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Submission For The Record of Bart P. Billings, Ph.D., Carlsbad, CA (Psychologist and Author)

I.   Role of Psychiatric Medications in Suicide:

If you were the parent of a son or daughter serving in the military, would you want your child being prescribed medication, on the battlefield or off, which contained a black-box warning that states:

Suicidality and Antidepressant Drugs

Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of Zoloft or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need. …

A medication guide appears at the end of the label.  The label states, “The prescriber or health professional should instruct patients, their families, and their caregivers to read the medication guide and should assist them in understanding its contents.”

The medication guide gives specific guidance about identifying danger signs:

Call a health care provider right away if you or your family member has any of the following symptoms especially if they are new, worse, or worry you:

  • Thoughts about suicide or dying
  • attempts to commit suicide
  • new or worsening depression
  • new or worsening anxiety
  • feeling very agitated or restless
  • panic attacks
  • trouble sleeping (insomnia)
  • new or worsening irritability
  • acting aggressive, being angry, or violent
  • acting on dangerous impulses
  • an extreme increase in activity and talking (mania)
  • other unusual changes in behavior or mood

Identical or nearly identical warnings and information can be found in all antidepressants labels. The strongest warning pertains to children and young adults up to age 24, which includes many young military personnel.

From 2002 through 2008, there has been nearly a doubling of psychiatric medications prescribed to our military personnel and their families. At the same time, there has been a surge in the number of suicides among service members and their family members that appears to correlate directly with the increase use of psychiatric medication.

Stop and think about the fact that military personnel, who carry a weapon 24 hours a day, seven days a week, for a year deployment, can be given a medication that has a black box warning, indicating a potential side effect can be suicide as well as aggressive, angry and violent behavior that can lead to homicide. If a medical practitioner prescribed this type of medication in the civilian community, to a patient who constantly carried a loaded weapon (had a permit to do so) and had extensive training on how to use this weapon, they could likely be charged with mal-practice and possibly loose their license to practice medicine. If there was a suicide or homicide by this patient, directly related to this prescription, then the practitioner could be criminally charged.

When discussing this issue with several civilian private practice physicians, they stated that they would not prescribe psychiatric medications to this type of patient but would refer the patient for counseling. This is not the case with many Veterans Administration (VA) psychiatrists, who in most cases prescribe psychiatric medications to the veterans they treat. I was recently at a professional conference at a local college where a VA psychiatrist admitted openly that he prescribed psychiatric medication to 98 percent of the patients who he treated at his clinic located in north county San Diego.

In 2008, the New York Times reported Dr Ira Katz, head of mental health services in the VA wrote an email to his staff stating: The VA should be quiet about the rate of suicide attempts with veterans receiving VA services. It should be noted that about 1000 suicide attempts a month were reported in veterans seen at VA facilities. Again, one must look at the relationship between extensive numbers of psychiatric medication being prescribed at the VA and the large number of suicides and attempted suicides by veterans receiving services at the VA. 

For the past 27 years, I have been living within 15 minutes from Camp Pendleton Marine Base, which is a major staging area for Marines sent into battle and returning from battle. My proximity to one of the largest Marine bases in the world has allowed me to see first hand what many young military personnel and their families experience. I have seen military personnel as patients, as an expert doing evaluations for legal cases involving Marines and as a member of an advisory board at Palomar Community College providing scholarships to military personnel and their families. I have spoken with Marines at various social functions as well as through service clubs and charity events. This exposure has helped me to conclude that one of the biggest fears that a Marine has in discussing his personal combat stress reactions to others is that he will be medicated.

In 2007, a reporter, Rick Rogers from the San Diego Union Tribune, published a story stating that more Marines died at Camp Pendleton from suicide, homicide and motorcycle accidents (34  percent increase in motorcycle deaths between 2007 and 2008) than Marines deployed from Camp Pendleton who died in combat.

This same reporter, previous to this article, reported that Marines and other military personnel were being sent into combat while on psychiatric medication. He was one of the first reporters in the country to report on this policy, developed by the chief psychiatrist’s in all military services. An article in Time magazine a few years ago discussed the medication of our military in depth and identified, by name, the leading proponents of endorsing the use of psychiatric medication on the battlefield. Principally Colonel Cameron Ritchie of the Army and Captain William Nash of the Navy.

