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Doctor did not discuss risk of suicide with Sara Carlin Continued from page1 3 · Wednesday, June 16, 2010 OAKVILLE BEAVER · www.oakvillebeaver.com family that Sara was experiencing some anxiety during her last year of high school, as she was preparing to leave home for university, and went to Stanton to see what could be done to alleviate it. Stanton testified about this 30-minute visit, which took place on Feb. 20, 2006, stating far more was going on with Sara than just a little anxiety. "Her presenting problem, what she stated to me first, was that she was having a lot of anxiety. She said she'd seen a naturopath in the past for the same thing, but the naturopath medications she'd been given didn't work," said Stanton. "Then she went on to describe her symptoms, her hands were clammy, she was short of breath, she was having episodes of sweatiness, she was pale, she couldn't control these episodes, she was extremely emotional during the episodes, she was having two or three of them everyday and they were lasting for between five and 10 minutes each time." According to Shannon, Sara said she was having trouble sleeping, that she was having lots of nightmares, that she had no energy and was feeling very negative and depressed. When questioned about the stress in her life, Stanton said Sara told him she had a heavy workload at school, she was having trouble with her boyfriend and there was a lot of tension at home. Stanton said he asked about drug and alcohol use, which she denied. Stanton diagnosed Sara as suffering from both a panic disorder and depression. To get this under control he prescribed Paxil to Sara at a dose of 10 mgs per day, as well as the sedative Ativan to help Sara deal with her panic attacks. Sara's parents were not informed their daughter was being placed on Paxil. Stanton said Sara, then 17 years and seven months, had specifically requested her medical information be kept confidential. Stanton said children 16 and over are allowed to request medical confidentiality in Ontario with doctors prevented, by law, from breaking that confidentiality. Stanton said this confidentiality is important because patients are more frank about their medical issues when they know their parents are not going to find out about them. Stanton was asked by both Coroner's counsel Michael Blain and Carlin lawyer Gary Will whether he had told Sara Paxil could produce suicidal thoughts in people under 18. Stanton said he informed Sara how the drug worked and advised her to contact him if it made her feel worse. The possible increased risk of suicide was not "The person is in a pretty vulnerable state at that point and I find that if you say to the person, `This could cause you to commit suicide,' it's really hard to engage the person with the medication." Dr. Tom Stanton, Sara Carlin's family physician Sara Carlin mentioned. "The person is in a pretty vulnerable state at that point and I find that if you say to the person, `This could cause you to commit suicide,' it's really hard to engage the person with the medication," said Stanton. "I find that a better way to say that is that sometimes it can make you feel worse and if there are any side effects or anything that you notice is different, then you need to talk to me about those." A follow-up appointment with Sara in March 2006 indicated the medication appeared to be helping somewhat, said Stanton, with Sara experiencing less panic and sleeping more. Since the medication appeared to be working, Stanton said he doubled the Paxil dose from 10 mgs to 20 mgs and prescribed Imovane to help her sleep. Because the Ativan did not appear to be doing anything, that prescription was not renewed. At this point, Stanton referred Sara to a psychotherapist to get at the root cause of the anxiety. When asked if he'd consider more frequent, perhaps weekly monitoring, Stanton said he did not think it was necessary, because he was not hearing anything from Sara he didn't like. April and June appointments were also positive, Stanton said, with Sara stating the Paxil was helping her and that she was happier, sleeping more, crying less and experienced less sadness. At this point, the Paxil dose was not changed. Sara missed an August appointment, but made the September appointment where she was seen by Stanton's colleague Dr. Lynne Benjamin. At this point, Sara was attending the University of Western Ontario where she was having more panic attacks and feeling more anxiety. Benjamin increased the Paxil dose to around 30 mgs per day. At an appointment in October with Benjamin, Stanton testified Sara said school was terrible and she was going to quit. She also reported sleeping poorly and increased panic when she was driving. Correction A headline in the Wednesday, June 9 Oakville Beaver incorrectly identified Sara Carlin's deceased older brother Brendan as her younger brother, The Oakville Beaver regrets the error and apologizes for any inconvenience it may have