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Macmillan Childrens Publishing Group

Medication Madness

The Role of Psychiatric Drugs in Cases of Violence, Suicide, and Crime

Peter R. Breggin, M.D.

St. Martin's Griffin


Medication Madness

Chapter 1
Killing the Pain--and Almost the Cop
IF HARRY HENDERSON had been able to reflect on his behavior at the time, his mission would have seemed tragically and senselessly absurd--something no man in his right mind would consider carrying out. Nothing in Harry's thirty-eight years suggested that he was capable of such a horrendous act. Yet he would become an extreme example of the havoc caused by medication madness.
Everything was going well with Harry's wife and family. After the catastrophe, many family and friends confirmed to me that Harry's marriage was a model for others; in his brother's words, "the best in the family." Meanwhile, it was Harry's most successful year financially. He owned a small business and expected to continue making a comfortable living. He was known for his meticulous work and his scrupulous honesty. Since he and his wife Cindy did most of the work, he had limited expenses, and he was generous to the relatives he employed.
Harry was an elder of his church with considerable responsibility for administration and teaching. He and Cindy had no children; their family was the church and the community surrounding it.
When Harry's mother- and father-in-law needed a place to live, he encouraged them to buy the duplex adjoining his own house, and then he went to work renovating it free of charge. His wife hadn't pushed him into it. That's the way Harry was: he saw a need and he tried to take care of it.
In my many years of forensic work as a psychiatrist and medical expert, I have rarely conducted so many wholeheartedly positive face-to-face interviews and read so many laudatory testimonial letters about an individual. Somany people were eager to tell me about his good qualities, I had to meet with them as a group in Harry and Cindy's kitchen. Harry wasn't there because he was languishing in jail.
Did Harry need to be in jail? Was he violence prone? As far as I could ascertain, the only time Harry ever displayed aggression was at age fifteen: A classmate called his girlfriend a "bitch" while she was standing beside him and Harry hit the boy without inflicting serious injury.
Harry had to rise above an abusive childhood. His alcoholic father and beleaguered mother barely took care of him and his brothers and sisters. If Harry were the self-congratulatory sort, he could have exuded pride at being a self-made man. Instead, his childhood left him with a Lincoln-esque sadness. He had accepted these "blue" feelings as "just the way I am," and no one who knew him described him as depressed.
Not viewing himself as depressed, Harry never considered seeking treatment until he happened to visit his family doctor for an annoying gastrointestinal problem. The problem eventually went away but something else happened that day in the doctor's waiting room--something that would forever change his life and the lives around him. Harry noticed a flyer about depression and its treatment. Couched as an "educational" brochure and prominently displayed in the doctor's office, it was really an advertising pamphlet for a pharmaceutical product. For the first time in his life, Harry thought, "Maybe I'm depressed."
Harry was dealing with two stressors in his life: in-laws who were making excessive demands on him, and his own mother who was dying of Alzheimer's disease. In his criminal case, I wrote to the court, "It is no exaggeration to say that all of these problems were related to his sense of altruism and responsibility; none of them were selfish or self-centered in nature."
Following his physical, which revealed nothing to be worried about, Harry talked briefly to the physician's assistant about feeling "blue" on and off for much of his life. Although Harry does not recall being at all suicidal or reporting such feelings to the doctor, the medical record states that he had some suicidal feelings in recent times. But never in his life had Harry experienced anything remotely like the compulsive drive toward violence that would soon overcome him.
Harry walked out of the medical office with a prescription for Paxil 20 mg per day. Paxil is one of the commonly used Prozac copycats that also include Celexa, Lexapro, Luvox, and Zoloft (see table I in appendix A). All are selective serotonin reuptake inhibitors (SSRIs) that block the normal removal of the neurotransmitter serotonin from its active site in between neurons in thebrain. Among them, in my clinical experience, Paxil is the antidepressant most often implicated in acts of violence and suicide.
One month later, Harry's prescription was increased to 30 mg and then 40 mg per day over a one-week period, well within the suggested dose range for treating depression. However, most negative psychiatric reactions to antidepressants occur within the routine dosages, often when the dose has been recently changed, either up or down.
