: The Role of Akathisia”
  – “This is the first report, to our knowledge, of patients restarted
  on fluoxetine (Prozac) after a previous suicide attempt during fluoxetine
  treatment.” . . .”When re-exposed to fluoxetine, the patients
  again developed akathisia and suicidal ideation. The suicidal feelings abated
  when the akathisia was treated by the discontinuation of the fluoxetine
  (Prozac) or the addition of propranolol.” Exhibit 131 (Cross-examination)

• January 23, 1992 – Lilly memo regarding upcoming meeting with Taiwanese
  doctors (Drs. Lu and Ko) to discuss the report on their study results entitled
  “suicidal attempts and fluoxetine (Prozac) treatment.” Exhibit
  133

• April 8, 1992 – Weinstein (Lilly employee) Report – “Mission Accomplished.
  Professor Lu will not present or publish his fluoxetine (Prozac) vs. maprotiline
  suicidality data.” Exhibit 144

• March 3, 1993 – Forsyth’s deaths

• 1994 – Dr. David Healy’s Article “The Fluoxetine and Suicide Controversy”
  – Dr. Healy concludes: “In the opinion of this author, the volume of
  case reports and other studies is sufficient to demonstrate that antidepressants
  and antipsychotics may induce suicidal ideation in certain individuals under
  certain conditions.” Exhibit 153

• 1995 – Dr. Jick’s Study “Antidepressants and Suicide” – “The
  results indicate that only fluoxetine (Prozac) has a rate that seems to
  be substantially higher than that of the other antidepressants.” Exhibit
  155

• June 1998 – Dr. Roger Lane’s article “SSRI-Induced Extrapyramidal Side-Effects
  and Akathisia; Implications for Treatment” appears in the Journal of
  Psychopharmacology. “SSRI-induced akathisia is a relatively rare but
  is frequently unrecognized when it does occur.” . . . “The precise
  definition of akathisia is a matter of controversy, as is the relative importance
  of the objective and subjective aspects of the disorder. Is akathisia a
  movement disorder or an intense and uncomfortable mental state . . .”
  “It may be less of a question of patients experiencing fluoxetine (Prozac)-induced
  suicidal ideation, than patients feeling that ‘death is a welcome result’
  when the acutely discomforting symptoms of akathisia are experienced on
  top of already distressing disorders.”

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