by Art Levine
The published data on all antidepressants for young people is nearly as troubling as that found in Study 329. For children, adolescents and young adults up to age twenty-four, the risks of suicidal behavior and aggression in clinical trials are reportedly at least twice as great with antidepressants when compared to placebos, according to a 2016 BMJ overview and other studies, although some young people clearly benefit from those medications.
In a situation similar to the wave of off-label prescribing of antipsychotics, many adults who probably could be helped by antidepressants aren’t getting them at all, while those who likely don’t need them are receiving them unnecessarily. Even as the use of antidepressants among those twelve and older has increased roughly 400 percent since the late 1990s, a remarkable August 2016 study in JAMA Internal Medicine and other reports have found that most people taking the drugs don’t have mental illnesses justifying their use. Meanwhile, remember, suicides have soared to a thirty-year high across most age groups. By analyzing recent patient survey data, a Columbia University team discovered that less than 30 percent of people with signs of depression were getting treatment, including antidepressants, while Columbia University and Johns Hopkins researchers concluded in separate studies that close to 70 percent of those who received antidepressants never had major depression, generalized anxiety or obsessive compulsive disorders that could offer a rationale for the prescribing. Dr. Mark Olfson, a professor of psychiatry at Columbia University Medical Center, told NPR about the unnecessary prescribing, “There are simpler forms of psychological interventions that can be adapted for primary care,” including counseling and exercise—rather than turning to antidepressants first.
Given this upsurge, it’s especially necessary to vigilantly track side effects, because as many as one out of every hundred patients may experience violent and homicidal thoughts, leading a few people to commit murder. In 2001, a jury awarded $6.4 million to the family of a man who killed his wife, his daughter, his granddaughter and then himself after taking the antidepressant Paxil made by GlaxoSmith Kline. (Such lawsuits have sharply dropped since the FDA required black-box warnings about increased suicide risk for teens and young adults, starting in 2004, while adding other warnings on the risks of aggressiveness, mania and hallucinations.) But the dangers continue: British documentary filmmaker Katinka Blackford Newman in her recent book, The Pill That Steals Lives, profiled murderers without previous histories of mental illness who became delusional and violent after taking antidepressants. She began the book after she recovered from a psychotic decline that went on for a year after taking Cymbalta, which initially led to her hospitalization after stabbing herself with a knife and wanting to kill her own kids—even though she wasn’t even clinically depressed when she began using the medication.
Whatever the final truth about the risks and benefits of using antidepressants, careful monitoring is especially vital with young people receiving these psych drugs. That’s precisely what is generally missing in busy public clinic settings. There’s rarely time, encouragement or rewards for careful prescribing in the real world of public mental health systems, whether funded by Medicaid or run by the VA and military.
The danger to mentally ill veterans continues, despite all the hearings and initial media scrutiny. For example, in 2014 the GAO found that a software error in diagnostic coding led the agency to omit “major depression” entirely in the records of a third of the patients the GAO reviewed. The VA didn’t fix the error until after the GAO issued its report based on a sampling of thirty cases, but the mistakes in these patients’ medical records before the “fix” was implemented have been left intact. These sorts of errors still affect an unknown number of other veterans, possibly tens of thousands. As a result of this and other record-keeping flaws, the department—and its harried clinicians often just doling out drugs or downplaying suicidal signs—still doesn’t have accurate information about all the veterans burdened by this depressive disorder that can be a prelude to suicide.
