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November 10, 2019 by Robert Whitaker & Derek Blumke | MadInAmerica.com

Screening + Drug Treatment = Increase in Veteran Suicides

The alarm over suicides of military veterans has been regularly sounded over the past 15 years, prompting the U.S. Department of Veterans Affairs to declare that “preventing suicide among Veterans is the VA’s top clinical priority.” The VA’s 2019 report on suicide provides reason to sound the alarm again, for it tells of a suicide rate that has continued to climb, particularly for younger veterans who have served since 9/11.

Indeed, a close review of VA data provides reason to conclude that the rise in suicide is being driven, at least in part, by the VA’s suicide prevention efforts. Its screening protocols have ushered an ever greater number of veterans into psychiatric care, where treatment with antidepressants and other psychiatric drugs is regularly prescribed. Suicide rates have increased in lockstep with the increased exposure among veterans to such medications.

According to the 2019 report, the age-adjusted suicide rates for all veterans rose from 25.5 per 100,000 population in 2005 to 35.8 per 100,000 in 2015, a 40% increase.1 The rate for veterans using Veterans Health Administration (VHA) facilities rose from 29.6 per 100,000 in 2005 to 40.1 in 2017, a 35% increase.

The increase in suicide was even more pronounced for veterans 18 to 34 years old. The suicide rate for this group increased from 25.3 per 100,000 in 2005 to 44 per 100,000 in 2017, a 74% increase. For this age group using VHA facilities, the suicide rate rose from 20.9 per 100,000 in 2005 to 51 per 100,000 in 2017, a 144% increase.

In a previous MIA Report, we made the case that “suicide prevention efforts,” which are based on the premise that suicide is a “public health” problem that can best be addressed by getting more people diagnosed and into treatment, have fueled a steady rise in suicide rates in the United States since 2000. An investigation into the rise in suicide among veterans can be seen as a “replication” study. In the VA’s data, is it possible to identify the same treatment-related forces at work?

There is, buried in the VA’s 2016 suicide report, data on the suicide rates for treated and untreated patients that make this a question of particular urgency.

Suicide in the Civilian Population

The initiation of suicide prevention efforts in the United States began in the late 1980s, shortly after Prozac—the first “selective serotonin reuptake inhibitor” antidepressant—came to market. The American Foundation for Suicide Prevention was established then, and although it promoted a “public health” message, it was a non-profit that was funded, to a significant extent, by pharmaceutical companies, which understood that a “suicide prevention” campaign would boost sales of their drugs. Academic psychiatrists with financial ties to the makers of antidepressants led its scientific advisory board and served terms as directors of the foundation.

The American Foundation for Suicide Prevention promoted a very simple message to the American public. Suicide was said to be a “public health” problem that was “under-recognized.” Many people with mood disorders went “untreated” and this was the population at particularly high risk of suicide. People who were feeling depressed or suicidal were urged to seek help from mental health professionals. The Foundation pushed screening programs as a way to get more people into treatment. Its advisory board and presidents touted antidepressants as “anti-suicide” pills.

“Use of antidepressants to treat major depressive episode is the single most effective suicide prevention measure in Western Countries,” said Columbia University psychiatrist John Mann, who had long been a fixture on the Foundation’s scientific advisory board, and served for a time as its president.

The American Psychiatric Association, the National Alliance on Mental Illness, and the pharmaceutical companies that sold antidepressants all helped promote this message to the public. In 1997, their efforts prompted both houses of Congress to declare suicide a “national problem.” Two years later, U.S. Surgeon General David Satcher issued a “Call to Action to Prevent Suicide,” and the U.S. Department of Health and Human Services formed a task force, composed of individuals and organizations from the private and public sectors, to develop a “National Strategy for Suicide Prevention.” The task force published its recommendations in 2001, which doubled-down on the “public health” approach that had been promoted by the American Foundation for Suicide Prevention.

Government agencies at all levels—federal, state, and local—launched suicide prevention efforts. Crisis call centers were established; depression screening programs were initiated; checklists for assessing the risk of suicide in depressed patients were developed; and medical professionals were trained to recognize the “warning signs” of suicide. The goal was to get more people struggling with mood disorders into treatment, with antidepressants recommended as a first-line therapy.