At a past educational conference that I was invited to 3 years ago, as a VIP at Camp Pendleton, I had an opportunity to ask the commanding general of the Camp Pendleton Marine Base what he thought about Mr Rogers article regarding Marines being sent into combat while on psychiatric medication. His response was similar to many other combat commanders I have spoken with, who have been educated by military psychiatrists. He stated that mental health diseases should be treated like any physical disease, and that would be by administering medication. He stated that if you had an infectious disease, you would get an antibiotic and if you had a mental disease, psychiatric medication could be similarly administered. When I mentioned that the side effects of antibiotic’s had no black box warning of possible suicide and psychiatric medication did, he was quick to state he never took medication himself and wouldn’t do so.

The questions that need to be asked;

  • How can medical practitioners in the military and the VA get away with what, in the civilian community, could be considered mal-practice and in certain cases criminal?
  • Why are military mental health psychiatrists or their disciples, who initially recommended the use of these types of medication to their mental health subordinates, who are located on the battlefield, still in positions of leadership and funded, with the responsibility to explain the causes of continued escalation of suicides in the military?
  •  Why hasn’t there been a change in mental health leadership who has consistently failed to stop the drastic increase in suicides and homicides in the military?
  •  Why haven’t there been widely published post mortem reports on all suicides and homicides, both on the battlefield and at home, clearly identifying if the victim was on psychiatric medications? 
  •  Does anyone believe that military mental health staff who advocated initially using psychiatric medication, will ever do research that demonstrates that the same medications they recommended be used on our military personnel has direct side effects that can lead to suicide and homicide?

Hopefully some, if not all of these questions can be answered in testimony provided at these congressional hearings. 

I don’t believe the current increase in suicides and homicides in the military is a coincidence, based on my personal observations, as well as other professionals’ observations and writings on the subject. A recent text, “Medication Madness” written by a world renowned Psychiatrist, Peter Breggin MD, on adverse reactions to medications, discusses in depth the science and end results of adverse reactions to psychiatric medications. This text should be read by anyone taking or prescribing medication. I have personally spoken with psychiatrists, who work with military personnel, who have informed me they changed the way they currently treat their patients (reducing their use of medication) after hearing Dr Breggin speak about adverse effects of psychiatric medication.

At the 17th Annual International Military and Civilian Combat Stress conference in May 2009, everyone attending the conference heard an Army social worker state that the use of psychiatric medication on the battlefield was rampant. She had completed 2 one-year tours of duty in Iraq and Afghanistan and estimated that 90 percent of the US combatants have used, at one time or other, psychiatric medications. She explained that they are being handed out, not only by physicians but also by physicians assistants, nurses, medics and even from soldier to soldier. She was told by various psychiatrists, while deployed, to support medicating troops and in one instance that her services on the battlefield were useless since she could not prescribe medication.

At the same combat stress conference, an Army Lieutenant Colonel commander described how some of his troops, after returning to Germany from Iraq, were given psychiatric medications and how their behavior deteriorated after receiving the medications. 

Prescriptions for all TRICARE beneficiaries, according to a Department of Defense (DoD) claims database (attachment 1 and 2), indicate that in 2002 a total of 3,739,914 prescriptions for antidepressants and antipsychotics were issued. In 2008 the number of these prescriptions rose to 6,413,035 (attachment # 1.and 2.).

Figures for 2009 are not available at this time but based on the steady progression of increased amounts of medications prescribed, one would assume the total prescriptions, to date, would be over 7 million.

In 2009, the number of suicides in the military surpassed the civilian death rate from suicide. The suicide death rate for military personnel was 20.2 per 100,000 while the civilian death rate was 19.2 per 100,000. Veterans between the ages of 20 to 24 had a suicide death rate of 22.9 per100, 000, which is 4 times higher than non-vets the same age. It should also be noted that statistics indicate that there are 10 failed attempts at suicide for each actual completed suicide.

This is the first time in decades that military suicides are at the current level. Presently we now have the highest level of suicides in the military that we have seen in three decades. Since 2001 there have been 2,100 suicides in the military, triple the number of troops that have died in Afghanistan and half of all US deaths in Iraq.  The correlation of increased suicides, as well as homicides, in the military, and the increased use of medications, with a side effect of suicide, irritability, hostility and aggressiveness does not appear to be a coincidence, but a direct link to adverse reactions a person may experience when taking these medications.

A recent study was performed in Sweden (attachment # 3):

 Rickard Ljung, M.D., Ph.D., Charlotte Björkenstam, M.Sc. and Emma
Björkenstam, B.Sc; Ethnic Differences in Antidepressant Treatment Preceding
Suicide in Sweden, Psychiatric Services 59:116-a-117, January 2008 http://ps.psychiatryonline.org/cgi/content/full/59/1/116-a
Janne Larsson, reporter - investigating psychiatry, Sweden mailto:janne.olov.larsson@telia.com 

This study linked a direct relationship between people taking antidepressants or antipsychotic medications and suicide.

