Psychiatrists and mental health experts spoke about the relationship between medication and veterans' suicides when the House Veterans' Affairs Committee hosted a committee hearing on the topic on Wednesday. Although speakers offered different views on whether antidepressants help to decrease veterans' chances of committing suicide, there was agreement that suicide is a topic of concern, as suicide rates climb among young veterans who have deployed to Iraq and Afghanistan.

Bob Filner, chairman of the House Committee on Veterans' Affairs, said, "The purpose of today's hearing is to explore the potential relationship, if any, between psychiatric medications and suicides. With post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) being the signature wounds of the current war in Iraq and Afghanistan, mental health issues have naturally taken centerstage. Research has shown that mental disorders and substance-abuse disorders are linked to more than 90 percent of people who die by suicide. Today, suicides among service members and veterans continue to increase at an alarming rate, far exceeding the comparable suicide rates among the general population. It is a tragedy that our service members and veterans survived the battle abroad only to return home and fall to suicide. With the widespread availability and use of psychiatric medications to address mental health disorders, it begs the question of whether these drugs prevent or lend a hand in suicides."

Some doctors are convinced that psychiatric drugs often adversely impact the individuals' better judgment and lead people to lose control over their emotions and actions, Filner said, adding that suicides may be driven by so-called drug-induced adverse reactions and intoxications. On the other hand, Filner said, some research studies show that suicide attempts were lower among patients who were treated with antidepressants than those who were not. In other words, he said, antidepressants had a protective effect and did not support the hypothesis that antidepressants place patients at greater risk of suicide.

"Through this hearing, we will explore the two opposing schools of thought on the relationship with psychiatric medication and suicides," Filner said. "In this process, we will also seek to better understand the reasons why more and more service members and veterans are taking their own lives and what the Department of Veterans Affairs (VA) and the Department of Defense are implementing in this struggle to prevent more suicides."

Speakers included Ira Katz and Loree K. Sutton. Katz M.D., Ph.D., is deputy chief patient care services officer for Mental Health Services, Veterans Health Administration and US Department of Veterans Affairs. Brig. Gen. Loree K. Sutton M.D., is director of Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and is special assistant to the assistant secretary of defense for health affairs, US Department of Defense (DoD).

Other speakers were Peter R. Breggin M.D., psychiatrist and author from Ithaca, New York; Bart P. Billings Ph.D., psychologist and author from Carlsbad, California; Andrew C. Leon Ph.D., professor of biostatistics in psychiatry and public health of Weill Cornell Medical College; M. David Rudd Ph.D., ABPP, dean, College of Social and Behavioral Science of the University of Utah on behalf of the American Psychological Association; Annelle Primm M.D., M.P.H., deputy medical director for minority affairs of the American Psychiatric Association; and Donald J. Farber, Esq., commander, US Navy (retired) from San Rafael, California.

Primm, an associate professor of psychiatry at the Johns Hopkins School of Medicine, spoke on behalf of the American Psychiatric Association (APA), a medical specialty organization that represents 37,000 psychiatric physicians nationwide.

The APA advocates for immediate and seamless access to care for psychiatric and substance use disorders for America's military and their families. "As physicians, researchers and family members, the APA has noted with increasing concern the increase in suicide attempts and completed suicides by veterans and those currently serving, and has advocated for direct action to address this major problem," Primm said.

Beginning in 2002, the suicide rate among soldiers rose significantly, reaching record levels in 2007 and again in 2008 despite the Army's major prevention and intervention efforts, she said.

Primm said, "Many of the most dramatic improvements in the effective treatment of mental illness have come as a result of newer and better medications, especially a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) which can be utilized to help manage PTSD symptoms. These medications have meant remarkably positive changes in the lives of tens of millions of Americans."

However, Primm said, "Medications, when utilized, should be in conjunction with supportive therapies such as cognitive behavioral therapy. The prescribing and monitoring of brain medication should, however, be overseen by those with medical education, training and clinical experience."

Also, Primm said, "there is no evidence to suggest that these medications increase the risk of actual suicide. It does appear that these medications may increase the likelihood that some patients will actually tell someone about their suicidal thoughts or even about a suicide attempt. From my perspective, as a psychiatrist, this is actually a good thing, because it means you have the opportunity to intervene and to keep the person safe. The teenage suicide rate in the country had actually declined by over 25 percent since the early 1990s, in a manner consistent with the increased use of SSRI antidepressants."

