June 3, 2008 - “Is U.S. Health Care Really the Best in the World?”   Such was the title of Dr. Barbara Starfield’s clarion call to fellow medical professionals in a July 2000 issue of JAMA, the prestigious journal of the American Medical Association.  Drawing upon statistics from a variety of high quality sources – including a pivotal 1998 meta-analysis of drug-induced fatalities, and a 1999 report by the Institute of Medicine on medication errors – the author revealed that the health care system itself had become the third leading cause of death in our country, after heart disease and cancer.  

In the eight years which have passed since the appearance of the Starfield paper, the scope of iatrogenic injury has expanded rather than reversed.   Presumably, denial has played no small role in this problem.  It is notable that the CDC’s annual health care statistics have consistently excluded the categories of “medication adverse effects” and “deaths due to medication errors.”  One wonders if the federal government has believed that by ignoring these problems, they might encourage others to do the same.
 
It is against this backdrop of recalcitrant denial that military and civilian medical professionals, along with government officials, have turned their attention to the problem of soldier and veteran suicide.  According to the Army’s top psychiatrist, Colonel Elspeth Richie, Army suicides in 2007 reached the highest level on record with 115 confirmed fatalities, and an incidence rate of 19 suicides per 100,000 soldiers.   Similar developments have plagued non-active duty personnel.  According to Veterans Affairs Secretary, Dr. James Peake, the true incidence of veteran suicide remains unknown.  However, the VA has recently estimated that 6,500 former soldiers, airmen, and sailors die by suicide each year.   Using the U.S. Census Bureau’s most recent figures of 23.7 million veterans, the annual incidence rate of suicides in this population is 27 per 100,000.  In short, the problem of soldier suicide is at least two times higher than the national background rate, and it is expected to worsen over time.

Reacting in part to this epidemic of self-destruction, the RAND corporation recently completed a comprehensive report on the prevalence and treatment of neuropsychiatric injuries among the active duty and veteran communities.  Entitled “Invisible Wounds of War,” the study focused upon the problems of Traumatic Brain Injury, PTSD, and major depression. 

In the process of producing a work which spanned 498 pages, the authors focused upon “evidence based” recommendations drawn essentially from corporately funded sources.   Perhaps the RAND researchers were unaware of the 2008 paper by Turner et al., in which it was revealed that a full 31% of the clinical trials involving antidepressants – most of them negative – went unpublished.  Unsurprisingly, the RAND report conveyed a myopic view of pharmacotherapies which excluded a serious discussion of iatrogenic harm.  For example, the problem of antidepressant-related suicide received a mere twelve lines of attention.  Even then, no mention was made about the existence of Black Box Warnings for this hazard, and no information was presented with respect to the physiological mechanisms through which these drugs would be reasonably expected to induce or worsen impairments of judgment, mood, and impulse control.

The composition of the VA’s newly formed Blue Ribbon Work Group on Suicide Prevention portends a set of treatment recommendations marked by similar oversights and omissions.   Of nine civilians appointed to a special Expert Panel on suicide, it is striking that one third of them have past or continuing financial ties to the pharmaceutical industry.  More importantly, in contradiction to valid epidemiological and scientific findings, these members have repeatedly denied the link between antidepressants and self-harm.   While financial conflicts of interest need not prevent an objective consideration of epidemiological evidence and neurobiology, what makes this panel so special is the fact that it features members who have voted against, testified against, or publicly railed against the Food and Drug Administration’s decision to add (and then strengthen) warnings about drug-related suicide.  

More than likely, it is too late for Dr. Peake to change the composition of this specific  advisory panel to the Blue Ribbon Work Group.  However, for the sake of the safety and well-being of the men and women in uniform, of their families, and of the public at large, one must hope that federal officials will eventually insist upon the formation of a new
panel or committee – one that will be qualified and willing to discuss a number of pressing concerns, including:

- the prudence of initiating or continuing troops on mind-altering drugs in theater

- the possibility that drug-induced violence can never be reliably predicted or
      prevented via “frequent monitoring”

- the potential for returning troops to experience drug-withdrawal suicide (or homicide), due to temporal gaps between treatment in-service and treatment within the VA system

- the probability that psychiatric drugs change the brain in ways which prevent, rather than facilitate, long term recovery.

Psychiatrists, both within and beyond the military, have historically ignored the problems of target organ toxicity and allostatic load, including the iatrogenic phenomena of endocrine disruption and chemical imprinting.  A full discussion of each of these issues lies beyond the scope of this essay.  However, no less than the neurological and psychological conditions which arise from the events of the battlefield, it is time for a Blue Ribbon Work Group to prevent and mitigate the consequences of neuropsychiatric drugs.  For far too long, these have also contributed to the “Invisible Wounds of War.”
 
Selected References

Hefling K (May 8, 2008).  “Questions and answers about veteran suicide.”  Accessed on 01 June 2008 at: http://www.signonsandiego.com/news/military/20080508-1325-veteransuicide-q&a.html

Lazarou J, Pomeranz BH, and Corey PN (1998).  Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-Analysis of Prospective Studies.  JAMA 279 (15): 1200-1205.

Lorge EM (May 30, 2008).  “Army Continues Fight Against Soldier Suicides.”  Accessed on 01 June 2008 at: http://www.army.mil/-news/2008/05/30/9523-army-continues-fight-against-soldier-suicides/

Starfield, Barbara (2000).  Is US Health Really the Best in the World ?  JAMA 284 (4):
483-485.

Turner EH, Matthews AM, Linardatos E, Tell RA, and Rosenthal, R (2008).  Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy.  New England Journal of Medicine 358: 252-260. 

Note:  Dr. Grace E. Jackson is a former Navy psychiatrist who resigned her commission in 2002 for reasons of professional conscience.  A private practice clinician, forensic consultant, lecturer, and author, she can be reached at grace.e.jackson@att.net.