“Thus it can be said that 561 (45 percent) of ALL male and female 1,255 persons (18-84) who committed suicide in Sweden 2006 had filled a prescription for antidepressant drugs OR neuroleptics (not at all counting other psychiatric drugs) within 180 days before their suicide”.

Overall conclusions of the study indicated that approximately 46 percent of people taking these medications committed suicide. The study found a direct link between the use of psychiatric medication as described above and suicide.

There are many other studies that cite similar and even more significant findings, but since I don’t consider myself an expert in the science of these medications, I will defer all questions in regard to the science behind these medications to Peter Breggin, MD, who will provide extensive testimony in this area. Dr Breggin has a prestigious background with the National Institute of Mental Health (NIMH) and elsewhere, where he researched the science of the medications we are discussing.

Also information on the Internet website www.ssristories.com lists hundreds of civilian and military cases of death, suicide, attempted suicide etc. that are linked to psychiatric medication. It identifies such cases of sudden death in soldiers taking a combination of psychiatric medications, the May 11th, 2009 Iraq mental health clinic shooting where 5 soldiers were killed by a soldier on psychiatric medication. 

On the other side of the coin, I have not observed significant long-term studies that have ever shown any psychiatric medication to be effective in treating Post Traumatic Stress Disorder (PTSD), for which significant prescriptions in the military are written. I am not saying that the FDA hasn’t seen research presented to them by pharmaceutical companies, that allowed them to approve these medications for treating PTSD, but am concerned that these studies were less than one would desire to approve treating all our military as well as their families. When positive results are reported, they are typically short-term, not long-term effects.

II. National Tri-Service Combat Stress Conference:

As a retired military officer and founder and director, of the longest running combat stress conference in the world, I have had the opportunity to talk with numerous active and reserve military personnel and their families. I have also heard presentations from experts from throughout the world on combat stress reactions to combat. As a clinical psychologist and mental health professional for over 42 years, I have had the opportunity to see patients while in the military (33years, 9 months in USAR), as well as in my civilian practice. These experiences have also allowed me to teach classes on combat stress reactions in the military as well as in the civilian community.

I have been honored with military awards (attachment # 4.) and my work has been lauded by DoD officials for developing the International Military and Civilian Combat Stress Conference, as well as other programs (attachment # 5., 6., 7. and 8.).

As a military and as a civilian psychologist, I have had an opportunity to develop first- hand opinions regarding, not only the relationship between psychiatric medications and suicide, but other adverse reactions our military personnel experiences that interfere with their performance on the battlefield and when returning home to their families.

My overall observations and clinical experience leads me to state, emphatically, that integrative treatment approaches in treating combat stress and related problems is more effective in the long run, than prescribing drugs, both as a force multiplier and a money saver.

Integrative approaches–such as individual counseling, bio-feedback, guided imagery, progressive relaxation, peer counseling, cognitive-behavioral therapy, virtual reality therapy, implosive therapy, hypnosis, etc. have little or no adverse reactions and there is research that shows them to be effective both short-term and long-term. It should be noted that during the first Persian Gulf War, combat stress chambers were successfully used to reduce stress.  This is more that can be said currently of psychiatric medication. A recent book written in 2007 by a world renowned psychologist, Stanley Krippner, Ph.D. and his associate, Daryl S. Paulson, Ph.D. titled “Haunted by Combat”, as well as an Epilogue to this text presently being published in the 2010 paperback, gives extensive examples and findings as to the success of providing integrative mental health treatment protocols.

If one considers that the average cost of a prescription for an antidepressant or antipsychotic can cost anywhere from $25 to $50 each, then the cost the DoD is billed for so-called mental health prescriptions should likely exceed $2 billion a year. This level of funding could pay for all the mental health professionals needed to provide the integrative treatment programs our military personnel and their families need, with no fear of adverse reactions and every expectation of success. If implemented, there are strong indications that the suicide rate would drop dramatically, as well as the increasing number of soldiers being diagnosed with PTSD and other reactions to combat stress.

During the first Persian Gulf War, I was in a medical unit, the 6252nd U.S. Army Reserve Hospital, which deployed most of its military personal. Upon returning after the war ended, I observed many varied problems among the soldiers. These problems consisted of emotional difficulties, marital difficulties, financial problems, general health problems, legal problems, family problems, spiritual problems, etc.

What was striking at the time was that most of these problems could have been minimized or completely avoided if the soldiers were better prepared prior to deployment. With the assistance of the commanding general of the 6252nd and the staff of our Combat Stress Company, I developed a readiness protocol to address all of the issues one had to deal with prior to and when actually deployed, as well as when returning home. We came up with a 20-minute interviewing manual that, with minimal training, one could administer to each member of a military unit.

