Is it the Drugs, or the War? Yes.

Author: Johanna Ryan, Labor Activist with Illinois Workers Compensation Lawyers (Chicago) & RxISK Community Advisory Board Member, April 15, 2014

Within hours of Spec. Ivan Lopez’ deadly shooting spree and subsequent suicide in Fort Hood, Texas, the denials started to flow. We learned that yes, he had been to Iraq, but only for four months. He had not been in combat – he was only a truck driver. He had told Army doctors he had sustained a traumatic brain injury – but there was no documentation of this in his service records. And yes, he was being evaluated for possible Post-Traumatic Stress Disorder (PTSD) … but that did not mean he had it!

What the Army did acknowledge was that Lopez was undergoing psychiatric treatment at Fort Hood. The base commander, Lieutenant General Mark Milley, told reporters that “we have very strong evidence looking into his medical history that indicated an unstable psychiatric condition” which was the “fundamental underlying factor” in the tragedy. “He was not diagnosed, as of today, with PTSD, he was undergoing a diagnosis process to determine if he had PTSD. That is a lengthy process,” Milley stressed.

“He was undergoing a variety of treatment and diagnoses for mental health conditions, ranging from depression to anxiety to some sleep disturbance. He was prescribed a number of drugs to address those, including Ambien,” U.S. Army Secretary John McHugh told a Senate committee. He added that Spec. Lopez had a “clean record” without disciplinary actions, and Army psychiatrists had seen no sign that he was either suicidal or potentially violent.

A “number of drugs” – for a man recently diagnosed with depression, anxiety and trouble sleeping? A man with no prior history of violence or suicidal thinking? To many of us, this raised the possibility that Ivan Lopez’ inexplicable rage was treatment-induced. In last week’s column, Dr. David Healy said that to blame Lopez’ underlying mental and emotional problems for his actions spoke of a denial that was “close to psychotic.” “If Lopez was so ill that his illness was likely to cause the problem, he should not have been in service,” he said. “If he was able to work, the scientific evidence suggests his drug was more likely to cause the problem.” (If the denials that Spec. Lopez’ war experiences caused his problems came thick and fast, the denial of a psychotropic drug effect was so automatic that in most cases the military brass did not have to deal with it. Most media sources were far too polite to raise such a “fringe” theory.)

A quick look under the hood

But to many recent veterans of the Iraq and Afghanistan wars, neither Ivan Lopez’ tragedy nor the Army’s denials were all that surprising. Asked whether Lopez’ violent end should be blamed on his mental and emotional state, or his treatment, they said the answer was “Yes.”

The Under the Hood Café was opened by antiwar veterans and their supporters in 2009 as a safe space for soldiers to express themselves, learn their rights and talk about the war and its impact on them. On Friday, April 4 the staff of Under the Hood released a statement on the tragedy which said in part:

This event is dreadful and unbearable, but not unimaginable in the wake of previous shootings at Fort Hood and across the country. The military and its commander-in-chief have heard repeatedly from Under the Hood members and the wider Fort Hood community about some of the conditions that contribute to incidents like this: service members reeling from multiple deployments, untreated PTSD and TBI, over-medication coupled with lack of personal support, service members waiting and waiting for help, stigmatized and traumatized by what they have experienced in service.

The military often frames the issues affecting military communities as issues affecting single individuals. Yet, the issues affect many. The suicide rate within the military is staggering. The military needs to stop pointing the finger without looking at the root causes. We demand access to quality mental health care and the right to heal. We want change.

In an interview with Democracy Now’s Amy Goodman, two vets involved with the café explained why the military sought to pin the blame for both rare outbursts of violence, and all-too-common military suicides, on the problems of the individual soldier. Café manager Malachy Muncy had driven a truck on two deployments to Iraq. Ryan Halloran of Iraq Veterans Against the War (IVAW) had been in Iraq in 2011, like Lopez. Both expressed disbelief that Lopez’ experiences in Iraq were “non-combat.” And both said that soldiers under mental and emotional stress were often diagnosed with non-service connected ailments.

“I had trouble getting help when I came back from Iraq, as well when I was at Fort Hood,” said Halloran. “I got a slew of diagnoses: depression, anxiety, bipolar personality disorder. I mean, basically everything but PTSD, for the longest time. But, you know, I’m not unique in that. I think that a lot of DOD physicians really hesitate to give the PTSD diagnosis. And I’m not going to speculate as to why that is, but I’ll definitely say that it affects that service member’s ability to get benefits on the other side.”

He added that “When I was deployed in Iraq and somebody was having a hard time, the first reaction that any physician assistant would have would to be give us drugs and keep us doped up. And their primary goal was to keep us as doped up, or as doped up as was needed, ’til we can get through the deployment.” Muncy, who returned from his second deployment to Iraq fighting an addiction to painkillers, agreed.