These efforts have been successful in that regard: the prescribing of antidepressants has increased steadily since 2000. Yet, since 2000, the age-adjusted suicide rate for the American population, rather than decrease, has risen steadily, from 10.4 per 100,000 to 14.0 per 100,000 in 2017.

The failure of this approach to suicide prevention, which emphasizes getting people into treatment, is not a uniquely American phenomenon. In the 1990s, the World Health Organization urged countries around the world to develop national mental health policies and to improve their mental health services, which included providing their citizens with better access to psychiatric medications. The belief was that this would lead to better mental health outcomes, which would become visible in the form of reduced suicide rates.

Researchers from the UKDenmark and Australia have now conducted three studies of whether such efforts have affected suicide rates, and all came to the same conclusion: improved access to psychiatric services and psychiatric drugs was associated with an increase in national suicide rates.

In a similar vein, a large Danish study of suicides in Denmark from 1996 to 2009 came to the disturbing conclusion that the risk of suicide escalated dramatically upon entry into psychiatric care. They found that, in comparison to a matched control group who hadn’t had any involvement with psychiatric care during the previous year, the risk of suicide was:

  • 5.8 times higher for people receiving psychiatric medication (but no other care)
  • 8.2 times higher for people having outpatient contact with a mental health professional
  • 27.9 times higher for people having contact with a psychiatric emergency room
  • 44.3 times higher for people admitted to a psychiatric hospital

Although it could be expected that the suicide risk would increase for each step up the “treatment” ladder, what surprised the researchers was that it occurred even in those who were married, and in those with higher incomes or higher levels of education and no prior history of attempted suicide.

In an accompanying editorial, two Australian experts in suicide research wrote that the findings “raise the disturbing possibility that psychiatric care might, at least in part, cause suicide.”

The Impact of Antidepressants

Although the promoters of suicide prevention programs have touted antidepressants as a treatment that reduces the risk of suicide, evidence that the drugs might have the opposite effect arose in the first clinical trials of Prozac. A significant percentage of patients given Prozac suddenly developed suicidal thoughts, and after Prozac came to market, there were numerous case reports of patients prescribed the drug committing suicide. By the early 1990s, with Paxil and other SSRIs entering the marketplace, the FDA was forced to convene a public hearing on this concern.

The controversy has circulated within research circles—and in the public mind—ever since.

There is clear evidence that SSRIs and SNRI antidepressants can provoke suicidal impulses and acts in some users, and the reason is well known. SSRIs and other antidepressants can stir extreme restlessness, agitation, insomnia, severe anxiety, mania and psychotic episodes. The agitation and anxiety, which is clinically described as akathisia, may reach “unbearable” levels, and akathisia is known to be associated with suicide and acts of violence, including homicide.

At the same time, there are many people who tell of how SSRIs or some other antidepressant saved their lives, as their suicidal impulses waned after going on the drugs. Individual responses to antidepressants may vary greatly, and so the public health question is about the net effect of these drugs on suicide rates. On the whole, do they increase or decrease the risk of suicide in people so treated?

There are several types of studies that provide an “evidence base” for answering that question.

Randomized Clinical Trials (RCTs) 

RCTs are seen as the “gold standard” for assessing the merits of a drug treatment, at least over the short term, as the trials typically last only six weeks or so. Thus, the trials might be expected to identify whether SSRI and SNRI antidepressants trigger any increase in suicidal behavior when patients are first put on the medication.

The FDA, in its review of industry-funded RCTs of SSRIs and other antidepressants, concluded that these drugs increase the risk of suicidal thinking for those under 25 years old; have a neutral effect on those 25 to 64 years old; and are protective against suicidal thinking for those over 64.

However, it is well known that the pharmaceutical companies sought to downplay—or hide—suicidal risks in the trial reports they sent to the FDA. In 2003, UK psychiatrist David Healy and a team of Canadian researchers conducted an exhaustive meta-analysis of all RCTs of SSRIs, which incorporated findings from trials that weren’t funded by pharmaceutical companies, and they found that suicide attempts were 2.28 times higher for those treated with an SSRI compared to placebo.

