Saturday, March 26, 2011

Pharmacological Misinformation Foisted on Unsuspecting Public

An article from January is making the rounds again. One in nextgov's exposé-like series on America's Broken Warriors, it highlighted the fact that 20% of U.S. active duty troops are on psychotropic medications. While this may not be a good thing, the article was filled with erroneous information about specific psych meds and general scare-mongering from antipsychiatry "experts" pitching their books. Let's take a look.
Military's drug policy threatens troops' health, doctors say

By Bob Brewin 01/18/2011

Army leaders are increasingly concerned about the growing use and abuse of prescription drugs by soldiers, but a Nextgov investigation shows a U.S. Central Command policy that allows troops a 90- or 180-day supply of highly addictive psychotropic drugs before they deploy to combat contributes to the problem.

The CENTCOM Central Nervous System Drug formulary includes drugs like Valium and Xanax, used to treat depression, as well as the antipsychotic Seroquel, originally developed to treat schizophrenia, bipolar disorders, mania and depression.
1. Valium (diazepam) and Xanax (alprazolam) are not used to treat depression. These sedative-hypnotic benzodiazepine medications are primarily used to treat anxiety disorders.

2. The atypical antipsychotic Seroquel (quetiapine) was originally developed to treat schizophrenia, although now it is prescribed for bipolar disorder and major depression. Off-label usage of quetiapine, including as a sleep aid, is controversial and I won't be discussing it further here. That topic could easily take up several posts of its own.

The article continues:
A June 2010 internal report from the Defense Department's Pharmacoeconomic Center at Fort Sam Houston in San Antonio showed that 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.

Dr. Grace Jackson, a former Navy psychiatrist, told Nextgov she resigned her commission in 2002 "out of conscience, because I did not want to be a pill pusher." She believes psychotropic drugs have so many inherent dangers that "the CENTCOM CNS formulary is destroying the force," she said.
Here we see Dr. Jackson's antipsychiatry agenda first established. All psych drugs are bad. Also note that Dr. Jackson resigned in 2002, before the war in Iraq began on March 20, 2003. So she doesn't have first hand experience with current prescribing practices or the effects of these medications on troops in Iraq and Afghanistan, which is what the article is about.

We also have quotes from one of the leading antipsychiatry advocates, Dr. Peter Breggin:
Dr. Peter Breggin, an Ithaca, N.Y., psychiatrist who testified before a House Veterans Affairs Committee last September on the relationship between medication and veterans' suicides, said flatly, "You should not send troops into combat on psychotropic drugs." Medications on the CENTCOM CNS formulary can cause loss of judgment and self-control and could result in increased violence and suicidal impulses, Breggin said.
Dr. Breggin's credibility as an expert witness has been repeatedly questioned, however. I agree that mentally ill troops should not be sent into combat, but will also point out that untreated and unmedicated psychiatric disorders in a war zone can cause increases in violence and suicidal behavior.

Back to Dr. Jackson:
Jackson, the former Navy psychiatrist, now has a civilian practice in Greensboro, N.C. She said at least one drug on the CENTCOM formulary -- Depakote, an anticonvulsant, which military doctors prescribe for mood control -- carries serious physical risks for troops.
Really? Depakote (valproic acid) is an antiseizure medication also used to treat bipolar disorder. I would like to see statistics on how frequently it's prescribed for "mood control" in soldiers without bipolar disorder.1
Depakote is toxic to certain cells, including hair cells in the ears, and can lead to hearing loss. Troops in a howitzer battery who already run the risk of hearing loss should not take Depakote, she said.
3. Depakote is certainly not without its adverse effects, but hearing loss is an extremely rare side effect.2 In a study of 21 patients taking valproic acid (VPA) to control seizures, there were no differences in hearing thresholds between 125 and 16,000 Hz compared to age- and sex-matched controls (Incecik et al., 2007). In addition, there was no relationship between duration or dosage of drug and hearing levels.
The medication also can cause what she calls "cognitive toxicity," also known as Depakote dementia, impairing a person's ability to think and make decisions. Jackson said that while Depakote has been investigated as an adjunct therapy for cancer, its use has been limited due to the drug's effects on cognition.
4. Contrary to the notion of "Depakote dementia", VPA has been recognized for its potential to treat Alzheimer's disease (Nalivaeva et al., 2009; Zhang et al., 2010). VPA is a histone deacetylase (HDAC) inhibitor that might be able to prevent amyloid-beta aggregation in Alzheimer's disease by increasing the expression of clusterin, or apolipoprotein J (Nuutinen et al., 2010). This would in turn prevent the accumulation of amyloid plaques, a pathological feature in the brains of those with Alzheimer's.