AT THE TIME, Harry's wife Cindy did not connect the changes in her husband with his starting Paxil, but in retrospect it became clear. Usually, he was very gentle and considerate, a model husband, but now he sometimes became irritable. On one occasion he shocked Cindy by gesturing obscenely at a driver who had cut him off. Again, out of character for him, Harry cried uncontrollably while visiting his ailing mother and on another occasion burst unaccountably into tears on a weekend vacation. He also showed a maniclike lack of judgment, buying worthless or extravagant items at auctions, including a car the family didn't need. Again, this was not typical behavior for Harry Henderson.
Antidepressants frequently cause overstimulation of the brain and mind, ranging from insomnia and mild agitation to psychotic levels of mania. They can also drive compulsive behaviors. Harry would display all of these behaviors while taking Paxil.
Harry ran out of Paxil for one day and "crashed," sleeping for two days, but he had no idea this was a drug-withdrawal reaction. His doctor had failed to warn him about that eventuality and Harry did not check other sources of drug information. Of all the side effects Harry experienced, sexual dysfunction was the only one his doctor had mentioned to him and was, therefore, the only one Harry could identify as drug-related.
One friend who saw Harry several days a week at church activities noticed that Harry was "nervous and agitated," "fidgety," "forgetful," and "like a radio turned to all channels." But in general, Harry managed to keep his inner turmoil from almost everyone who knew him.
Eight months after starting on Paxil, Harry's dose was again increased, this time to 60 mg per day, somewhat above the recommended maximum of 50 mg per day for depression, but well within medical practice habits. Harry's mental state drastically worsened. He felt a growing, compulsive desire to put a stop to the strange pain inside his head, one of the most agonizing anddifficult-to-describe adverse effects of the newer antidepressants like Paxil, Zoloft, Prozac, and Celexa.
Harry began to think that his wife would also be better off dying, because "it wasn't right" to leave her behind to feel guilty and to suffer. Killing her and then killing himself was the morally correct thing to do. But the idea of harming her became so intolerable that he focused instead on destroying himself.
These impulses came out of the blue. Harry had none of the risk factors commonly found in people who become desperately suicidal. He was not abusing drugs or alcohol; he was not elderly; he did not suffer from a debilitating physical illness; he had not experienced a severe loss, trauma, or death of a loved one; and his business and finances were sound. Although Harry may have told his doctor that he had experienced suicidal feelings in the past, he never made suicidal threats or attempts. He was feeling pressured by his in-laws to work on their house and his mother was dying of Alzheimer's but everyone who knew him agreed that Harry had been handling these stresses without displaying unusual strain. Over the years, his depressed feelings had been relatively mild and at no time debilitating.
Harry began to search for a way to obtain a gun to kill himself. After failing in his attempts to purchase a pistol, he imagined finding a police officer on a bicycle. He could push over the officer's bike and seize his gun to kill himself. Harry drove around the city but could not find any cops on bikes. Besides, he felt no animosity toward the police and had donated money to the local police department. His brother-in-law was a fireman, a job that Harry associated in a positive way with the police force.
Then, Harry got a new idea. It made perfect sense at the time because it would pose no risk to others. He would break into a police car to get a shotgun; that way he wouldn't have to hurt anyone else. So he began driving toward the town police station where he knew he could find parked patrol cars. He was determined to get a gun without doing any harm to a policeman.
When interviewing Harry in jail, I inquired about his knowledge of guns. He had never handled one and had no idea about differences between automatic shotguns and pump guns, or what might be required to fire them. He had no idea if he could manipulate a long gun barrel into position to shoot himself. He was equally ignorant about handguns. He had no notion about safety catches. He didn't know that he would have to slide back a chamber to cock an automatic handgun. He was a man possessed with a mission; details or practical considerations didn't clutter Harry's mind. Fixated on his goal, nothing could stand in his way. Meanwhile, Harry had no idea that the drug was driving his wholly out-of-character behavior.
Before turning onto the street toward the police station, Harry happened to spot a patrol car parked by the side of the road down the block. A policeman sat in the car, apparently writing a traffic ticket for a driver he had pulled over to the curb ahead of him. Now a new impulse took over Harry. He stealthily drove his car into a parking area near the police car.
The policeman sat in his car with the turret lights flashing, ignorant of the fact that a man was planning to assault him most violently. Meanwhile, Harry's compulsion had completely seized him. In his own words he had "tunnel vision." He felt mesmerized: "All I could see was the red lights flashing like I was zonked out. All I could think was I can't stand this anymore--I got to do this."
