Army warns doctors against using certain drugs in PTSD treatment

The Army Surgeon General's office is backing away from its long-standing endorsement of prescribing troops multiple highly addictive psychotropic drugs for the treatment of post-traumatic stress disorder and early this month warned regional medical commanders against using tranquilizers such as Xanax and Valium to treat PTSD.

An April 10 policy memo that the Army Medical Command released regarding the diagnosis and treatment of PTSD said a class of drugs known as benzodiazepines, which include Xanax and Valium, could intensify rather than reduce combat stress symptoms and lead to addiction.

The memo, signed by Herbert Coley, civilian chief of staff of the Army Medical Command, also cautioned service clinicians against prescribing second-generation antipsychotic drugs , such as Seroquel and Risperidone, to combat PTSD. The drugs originally were developed to treat severe mental conditions such as schizophrenia and bipolar disorder. The memo questioned the efficacy of this drug class in PTSD treatment and cautioned against their use due to potential long-term health effects, which include heart disorders, muscle spasms and weight gain.

Throughout more than a decade of war in Afghanistan and Iraq, the military services have relied heavily on prescription drugs to help troops deal with their mental health problems during and after deployment. In a June 2010 report, the Defense Department's Pharmacoeconomic Center said 213,972, or 20 percent of the 1.1 million active-duty troops surveyed, were taking some form of psychotropic drug -- antidepressants, antipsychotics, sedative hypnotics or other controlled substances.

The Army, in a July 2010 report on suicide prevention, said one-third of all active-duty military suicides involved prescription drugs.

Mental health experts say the military's prescription drug problem is exacerbated by a U.S. Central Command policy that dates to October 2001 and provides deploying troops with up to a 180-day supply of prescription drugs under its Central Nervous System formulary.

That formulary includes Xanax, Valium and three other benzodiazepines to treat anxiety: Ativan, Klonopin and Restoril.

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The Army's new PTSD policy makes it clear that the risk of treating combat stress with benzodiazepines outweighs the rewards: "Benzodiazepine use should be considered relatively contraindicated in combat veterans with PTSD because of the high co-morbidity of combat-related PTSD with alcohol misuse and substance use disorders (up to 50 percent co-morbidity) and potential problems with tolerance and dependence."

After becoming dependent on these drugs, soldiers face enormous problems when they try to discontinue their use, the report said. "Once initiated in combat veterans, benzodiazepines can be very difficult, if not impossible to discontinue, due to significant withdrawal symptoms compounded by underlying PTSD symptoms," the document said.

The Army policy memo highlighting problems with benzodiazepines for PTSD treatment dovetails with a study published in the April issue of Current Psychiatry Online by Jolene Bostwick, clinical assistant professor of pharmacy at the University of Michigan College of Pharmacy.

Bostwick wrote "benzodiazepine administration fails to prevent PTSD and may increase its incidence." She added, "use of benzodiazepines for PTSD is associated with withdrawal symptoms, more severe symptoms after discontinuation and possible disinhibition, and may interfere with patients' efforts to integrate trauma experiences."

Army clinicians who prescribe Risperidone, Seroquel and other second-generation antipsychotic drugs "must clearly document their rationale concluding that the potential benefits outweigh the known risks and that informed consent has been conducted," the policy memo said.

Seroquel has been implicated in the deaths of combat veterans and the Veterans Affairs Department reported in August 2011 that Risperidone was no more effective in PTSD treatment than a placebo. VA spent $717 million on the drug over the past decade. The military has spent $74 million over the past 10 years on Risperidone, a spokeswoman for the Defense Logistics Agency said.

An Army doctor who declined to be identified told Nextgov "these long-overdue policy changes are welcome, but they will further shift the mental health care of soldiers to an already overstressed VA and will result in the separation of many mentally stressed volunteers, who just months earlier had been counseled to steel themselves for a career of perpetual deployment and had been willing to sacrifice the best years of their lives to do so."

This long-serving Army clinician said, "the nation needs to take a long, hard look at what delayed the institution of these policies, and why the priorities of our Army medical leaders have too often favored the manpower needs of the Army rather than the mental health of its soldiers."

Dr. Grace Jackson, a former Navy psychiatrist who resigned her commission in 2002 "because I did not want to be a pill pusher" said the new Army policy shows "they are finally admitting to some problems associated with at least one class of psychiatric medication." But, Jackson said, the Army policy does not address problems with other classes of prescription drugs, including antidepressants and selective serotonin re-uptake inhibitors (SSRIs), such as Prozac, in the treatment of PTSD. Clinical studies, Jackson said, have shown these drugs to be no better than placebos -- but far more dangerous in the treatment of PTSD.

The Army also has ignored the role antipsychotic drugs play in the "sudden deaths" of troops diagnosed with traumatic brain injury due to undiagnosed endocrine abnormalities Jackson said.

The use of antipsychotic drugs to treat troops with TBI can cause changes in growth and thyroid hormones, which can in turn trigger a variety of cardiac-related events that could result in sudden deaths, Jackson said.

Though the Army has adopted a new policy on the use of benzodiazepines, Jackson said the Defense Department overall is still wedded to a policy of using drugs to treat metal problems even when scientific evidence "demonstrates poor risk-benefit ratios."

The Army policy memo encouraged clinicians to look beyond drugs to treat PTSD and suggested a range of alternative therapies, including yoga, biofeedback, acupuncture and massage.