Two recent analyses of clinical trial data have led to similar findings. First, after reviewing 64,381 pages of clinical study reports filed with the European Medicines Agency, Peter Gøtzsche and colleagues concluded that antidepressants doubled the risk that patients would experience akathisia, a known risk factor for suicide.

Second, European researchers Michael Hengartner and Martin Plöderl conducted an exhaustive review of the trial data submitted to the FDA for all antidepressants approved from 1991 to 2013, a database that numbered more than 40,000 patients, and they determined that suicide attempts were 2.5 times higher for those taking antidepressants compared to placebo.

Observational Studies in Primary-Care Patients

During the past 25 years, there have been hundreds of studies of different types—observational studies, epidemiological studies, and so forth—that have sought to assess whether antidepressants are protective against suicide, or conversely increase suicide rates. Those studies have produced a welter of conflicting findings. However, the studies that are of most relevance to suicide prevention efforts are those that look at patients diagnosed with depression in a primary care setting, and then chart suicide rates for those who take an antidepressant and those who avoid doing so.

That initial choice serves as a fork-in-the road moment, the patients heading down either a medicated path or a non-medicated one. There are at least three studies that provide a comparison of suicide rates for these two paths following a diagnosis of depression in primary care.

  • In a 1998 study of 35,436 people in the Puget Sound area of Washington, the risk of suicide was 43 per 100,000 person years for those treated with an antidepressant in primary care, compared to zero per 100,000 person years for those treated in primary care without antidepressants.
  • In a 2003 analysis of UK patients treated in primary care for depression (or for other “affective disorder”), Healy and Chris Whitaker concluded that the suicide rate for those taking an SSRI was 3.4 times greater than for those who chose “non-treatment.”
  • In a study of 238,963 UK patients who experienced a first episode of depression between 2000 and 2011, researchers reported that there was an increased risk of suicide for those treated with SSRI antidepressants during the first month of treatment, and again in the first month after quitting the drug.

This last study reveals why observational studies that simply assess medication use at the time of a suicide may present skewed results. The high-risk period that occurs when someone is withdrawing from an SSRI antidepressant is a risk that comes from going on the drug in the first place, yet, in most observational studies, the suicide is chalked up to the “off medication” column.

There are other classes of drugs that may contribute to an increased suicide risk, most notably benzodiazepines. Polypharmacy does so as well. The focus on antidepressants is because this class of drugs is regularly touted, in suicide prevention programs, as protective against suicide.

Suicide Prevention at the VA

The VA launched a focused suicide prevention effort in 2006, when it appointed a National Suicide Prevention Coordinator. The following year it established a toll-free Veterans Crisis line, and since then it has steadily increased the resources devoted to this effort. One such effort was its Make the Connection campaign, which spent nearly $20 million to market the VHA’s services to veterans.

Like the federal government, the VA conceives of “suicide” as a “public health” problem, and thus its bottom-line goal is to increase the identification of mental health problems in the veteran community, and get those who are given a mental health diagnosis into treatment, which is expected to reduce the suicide risk.

About two-thirds of the 20 million veterans in the United States do not use Veterans Health Administration (VHA) facilities, and the VA, since it launched its toll-free crisis line in 2007, has regularly conducted mental health awareness campaigns to encourage veterans who are not users of VHA care to seek medical help for such problems. In 2018, it partnered with a pharmaceutical company, Johnson & Johnson, to promote a No Veteran Left Behind campaign, which featured Tom Hanks and urged “each and very American” to reach out to veterans in crisis and help get them “mental health services.” The communications plan, the VA stated, was “led by Johnson & Johnson.”

Within its own VHA facilities, the VA has introduced mandatory screening for all vets. Every vet entering the system is screened for depression, PTSD, and substance abuse, and all those who are diagnosed with a psychiatric disorder are assessed for “suicidal intent.” Such screening continues to be a regular feature of VHA care, as screening of some type is part of every patient appointment. Every vet is screened annually for depression, and all of those diagnosed with PTSD upon entry into VHA care are rescreened for this disorder for the next five years.

