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Saturday, June 07, 2008

Are PTSD-Medicated Veterans Dying in Sleep -- or Committing Suicide?

Important story on the cluster of OEF/OIF veterans who have recently been found to have died in their sleep, or thought to have committed suicide, while heavily medicated and being treated for PTSD. First, a May 23 introduction by Julie Robinson of the Charleston Gazette:


A Putnam County veteran who was taking medication prescribed for post-traumatic stress disorder died in his sleep earlier this month, in circumstances similar to the deaths of three other area veterans earlier this year.

Derek Johnson, 22, of Hurricane, served in the infantry in the Middle East in 2005, where he was wounded in combat and diagnosed with post-traumatic stress disorder while hospitalized.

Military doctors prescribed Paxil, Klonopin and Seroquel for Johnson, the same combination taken by veterans Andrew White, 23, of Cross Lanes; Eric Layne, 29, of Kanawha City; and Nicholas Endicott of Logan County. All were in apparently good physical health when they died in their sleep.

Johnson was taking Klonopin and Seroquel, as prescribed, at the time of his death, said his grandmother, Georgeann Underwood of Hurricane. Both drugs are frequently used in combination to treat post-traumatic stress disorder. Klonopin causes excessive drowsiness in some patients.

He also was taking a painkiller for a back injury he sustained in a car accident about a week before his death, but was no longer taking Paxil.

In educational interest, article(s) quoted from extensively.

Continuing:

Stan White, father of soldier Andrew White, has become an advocate for families of returning veterans with post-traumatic stress disorder. During his son's struggle with the disorder and since his death, White has tracked similar cases. He knows of about eight in the tri-state area of Kentucky, Ohio and West Virginia.

He and his wife, Shirley, introduced themselves to the Johnsons and Underwoods at Derek's funeral and offered their help. He is in contact with the office of Sen. Jay Rockefeller, D-W.Va., who is a member of the Veterans' Affairs Committee. Rockefeller requested an investigation into these deaths, which is ongoing, said Steven Broderick, the senator's press secretary.

"When I talked to his family about Derek, I realized it was the same old story," said White. "It was all too familiar. He was taking those same drugs as the others, and, yes, I believe they are still prescribing that combination."

After speaking with family members, White wonders if the patients are taking the medicine as prescribed. He said PTSD patients suffer short-term memory loss and shouldn't be relied upon to track their medications.

Georgeann Underwood agrees.

"You shouldn't put vulnerable, mentally unstable people on drugs like that," she said.

An outgoing, personable young man who worked at several jobs to support his young family, Johnson frequently was offered other jobs by customers in the stores where he worked, Underwood said. In 2006, he returned from the Middle East depressed and short-tempered. Johnson had operated an M249 Squad Automatic Weapon, or rapid-fire machine gun, and rarely spoke about his experiences there.

After his military prescriptions ran out, Johnson's medications were prescribed by private physicians because he refused to go the VA hospitals where he said he was required to wait long periods of time for appointments. His grandparents paid for his medications.

"He had a very short fuse," Ray Johnson said. "That was the biggest difference in his personality after he came back."

Until his death, he worked 12 or 16 hours a day. He was an electrical apprentice at the John Amos Power Plant until he was let go when his work hours approached the union limit for apprentices. He was on his way to apply for another job when the car he drove was rear-ended on April 24.

Johnson died May 2.

A similar case today in the Carlsbad [NM] Current Argus:

On May 20, Marine Cpl. Oligschlaeger, 21, was found dead in his barracks room at Twentynine Palms Marine Corps Air Ground Combat Center in California. Oligschlaeger was a mortar man assigned to the 1st Marine Division, and had recently returned from his second tour of duty in Iraq.

While the death was initially viewed as a suicide, Oligschlaeger's family and friends are not ready to concede that he willingly ended his life. The family will wait for the autopsy report from the Marine Corps, Smith said.