Harry sat waiting in his car with the engine idling until the policeman began to open the door to his cruiser. Perhaps fifteen or twenty feet separated them. The moment the man's feet hit the pavement, Harry went into action. Keeping his left foot pressed on the brake for an instant, he pumped down hard on the gas pedal to rev up the engine. As the policeman turned wide-eyed in his direction, Harry burned rubber and drove his car into the officer, knocking him flat to the ground, and bashing in the side of his patrol car.
Next, Harry backed his car off of the prostrate man, leaped out, and heard the officer calling out, "He's trying to kill me." Harry bent over and tried to reassure him, "I just want your gun. I just want your gun." He wanted the cop to know that he wished him no harm.
Harry's memory is mostly blank for the next minute or two. He remembers someone restraining his arm as he tried to grapple for the officer's gun. He heard someone saying, "Oh, he's going for his gun." He envisioned getting the gun, pushing it into his own body, and pulling the trigger. He next remembers someone holding him down. Two men had intervened to drag him off the policeman.
The policeman was badly injured. He was cut, bruised, and shocked. One of his legs was broken. But with the help of good Samaritans, he fought off the crazed stranger who was trying to grab his gun from his holster.
During this horrendously violent assault on the officer, Harry--a man known for his gentle, caring nature--had given no thought to the harm he was inflicting on another human being. "I wasn't thinking about anything but dying. I obviously didn't think about consequences for anyone else." He had no plan for escaping or he wouldn't have run his own car into the cruiser. He felt compelled to end his life on the spot, then and there, at any cost.
After the assault was over, Harry failed to grasp the enormity of what he had done, nearly crippling or killing an innocent person, an officer of the lawwhose position he ordinarily held in respect. Later, after the Paxil effects began to wear off, Harry grew dismayed and remorseful. He became Harry Henderson again--and yet his life would never be the same. The man who had suffered from excessive feelings of responsibility for others throughout most of his life now had something really dreadful to feel guilty about. He entered into a period of deep depression.
Unexpectedly, the policeman Harry had assaulted came to Harry's legal rescue. After reading my detailed scientific evaluation of Paxil's capacity to cause compulsive, violent suicide, and my clinical analysis of Harry's particular case, the policeman decided that Harry was the victim of medication madness and should be dealt with leniently.
In mid-2002, when Harry Henderson drove his car into the policeman, there was hardly another psychiatrist in America who would have taken his case. Nearly all were in denial, and most remain in denial, about the capacity of antidepressants to drive people over the edge. Even today, after the FDA has acknowledged that the newer antidepressants like Paxil and Prozac cause suicidality, there are only very few psychiatrists with the combination of expertise and determination required to take a stand in court against powerful drug-company interests. If I hadn't intervened in Harry Henderson's case, he might have spent much of the rest of his life in jail. Instead, my analysis of his case led the prosecution and the judge, as well as the injured policeman, to rethink their attitudes regarding their originally tough stance toward Harry. He was allowed to plead to a lesser charge that resulted in his release from jail after a relatively short stay.
Several months after the resolution of his case, Harry drove a considerable distance with his wife to see me to get help in dealing with the emotional aftermath of what had happened to him. The law had forgiven him more readily than he could forgive himself. With additional help from a local counselor and from his wife, it took Harry more than a year to begin his recovery from disabling guilt over what he had done. I am hopeful that some day he will feel fully recovered from the emotional aftereffects of his bout with medication madness, but it will take time.
MEDICATION SPELLBINDING occurs along a continuum from mild to severe, and Harry was driven into extreme madness. His reactions on Paxil displayed all four aspects of spellbinding by medication:
• His mental condition deteriorated without his appreciating it.
• He had no idea that his psychiatric drug had anything to do with what was happening to him.
• Although he was getting worse, he at times thought he was doing better than ever, especially when he became euphoric and went on spending sprees.
• Ultimately, he developed compulsive, destructive behaviors that took over and ruined his life.