With this regular screening in place, the percentage of VHA patients with a mental health diagnosis has increased steadily. In 2014, 41% of VHA-using veterans had a mental health or substance abuse diagnosis (SUD), with depression the most common diagnosis.2 Although the VA’s most recent suicide reports haven’t detailed this diagnostic information, it can be safely assumed that this steady increase in diagnosis has continued, and that perhaps 44% of VHA-using veterans had a mental health/SUD diagnosis in 2017.

Treatment in the VA

The VA’s clinical care guidelines for treating depression and PTSD, which are the two most commonly diagnosed psychiatric disorders, recommend SSRI and SNRI antidepressants as first-line therapies. However, the guidelines also provide recommendations for CBT and other psychotherapies, and particularly in primary care settings, these treatments may be offered as stand-alone therapies.

Even so, the prescribing of antidepressants to those diagnosed with depression or PTSD is routine. According to a 2015 report by the U.S. General Accounting Office (GAO), 94% of all VHA patients diagnosed with depression from 2009 to 2013 were prescribed an antidepressant. Studies of VHA patients diagnosed with PTSD have reported that about 80% are prescribed a psychiatric medication, with antidepressants the drug class of choice.

2019 GAO report that sampled prescribing practices at a small number of VHA facilities found that only 15% of diagnosed patients were offered psychotherapy in lieu of drug treatment. Forty-four percent were offered a combination of both, and the remaining 41% drug treatment only.3

Polypharmacy is also common in VA settings, particularly since half of those diagnosed are said to be co-morbid for two or more mental disorders. The 2019 GAO report found that among those diagnosed with depression who were treated in “primary care and specialty mental health care” settings, 35% percent were taking two classes of psychiatric drugs, and 15% three classes of drugs. The polypharmacy was even more pronounced for those diagnosed with PTSD: 36% were taking two classes of psychiatric drugs and 25% were taking three or more classes.4

Suicide Rates For VHA Patients

As noted above, the suicide rate among veterans has been steadily rising since 2005. The VA, in a 2016 report, divided the VHA-using patients into four subgroups:5

  • Undiagnosed and untreated (for a mental health or substance abuse disorder)
  • Undiagnosed and treated (with either a psychiatric drug or non-pharmacologic treatment)
  • Diagnosed and untreated
  • Diagnosed and treated

If antidepressants are effective in reducing suicide risk, it is easy to see how the suicide rate for the four groups should stack up.

Given that the VHA regularly screens for mental health disorders, the “undiagnosed” patients apparently do not show the symptoms of depression, PTSD or any other psychiatric disorder that, during the screening process, would generate a diagnosis. These patients should be at a low risk of suicide, and thus any treatment to patients in this “undiagnosed” category should—at least in theory—further reduce this risk since it is being prescribed as a balm for whatever ailment is bothering the patients. As such, the undiagnosed/treated patients could be expected to have a lower suicide rate than the undiagnosed/untreated group.

The “diagnosed” patients should be at a higher risk of suicide. Suicide prevention efforts focus on getting these patients into treatment, with antidepressants seen as a first-line therapy than can lower the risk of suicide. Thus, if suicide prevention efforts are helpful, the suicide rate for the diagnosed patients who are treated should be lower than for diagnosed patients who, for whatever reason, shun treatment. The 2019 GAO report found that 18% of diagnosed patients did not get treatment.

Here are the results.

First, those without a diagnosis who got MH treatment were more likely to die by suicide than those without a diagnosis who did not access such treatment. In 2014, those who got treatment died at twice the rate of the “untreated” group.

Second, those with a mental health or substance abuse diagnosis who got mental health treatment were roughly twice as likely to die by suicide than those who had a diagnosis but did not access mental health treatment.

This difference in suicide rates for the treated and untreated groups is consistent over time, year after year. Moreover, these findings are based on the VA’s review of millions of patient records. The VA published them in a 2016 report that it touted as the “most comprehensive analysis of Veteran suicide in our nation’s history.”