On the other hand, Breggin said he disapproved of antidepressants. Breggin has written a lot about antidepressants causing violence, suicide and other abnormal behavioral reactions. He said, "There is overwhelming evidence that the newer antidepressants commonly prescribed in the military can cause or worsen suicide, aggression and other dangerous mental states. There is a strong probability that the documented increase in suicides in the military, as well as any increase in random violence among soldiers, is caused or exacerbated by the widespread prescription of antidepressant medication." Also, he said, "Little will be lost and much will be gained by curtailing the prescription of antidepressants in the military."

Breggin argued, "There is a strong probability that increasing suicide and violence rates among active duty soldiers are in part caused or exacerbated by the widespread prescription of antidepressant medication. Antidepressants should be avoided in the treatment of military personnel."

The VA has responded aggressively to address previously identified gaps in mental health care by expanding mental health budgets, Katz said. "In fiscal year (FY) 2010, VA's budget for mental health services reached $4.8 billion, while the amount included in the President's budget for FY 2011 is $5.2 billion. Both of these figures represent dramatic increases from the $2.04 billion obligated in FY 2001," Katz said. "VA has increased the number of mental health staff in its system by more than 5,000 over the last three years."

Also, Katz said, "appropriate use of psychotherapeutic medications is a key component of overall mental health care, but medications, like all treatments, can be associated with risks as well as benefits; VA has systems to monitor for adverse effects associated with medication use and programs to enhance the safety of pharmacological treatments" and "VA's mental health and suicide prevention activities are effective and evidence-based."

He said, "Data demonstrate that young adult veterans are coming to VA for their mental health needs, and those veterans who may be vulnerable to suicidality as an adverse effect of antidepressant medications have lower suicide rates when they come to VA for health care."

In addition, Katz said, "Associations between suicide and medications have been difficult to evaluate because, for each, medications have been demonstrated to be effective for the treatment of conditions that are, themselves, risk factors for suicide. In most contexts, this can make it difficult to sort out what effects may be due to medication and what to the underlying condition."

Katz said that the VA has been concerned about increases in suicidal ideation and other symptoms of suicide as adverse drug effects. Also, he said that the Serious Mental Illness Treatment Research and Evaluation Center (SMITREC) conducts ongoing analyses of risk factors for veterans' suicides and shares its findings to the field. Currently, SMITREC is collaborating with VA MedSAFE to conduct a broad-based, exploratory evaluation of the associations of medications with suicide. In addition, Katz said that to promote suicide prevention, the VA established a strong partnership with the Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) to operate a Veterans Call Center as part of the National Suicide Prevention Lifeline. The VA also has appointed suicide prevention coordinators and care managers at each VAMC and the largest community-based outpatient clinics. Altogether, the VA employs over 400 staff members who focus specifically on suicide prevention.

The VA's mental health care services are working, Katz said: He said that in 2005, 2006 and 2007, respectively, those who came to the VA were 56, 73 and 67 percent less likely to die from suicide. "Those who utilized VA services were, to some extent, protected from suicide with an effect that appeared to increase during the time of VA's mental health enhancements," he said. "VA recognizes the concerns raised by FDA and others about the use of antidepressant medications among young adults as a potentially vulnerable population, but it has found that the risk of suicide is lower among the young adult veterans who come to VA for care and that the rates appear to be dropping."

Sutton said that the DoD recognizes that the total number and rate of suicides continue to rise and this is of deep concern at all leadership levels. "Suicide has a multitude of causes, and no simple solution," she said. "There are many potential areas for intervention, and it is difficult to pinpoint the best approach because each suicide is unique. Recognizing this, the Department of Defense is tackling the challenge using a multi-pronged strategy involving comprehensive prevention education, research and outreach."

A critical component of the DoD's strategy is advancing research. A pilot study that showed promise in the civilian sector is the Caring Letters Program. In a randomized clinical trial, sending brief letters of concern and reminders of treatment to patients admitted for suicide attempt, ideation or for a psychiatric condition was shown to dramatically reduce the risk of death by suicide. In an effort to determine the applicability to military populations, the National Center for TeleHealth and Technology (T2) is piloting a program at Ft Lewis, Washington. Since its inception in July 2009, 81 letters have been sent. Efforts are currently underway to plan a multi-site, randomized, control trial.

"The Department of Defense's current initiatives to address the challenges placed on service members and their families are progressing," Sutton said, "but we recognize that there is still much to be done."

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