HARRY HIMSELF FOUND it hard to believe that a drug could have made him do such terrible things, and he did not advocate well for his cause. For example, while in jail, Harry had written numerous letters of encouragement to friends and fellow parishioners, confirming his generous and caring nature, but I only learned about these letters from other people. In his interviews with me, Harry made no claim to being insane or psychotic at the time of the crime. Like most people who are spellbound by medication, he had so little memory or appreciation for how disturbed he had become on Paxil that most of the information about his emotional deterioration had to come from other people.
Harry could not explain this obsessive desire to die that ran roughshod over his normal moral restraints but he made no effort to attribute his actions to the drug. Until I shared it with him, he had no idea that there was a large body of scientific literature documenting obsessive suicidality and madness produced by Paxil and similar antidepressants such as Prozac, Zoloft, and Celexa.
Harry was fortunate in working with Pennsylvania criminal attorney George Matangos who believed that his client was a good man driven mad by Paxil and he was eager to utilize my expertise. In the conclusion to my hefty 11,000-word report to the court about the criminal charges against Harry, I summarized the reasoning process that goes into determining if a drug has caused or contributed to an act of violence--the same reasoning I have described more elaborately in my scientific papers and books.1
HERE ARE SEVERAL CRITERIA that can be used to determine if a medication has caused or contributed to an individual's abnormal behavior:
• A recent change (up or down) in the dose of the medication;
• A relatively sudden onset and rapid escalation of abnormal thoughts and behavior;
• Escalating symptoms of drug toxicity, such as insomnia, agitation, memory dysfunction, hallucinations, or other abnormal behaviors leading up to the event;
• An unusually violent, irrational, bizarre, or self-defeating quality to the behavior;
• An obsessive, compelling, and unrelenting quality to the behavior;
• A prior history indicating that the abnormal behaviors were uncharacteristic and unprecedented before exposure to the drug;
• The individual's subjective feeling that the drug-induced emotions and actions are alien, inexplicable, and ethically repugnant;
• Gradual disappearance of the abnormal mental state after stopping the medication (although some residual effects may last much longer).

In addition to these criteria that are specific to the individual case, there should be scientific evidence that the drug can alter brain function, causing abnormal mental and behavioral states.
Not every case of medication madness meets all of these criteria, but Harry Henderson's did.
In medical terms, at the time Harry assaulted the policeman he was suffering from a "Substance-Induced Mood Disorder with a mixture of Depressive and Manic Features." The substance, of course, was Paxil. We will find that every class of psychiatric medication can produce mood disorders.
Substance-induced mood disorder is an official diagnosis (292.84) in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) in 2000. As I wrote in my report to the court, "This is a genuine central nervous system neurological disorder caused by drug-induced disruption of neurotransmitter systems." Consistent with this, and typical of almost all my cases, Harry's mood and outlook improved when the Paxil was stopped. This improvement in his emotional state occurred even though Harry was in jail facing trial for his actions while undergoing enormous remorse over what he had done to the policeman, and despite the fact that his life and the life of his family had been drastically transformed for the worse.
I PURPOSELY EMPHASIZED that Harry was suffering from a "genuine central nervous system neurological disorder" rather than a vague and ill-defined "mental illness." Psychoactive drugs like Paxil have a physical impact on the brain. Instead of claiming that Harry was not guilty by reason of insanity, my analysis in this and similar cases leads to a conclusion of involuntary intoxication caused by a drug-induced neurological impairment.
With good reason, most of us want to hold drug abusers and alcoholics responsible for their actions. We believe that they should have anticipated the potential negative consequences of using intoxicating agents and taken responsibility for themselves. Similarly, the law offers little or no relief to someone who knowingly drinks or takes illegal drugs, and then commits a crime. The law treats drunkenness as a voluntary, rather than involuntary, intoxication.
The legal system looks more sympathetically on people who become intoxicated against their will or without foreknowledge of the drug's potential to cause them to behave badly. This is considered an involuntary intoxication. I explained in my report:
Because Harry was unaware of the potential for this medication to produce abnormal thought processes and behavior, and because it was medically prescribed to him, Harry's condition qualifies as an involuntary intoxication.
As a result of this medication-induced physical disorder of the brain, Harry was (1) unable to exercise his customary moral judgment, (2) unable to control his violent impulses, (3) unable to appreciate the consequences of his violent actions, and (4) unable to appreciate right and wrong in regard to what he was doing, including the wrongness of striking the policeman with his car.