"He suffered from post traumatic stress disorder, and he was struggling with it. He was on eight different medications. From what we have learned, there was not much medical supervision on how he was to take the medications," Smith said.

"His Marine friends have said that, knowing Chad and having fought by his side, they don't believe he was capable of committing suicide. Our family feels the same way."
Smith, whose daughter, Julie, was raised in Carlsbad and graduated from Carlsbad High School, said her grandson graduated from McNeil High School in Austin, Texas, and immediately joined the Marines. ...

Oligschlaeger officially became a Marine on July 18, 2004. He graduated from boot camp in October of that year and then headed to the School of Infantry at Camp Pendleton, Calif. On completion of the school, he was designated as a mortar man and was assigned to the 3rd Battalion, 7th Marines, 1st MARDIV based at Twentynine Palms. In 2005, within just a few short months of his enlistment, he found himself deployed to Ar Ramadi in Iraq.

"When he came home, he said he did not want to go back," Smith said, recalling a conversation with him. "Last year, he learned that he was being sent back. He expressed again that he didn't want to go back. He was told that he would follow orders or the alternative would be a dishonorable discharge. So he went back to Iraq." She said when he returned, he struggled to come to terms with what he had seen and done in Iraq and sought help from the military.

"At the age of 18, he had seen more horrors than I have ever seen in my life," Smith said. "I don't know if I could hold someone in my arms that was badly wounded and watch him die, or see dead bodies all around. He really struggled with that after his first tour in Iraq."

She said Oligschlaeger's second tour added to his stress.

But with his enlistment up just before he died, "he was getting ready to get out, marry his fiancée and go to school to become a firefighter and a paramedic."
Since her grandson's death, Smith said she has learned more about PTSD and how little help there is available to service men and women, and their families who are dealing with it.

"I always thought that anyone in the military who has fought in a war is well taken care of if wounded physically or suffering with PTSD," she said. "But that's not the case, I have learned. "They give PTSD patients a bunch of pills. Where's the counseling they need? Where's the compassion for those who come home hurt after fighting for our freedoms? It's not right." ...

"It upsets me to find out that in Chad's case, and probably in many more cases, the military gives these kids suffering from PTSD all this medication and does not monitor them. It's disgraceful," she said.

In February, the Army Times reported:

[T]he Army found a new “trend” as it grouped all of its wounded soldiers into one system where they could be carefully monitored: 11 deaths in that population due to suicide, accidental overdose by prescription medications, and in motor vehicle accidents. Schoomaker said the combination of multiple prescription drugs — usually pain medication — mental health issues, alcohol and no supervision on the weekends are contributing to the problem.

Lt. Gen. Eric B. Schoomaker, the Army’s surgeon general, said there has been “a series, a sequence of deaths” in the new, so-called “warrior transition units.” Those are special units set up last year to give sick, injured and war-wounded troops coordinated medical care, financial advice, legal help and other services as they transition toward either a return to uniform or back into civilian life.

Without giving a number, Schoomaker said the deaths among the convalescing troops were “accidental deaths, we believe, often as a consequence of the use of multiple prescription and nonprescription medicines and alcohol.”

“This isn’t restricted to the military, alone, as we all saw the unfortunate death of one of our leading actors recently,” Schoomaker told Pentagon reporters. ... Schoomaker said he didn’t know whether the number of overdoses among soldiers was on the rise, but would try to provide statistics as soon as possible. The series of deaths was noticed and is getting attention partly because the new units concentrate the Army’s temporarily disabled and ill into special groups, thus making it possible for leaders to track and tabulate their health issues more closely and carefully than ever before.

AP fleshes things out:

There have been at least three accidental drug overdoses and four suicides among soldiers in special units the Army set up last summer to help war-wounded troops, officials said late Thursday.

A team of pharmacists and other military officials met early this week at the Pentagon to look into the deaths in so-called "warrior transition units" - established to give sick, injured and wounded troops coordinated medical care, financial advice, legal help and other services as they attempt to make the transition toward either a return to uniform or back into civilian life.

