Medicating the military
http://www.airforcetimes.com/news/2010/03/military_psychiatric_drugs_031710w/
Use of psychiatric drugs has spiked; concerns surface about suicide,
other dangers
By Andrew Tilghman and Brendan McGarry
Mar 17, 2010
At least one in six service members is on some form of psychiatric drug.
And many troops are taking more than one kind, mixing several pills
in daily "cocktails" for example, an antidepressant with an
antipsychotic to prevent nightmares, plus an anti-epileptic to reduce
headaches despite minimal clinical research testing such combinations.
The drugs come with serious side effects: They can impair motor
skills, reduce reaction times and generally make a war fighter less
effective. Some double the risk for suicide, prompting doctors and
Congress to question whether these drugs are connected to the
rising rate of military suicides.
"It's really a large-scale experiment. We are experimenting with
changing people's cognition and behavior," said Dr. Grace Jackson, a
former Navy psychiatrist.
A Military Times investigation of electronic records obtained from
the Defense Logistics Agency shows DLA spent $1.1 billion on common
psychiatric and pain medications from 2001 to 2009. It also shows
that use of psychiatric medications has increased dramatically
about 76 percent overall, with some drug types more than doubling
since the start of the current wars.
Troops and military health care providers also told Military Times
that these medications are being prescribed, consumed, shared and
traded in combat zones despite some restrictions on the deployment
of troops using those drugs.
The investigation also shows that drugs originally developed to treat
bipolar disorder and schizophrenia are now commonly used to treat
symptoms of post-traumatic stress disorder, such as headaches,
nightmares, nervousness and fits of anger.
Such "off-label" use prescribing medications to treat conditions
for which the drugs were not formally approved by the FDA is legal
and even common. But experts say the lack of proof that these
treatments work for other purposes, without fully understanding side
effects, raises serious concerns about whether the treatments are
safe and effective.
The DLA records detail the range of drugs being prescribed to the
military community and the spending on them:
* Antipsychotic medications, including Seroquel and Risperdal, spiked
most dramatically orders jumped by more than 200 percent, and
annual spending more than quadrupled, from $4 million to $16 million.
* Use of anti-anxiety drugs and sedatives such as Valium and Ambien
also rose substantially; orders increased 170 percent, while spending
nearly tripled, from $6 million to about $17 million.
* Antiepileptic drugs, also known as anticonvulsants, were among the
most commonly used psychiatric medications. Annual orders for these
drugs increased about 70 percent, while spending more than doubled,
from $16 million to $35 million.
* Antidepressants had a comparatively modest 40 percent gain in
orders, but it was the only drug group to show an overall decrease in
spending, from $49 million in 2001 to $41 million in 2009, a drop of
16 percent. The debut in recent years of cheaper generic versions of
these drugs is likely responsible for driving down costs.
Antidepressants and anticonvulsants are the most common mental health
medications prescribed to service members. Seventeen percent of the
active-duty force, and as much as 6 percent of deployed troops, are
on antidepressants, Brig. Gen. Loree Sutton, the Army's
highest-ranking psychiatrist, told Congress on Feb. 24.
In contrast, about 10 percent of all Americans take antidepressants,
according to a 2009 Columbia University study.
Suicide risks
Many of the newest psychiatric drugs come with strong warnings about
an increased risk for suicide, suicidal behavior and suicidal thoughts.
Doctors and, more recently, lawmakers are questioning whether the
drugs could be responsible for the spike in military suicides during
the past several years, an upward trend that roughly parallels the
rise in psychiatric drug use.
From 2001 to 2009, the Army's suicide rate increased more than 150
percent, from 9 per 100,000 soldiers to 23 per 100,000. The Marine
Corps suicide rate is up about 50 percent, from 16.7 per 100,000
Marines in 2001 to 24 per 100,000 last year. Orders for psychiatric
drugs in the analysis rose 76 percent over the same period.
"There is overwhelming evidence that the newer antidepressants
commonly prescribed by the military can cause or worsen suicidality,
aggression and other dangerous mental states," said Dr. Peter
Breggin, a psychiatrist who testified at the same Feb. 24
congressional hearing at which Sutton appeared.
Other side effects increased irritability, aggressiveness and
hostility also could pose a risk.
"Imagine causing that in men and women who are heavily armed and
under a great deal of stress," Breggin said.
He cited dozens of clinical studies conducted by drug companies and
submitted to federal regulators, including one among veterans that
showed "completed suicide rates were approximately twice the base
rate following antidepressant starts in VA clinical settings."
But many military doctors say the risks are overstated and argue that
the greater risk would be to fail to fully treat depressed troops.
For suicide, "depression is a big risk factor," too, said Army
Reserve Col. (Dr.) Thomas Hicklin, who teaches clinical psychiatry at
the University of Southern California. "To withhold the medications
can be a huge problem."
Nevertheless, Hicklin said the risks demand strict oversight. "The
access to weapons is a very big concern with someone who is feeling
suicidal," he said. "It has to be monitored very carefully because
side effects can occur."
Defense officials repeatedly have denied requests by Military Times
for copies of autopsy reports that would show the prevalence of such
drugs in suicide toxicology reports.
'Then it's over'
Spc. Mike Kern enlisted in 2006 and spent a year deployed in 2008
with the 4th Infantry Division as an armor crewman, running patrols
out of southwest Baghdad.
Kern went to the mental health clinic suffering from nervousness,
sleep problems and depression. He was given Paxil, an antidepressant
that carries a warning label about increased risk for suicide.