If I had developed the concept at the time, I could have added that Harry was a classic example of a man spellbound by medication in that he did not realize how mentally impaired he had become, did not attribute his dramatic transformation to the drug, and felt compelled to take actions that would ordinarily have appalled him. The more disturbed Harry became, the more his thoughts and actions seemed sensible and his actions inevitable to him. At the moment of violence, he was compulsively and inexorably focused on the act as if he had no choice at all.
Harry not only displayed obsessive violence on Paxil, his depression worsened and he eventually began to show some maniclike symptoms. In Harry's story, the more subtle manic aspects included his increased irritability, mood swings, and extravagant purchases. In other cases we'll see people who suffer from more grossly apparent manic episodes caused by psychiatric drugs.
HARRY DESCRIBED his destructive actions as an attempt to stop the "pain" inside his head.2 When taking SSRI antidepressants such as Prozac, Zoloft, Paxil, and Celexa--and more commonly during withdrawal from the drugs--individuals frequently cite indescribable mental and physical pain inside their heads as their greatest source of unendurable distress. Because most of these antidepressants are relatively short acting, more than half the drug is eliminated from the body in less than a day, so that people can go into withdrawal between doses. Harry's painful feelings inside his head could have resulted from direct toxic-drug effects, from interdose withdrawal effects, or from a combination of both.
Typically, the pain is both physical and emotional, making the individual feel tortured from the inside out. Sometimes the unbearable sensations are compared to "shocks" and "electricity" or to "impulses," often localized inside the head but sometimes spreading throughout the body. Two days after one of my patients began tapering off her last small dose of Paxil, she endured several days of throbbing headaches like "knives stabbing into my brain," as well as dizziness and depression with fits of inexplicable, uncontrollable weeping.
When patients attempt to describe the "weird feelings" caused by antidepressants, frustration often sets in. There is no adequate vocabulary to communicate the bizarre internal experience. Unsympathetic or uninformed physicians often fail to realize that the prescribed medication is causing this torture. Instead, the doctors blame the patient's "craziness" and increase the dose of the offending agent, too often with tragic consequences. Or, the misinformed doctors attribute the mental deterioration to an "unmasking" of the patient's supposedly underlying mental illness, and then add yet another mind-altering drug to the treatment regimen.
SOME OF THESE BIZARRE SENSATIONS MEET the diagnostic criteria for akathisia, a drug-induced neurological disorder that is known to drive people to suicide and violence, and to madness. Akathisia means the inability to sit still and the syndrome is usually but not always associated with a compulsive need to move about in a futile attempt to stop the torment. Several people observed that Harry was agitated and restless in the days before he assaulted the policeman. Because the Paxil had caused such obvious agitation and maniclike behavior in Harry, in my initial evaluation and report I did not focus on this more subtle clinical syndrome--but his case nonetheless provides an example.
Several years earlier, when I gained access to sealed company records in a product-liability suit against GlaxoSmithKline, the manufacturer of Paxil, I investigated the relationship between akathisia and suicidal or violent behavior. Although the drug company systematically tried to avoid diagnosing patients with the dread disorder akathisia, a number of cases turned up in their European database. Working with my research assistant Ian Goddard, we found many correlations between akathisia and suicidal behavior, including completed suicides.3
The official American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), is the diagnostic bible of psychiatry. It discusses akathisia at length in both of the two most recent editions (1994 and 2000). This conservative, establishment textbook specifically warns, "Akathisia may be associated with dysphoria, irritability, aggression, or suicide attempts." Dysphoria is painful emotion; irritability is overreacting with anger or hostility; aggression and suicide speak for themselves.
This heavily relied-upon diagnostic authority further warns that akathisia can lead to "worsening of psychotic symptoms or behavioral dyscontrol." Behavioral dyscontrol means loss of impulse control. Almost the entire description applies to Harry Henderson, as well as to many other cases in Medication Madness.