The soldier would respond for themselves as well as for their family. The program was called the Human Assistance Rapid Response Team (HARRT?brochure attached # 9. and 10.). Members of the combat stress company administered the instrument to military units with significant success. Readiness problems improved and returning prematurely from deployment dropped. The HARRT program also identified SUICIDE IDEATION and HOMICIDE IDEATION.

Out of the HARRT program, a 2-day conference (attachment # 11.) was born to teach how the HARRT program could be utilized and improved. This conference led to an annual National Tri-Service Combat Stress Conference held for 15 years at Camp Pendleton Marine Base in California. Today this conference, which is held the first week of May, is going into its 18th year and has been re-named The Annual International Military and Civilian Combat Stress Conference.

In December of 1997, I was invited to the Pentagon by Brigadier General Richard Lynch to address the Army Reserve Forces Policy Committee’s Mobilization Sub-committee in regard to the HARRT program. The committee was made up of seven Major Generals with command experience. After my presentation of the HARRT program, Major General Donald F. Campbell, Chairman of the Committee stated that the total committee supported the implementation of the HARRT program (attachment#12). Major General Campbell stated in his letter “As chairman of that mobilization subcommittee, I am pleased that our decision to support your program has assisted you in your commitment to pursue your goal of fully implementing the HARRT Program with all our military services, both Active and Reserve”.  

Major General Hennis, who was one of the committee members of the above mentioned panel and a commanding general for the National Guard in one of our southern states requested at the committee meeting that the HARRT program be first fully implemented for all members of the National Guard in his state. Since there was no follow-up funding from the DoD to fully implement the HARRT program, this request could not be followed up on at the time. This lack of funding and follow up from DoD was repeated on other occasions resulting in the underutilization of an admittedly viable program. In another instance, a National Guard Special Forces unit in California specifically contacted me to perform the HARRT interviews on all their members prior to deployment. Since there was no funding and orders to honor their request received from DoD, the request could not be implemented. The Special Forces commander was upset and disappointed his request could not be honored and had to deploy knowing his unit could have been better prepared to depart.  

On May 28, 1999, I was invited to visit the Department of the Army’s Office of the Surgeon General. As a result of the visit, a letter was written (attachment #2) commentating favorably on the Combat Stress Conference, the Prisoner of War Conference and the HARRT program. A comment in the letter specific to the HARRT program is a follows: “It is reasonable to expect that this program alone will directly benefit hundreds of thousands of service members and their families”. This comment was related to a then recent DOD directive 6490.5, instructing all military organizations to implement Combat Stress programs.

From 1997 and later in 1999, when the HARRT program and Combat Stress Conferences were initially supported by the above-mentioned DoD organizations at the Pentagon, there has been little follow-up by DoD to fully follow through and implement these viable Combat Stress educational and preventative programs. This lack of follow-up has predictably resulted in many hardships for military personnel as well as their families. No one knows how many suicides and homicides could have been averted if these, admit ably quality Combat Stress programs could have been fully implemented back in 1997 or 1999. Instead the DoD has supported the extensive use of psychiatric medication, which appears to have worsened the problems of combat stress, which can be readily measure by the increases in suicide and homicide in the military.

In 2005, the military command, from the Tri-Service Combat Stress Conference founding organization (6252 USAH), stated it did not have the staff or funding to continue the Tri-Service Combat Stress Conference and asked myself and other retired officers if we could continue the conference privately, with no military funding or support. This request was shocking, due the fact that the need for combat stress training was elevated since the beginning of the War on Terrorism. This lack of support for combat stress training was consistent with the lack of DoD follow-up mentioned above. This challenge to continue the training conference was taken up by a few dedicated retired officers and today the conference still continues and is now the longest running and in my mind, one of the best conferences held in the world on combat stress. It should be noted that in 1999, when I visited the DoD to discuss the conference, I suggested that the DoD take over the conference due to the important nature of the content and the fact that when I retired I was fearful the conference would not continue. I was told that I was doing a good job both verbally and in writing but that they were not interested in assuming leadership of the conference.

To date, the International Civilian and Military Combat Stress Conference have trained thousands of military and civilian personnel on how to effectively deal with combat stress related problems. It has also motivated other military and civilian groups to start their own conferences on combat stress. It is considered by many to be the gold standard of all combat stress conferences, as demonstrated by the many world-renowned military and civilian instructors and federal and state legislative people who have attended and have given presentations over the years.

(For conference history and previous instructors see www.tservcsc.bizhosting.com).

