WASHINGTON, DC—Suicide rates among servicemembers and veterans remain high, causing concern that VA and military health care could be doing more in terms of prevention and treatment. Now some legislators have questioned whether certain treatments—what some are describing as an overuse of antidepressant medications, which have been linked to increased suicidal ideations—might be doing more harm than good.
The crux of the problem is one that civilian physicians have been dealing with for over six years—how to balance the possible risk of increased suicidal thoughts with antidepressants versus treating depression, which is definitively linked to suicide.
SSRIs and Suicide
The newer type of antidepressants—SSRIs (selective-serotonin reuptake inhibitors), which were first released in the 1980s—have long been caught up in a debate over whether they are responsible for an increase in suicide among those taking them. The debate started in earnest about 10 years ago, when the media began covering reports linking SSRIs, such as Prozac® and Paxil®, to increases in suicidal thoughts in young adults and adolescents. The FDA became involved shortly thereafter, conducting its own analysis of existing trials. That review found that pediatric use of antidepressants was linked to a doubling of suicidality—mostly suicidal thinking—though no suicide deaths were reported.
Two years later, another FDA analysis of antidepressant use in adults found no similar increase in those groups. However, in 2004, an FDAadvisory committee recommended the inclusion of a black box label on all antidepressant medications describing the risk of suicidality in children and adolescents. Because that danger might extend into patients in young adulthood, it has raised some concern for those veterans and servicemembers—many still in their teens and early 20s—whose experiences in combat already increase their risk of suicide.
“Research has shown that mental disorders and substance-abuse disorders are linked to more than 90% of people who die by suicide. Today, suicides among servicemembers and veterans continue to increase at an alarming rate, far exceeding the comparable suicide rates among the general population,” explained Rep Bob Filner, D-CA, chairman of the House VA Committee, at a hearing on the subject last month. “There are some doctors who are convinced by their clinical experience that psychiatric drugs often adversely impact the individuals’ better judgment and lead people to lose control over their emotions and actions.”
On the other hand, he noted there are studies that suggest antidepressants have a protective effect, with suicide attempts lower among patients treated with antidepressants than those who were not.
Same Data, Different Interpretations
The sometimes contentious hearing showcased two opposing schools of thought. The first was voiced by Dr Peter Breggin, a practicing psychiatrist, who became one of the first physicians to write extensively about SSRIs causing abnormal reactions in the early 1990s. He became the scientific expert on over 100 combined cases against Eli Lilly concerning Prozac-induced violence and suicide.
“The FDA itself concluded that newer antidepressants doubled the rate of suicidal behavior in children, youth and young adults up to age 24, which of course is very menacing for the soldier population,” Breggin testified. “You get a doubling of rates. What does this mean? The clinical trials are very short. Most of them average six weeks. Suicidal patients are excluded from clinical trials. [Patients in the trial] are observed weekly by experts and are informed of all the dangers. And they’re given huge hope. When you get a doubling of suicidal attempts and ideations under those conditions, you can assume that in the military or clinical practice, it will be increased by multiples.”
Asked if he believed military servicemembers taking the drugs were properly informed of the warnings associated with the medication, Breggin said that he did not. “Last year I spoke at a military stress conference. I talked to general and mental health professionals. And they agreed that these warnings are hardly ever presented to the soldiers. And the Army was acting as if it was unaware [of the dangers].”
The other side of the argument was presented by Andrew Leon, PhD, who served as a consultant to FDA and NIH and was the biostatistician on the FDA’s Psychopharmacological Drug Advisory Committee from 2003 to 2008. “Depression is a life threatening illness. Suicidality is a symptom of depression, whether treated or untreated. Depression increases the risk of suicide.Antidepressant medication can reduce the suffering from depression. To reduce the risk of suicide, clinicians must carefully monitor veterans with depression, whether treated or untreated.”
He explained that the argument comes down to risk versus benefit. While the analysis of pediatric trials showed a doubling of risk of suicidality, that risk was still at only 3% with no deaths by suicide. The adult trials studied showed no suicidality increase in those taking the drugs, and that the drugs conveyed significant protection from suicidality for ages 65 and over. While there was some risk, he said the benefits still outweighed them.