The Army said officials had determined that among those troops there have been 11 deaths that were not due to natural causes between June and Feb. 5. That included four suicides, three accidental overdoses of prescribed medications, three deaths still under investigation and one motor vehicle accident, the Army said.

Time's Mark Thompson introduces us to Iraq vet Sergeant Christopher LeJeune in "America's Medicated Army:"

LeJeune visited a military doctor in Iraq, who, after a quick session, diagnosed depression. The doctor sent him back to war armed with the antidepressant Zoloft and the antianxiety drug clonazepam. "It's not easy for soldiers to admit the problems that they're having over there for a variety of reasons," LeJeune says. "If they do admit it, then the only solution given is pills."

While the headline-grabbing weapons in this war have been high-tech wonders, like unmanned drones that drop Hellfire missiles on the enemy below, troops like LeJeune are going into battle with a different kind of weapon, one so stealthy that few Americans even know of its deployment. For the first time in history, a sizable and growing number of U.S. combat troops are taking daily doses of antidepressants to calm nerves strained by repeated and lengthy tours in Iraq and Afghanistan. The medicines are intended not only to help troops keep their cool but also to enable the already strapped Army to preserve its most precious resource: soldiers on the front lines. Data contained in the Army's fifth Mental Health Advisory Team report indicate that, according to an anonymous survey of U.S. troops taken last fall, about 12% of combat troops in Iraq and 17% of those in Afghanistan are taking prescription antidepressants or sleeping pills to help them cope. ...

[I]f the Army numbers reflect those of other services — the Army has by far the most troops deployed to the war zones — about 20,000 troops in Afghanistan and Iraq were on such medications last fall. The Army estimates that authorized drug use splits roughly fifty-fifty between troops taking antidepressants — largely the class of drugs that includes Prozac and Zoloft — and those taking prescription sleeping pills like Ambien.

In some ways, the prescriptions may seem unremarkable. Generals, history shows, have plied their troops with medicinal palliatives at least since George Washington ordered rum rations at Valley Forge. During World War II, the Nazis fueled their blitzkrieg into France and Poland with the help of an amphetamine known as Pervitin. The U.S. Army also used amphetamines during the Vietnam War. ...

The increase in the use of medication among U.S. troops suggests the heavy mental and psychological price being paid by soldiers fighting in Iraq and Afghanistan. Pentagon surveys show that while all soldiers deployed to a war zone will feel stressed, 70% will manage to bounce back to normalcy. But about 20% will suffer from what the military calls "temporary stress injuries," and 10% will be afflicted with "stress illnesses." Such ailments, according to briefings commanders

Information on the medication-suicide issue:

Last year the U.S. Food and Drug Administration (FDA) urged the makers of antidepressants to expand a 2004 "black box" warning that the drugs may increase the risk of suicide in children and adolescents. The agency asked for — and got — an expanded warning that included young adults ages 18 to 24, the age group at the heart of the Army. The question now is whether there is a link between the increased use of the drugs in the Iraqi and Afghan theaters and the rising suicide rate in those places. There have been 164 Army suicides in Afghanistan and Iraq from the wars' start through 2007, and the annual rate there is now double the service's 2001 rate.

At least 115 soldiers killed themselves last year, including 36 in Iraq and Afghanistan, the Army said on May 29. That's the highest toll since it started keeping such records in 1980. Nearly 40% of Army suicide victims in 2006 and 2007 took psychotropic drugs — overwhelmingly, selective serotonin reuptake inhibitors (SSRIs) like Prozac and Zoloft. While the Army cites failed relationships as the primary cause, some outside experts sense a link between suicides and prescription-drug use — though there is also no way of knowing how many suicide attempts the antidepressants may have prevented by improving a soldier's spirits. "The high percentage of U.S. soldiers attempting suicide after taking SSRIs should raise serious concerns," says Dr. Joseph Glenmullen, who teaches psychiatry at Harvard Medical School. "And there's no question they're using them to prop people up in difficult circumstances."