Muncy, Holleran and their comrades have campaigned for several years to “Stop the Deployment of Traumatized Troops” and defend the “right to heal.” In effect, they agree with David Healy that if Ivan Lopez’ mental condition was severe enough to render him capable of such desperate acts, he should not have been in service. What they’re telling us, however, is that too often drugs may be used to patch up a soldier on the brink of collapse. The effect could be the opposite of what’s intended.

Marriage of convenience

What we have here looks like a marriage of convenience between two interest groups, both of which have a lot to gain by locating Ivan Lopez’ troubles between the ears of a single “mentally ill” soldier. His commanders need to absolve the war and the military from any responsibility for driving him to violence. His treating physicians are wedded to a theory of “biological brain diseases” for which the medications they hand out are targeted treatments. They have their own questions to avoid – and they are happy to help the military focus on Lopez and his alleged pathology rather than face questions about their treatments.

As I recounted in a guest post on David Healy’s blog in 2012, multi-drug treatments have become the linchpin, not only of the treatment of veterans but of the U.S. military’s attempts to keep traumatized troops at the front lines. Drugs whose use would once have excluded people from military service altogether have become acceptable tools to manage “stress” even in combat.

SSRI antidepressants like Paxil, Zoloft and Celexa are among the drugs used to treat the severe anxiety symptoms most of us would call PTSD: nightmares, flashbacks, insomnia and hyper-vigilance. But they’re far from the only ones. The military’s toolkit also includes antipsychotics like Seroquel and Risperdal, anticonvulsants like Topamax, benzodiazepine tranquilizers like Xanax and Klonopin, and opioid painkillers like oxycodone. Sleep aids like Ambien (the only one of Spec. Lopez’ prescriptions that has been identified) are also handed out freely. A common “cocktail” in use two years ago was Paxil, Seroquel and Klonopin, often in addition to opioid narcotics for physical pain. Opiates have also been linked with violence by some experts, particularly in people who have suffered a concussion or other brain injury – often called the “signature injury” of the Iraq war.

Almost any of these drugs can be shown to provide some relief in the short term from crippling anxiety for the majority of people, often at the price of sedation, emotional numbness and decreased ability to function. Yet most of them also have the ability to trigger akathisia, an agonizing inner restlessness and agitation that can lead to suicide. Violent thoughts, dreams and impulses can also be triggered in people who have never had such thoughts before.

If this can happen to civilians living largely safe and nonviolent lives, what are the drugs’ effects on war veterans – or active duty soldiers re-deployed to a combat zone? The only honest answer is that nobody knows. Paxil and Zoloft became FDA-approved treatments for PTSD based on general population studies. Yet a VA study found Zoloft to be ineffective in a military population. This is often described as a gender effect, but it could just as easily be an effect of war. Civilians being treated for PTSD are often victims of past domestic violence or of a single traumatic event such as a violent crime or serious accident. Combat veterans, by contrast, have usually endured a 24-7 environment of extreme violence in which they were victim, witness and active participant. And nothing in the treatment of civilian PTSD has explored the use of drugs to send people right back into the traumatic situations that produced their plight.

On March 1, the same day he purchased the .45-caliber pistol he used in the attack, Specialist Lopez wrote on his Facebook page that “My spiritual peace has all gone away, I am full of hate, I believe now the devil is taking me.” This was not the man that his parents, his old friends or his wife and child remembered: the quiet, friendly devout Catholic and avid musician, the policeman who played in Puerto Rico’s National Guard marching band and gave presentations to schoolchildren. It does bear an uncanny resemblance to someone in the grip of drug-induced akathisia. It also describes a feeling that a lot of Iraq combat veterans would admit having endured, with or without drugs.

Perhaps the lethal combination of combat stress and drugs is the real answer. We’ll only know if the men and women living under these often unbearable pressures get a chance to speak – and if we listen.

Save the date: Memorial Day, May 26, 2014

On ‘Memorial Day’ Iraq Veterans Against the War will issue a report on the treatment of physically and mentally wounded soldiers at Fort Hood. It’s a project that was underway before the April 2 shootings but its importance is even more obvious now. Drug safety activists may find we have a lot to communicate to these veterans about their findings. We will have a chance to learn a lot as well. A real dialogue could begin to provide us with some answers about the epidemic of drug-related tragedies many of us feel we have been living through.

POSTSCRIPT: In recent days, Fort Hood’s commanders have shifted the narrative once again. Gen. Milley told reporters that Ivan Lopez’ “underlying medical conditions” were not the “direct” cause of his actions. The immediate precipitating factor for three murders and a suicide, he said, was more likely a dispute with unit officers over a denied home leave. Is this explanation more convincing?