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THE VA’S LEADERSHIP HAS NEVER FULLY ACKNOWLEDGED ANY MAJOR FAILURES in the agency’s approach to the wave of suicides, even after all the shocking news stories about veterans shooting themselves, driving off cliffs and hanging themselves after being denied treatment or disability benefits. Nearly a decade ago, there was little done nationally after Lucas Senescall, a depressed Navy veteran, hanged himself in his garage with an extension cord in July 2008, three hours after being turned away by the VA medical center in Spokane. As first reported by the Spokane Spokesman-Review, in a one-year span starting in July 2007, twenty-one veterans in the Spokane area were publicly reported to have killed themselves, fourteen of whom had received care at the VA. (The full scope of the suicides by Spokane patients was undercounted by the VA under the watch of the hospital director, Sharon Helman, who was transferred to another facility in 2008—until she took over the Phoenix VA in 2012 and began faking wait-time outcomes. She apparently continued undercounting VA suicides in the Phoenix area as well, The Arizona Republic found.) Under a local media spotlight and facing a raft of potential lawsuits, the Spokane Veterans Affairs Medical Center grudgingly increased its suicideprevention efforts.
Yet the sort of concerted initiatives undertaken in Spokane were either missing in most VA hospitals and clinics, or done in a way that only appeared, on paper, to comply with whatever new guidelines were put in place. Less than a third of Iraq and Afghanistan war veterans with PTSD even receive specialized mental health care treatment from the VA, according to internal agency documents obtained by Veterans for Common Sense (VCS) that were even more damning than the RAND Corporation findings.
In court filings and at a trial resulting from a 2007 lawsuit, the attorneys and leaders of VCS, joined by Veterans United for Truth, made a compelling case for immediate court-ordered relief. The veterans groups showed that 1,400 veterans died in one six-month period while waiting for their disability claims appeals to be heard. The lawsuit also highlighted that as far back as 2005, the VA Inspector General found some VA health facilities were improperly “gaming” and falsifying wait-time information. But that didn’t set off alarms in Congress, the VA or the media until the Phoenix VA scandal almost a decade later.
The only strong ruling in favor of the veterans’ lawsuit came in May 2011 when a three-judge Ninth Circuit appeals court panel upheld the merits of the lawsuit and declared that delays in providing care deprived veterans of their constitutional rights, opening the way to court-ordered injunctive relief. “VA’s unchecked incompetence has gone on long enough,” Judge Stephen Reinhardt wrote for the majority. “No more veterans should be compelled to agonize or perish while the government fails to perform its obligations.” The public and Congress didn’t start to respond to that failure until the Phoenix scandal broke open three years later.
Unfortunately, the VA didn’t see any of these tragedies or the lawsuit as a wake-up call. Instead of responding directly to the rising tide of suicides or the striking failures demonstrated in the lawsuit, agency officials fought the case on narrow technical grounds for six years. Their assertion: the courts lacked the constitutional authority to order the VA to institute reforms. While the VA’s lawyers were arguing against making any improvements in court, numerous veterans in Tomah and Phoenix and across the country were dying in increasing numbers because they couldn’t obtain quality care in the VA system.
In 2012, the full Ninth Circuit agreed with the VA’s constitutional arguments and overturned the Reinhardt ruling, saying it was up to Congress to repair the VA. The VA eventually triumphed in the Supreme Court in February 2013, when the court refused to hear an appeal of the lower court decision.
The lawsuit did spur the VA to create its now-failing crisis line in 2007. It also helped create momentum for a new law in 2008 enabling most veterans to receive free VA medical care for up to five years after their discharge from a combat zone, in part to accommodate the long wait times for disability claims the lawsuit
and congressional hearings exposed.
Yet the VA remained a disaster zone. Before the issue became a high-profile national scandal in 2014, the evidence of the agency’s deadly failures was clearly laid out in that early VCS lawsuit and Inspector General reports, coupled with media accounts. Even as early as 2009, the Inspector General found there wasn’t a single suicide prevention specialist at any one of the agency’s approximately eight hundred community-based outpatient clinics, where most veterans get their health care.
The VA’s reluctance to respond in an effective manner to veterans’ mental health needs was originally considered a byproduct of Bush administration attitudes that saw veterans with PTSD as malingerers and fakers. But all that was supposed to change with the election of the dedicated young president, Barack Obama, in 2008. Within a few years, however, a few progressive veteran groups’ leaders, influential media outlets including The New York Times and even some Democratic members of Congress were openly critical of the mounting signs of a VA in disarray, unable to respond to the rising demand for mental health services.
