March 24, 2010

MILITARY HEALTH SYSTEM'S PROGRAMS, POLICIES, AND INITIATIVES

 

Chairman Webb, Ranking Member Graham and distinguished Members of the Subcommittee: thank you for your invitation to appear before you this morning.
I am pleased to have this opportunity to discuss with you the issue of the deteriorating mental health of so many of our combat troops. On behalf of the American families whose loved ones have gone into harms way I come before you today to discuss the strains that have been placed upon our all volunteer force.
 
In 2009, an unprecedented 160 active duty Army suicides were reported, representing a 15 percent increase over the previous year. In response to this growing concern I proposed an amendment (#1475) to the 2010 National Defense Authorization Act which would have required the Department of Defense to report to Congress annually, for the next five years, the number and percentage of service members who were prescribed antidepressant medications while serving in Iraq and Afghanistan. It would have also required that a study be initiated to investigate the relationship between the increased number of suicides and attempted suicides by members of the Armed Forces and the increased number of antidepressants and other behavior modifying prescriptions being used to treat anxiety for our combat troops. 
 
This amendment was successfully accepted into the Senate's version of the NDAA, but was unfortunately removed during the conference process.
 
As a follow-up to my amendment, I also sent a letter to Defense Secretary Gates last November, asking him to provide details on the number of troops being prescribed antidepressant medications while serving in Iraq and Afghanistan. The intent of this letter was to get a preliminary assessment of the number of troops being affected by the Department of Defense's policies on mental health care in theater. This information, when coupled with the committee's requirement for the DoD to demonstrate their policies on how they manage patients prescribed antidepressants in-theater, would begin to provide insight into how the DoD was addressing this significant issue.
 
            As background to this discussion, I would like to first invite your attention to the following information. In October 2004, the FDA directed manufacturers of a certain class of anti-depressants known as Selective Serotonin Reuptake Inhibitors - commonly referred to as SSRI's - to add a black box warning that alerted the public to the increased risk of suicidal thoughts by children and adolescents. By May of 2007, the FDA further directed that the warning be extended to include young adults from ages 18 to 24, with an emphasis towards the first six weeks of initiating treatment.
 
            The FDA's decision to extend the black box warning was the result of scientific findings that children with major depressive disorders showed significant increases in the risk of "possible suicidal ideation and suicidal behavior." An additional analysis indicated a one-and-a-half fold increase in the potential for suicide in the 18-24 year old age group. For the purpose of today's hearing, it is critically important to understand that this same age group - 18-24 year olds - comprises about 41 percent of our young men and women currently deployed to Iraq and Afghanistan.
 
Now, during the 2005 to 2008 time period (the last year full data were provided by the DoD) there was a 400 percent increase in the prescription of antidepressants and other drugs used to treat anxiety - a disproportionate number of which are the SSRIs I just described.  Of the 18,155 troops taking antidepressants while on deployment in 2008, 98.5 percent of them initiated the use of the drug while on deployment. 
 
Data contained in the Army's Fifth Mental Health Advisory Team Report indicate that roughly 12 percent of combat troops in Iraq and 17 percent of those in Afghanistan were taking prescription antidepressants or sleeping pills to help them cope with the stress of their deployments. And while the sixth report - released in late 2009 from this same group of mental health professionals - shows that the suicide rate in Iraq had since stabilized, it more tellingly indicates that the suicide rate in Afghanistan doubled during the same timeframe.
 
It bears repeating that military personnel, who are being called upon to serve in a forward deployed combat area, often for up to a yearlong deployment, are being prescribed medications with a warning that indicates potential side effects which include an increased risk of suicide as well as aggressive, angry or violent behavior. 
 
This deeply concerns me, and it should equally concern those who are responsible for the long term mental health of our service members .
 
I submit, for your consideration, the following questions that I hope you will agree merit a response from those charged with caring for these young men and women:
 
  • If the DoD is medicating personnel in forward deployed combat areas, how are they maintaining the necessary oversight of these Soldiers, Sailors and Marines, especially during the initial six-week window when the increased risk of suicidal thoughts is said to occur?
  • Are these personnel removed from combat status? (At least during the first six weeks of medication). 
  • Who makes the determination of whether a service member undergoing mental health treatment in-theatre is deemed fit-for-duty? Is it the physician or mental health professional, or is it the service member's operational commander, and if so, is this the right person to make that decision? Why?
 
Let me in closing recognize that the DoD has made significant strides in addressing both its pre-deployment health care screenings and its post-deployment health care follow-ups and treatment when necessary. It has also achieved many positive steps towards de-stigmatizing the process of seeking and obtaining mental health care for our troops. 
 
In light of this, I recognize that to move forward with a review of DoD's procedures, great caution must be exercised so as to avoid undoing the progress that has been made. Due diligence, however, dictates that Congress utilize its oversight authority in this matter and investigate whether the DoD's current policies regarding the use of prescription antidepressant drugs - most notably those known adverse side effects - pose an unacceptably high risk to our troops - especially while they are serving in forward operating areas.
 
Since the beginning of the current conflicts there has been a steady increase in the number of suicides and suicide attempts by current and past members of our armed forces.  We have been told that there is no one reason for this increase, but rather a combination of causes and stressors. However, we cannot ignore that this has occurred at the same time as we have witnessed a four-fold increase in the number of psychiatric medications being prescribed to our men and women serving in combat areas.  
 
Admittedly, much debate continues within the scientific and mental healthcare communities over the potential relationship and extent between the use of psychiatric medication and suicide. 
 
Mr. Chairman, we owe it to our service members - past, present and future - and to their families, to do everything in our power to ensure that the mental healthcare they receive is the best our nation can offer. For this reason, I ask that you and the rest of my Senate colleagues will again consider requiring the implementation of an annual reporting mechanism for DoD to come before Congress and disclose the extent to which it is employing antidepressant medications to treat the wartime stress and overall mental health of our service men and women. I would also ask that the DoD be directed and sufficiently funded to contract for a scientific, peer-reviewable study of the potential relationship between this increased use of antidepressant medications and the increased number of military suicides.
 
I thank you again Mr. Chairman, Ranking Member Graham and the distinguished Members of this Subcommittee. I hope that my testimony before you today has been truly enlightening, and will serve as a call to action on this important issue.