There is a third comparison that can be made that leads to a particularly troubling finding. It could be expected that in any comparison between the less severely ill (the undiagnosed) and the more severely ill (the diagnosed), the less severely ill group would have a lower suicide rate, regardless of any treatment effect. Yet, from 2010 to 2014, those without a diagnosis who got MH treatment were more likely to die by suicide than those with a diagnosis who were “untreated.”

In sum, the data for the four subgroups tells of a suicide risk in 2014 that increased in this steplike fashion:

Undiagnosed/untreated: 24.8 per 100,000
Diagnosed/untreated:  34.4 per 100,000
Undiagnosed/treated : 47.6 per 100,000
Diagnosed/treated: 68.2 per 100,000

This is a finding that runs directly counter to the variable suicide rates that would be expected if “treatment” for a mental health condition were effective. However, it is a finding consistent with RCT data showing that antidepressants double the risk of suicide compared to placebo. In the comparison for “diagnosed” patients, that is precisely the increase seen in the treated group.

The Perils of Diagnosis 

The suicide rates for those diagnosed with a mental health or substance abuse diagnosis have remained stable since 2005. Year after year they have hovered around 70 per 100,000 population. The reason that the suicide rates for VHA patients have been rising is that the VA’s suicide prevention efforts—the outreach campaigns and the mandatory screening—have led to a steady increase in the number of veterans diagnosed and treated for those disorders, and as the VA’s subgroup data shows, this moves patients into a category that has the highest suicide rate.

This gets to the mathematical heart of why the VA suicide prevention efforts have failed. The effort is based on the premise that screening will get patients into treatment that will lower their suicide risk, thus lowering the overall suicide rates. But the subgroup data shows that treatment is elevating the risk of suicide, which leads to this tragic equation: screening + drug treatment = increase in veteran suicides.

The rise in suicide among younger veterans reveals, with great clarity, the perils of screening that leads to treatment with psychiatric drugs.

The VA, as part of its suicide prevention strategy, has sought to bring younger veterans newly discharged from the military into VHA care so that an initial screening for depression, PTSD, and other psychiatric disorders can be done, and their suicide risk assessed. There were 1.2 million veterans who entered VHA care from 2002 to 2015, and 58% of those veterans were given a psychiatric diagnosis.

With this screening protocol and outreach in place, the number of 18-to-34-year-old veterans who received VHA care grew rapidly from 2005 to 2017, from 344,938 to 687,936. Given that 58% of veterans entering care during this period were given a psychiatric diagnosis, it is reasonable to conclude that a high percentage of this population were prescribed antidepressants and other psychiatric medications, which means they were ushered into the “diagnosed and treated” subgroup with the highest risk of suicide.

The suicide numbers tell the tragic result. The suicide rate for VHA-using veterans 18-to-34-years-old rose from 20.9 per 100,000 in 2005 to 51 per 100,000 in 2017, a 144% increase. Moreover, because the number of VHA patients in this age category grew as well, the total number of suicides by younger veterans in VHA care jumped from 68 in 2005 to 351 in 2017, a five-fold increase.

Veteran Suicides Outside VHA Care

The VHA is understood to provide care to veterans with greater social and medical difficulties than those veterans who receive care outside the VHA. Yet, in non-VHA settings there are similar pressures to screen for depression and prescribe antidepressants to those who are so diagnosed.

If such pressures are driving up suicide rates for VHA-using veterans, then it could be expected that they would do so in general medical settings as well. The VA’s 2019 report documents that this is so. The suicide rate for all non-VHA using veterans rose from 24.3 per 100,000 in 2005, to 33.9 per 100,000 in 2017, a 40% increase.

And just like in the case of young VHA-using veterans, the increase in the suicide rate among veterans ages 18 to 34 has been particularly pronounced in non-VHA settings, rising from 26.2 per 100,000 in 2005 to 41.1 per 100,000 in 2017, a 57% increase.