The VA’s resistance to giving timely treatment and accurate PTSD diagnoses was abetted by the military’s policy of booting out active-duty troops with cooked-up diagnoses and the denial of PTSD claims. Those actions, in turn, limited those veterans’ ability to get disability benefits or receive long-term free health care from the VA; that’s because the military classified them as not having any “service-related” illnesses.
By 2010, for example, at least 31,000 service members were discharged under the vague diagnosis of having a preexisting, lifelong “personality disorder” instead of a service-connected mental illness, such as PTSD. These sorts of bogus diagnoses, including “adjustment disorder,” prevented veterans from collecting their full disability benefits, and limited their opportunities to access in many cases either free health care for life or specialized PTSD treatments at the VA. (It’s not widely known that veterans of the Iraq and Afghanistan wars are entitled, in theory, to five years of totally free health care after they leave the military, as long as they weren’t dishonorably discharged, but after that point they could face some out-of-pocket costs for VA treatment if they are classified as not being injured physically or mentally during their military service.) In 2015, the GAO found that the Department of Defense still engaged in shady diagnostic practices that misclassified service members, robbing them of veterans’ disability payments and the full scope of VA health care.
Some of those suffering from genuine service-related psychiatric conditions may also engage in misconduct—such as smoking marijuana while in the military—that brands many with an “Other Than Honorable” (OTH) discharge that bars them permanently from any VA health care unless they successful appeal their classification. In 2014, three veterans groups, including Vietnam Veterans of America, joined a class-action lawsuit on behalf of tens of thousands of veterans who developed PTSD during their service but received an OTH discharge; indeed, PTSD wasn’t even a diagnostic category until 1980. The lawsuit led the military to loosen its standards in allowing discharge upgrades for veterans of all ages with PTSD, but DOD’s appeals process is still so onerous that in the Army, for example, only 164 veterans applied for an upgrade in 2015.
And after tens of thousands of veterans have been branded with the OTH discharge by the military, they’re then confronted by the VA’s own barriers. About 125,000 veterans who served since 2001—over 6 percent of all post-9/11 vets—are still receiving such “bad papers” discharges, and the VA hasn’t reviewed their cases. As a result, according to a 2016 report by Harvard Law School’s Veterans Legal Clinic and the Swords to Plowshares advocacy group, the VA has largely ignored a federal eligibility law allowing the agency to take into account these veterans’ mental health conditions and offer them care. “In most cases, the VA refuses to provide them any treatment or aid,” the study concluded, obstacles that contributed to their committing suicide at twice the rate of other veterans. In the face of mounting public pressure, Shulkin, the new VA Secretary, announced in March 2017 that the agency would begin offering mental health services to OTH veterans at VA emergency rooms, the counselor-staffed Vet Centers and the Veterans Crisis Line. But as Bradford Adams, the supervising staff attorney at Swords to Plowshares, points out, the VA is already doing that for any veteran. In fact, the bally-hooed reforms don’t extend to offering psychiatric or neurological care. “These veterans need services, not lip service,” he says.
What’s especially cruel is that these misguided discharges and diagnostic ruses can force veterans who have been kicked out of the military to pay back their enlistment bonuses, which can be as high as $40,000. That burdens them with debt as the traumatized veterans struggle to find jobs. In addition to financial difficulty, the black marks of an OTH discharge, or getting severed from the military for having a spurious “adjustment” or “personality” disorder, can prevent them from landing jobs.
On any given night more than 300,000 jobless veterans of all ages, mostly men, are living on the streets or in shelters. Meanwhile, the questionable psychiatric discharges alone save the military $4.5 billion in medical care and are used to save the government $8 billion in disability compensation payments, according to the Vietnam Veterans of America.
