Monday, April 8, 2013

The Psychopharmacological Assault on Our Soldiers

During the war in Vietnam our military leaders put the soldiers in their charge at risk from dangerous chemicals such as Agent Orange. In order to accomplish what they felt was their mission they created a generation of psychologically damaged and physically unhealthy veterans. Recent evidence suggests that the military may be repeating that mistake with the current cohort assembled to wage war in Iraq and Afghanistan. The dangerous chemicals being introduced this time around are not defoliants, but psychoactive drugs designed to alter brain function and control behavior. These drugs have only limited approval for use by the FDA for treatment of those suffering from mental illness.

One of the most disturbing trends within our military population is the increased incidence of suicide. More of our personnel died from suicide than from military action in 2012. This source provides recent data.

Note that the number of suicides has been increasing while the number of soldiers involved in military action has been decreasing.

Richard A. Friedman, director of the psychopharmacology clinic at the Weill Cornell Medical College, provided an article in the New York Times that notes the suicide issue and proceeds to accuse the Armed Services of misusing psychoactive drugs in an attempt to counter the results of stress experienced by soldiers.

"....according to data not reported on until now, the military evidently responded to stress that afflicts soldiers in Iraq and Afghanistan primarily by drugging soldiers on the front lines. Data that I have obtained directly from Tricare Management Activity, the division of the Department of Defense that manages health care services for the military, shows that there has been a giant, 682 percent increase in the number of psychoactive drugs — antipsychotics, sedatives, stimulants and mood stabilizers — prescribed to our troops between 2005 and 2011. That’s right. A nearly 700 percent increase — despite a steady reduction in combat troop levels since 2008."

"The prescribing trends suggest that the military often uses medications in ways that are not approved by the Food and Drug Administration [FDA] and do not comport with the usual psychiatric standards of practice."

Friedman points out that the military is supposed to carefully assess recruits and weed out those who might have psychological problems. Therefore one should expect less need for psychoactive drugs than exists in the general population. That is definitely not the case.

"The data suggest that military doctors may prescribe psychoactive drugs for off-label use as sedatives, possibly so as to enable soldiers to function better in stressful combat situations. Capt. Michael Colston, a psychiatrist and program director for mental health policy in the Department of Defense, confirmed this possibility. In an e-mail to me, Dr. Colston acknowledged that antipsychotic drugs have been used to treat insomnia, anxiety and aggressive behavior."

This experimental use of drugs on the soldiers is troubling to Friedman.

"The trouble is that we have no idea whether it’s effective — or safe — to use antipsychotic drugs on a continuing basis to treat war-related stress or to numb or sedate those affected by it."

Friedman uses treatment of post-traumatic stress disorder (PTSD) to illustrate the issues associated with these practices.

"Note that the military uses antipsychotic drugs to treat post-traumatic stress disorder, even though there is but weak evidence that these drugs effectively treat it. A recent randomized, controlled clinical trial involving nearly 300 veterans found that the antipsychotic risperidone was no better than a placebo as an adjunct in treating PTSD. Yet in 2007, PTSD was the most common off-label diagnosis for those, within the Department of Veterans Affairs, treated with psychoactive medications."

"In treating soldiers who have PTSD symptoms with antipsychotic medications, the military is violating its own treatment guidelines, which clearly state that S.S.R.I. antidepressants are the preferred first line of treatment for PTSD. The military medical leadership has, in fact, expressed concern about prescribing trends. In February 2012, the assistant secretary of defense for health affairs, Dr. Jonathan Woodson, wrote in a memo to the military’s leadership that the ‘greatest concern is the suspicion of the over-prescription of antipsychotic medications for PTSD’."

Dr. Woodson is correct in being concerned.

"Another reason to worry about liberal off-label use of antipsychotic medications is that they have long-term adverse health risks, including tardive dyskinesia, a potentially irreversible movement disorder."

"There are other disturbing prescription trends in the military. The number of prescriptions written for potentially habit-forming anti-anxiety medications — like Valium and Klonopin — rose 713 percent between 2005 and 2011. The use of sedating anticonvulsants — Topamax, Neurontin and Lyrica — increased 996 percent during this period. (Prescriptions for these three drugs increased 94 percent during the same period in the civilian population.)"

"None of these anticonvulsants are F.D.A.-approved for psychiatric use and none are without risk: anticonvulsants can impair short-term memory and fine-motor coordination, which would adversely affect combat performance."

Friedman is careful not to directly accuse the military doctors of unethical behavior, but he cannot help but issue these comments:

"It seems that the military favors quick-acting — and less effective — anticonvulsants and antipsychotics over antidepressants, which can take several weeks to work."

"There is an analogy, perhaps, between the military’s use of psychoactive drugs and the practice of pumping athletes full of steroids so they can continue to compete despite physical pain; athletes — and also soldiers — whose performance is chemically enhanced in this way may, however, unwittingly sustain more serious injuries as a result."

An article by Martha Rosenberg is less kind in evaluating the military and its drug prescribing practices. She points out that many of the drugs being discussed are known to increase the probability of suicidal behavior.

"One in six service members was on a psychoactive drug in 2010 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,’ said Military Times."

"The pills and pill cocktails many troops are prescribed are clearly linked to suicidal thoughts and behavior. Antidepressants like Prozac and Paxil, antipsychotics like Seroquel and Zyprexa and anti-seizure drugs like Lyrica and Neurontin all carry clear suicide warnings and all are widely used in the military. Almost 5,000 newspaper reports link antidepressants to suicide, homicide and bizarre behavior on the website The malaria drug Lariam is also highly correlated with suicide and its use actually increased in the Navy and Marine Corps in 2011, according to the Associated Press."

David Healy is a psychopharmacologist who occasionally arouses the ire of his colleagues by dredging up inconvenient historical data. He looked up suicide rates for schizophrenic patients before the age of medicinal treatment (1875-1924) and compared them to the rates that exist when current medications are used (1994-1998). He concluded that the use of modern antipsychotic medications—the ones being prescribed to our soldiers—increased the suicide rate among schizophrenics by a factor of 20.

Rosenberg seems to have a point.

Rosenberg takes yet another step and raises the issue of unethical behavior.

"Several powerful military psychiatrists and administrators are also consultants to Big Pharma who shamelessly enroll veterans in drug studies and promote the pills that drug companies pay them to promote. Who can say conflict of interest?"

If this statement strikes the reader as a bizarre dip into a conspiracy theory, the reader should remember that conspiracy theories are popular because, occasionally, conspiracies actually exist.

Let us turn now for some insight to Ben Goldacre and his book: Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients.

"....we will see that pharmaceutical companies spend tens of billions of pounds every year trying to change the treatment decisions of doctors: in fact, they spend twice as much on marketing and advertising as they do on the research and development of new drugs. Since we all want doctors to prescribe medicine based on evidence, and evidence is universal, there is only one possible reason for such huge spends: to distort evidence-based practice....Doctors spend forty years practising medicine, with very little formal education after their initial training. Medicine changes completely in four decades, and as they try to keep up, doctors are bombarded with information: from ads that misrepresent the benefits and risks of new medicines; from sales reps who spy on patients’ confidential prescribing records; from colleagues who are quietly paid by drug companies; from ‘teaching’ that is sponsored by industry; from independent ‘academic’ journal articles that are quietly written by drug company employees; and worse."

Drug companies do wondrous things at times, but in the field of interest here, mental illness, there is little science to go on, and what exists is mostly created by the drug companies themselves. That is a situation reeking with potential ethical issues.

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