There is one other noteworthy element in this last comparison of suicide rates in the two settings. At the start of the VA’s suicide prevention efforts, the suicide rate was lower in VHA settings than in non-VHA settings for the 18-34 age group. Yet, since 2005, the increase in the suicide rate for young veterans in VHA facilities, where screening is imposed with a military rigor, has been much greater than in non-VHA settings. In 2017, the rate was 24% higher for VHA-using young veterans. This may be one more data point telling of the harm done from the VA’s suicide prevention efforts.

The Puzzle Pieces Fit Together

The rising suicide rate among veterans since 2005, which is when the VA launched its focused suicide prevention efforts, simply serves as a starting point for an investigation: is there evidence that could explain why such efforts would drive suicide rates upwards?

In this case, there is evidence of many types that fit together into a coherent whole. Specifically:

  • Efforts to improve mental health programs and increase access to psychiatric drugs in global settings have led to increased suicide rates.
  • RCTs have found that antidepressants increase the risk of suicide.
  • Observational studies of depressed patients treated in primary care have found that those who take antidepressants have a higher rate of suicide during follow-up periods
  • The VA reports tell of an increasing number of veterans exposed to antidepressants and other psychiatric drugs.
  • In the VA’s subgroup findings, treated patients in both the diagnosed and undiagnosed comparisons have much higher suicide rates than the untreated patients.
  • In the VA’s subgroup findings, from 2010 forward, treated patients without a diagnosis had a higher suicide rate than untreated patients with a diagnosis.

As can be seen, there is in this review a collection of evidence that tells of psychiatric treatment that increases the risk of suicide, with the RCT data for antidepressants at the center of this “evidence base.” The VA’s suicide reports tell of an increasing number of veterans diagnosed and treated with antidepressants, which could be expected to produce a rising suicide rate, and that is precisely what has occurred since 2005, when the VA initiated its focused suicide prevention efforts.

The VA’s Explanations for the Rising Suicide Rates

The VA reports tell of how suicide rates have risen for all veterans, both for those who use VHA care and those who do not. The VA offers several explanations for this rise in suicide in both settings.

First, it notes that this rise has occurred against a backdrop of rising suicide rates in the general public, and thus is not limited to the VA. Second, the VA explains that the suicide rate is higher for VHA-using veterans because, as a group, they suffer from a broader range of ills than the non-VHA-using veterans, such as physical illness, combat injuries, fewer financial resources, and homelessness. Third, the reports cite research comparing the two medical systems that found that “engagement in VHA mental services was associated with decreased rates of suicidal ideation and suicide attempts.”

All of that may be true. But none of these explanations address the basic question investigated in this MIA Report: Do suicide prevention efforts that focus on screening for depression and other mental health disorders, with those so diagnosed then regularly treated with antidepressants, increase suicide rates?

If so, they could be expected to increase the suicide rate in the general public, in veterans that use non-VHA medical facilities, and in VHA-using veterans. And that is precisely what has occurred since suicide prevention efforts have been introduced into general medical settings, and into VHA care.

Harm Done 

There have been more than 70,000 suicides by veterans since 2006, when the VA launched its suicide prevention efforts. It is impossible to calculate the extent of the harm done that is evident in this review of the rising suicide rates in this community of 20 million veterans. However, it is easy to conclude that if suicide rates had remained stable at the rate they were in 2006, there would have been 10,000 to 15,000 fewer suicides among our veterans.

That is a number greater than the total of all combat deaths since 9/11.

All of this begs for further investigation by the U.S. Department of Veterans Affairs.

Footnotes

  1. See the National Data Appendix to the 2019 National Veteran Suicide Prevention Annual Report, which can be found here
  2. See figure 2, page 8 of VA report, “Suicide Among Veterans and Other Americans 
  3. See table 5 of 2019 GAO Report, “VHA Improved Certain Prescribing Practices, but Needs to Strengthen Treatment Plan Oversight.” 
  4. See figure 6 of  2019 GAO report. The polypharmacy statistics cited here are for veterans treated in “primary cafe and specialty mental health care.” 
  5. See table 1, page 11 of VA Report, “Suicide Among Veterans and Other Americans.” 

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