A few days later, while patrolling the streets in the gunner's turret
of a Humvee, he said he began having serious thoughts of suicide for
the first time in his life.
"I had three weapons: a pistol, my rifle and a machine gun," Kern
said. "I started to think, 'I could just do this and then it's over.'
That's where my brain was: 'I can just put this gun right here and
pull the trigger and I'm done. All my problems will be gone.'"
Kern said the incident scared him, and he did not take any more drugs
during that deployment. But since his return, he has been diagnosed
with PTSD and currently takes a variety of psychotropic medications.
Other side effects cited by troops who used such drugs in the war
zones include slowed reaction times, impaired motor skills, and
attention and memory problems.
One 35-year-old Army sergeant first class said he was prescribed the
anticonvulsant Topamax to prevent the onset of debilitating
migraines. But the drug left him feeling mentally sluggish, and he
stopped taking it.
"Some people call it 'Stupamax' because it makes you stupid," said
the sergeant, who asked not to be identified because he said using
such medication carries a social stigma in the military.
Being slow or even "stupid" might not be a critical problem for
some civilians. But it can be deadly for troops working with weapons
or patrolling dangerous areas in a war zone, said Dr. John Newcomer,
a psychiatry professor at Washington University in St. Louis and a
former fellow at the American Psychiatric Association.
"A drug that is really effective and it makes you feel happy and calm
and sleepy … might be a great medication for the general population,"
Newcomer said, "but that might not make sense for an infantryman in a
combat arena.
"If it turns out that people on a certain combo are getting shot
twice as often, you would start to worry if they were as 'heads up'
as they should have been," Newcomer said. "There is so much on the
line, you'd really like to have more specific military data to inform
the prescribing."
Military doctors say they take a service member's mission into
consideration before prescribing.
"Obviously, one would be concerned about what the person does," said
Col. C.J. Diebold, chief of the Department of Psychiatry at Tripler
Army Medical Center in Hawaii. "If they have a desk job, that may
factor in what medication you may be recommending for the patient
[compared with] if they are out there and they have to be moving
around and reacting fairly quickly."
Off-label use
Little hard research has been done on such unique aspects of
psychiatric drug usage in the military, particularly off-label usage.
A 2009 VA study found that 60 percent of veterans receiving
antipsychotics were taking them for problems for which the drugs are
not officially approved. For example, only two are approved for
treating PTSD Paxil and Zoloft, according to the Food and Drug
Administration. But in actuality, doctors prescribe a range of drugs
to treat PTSD symptoms.
To win FDA approval, drug makers must prove efficacy through rigorous
and costly clinical trials. But approval determines only how a drug
can be marketed; once a drug is approved for sale, doctors legally
can prescribe it for any reason they feel appropriate.
Such off-label use comes with some risk, experts say.
"Patients may be exposed to drugs that have problematic side effects
without deriving any benefit," said Dr. Robert Rosenheck, a professor
of psychiatry at Yale University who studied off-label drug use among
veterans. "We just don't know. There haven't been very many studies."
Some military psychiatrists are reluctant to prescribe off-label.
"It's a slippery slope," said Hicklin, the Army psychiatrist.
"Medication can be overused. We need to use medication when indicated
and we hope that we are all on the same page … with that."
Combinations of drugs pose another risk. Doctors note that most drugs
are tested as a single treatment, not as one ingredient in a mixture
of medications.
"In the case of poly-drug use – the 'cocktail' where you are
combining an antidepressant, an anticonvulsant, an antipsychotic, and
maybe a stimulant to keep this guy awake that has never been
tested," Breggin said.
Newcomer agreed. "When we go to the literature and try to find
support for these complex cocktails, we're not going to find it," he
said. "As the number of medications goes up, the probability of
adverse events like hospitalization or death goes up exponentially."
Looking for answers
Pinpointing the reasons for broad shifts in the military's drug use
today is difficult. Each doctor prescribes medications for the
patient's individual needs.
Nevertheless, many doctors in and outside the military point to
several variables some unique to the military, some not.
A close look at the data shows that use of the antipsychotic and
anticonvulsant drugs, also known as "mood stabilizers," are growing
much faster than antidepressants. That may correlate to the
challenges that deployed troops face when they arrive back home and
begin to readjust to civilian social norms and family life.
"The ultimate effect of both of these drugs is to take the heightened
arousal the hypervigilance and all the emotions that served you
once you were deployed and help to turn that back down," said Dr.
Frank Ochberg, former associate director for the National Institute
of Mental Health and a psychiatry professor at Michigan State
University who reviewed the Military Times analysis.
Dr. Harry Holloway, a retired Army colonel and a psychiatry professor
at the Uniformed Services University of the Health Sciences in
Bethesda, Md., said the increased use of these medications is simply
another sign of deployment stress on the force.
"For a long time, the ops tempo has been completely unrelieved and
unrestrained," Holloway said. "When you have an increased ops tempo,
and you have certain scheduling that will make it hard for everyone,
you will produce a more symptomatic force. Most commanders understand
that and they understand the tradeoffs."
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THE FULL INVESTIGATION:
* Could meds be responsible for suicides?
http://www.airforcetimes.com/news/2010/03/military_drugs_dangers_031710w/
* Downrange: 'Any soldier can deploy on anything'
http://www.airforcetimes.com/news/2010/03/military_drugs_downrange_031710w/
* How drugs enter the war zone
http://www.airforcetimes.com/news/2010/03/military_drugs_enterwarzone_031710w/
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