During his work on an NIMH depression study—one that followed patients, including those not on antidepressants, from the late 70s through 2009—Leon was able to look at data on patients in a real-world setting. The study found that antidepressants significantly reduced the risk of suicide attempts and suicide deaths in adults. Another study on post-mortem reports for youth suicides found that 95% of suicide deaths in New York City during that time period were by people not taking antidepressants. “A cause and effect relationship has not been established between antidepressants and suicide. This is one of the most controversial issues in the field of psychiatry. It’s one in which a lot of people write and speak without access to all the data.”
Though the two experts found little common ground—Breggin accused Leon of ignoring “mountains of suicidality evidence,” while Leon labeled much of Breggin’s testimony as blatantly incorrect—they did agree on one point: patients suffering from depression, either on or off antidepressants, need close observation.
“What’s most important are those first few weeks that a patient starts on an antidepressant,” Leon explained. “Monitoring is critically important. A physician has to follow up with the patient once or a couple times a week. It can’t be like, ‘Here’s 90 pills, come back in three months.’”
While committee members noted that they had heard no complaints of veterans being given medication indiscriminately, they posed questions to VA and DoD mental health leaders about how antidepressants should be used to treat veterans and servicemembers.
“The appropriate use of psychotherapeutic medications is a key component of appropriate mental health care, but medications, as with all treatments, can be associated with risks,” explained Dr Ira Katz, VA’s mental health chief. “VA has systems in place to monitor for effects of medication use.”
VA’s electronic medical record allows for swift reporting of adverse drug events and the ability to track trends of known safety issues, Katz noted. Also, in recent years VA has made an effort to integrate mental health services into primary care. This helps ensure that veterans are monitored effectively while receiving mental health services. “VA requires these treatment programs include evidence based care management, providing repeated contact with patients to educate them about their conditions, about medications, and about other treatments, as well as ongoing evaluation of both therapeutic outcomes and adverse effects. Research has demonstrated that these care management interventions can decrease depression and other conditions and reduce suicidal ideation.”
He noted that young adult veterans—those who might be most vulnerable to increased suicidality as a side effect of antidepressants—have a lower suicide rate when they receive treatment in VA than their peers in the general population. “In 2005, 2006 and 2007, respectively those patients receiving care in VA were 56%, 73% and 67% less likely to die from suicide.”
Uncharted Territory for the Military
Brig Gen Loree Sutton, MD, testified that the military is in “uncharted territory” in terms of psychological stress placed on servicemembers. “Never in the history of our republic have we placed so much trauma on the shoulders of so few for so long.” Approximately 20% of servicemembers in theatre are on antidepressants, with the majority (17%) taking SSRIs. This closely approximates utilization rates for the general population.
Sutton hopes that ongoing research will help military physicians understand the effect of trauma and stress on troops and the best ways to treat it. She pointed at the collaboration between the Army and NIMH on the STARRS Study—a five year assessment of risk and resilience in servicemembers. “It promises to revolutionize how we benchmark our practices, bring applications to the field, gain the evidence, and apply [that evidence] as we go.” Data collection from the study begins this month, with the Army scheduled to receive quarterly reports on the study’s findings.
Regarding the debate on the safety of antidepressants, she told legislators that questioning the safety and efficacy of a medication can have serious impacts on servicemembers who need help dealing with depression. “We can talk about this issue of medication and safety and efficacy and suicidal ideation in the safety and confines of this government building, but what if I am a young troop or a family member, and I’m watching this web stream around the country and around the world. And I’m on antidepressants right now. Does that mean I’m going to kill myself? If I’m depressed [and] I’m thinking I need help, I’m not sure I would have the courage or the hope to get help after what I heard here today.”
Filner’s response to Sutton was that, if that soldier was his child, he would prefer to be fully informed of all the possible dangers. He also contended that, in order for all servicemembers at risk for suicide to get the help they need after returning home, the military needs to require each servicemember to be evaluated by a physician before being discharged.
Ranking Republican Rep David “Phil” Roe of TN agreed, saying, “You can’t command a veteran to do anything. They’re not going to follow any order [once they’re out]. If you’re going to do it, you need to do it when they’re still in the military. Having a really good evaluation and then being able to hand that [information] off to the VA is a very, very good idea.”