Even though wait times have worsened and the rigging of the VA’s appointment system is well known, there hasn’t been a comparable challenge to the related statistical gamesmanship on the supposedly shrinking disability backlog. The VA claims it has slashed first-time physical and mental disability claims delays by over 80 percent to just under 100,000. In fact, the actual number of total pending claims has grown to nearly 1.5 million because the VA simply wasn’t counting appeals and other disability-related claims, including 480,000 appeals that have been pending for more than four years, according to Gerald Manar, the recently retired director of National Veterans Service for the Veterans of Foreign Wars.
Tens of thousands of other disability claims never even made it into the VA’s cumbersome disability system to be counted as part of the backlog. For instance, as CBS News first reported in February 2015, Rusty Ann Brown, a claims reviewer for the Oakland VA system, found that 13,000 “informal” letters from veterans asking to apply for disability benefits were stuck in file drawers without a response between the late 1990s and 2012. “Half of the veterans were dead that I screened,” she told CBS News after she and a team were finally asked to review them. Yet, at hearings in March 2015, the VA undersecretary in charge of the Veterans Benefits Administration (VBA), Allison Hickey, still insisted, to the disbelief of legislators, that there were no problems at all. But the independent OSC concluded in October 2016 that the VA retaliated against Oakland whistleblowers and covered up its massive failures.
The sloth-like response of Hickey’s agency to veterans in need stood in sharp contrast to her efficiency in approving $400,000 in moving-related expenses for two regional directors who were accused by VA investigators of scheming to get easier jobs at the same salaries. (Another scathing Inspector General report led to Hickey’s resignation in October 2015, but the two accused VA scammers were returned to their high-ranking posts in 2016 by administrative judges after being demoted.)
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THE SAME SORT OF INACTION AND LACK OF ACCOUNTABILITY GUIDED THE VA’s response to new laws passed in the wake of the original VA scandal. Even legislative reforms that passed Congress in 2014 and early 2015—designed to address the lack of access by veterans to care—are already being undermined.
Spending for the Choice section of the legislation, which allowed veterans to go outside of the VA if they couldn’t get access to a nearby VA facility, was shaved to $10 billion by the time the program took effect in August 2014. But veterans’ advocates say that if fully applied, the plan would actually cost closer to $50 billion. Although the legislation passed with near-unanimous bipartisan support, it only proved how much ideology trumps meaningful reforms at the VA and throughout
the mental health system when partisan interests are at stake.
At first, it seemed that the most ludicrous part of the Choice plan was the VA’s attempt to limit its use to veterans who did not have a VA facility within forty miles of their home “as the crow flies.” After Jon Stewart excoriated that idea on The Daily Show, the VA changed its policy by allowing “forty miles” to be calculated by driving distance. That doubled the number of veterans who could be served—and potentially doubled the program’s costs to $20 billion.
But the Department of Veterans Affairs didn’t stop its efforts to prevent patients in need, especially those with PTSD, from going outside its troubled system. Their leaders initially claimed that few veterans were interested in enrolling in the Choice program at all.
But the Choice program as run by the VA posed dangers to veterans far greater than even the agency’s spin or semantic disputes over how far a crow flies. The new program designed to help veterans get speedier help outside the VA turned into a logistical nightmare that blocked veterans from getting care for months. It was also seen by critics as a boondoggle for two corporations: Tri-West Health Care Alliance, which landed a $72 million VA no-bid contract in twenty-eight mostly Western states, and its eastern US counterpart, Health Net—on top of the billions they were already contracted to receive for running an earlier network of specialized private sector “Community Care” providers. As exposed in September 2016 by CIR’s national radio program, Reveal, Tri-West raked in added bonuses from the Choice program every time one of their temp staffers, mostly without medical experience, called a veteran. But instead of being rewarded for actually arranging timely care, different staffers sometimes placed calls over and over again to the same veteran. Total health-care costs to the VA soared as well, but because the Choice program is funded by a separate federal revenue stream, nobody seemed to care. (The company and VA leaders say that implementing the complex program on a ninety-day rush schedule forced by Congress added expenses and problems, now basically fixed.) Yet some Tri-West workers were so ignorant, Reveal’s Lee Romney reported, “One gal told me the rep sitting next to her thought PET scans were for pets.”