At the onset of the current War on Terrorism, many expert presenters at the Combat Stress Conference warned that military personnel should not be medicated when on the battlefields or when eventually returning home. The overall consensus of presenters, as well as people attending the conference, was that integrative treatment was the most effective way of dealing with combat stress issues. I would estimate that only 2 percent of people attending the conference advocated medicating soldiers. This 2 percent consisted primarily of psychiatrists. It should be noted that most psychiatrists are primarily trained to administer medication and generally don’t have the training to provide integrative treatment. This lack of exposure to integrative treatment can be traced back to the medical schools that train psychiatrists. An example of this was when I recently questioned, at a conference where he was a presenter, a chief psychiatrist who worked in a VA clinic. He stated at this public forum that he medicates 98 percent of the veterans he sees as patients. This is not an isolated instance based on common psychiatry practice standards.

I have personally seen military personnel as patients, who explained that they were given antidepressants on the battlefield to simply try to stop smoking. One Marine explained to me that when he returned back home, he could find no indication in his medical record that he was ever given psychiatric medication. He experienced cognitive problems from the first time he was given the medication and when he complained to the medical staff, he was given even more psychiatric medication. It wasn’t until he, on his own, took himself off the medication after two years that he returned to normal functioning. This Marine was interviewed by me and California Assemblyperson Mary Salas’ (Chair of Assembly Veterans Committee) chief of staff, Francisco Estrada, to evaluate veteran’s services in California. This is not an isolated case since I have encountered many military personnel with the same experiences. The use of the psychiatric medications is prevalent on the battlefield, where it is being dispensed not only by medical doctors but also by physician’s assistants, medics, soldier to soldier, etc.

SUMMARY AND RECOMMENDATIONS:

Since the War on Terrorism began, there has been a steady increase in suicide and homicide in the military. There has also been a steady increase in the number of psychiatric medications purchased by DoD and prescribed to military personnel and their families. Research and the FDA (black box warning) have revealed that there is a direct relationship between the use of psychiatric medication and suicide. The black box warnings on the actual medication label also describe the link between the medication and suicide, as well as other cognitive effects, which can also trigger homicidal behavior.

There have been integrative treatment training programs, as well as actual treatment protocols, available since the end of the first Persian Gulf War that have been effective in treating and identifying residual effects of combat stress i.e. the Human Assistance Rapid Response Team (HARRT), Tri-Service Combat Stress Conference. These programs have been underutilized and under funded in favor of wide spread use of psychiatric medications with the result being increases in military suicide and homicide.     

A solution to the on going and increasing problems with suicide and homicide is not more medication but more integrative treatment programs administered by trained mental health providers, as well as military leadership personnel.

The full implementation of the HARRT program as a readiness tool, as well as its use as an instrument to identify potential suicide and homicide ideation is advisable. The HARRT program was recognized by DoD personnel as a valuable tool, as far back as 1997 and 1999, with recommendations at that time to fully implement the program.

Also DoD should recognize that all military personnel in combat experience Post Traumatic Stress (PTS)–notice there is not a “D” at the end. PTS for military personnel is a normal reaction to being in an abnormal environment, the battlefield. PTS becomes a disorder (D) when the soldier (term referring to individuals in all military organizations), does not learn ways of dealing with the PTS and how to normalizing themselves. If this normalization process does not occur, then the soldier can develop a disorder and the PTS can become Post Traumatic Stress Disorder (PTSD).  

It is critical that the DoD become aware of the difference between PTS and PTSD. If DoD can recognize that psychiatric medication has not been effective in treating combat stress, than a natural conclusion would be to turn their focus and finances to methods that have been approved and worked in the past to various degrees and expanding these programs.

One program that should be strongly considered for implementation by DoD should be a mandatory one (1) hour a day program for thirty (30) days for all military personnel returning from combat zones. This mandatory one hour a day, of structured mental training (MT), administered by trained staff, using a military wide standardized approach, will help all returning soldiers realize that they are having normal reactions from being in an abnormal battlefield environment. By learning methods of dealing with abnormal experiences and developing coping approaches through integrative treatment methods, they can return to normal functioning. There will no longer be a need for soldiers to hide what they are experiencing since all individuals, by attending mandatory MT programs, will realize that they are all human beings, in a similar situation, subjected to the same stresses and similar experiences.

Cutting back on the extensive use of psychiatric medication and implementing integrative programs such as the HARRT program, MT programs and similar programs throughout the military, could lead to strong expectations for significant decreases in PTSD, suicide and homicide in the military. This decrease would result in more soldiers being available for deployment, reduction in family and personal hardships and a reduction in psychiatric disability monies being spent, while in the military as well as when the soldier returns to civilian life after discharge.