While it's possible that VPA could produce impairments in some cognitive domains, proper studies are difficult because you have to control for the length of illness in untreated patients (since cognitive deficits can be caused by the disorder itself). One such report on currently medicated (n=33) and currently unmedicated (n=32) participants with bipolar depression failed to find group differences in visual memory and sustained attention (Holmes et al., 2008). Unfortunately, this study collapsed across participants on lithium and valproic acid. Further, the groups weren't matched on age, sex, and depression scores. Finally, the medicated individuals were more depressed, which might be expected to worsen performance on its own.

A double-blind cross-over design in healthy controls administered a relatively high dose of VPA for two weeks (800 mg the first week, 1,000 mg the second). There were no changes in memory, concentration, perceptual speed, motor speed, and subjective ratings relative to placebo (Trimble & Thompson, 1981). The drug did, however, slow response times in a category decision task. A review of the literature on cognition and anticonvulsants concluded: "Overall, deficits are subtle, especially in the therapeutic range" for valproic acid (Goldberg & Burdick, 2001). Not exactly a ringing endorsement for cognitive toxicity and Depakote dementia.

On to the next drug:
The antidepressant Wellbutrin, also on the CENTCOM formulary, likely poses a long-term risk of Parkinson's disease, especially for older troops, said Jackson, author of Drug-Induced Dementia: A Perfect Crime (AuthorHouse, 2009).
5. I found no published, peer-reviewed evidence that the antidepressant Wellbutrin (bupropion) increases the long-term risk of developing Parkinson's disease. [Guess we'll have to buy her book to find out why she said that.] Bupropion is a norepinephrine-dopamine reuptake inhibitor, unlike the better known selective serotonin reuptake inhibitors (SSRIs). A few reports have actually recommended buproprion for treating depression, panic disorder, and compulsive behaviors in patients with Parkinson's disease (Benincasa et al., 2010; Gebhardt et al., 2008; Załuska & Dyduch, 2011), although the lack of double-blind placebo-controlled studies was acknowledged.

I did find a few case reports that bupropion can induce a parkinsonian-like condition within a week or two, especially in elderly patients, that abates upon discontinuation (Szuba et al., 1992; Cheng et al., 2009). This is not the same thing as increasing long-term risk for Parkinson's in "older troops" given the drug.

I think I'll stop for now. The rest of the article covers the addiction potential of alprazolam (well-supported by the literature), the dangers of quetiapine (an issue not discussed here), and an unsupported statement from Jackson that "Seroquel has the addictive potential of opioids, such heroin."

Although these psychotropic medications are not without their risks and adverse side-effects, neither are they a societal evil capable of producing a military force of deaf, demented, and parkinsonian troops.


1 VPA has been shown to be ineffective in treating post-traumatic stress disorder (Davis et al., 2008; Hamner et al., 2009).

2 The ototoxicity of VPA was not mentioned in this 233 page book on Otoxtoxicity (PDF) or in this review of ototoxic drugs.


Benincasa D, Pellicano C, Fanciulli A, Pontieri FE. (2011) Bupropion abates dopamine agonist-mediated compulsive behaviors in Parkinson's disease. Mov Disord. 26:355-7.

Cheng WC, Liu CM, Hsieh MH, Hwang TJ. (2009). Bupropion-related parkinsonism and dystonia. J Clin Psychopharmacol. 29:616-8.

Gebhardt S, Röttgers H, Bäcker A, Schu U, Krieg JC. (2008). Treatment of panic disorder with bupropion in a patient with Parkinson's disease. J Clin Pharm Ther. 33:575-7.

Goldberg JF, Burdick KE. (2001). Cognitive side effects of anticonvulsants. J Clin Psychiatry 62 Suppl 14:27-33.

Holmes MK, Erickson K, Luckenbaugh DA, Drevets WC, Bain EE, Cannon DM, Snow J, Sahakian BJ, Manji HK, & Zarate CA Jr (2008). A comparison of cognitive functioning in medicated and unmedicated subjects with bipolar depression. Bipolar disorders, 10 (7), 806-15 PMID: 19032712

Incecik F, Akoglu E, Sangün O, Melek I, & Duman T (2007). Effects of valproic acid on hearing in epileptic patients. International journal of pediatric otorhinolaryngology, 71 (4), 611-4 PMID: 17270285

Nalivaeva NN, Belyaev ND, Turner AJ. (2009). Sodium valproate: an old drug with new roles. Trends Pharmacol Sci. 30:509-14.

Nuutinen T, Suuronen T, Kauppinen A, Salminen A. (2010). Valproic acid stimulates clusterin expression in human astrocytes: Implications for Alzheimer's disease. Neurosci Lett. 475:64-8.

