Sunday, March 22, 2009

"Soldier Suicide Rates Continue to Rise" - Suspect SSRIs

JAMA has recently posted a sad story: very high suicide rate among gulf war soldiers and vets.

Why? no one really knows.

But I am surprised that one obvious theory has not been covered: SSRI-related suicide.

The DoD and the VA simply do not have enough mental health counselors to conduct adequate counseling for these guys.

To manage the burden of psych problems, however, nearly every guy is given an Rx for an SSRI.

Newsweek, and some other media, have noted this. Vets get SSRI, not psychotherapy.

For PTSD, decent psychotherapy is definitely better than SSRIs.

The only drug that really helps some dimension of PTSD is prazosin - ridiculously inexpensive, with very clear empirical evidence. Simply enter "prazosin" and "sleep" and "PTSD" into pubmed, and start reading until you are convinced.

In the meantime, other drugs may have some wishy-washy evidence, but look at placebo effect, study design, etc., and enthusiasm fades for the Med approach.

A big problem is that these guys may not be the ones to give SSRIs like candy.

Google "SSRI" and "Suicide," and start reading.

How is a drug that is supposed to make things better contributing to suicide?

Well, NIH, that would be a good study to fund.

Nitric Oxide is one of the brain's neurotransmitters.
Among its roles, it has a role to curb or restrain or control aggression: For example:
2007: Impaired Nitric Oxide Synthase Signaling Dissociates Social Investigation and Aggression "These data suggest that further study of nNOS signaling is warranted in mental disorders characterized by social withdrawal and increased aggression."
2001: Brain serotonin dysfunction accounts for aggression in male mice lacking neuronal nitric oxide synthase"These results indicate an important role for NO in normal brain 5-HT function and may have significant implications for the treatment of psychiatric disorders characterized by aggressiveness and impulsivity."

SSRIs interfere with nitric oxide:
Finkel MS, Laghrissi-Thode F, Pollock BG, Rong J. Paroxetine is a novel nitric oxide synthase inhibitor. Psychopharmacol Bull. 1996;32(4):653-8.

The interference from SSRIs on nitric oxide could be the mechanism for the noted problem of bleeding in SSRIs (cf: Shen WW, Swartz CM, Calhoun JW. Is inhibition of nitric oxide synthase a mechanism for SSRI-induced bleeding? Psychosomatics. 1999 May-Jun;40(3):268-9.).
SSRIs may also lead to erectile dysfunction through interference with nitric oxide (cf:Angulo J, Peiró C, Sanchez-Ferrer CF, Gabancho S, Cuevas P, Gupta S, Sáenz deTejada I. Differential effects of serotonin reuptake inhibitors on erectile responses,NO-production, and neuronal NO synthase expression in rat corpus cavernosumtissue. Br J Pharmacol. 2001 Nov;134(6):1190-4.).

So, what does all of this have to do with the soldiers?
We know that plenty of sodiers are getting SSRIs when they complain about any mood/affect type problems. Because of the baseline mental difficulties, these guys may be at heightened risk to the agressive effects of SSRIs. This may be leading to the killings and the suicides.

How to figure this out?
The VA has cadres of researchers, and the best integrated electronic medical record ever. Just get one of the researchers to design a study to look at Rx SSRI and suicide.

I am afraid I am right. I hope I am, because the answer is fairly straightforward: SSRIs don't cure PTSD, so don't Rx them anymore to vets with various combat-related mood problems.
Give them prazosin if they have sleep disturbance, and give them the empirically validated psychotherapeutic strategies for PTSD: relaxation, cognitive therapy, in some cases some exposure therapy, support groups, family education, etc.

Combat PTSD is very difficult to treat. Tragically, without SSRIs, there will still be suicides among these people serving our country. For a lot of people with combat PTSD, there just won't be a cure - just management. Let's help the vets manage this without putting them at any greater risk for suicide by handing out the SSRIs like candy, or as if it were all we have for treatment of PTSD - cuz it is not all we have.

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