While we're focused on the DoD, from the VA:

Medication
Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant medicine. These can help you feel less sad and worried. They appear to be helpful, and for some people they are very effective. SSRIs include citalopram (Celexa), fluoxetine (such as Prozac), paroxetine (Paxil), and sertraline (Zoloft).

Chemicals in your brain affect the way you feel. When you have or depression you may not have enough of a chemical called serotonin. SSRIs raise the level of serotonin in your brain. There are other medications that have been used with some success. Talk to your doctor about which medications are right for you.

Even though I'm sharing quite a big chunk in the interest of education, head over to the Sidran Institute to read an article on PTSD medications for combat veterans written by military psychiatry expert Jonathan Shay, Md, Phd:

Everything I say here is my point of view, and carries no claim of special authority. Also, what I say here is no way complete. I have left out many important subjects, such as drug interactions, what medical conditions forbid the use of a given drug, overdoses and toxicity, and most specific side-effects. Also, many psychiatrists who also care about combat veterans will disagree with what I say here, particularly about the benzodiazepines like Ativan. Combat PTSD is moral, social, philosophical, and spiritual injury. The biological nature of human beings is to be moral, social, philosophical, and spiritual, so the injury also shows itself as medical disorders.

Healing is psychological, social, spiritual—no medicine can cure combat PTSD. However, healing can never mean a return to 17-year old innocence. Healing means building a good human life with others—a life that a veteran can embrace as his own.

Combat trauma brings about long-lasting changes in brain chemistry. We do not know whether these are permanent or can be reversed by psychological/social healing. A few existing medications can help some men with some symptoms of PTSD. We also do not know whether this changes the long-term outcome for the better, but the human payoff in reduced suffering is unmistakable.

Therapeutic effects (benefits) and side-effects

Drugs are dumb chemicals—they don’t know what they are. They aren’t born in a laboratory with a word spelled out across their foreheads “Anti-depressant!” or something like that. Most have been discovered by accident. Almost every drug known has multiple effects on the body. Which effect is a therapeutic (beneficial or main) effect and which is an unwanted side-effect is a human decision, not a chemical decision.

Illustrations: Think of the well-known drug Elavil (generic name: amitriptylene). What is it? An anti-depressant you say? Why is it used in the Intensive Care Unit to stabilize the heart beat of certain patients? Not because depression causes their irregular heart beat. Why is it used by neurologists to treat migraine? Not because depression causes migraine—and the doses that work for migraine are usually too small to touch a depression. The point is, of course that a drug doesn’t know what it is. Its successful human uses make it an anti-depressant, a migraine drug, an anti-arrhythmic.

What about side-effects? Again, this is a matter of the human purposes involved. Think of the anti-depressant trazodone (most common trade name: Desyrel). Its most prominent side-effect is drowsiness. I prescribe trazodone fairly often as a sleep medication to veterans who are on fluoxetine. It has the advantage that it doesn’t lose its effect with repeated use (which also means there’s little withdrawal syndrome when the veteran stops it), and it’s almost useless as a pill to kill yourself with. So here the side-effect is the main effect and the anti-depressant effect is a side-effect—Is anybody confused yet?

Important to remember: When a drug has several different effects, each effect has its own way of unfolding in time. How long a drug takes to produce its different effects, is often different for each effect. The side-effects may hit immediately and the main effect only develop after several weeks! With another drug it’s the opposite, with the main effect coming on immediately and the side effects happening later. An analogy: Think of a plant on your window sill. You’ve been away for the weekend and it’s gotten dry and droopy. You give it water and the leaves begin to respond almost as soon as the water goes on—the plant responds as soon as the water reaches the roots. If the roots dry out, again the plant wilts again. This is like a pharmacokinetic effect. If you put some fertilizer in the water, on the other hand, this reaches the roots as fast as the water reaches them, but you may not see any result for days or weeks. This is because the plant has to build new parts in its own cells. This is like a pharmaco-dynamic effect.