caused. At this point, the Paxil dose was increased to 40 mgs per day. During his testimony, Sara's father Neil said each of these increases seemed to be followed by sudden and adverse behavioural changes in Sara. The February introduction to Paxil was shortly followed by Sara being barely able to get out of bed during a family Palm Springs trip. The March increase, Neil said, was followed by Sara quitting her job at an optometrist's office for no real reason. Drug and alcohol abuse also became a problem during this period. The September increase was followed by Sara writing a letter very close to a suicide note, that was not found until after her death. The October increase was followed by Sara visiting the London emergency room after mixing sleeping pills, cocaine and alcohol. All of this reached its grim conclusion in the early days of May 2007 when Sara's pills went missing for a couple of days. Neil now believes that when the prescription was refilled Sara took several doses all at once to make up for the lost ones, something the literature on Paxil warns against. Sara was found dead shortly thereafter. Following the London incident, Stanton said he met with Sara's mother Rhonda, who told him about this incident at his office. "I said, `You have to take her to the emergency room in Oakville and have a crisis psychiatric assessment done,'"said Stanton. An emergency doctor assesses the patient first to make sure they are medically able to see the crisis team and then the crisis team comes in, and the crisis nurse and the psychiatrist assesses the person to see if they need to be in hospital. If they don't need to be in hospital, they give the patient the resources they need, the names of counsellors or whatever they determine is best. Stanton said he later heard from a Carlin family member that Sara was off drugs and alcohol and the situation was being handled at home. During a December appointment, Sara told Stanton she had stopped taking drugs and alcohol. She also told him that at her parents' suggestion she was weaning herself off Paxil and had already begun taking 20 mgs only every other day. Stanton warned this was dangerous and reestablished the dose at 20 mgs per day. The Carlins have previously testified that although they were concerned about the Paxil by this point, they did not tell their daughter to just stop taking it. Sara's last appointment with Stanton was in January of 2007. Additional appointments were made, but Sara never returned. The Carlin family has been critical of Stanton for what they consider a lack of follow up in their daughter's case, particularly when it became clear through a blood test that she was still mixing cocaine with Paxil. Stanton said doctors rely on the patients to come to them and make appointments. The day also saw Alexander speak about the motive for Sara's anxiety. Alexander was the psychotherapist Stanton referred Sara to in March 2006 with the actual appointment taking place in July of 2006. During that appointment, Alexander said Sara told her that she had been fine until Grade 6 when her older brother Brendan died. Sara said she had bottled up feelings of heartbreak, anger and sadness, but in the last two years had begun to experience anxiety and sadness, which steadily began to increase. Alexander said this got so bad Sara began to avoid going out and doing things because she was afraid of having panic attacks. The lawyer for GlaxoSmithKline, the manufacturer of Paxil, Teresa Walsh, would later list this fear of panic attacks as the possible cause of Sara's behaviour changes (quitting work and quitting sports) rather than Paxil side effects. On the subject of the Paxil, Alexander said Sara told her it had helped her immensely. During the session, Sara also sent out mixed messages about what was going on in her head with regard to suicide. On a form that was filled out before the session, Sara did check a box stating: "Have thoughts of killing myself, but I would not carry them out." When asked about this, Sara denied it was true. Alexander did discuss drinking with Sara. She said she was concerned as Sara told her she had been drinking a 26-ounce bottle of alcohol every weekend with friends for the last two years. Sara told Alexander she was doing this to numb herself to the pain she was feeling. Alexander said she warned Sara about drinking while taking Paxil because alcohol is a depressant and can make depression worse to the point where it could cause her to think about harming herself. Sara stopped coming to see Alexander after the first session. Alexander said her secretary tried without success to reschedule an appointment with Sara. Alexander said Stanton was not contacted about this because at that time Sara did not appear suicidal. ### 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 healthcare professional. Editor's note: See page 9 for testimony from Friday, June 11. See Mother describes daughter's downward spiral on insidehalton.com for testimony from Thursday, June 10.