Szuba MP, Leuchter AF. (1992). Falling backward in two elderly patients taking bupropion. J Clin Psychiatry 53:157-9.

Thompson PJ, Trimble MR (1981). Sodium valproate and cognitive functioning in normal volunteers. British journal of clinical pharmacology, 12 (6), 819-24 PMID: 6803819

Załuska M, Dyduch A. (2011). Bupropion in the treatment of depression in Parkinson's disease. Int Psychogeriatr. 23:325-7.

Zhang XZ, Li XJ, Zhang HY. (2010). Valproic acid as a promising agent to combat Alzheimer's disease. Brain Res Bull. 81:3-6.

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At March 27, 2011 8:02 AM, Blogger CCA said...

But surely and although what you say is right (distorted information concerning side effects) wouldn't you say that the use of polypharmacy in military men (and women) is an experssion of the medicalization/psychiatrization of American society? W.H. Rivers would have a field-day with the finding that instead of prescribing psychotherapy to his patients, the best thing is to load them with medication and send them back to the front!

At March 27, 2011 8:31 AM, Blogger The Neurocritic said...

I agree with you that medicating and sending troops back to the front isn't a good idea, and didn't mean to suggest otherwise. I actually agreed with Breggin on this issue. I also think that one doesn't have to resort to scientifically unsound scare tactics about psychiatric drugs to make this point.

At March 27, 2011 12:21 PM, Anonymous Anonymous said...

Let's work backward.

#5 - if you use the word "akathisia" instead of classic Parkinson's, then it does happen and therefore makes sense.

See, for example, CNS Spectr. 2011 Jan 15. pii: Stahl. The Mechanism of Drug-induced Akathsia. Stahl SM, Lonnen AJ.

At March 27, 2011 12:32 PM, Anonymous Anonymous said...

About #1:

"1. Valium (diazepam) and Xanax (alprazolam) are NOT used to treat depression."

Perhaps if you change the wording to match reality -- (SHOULD NOT be) -- things will make more sense.

Valium and Xanax are certainly used by people who can get their hands on them, as 'treatments' for depression.

And who knows what sorts of mis-precribing may be happening outside the U.S., in or near battle zones?

What they are doing is a mistake, but they probably don't know any better.

At March 27, 2011 12:53 PM, Blogger The Neurocritic said...

Anonymous March 27, 2011 12:21 PM

About #5: Then why single out bupropion for causing akathisia nee Parkinson's, when in fact the Stahl & Lonnen abstract says it's SSRIs (and antipsychotics) that can cause akathisia?

At March 28, 2011 4:04 PM, Anonymous Emmy said...

Another dirty secret about Seroquel off-label use is that it's being prescribed to treat OCD. These new drug's interactions with people's respective genomes are often not understood well enough to consider them as safe as older drugs. Did they mention the permanent facial tic that might develop?

Diazepam, well, that's been around forever so there's fewer surprises. I agree that the mood disorders with these drugs can be a problem, especially if the troops are drinking as well. But what are they supposed to do, drink tea??

At March 29, 2011 3:48 PM, Blogger Allison said...

Sorry to leave an unrelated comment, but I couldn't find any contact information for you on the site. I'm wondering if you accept guest posts. Please drop me an e-mail.



At March 30, 2011 7:22 PM, Blogger The Neurocritic said...

Allison - I have no way to contact you without an e-mail address.

At April 04, 2011 3:51 AM, Anonymous dj said...

I'm just wondering what these experts who've testified as to the risks associated with psychiatric drugs would recommend as an alternative? I agree that sending heavily-medicated troops into the field is a bad idea, but so is sending them out there with mental and emotional disorders.

At June 15, 2011 10:11 PM, Anonymous Anonymous said...

DJ, as someone who's struggled with mental health issues most of my life, I can only express what's worked for me. It hasn't been the multitude of drugs I've tried over the years. What's helped is therapy. Psychoanalysis, behavioral and cognitive therapies, etc. If your mind needs rewiring, a drug won't do it. You have to actually do the work. I can only speak for dealing with my own severe trauma and depression, but I've witnessed it work just as well with other mental disorders. The plus side is no nasty short term or long term unwanted effects.

At June 25, 2012 7:25 PM, Anonymous Anonymous said...

Just like Vietnam, except now the soldiers pay the corps for the dope, and it comes in little pills. Trust me, especially these newer, modern psychoactive drugs are whack. Their mechanism of action is not even known, so it is no surprise new side effects are found years later. Oops, that drug caused kids to kill themselves. Sorry about that ;o. I do not know if ALL psychiatrists are on the payroll or what, but ...


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