Example: Most anti-depressants reach the brain quickly, but take several weeks to have an anti-depressant effect. This is probably because the changes that have to take place in the cells take that long to happen. However, some side-effects like a dry mouth or drowsiness happen quickly because they do not require cells to make anything new, but only to do what they’re already doing faster or slower. ...

Characteristics of good drugs for combat PTSD

Makes something better for the veteran
Does not lead to tolerance
Does not lead to abuse
Cannot be used to commit suicide
Does not require blood tests
Does not cut a person off from the world or from himself
Causes few, bearable side-effects

Some good drugs for combat PTSD

--Serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), etc.

The main effect of fluoxetine on combat vets with PTSD whom I’ve worked with is to allow them more time to think before they act, particularly in anger. It does this without sedation or cutting a man off from himself or the world. The duration of anger, once aroused, is also shorter. Greater self-mastery of anger leads to an increase in self-respect and relief from a sense of humiliation. Most men feel humiliated after they go off on people in situations they really would not have, if they had had the freedom to choose. In addition to this, fluoxetine may have a direct anti-depressant effect in combat PTSD. Fluoxetine effects on self-control and rage may take many weeks to kick in, although I’ve seen it as soon as a week.

Fluoxetine is practically useless as a drug to overdose on, if the goal is suicide. All anti-depressants have been known to give long-time depressed people the energy to kill themselves, and fluoxetine is no different. Many combat veterans go through brief periods of intense despair during the first few months that they are feeling generally better, more alive, and are coming out of their bunkers. Support from other veterans, family, therapists is especially important during those times—nobody should try to go through it alone, or have to. Someone trying to go through it alone might try to kill himself during one of these times of despair. Remember that this is no special risk with fluoxetine, but is a risk when anyone recovers from severe depression. Several vets I’ve treated have had bouts of despair like this, but none has ever tried to kill himself during one, because support and therapy are built into the program I’m a part of. The much-publicized claim that Prozac has special powers make a previously non-suicidal person violently suicidal is without good foundation. Fluoxetine does have side effects, which not everyone can stand, and it doesn’t work for everyone. A full discussion of side-effects, some of which depend on the dose and others not, would be too long for this summary.

Fluoxetine is the first drug of its type to be released for use. Other drugs in the same family have now come along, sertraline (Zoloft) and paroxetine (Paxil). They have been tried by many combat vets around the country, and from what I hear they are not a lot different than fluoxetine as far as main and side-effects. In the relatively limited number of men I have treated with paroxetine and sertraline, this has been what I have heard from them. Paroxetine has a 24 hour half-life and no active metabolites [what the body turns the parent drug into], so if the actions of the drug are otherwise identical to fluoxetine, it will be a superior drug from a safety point of view, because it doesn’t hang around in the body so long. But on the down side, paroxetine may be expected to (and is reported to) have a withdrawal syndrome because it leaves the body so fast.

--Buspirone (Buspar)

This anti-anxiety drug works differently from the benzodiazepines (like Valium). Like anti-depressants it takes a few weeks to kick in. It takes effect gradually, like the tide coming in. It usually has few side-effects and may help some people with intrusive thoughts and nightmares. Buspirone has no street value and is almost useless as a suicide pill. I am not aware of other drugs in this family coming along, but I hope there will be. I have recently read the report of a colleague who works with combat veterans that the best results with buspirone come at doses above 60mg/day. I do not yet have enough personal experience with patients who have tried this, to confirm or deny this report.

--Beta-blockers: propranolol (Inderal), nadolol (Corgard), atenolol (Tenormin), etc.