After describing the horrific symptoms of akathisia, the diagnostic manual makes a key observation: that the newer SSRI antidepressants can cause akathisia with all its associated adverse effects.4
You might assume that such a dreadful and potentially deadly adverse drug reaction must be relatively rare. To the contrary, we have known for nearly two decades that akathisia is commonly associated with the newer antidepressants, like Paxil, Prozac, Zoloft, and Celexa. The watershed year was1989, when investigators reported on five cases of akathisia caused by Prozac.5 They reviewed the scientific literature, found rates of 9.7 to 25 percent for Prozac-induced akathisia, and concluded that Prozac "and perhaps other antidepressant drugs as well, may produce the side effect of akathisia fairly frequently." In 1990, the Public Citizen Health Research Group followed up with an estimated rate of 15 to 25 percent for Prozac-induced akathisia. While studies of SSRI-induced akathisia vary greatly in the frequency with which this disorder is observed, the weight of evidence confirms that it is common.
Soon after the introduction of Prozac in 1989, the connection between antidepressant-induced akathisia and suicide was documented in the scientific literature. For example, in 1991, a report was published on three cases of suicidality in patients suffering from Prozac-induced akathisia.6 Each case of compulsively suicidal feelings developed on Prozac and resolved when the drug was stopped. The self-destructive feelings returned when the drug was started a second time and then went away once more when the drug was again stopped.
The above process of starting and stopping drugs, and observing the patient's reactions, is called challenge (the drug is given, causing the symptom), dechallenge (the drug is withdrawn, stopping the symptom), and rechallenge (the drug is restarted, reinitiating the symptom). During rechallenge each of the patients developed akathisia and reported that this feeling had driven them to become suicidal each time. The challenge, dechallenge, and rechallenge results clearly confirmed a cause-effect relationship between the drug and the adverse effect of suicidal impulses.
In 1992, another group of researchers reported on five more cases of a Prozac-induced akathisia with suicidality.7 In all five cases, the akathisia and the suicidality disappeared when the drug was stopped or reduced in dosage. In one case, a rechallenge with an increased dose of Prozac reproduced the syndrome. The researchers concluded, "Our cases appear to confirm that certain subjects experience akathisia while taking fluoxetine [Prozac] and that this effect is dose-related in the individual patient." They declared that akathisia "can apparently be associated with suicidal ideation, sometimes of a ruminative intensity."
From Prozac to the newer drugs like Celexa and Lexapro, this group of SSRI-antidepressants share common characteristics, and indeed they now all carry the same black-box warning in their labels about causing suicidality in children and young adults. They all carry a string of warnings about a variety of abnormal behaviors including mania that we'll examine in more detail. However, in my clinical experience Paxil seems to be among the worst offenders,perhaps because it is more potent and shorter acting, giving it a strong, sudden impact.
IN BEYOND CONFLICT (1992), I developed a profile of the characteristics of perpetrators of violence. Based on the criteria in my book, here is my comparison between the perpetrator profile and Harry Henderson's profile:8
Perpetrators deny or minimize the damage they are doing to others. After recovering from the Paxil, Harry never lost sight of the harm his actions had done to the policeman, as well as to his wife and family, and to his church.
Perpetrators tend to rationalize the harm they are doing. Harry blamed himself and hesitated to attribute anything to the drug.
Perpetrators tend to blame the victim. Harry never blamed the unfortunate policeman, his doctor, or anyone else, for what he had done.
Perpetrators suppress their own feelings of empathy. Harry felt very badly about what he had done, wrote letters to try to make things right while he was in jail, and continued to feel remorseful after he was let out of jail.
Perpetrators tend to dehumanize their victims. Harry saw the policeman as a person whom he had badly injured.
Perpetrators tend to feel empowered through their perpetrations, gaining a sense of potency from injuring and controlling others. Harry felt completely demoralized by his actions.
Perpetrators seek to win conflicts through exercising authority, power, and domination. Harry tended to be conciliatory and even overly compliant.
Perpetrators tend to become grandiose and self-centered. Harry felt the opposite: helpless and preoccupied with the harm he had done to others.
Perpetrators become alienated from their genuine basic needs, especially those related to love. Harry did feel withdrawn. Gradually, he began to recover, to relate to his needs more fully again, and to reach out to his family.
Hardly any of the dozens of cases in this book fit the perpetrator profile before they became spellbound by medication. That is in part due to how I screen my cases before taking them but even more so it is due to the nature of medication madness--it can strike innocent, good people who harbor no tendencies to perpetrate violence against others.

MEDICATION MADNESS Copyright © 2008 by Peter R. Breggin, M.D. All rights reserved. For information, address St. Martin's Press, 175 Fifth Avenue, New York, N.Y 10010.