This family of drugs breaks the mind-body-mind vicious cycle in rage reactions, by blocking the body effects of adrenalin. For example, if someone at work says something offensive about Vietnam vets, the words start the mind working into rage. The rage starts in the mind—but within a second the body responds with adrenalin, which makes the gut burn, the heart pound, the muscles tense. These body changes send loud messages back up to the mind. For some veterans, the roar of the body drowns out all thought and shuts out everything else coming in. When adrenalin is roaring, it’s impossible for most people to think clearly and to take in non-combat possibilities in the situation. This is the mind-body-mind vicious cycle that beta-blockers break up. By blocking the adrenalin effect on the body they prevent the roar of the body from drowning out all thought and choice about what you really want. “Is it really in my interests to rip this guy’s lungs out? Is it really what I want to do?” When adrenalin is roaring these questions sometimes cannot be heard.

Some vets feel that these medications weaken them, because they associate being pumped up with adrenalin with their personal strength. When someone is over-medicated on these drugs (which started life as blood pressure meds) he is weaker because his blood pressure is too unstable, but this is usually not a problem with a correct dose. Tolerance does not develop to the anti-adrenalin effects of these drugs. Massive overdoses of a beta-blocker can be fatal, by dropping the blood pressure and slowing the heart to the point that the brain is not getting enough blood flow.

--Low-dose lithium

Some respected practitioners of PTSD pharmacotherapy speak highly of lithium to help veterans maintain their self-control when they are angry. This means doses of about 600mg/day, far less than is usually needed to treat bipolar affective disorder (manic-depressive disorder), and does not imply that the doctor recommending this thinks that the veteran is manic-depressive.

I agree that this can help some veterans, but I have found fluoxetine to be more reliable. It is also safer, in that lithium is readily fatal in a large overdose. For a veteran who cannot tolerate fluoxetine and whose life has been blighted by explosive violence, low-dose lithium may be a good thing to try. [no blood tests because of low dose]

Other drugs for special circumstances

--Trazodone (Desyrel) for sleep

Trazodone is a non-toxic anti-depressant that has a useful side-effect: It causes drowsiness, and people don’t get tolerant to this effect. Because fluoxetine slows the rate that the liver breaks down trazodone, much lower doses are needed for sleep by patients on fluoxetine than people who are not on fluoxetine.

--Quinine for nocturnal myoclonus

This is the “sleep jerks.” If quinine works, the veteran himself may not notice much but his wife has much better sleep.

--Low-dose antipsychotics for violent urges: thioridazine (Mellaril), mesoridazine (Serentil), etc.

The key here is brief treatment on an as-needed basis, controlled by the veteran himself [for a limited time, when hospitalization is not possible]. The doses needed have been low, and I prefer the sedating anti-psychotics like thioridizine and mesoridizine, which appear to carry the least risk of dangerous (neuroleptic malignant syndrome) or possibly irreversible (tardive dyskinesia) complications. An unexpected additional use for these drugs also involves brief, low-dose treatment: to help someone who wants to get off marijuana get through the withdrawal syndrome.

Future drugs

Many combat veterans with PTSD feel dead inside. It is possible that this psychic numbing comes from the brain making its own opium-like substances, and that opiate blockers can give people back their feelings. It is not yet clear whether this works.
I hope the future will bring a drug like clonidine (trade name: Catapres) that people do not develop a tolerance to. In my experience, about one out of five combat veterans with PTSD experience major improvement of almost all of their PTSD symptoms on clonidine—but the heartbreak has been that they grew tolerant to it in about a week. Any future drug in this family that does not induce tolerance to this effect will relieve much suffering. A new drug in this family, guanfacine (tradename, Tenex) has recently appeared, but I have no experience with it and have not heard any reports of usefulness to combat veterans with PTSD.

The most helpful drugs are likely to be ones that don’t yet exist.

Read Shay's full list of drugs to avoid and check the "medication" tag for related content or choose from those listed below.


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