A Las Vegas Army infantryman who was prescribed Prozac for depression and several weeks later killed himself in Iraq should have undergone at least three months of observation before returning to normal duties, psychiatrists and other medical experts said in interviews Wednesday.
Family and friends of Pfc. Travis Virgadamo say he told them he was prescribed daily doses of 12.5 milligram s of the anti depressant Prozac beginning in July. He died of a self-inflicted gunshot wound last Thursday outside of Baghdad, the military said.
Medical experts interviewed by the Sun said anyone given prescription anti depressants should be watched carefully and kept out of high-stress duty for at least three months.
Las Vegas psychiatrist Dr. Mark Collins said anyone on Prozac needs to be checked regularly for 90 days before being returned "to combat - the most stressful of all situations."
Collins said he has treated many firefighters and police officers with Prozac. "I would return them to light duty or partial duty for a three-month period."
Experts also noted that research has found that the drugs pose a special risk to teenagers. Virgadamo was 19.
Prozac's manufacturer, Eli Lilly and Company of Indianapolis, says in its warning that clinical studies indicate that antidepressants "increased the risk of suicidal thinking and behavior in children, adolescents and young adults with depression and other psychiatric disorders."
Dr. Andrew Leuchter, a professor of psychiatry at UCLA, said young combat soldiers in Iraq and Afghanistan are often treated with antidepressants and sent back into the field despite the risks.
"Unfortunately, they take kids out of these situations and put them right back in," Leuchter said. "The major factor for suicide is to have a major depressive episode."
Virgadamo's family told the Sun that the military said it is conducting an investigation into Virgadamo's death, which has not been classified as a suicide.
The widespread use of anti depressants to treat soldiers has presented the military with issues that have not arisen in previous wars because the drugs have been in widespread use for only two decades.
Questions about their use in Iraq are compounded by the extended tours military personnel are required to serve. Critics say the military does not have sufficient troop levels to withdraw large numbers of soldiers from the field simply because they suffer mental problems.
Although top military officials have denied that antidepressants are in widespread use in Iraq, a recent Pentagon survey found that 12 percent of soldiers - nearly one in eight - are taking prescribed medications for mental health or sleep problems.
A new Defense Department study found that troops who have undertaken at least one war zone deployment are experiencing serious psychological problems.
The report says hundreds of thousands of the more than 1 million U.S. troops who have served in Iraq or Afghanistan face severe mental health issues, including post-traumatic stress disorder, depression and anxiety.
The report also pointed to inadequate mental health care provisions and facilities, lack of trained staff and entrenched prejudice about mental health problems.
The report also questioned the practice of returning soldiers to front-line duty while they were taking medication s such as lithium or Prozac.
"I can't imagine something more irresponsible than putting a soldier suffering from stress on (Prozac or similar drugs), when you know these drugs can cause people to become suicidal and homicidal," said Vera Sharav, president of the Alliance of Human Research Protection, a patient advocacy group. "You're creating chemically activated time bombs."
The Pentagon would not provide details to the Sun about Virgadamo's treatment or condition in the weeks before his death. His family is asking the Army for more information.
Family members say that during his 15-day visit to Southern Nevada in July, Virgadamo was noticeably scared and told them he did not want to return to Iraq because of fears generated by horrific things he had witnessed there.
Relatives say that although they remain loyal to the military, they want honest answers about Virgadamo's death.
His father, Robert Virgadamo, said he has begun the process of obtaining his son's military medical records.
"I don't believe the military intentionally tried to hurt my son," he said. "I believe they tried to do what they could to help him. But I also believe someone made a mistake by sending him back to combat. I don't want restitution or retribution. I want only the truth."
The civilian medical profession questions whether military doctors take the same careful steps treating psychologically ill soldiers as civilian doctors do with mentally ill patients.
Keith Young, a Texas A&M associate professor of psychiatry, said that Prozac has never been tested on combat troops for depression, yet is being routinely used to treat soldiers' depression. Young is leading a $3 million study of post-traumatic stress disorder and the effects of Prozac on combat troops.
Mark Wheeler, a spokesman at UCLA Medical Center, said one of its top psychiatrists has complained that when he prescribes drugs to soldiers suffering from post- traumatic stress disorder, "even before he can send a follow-up letter about the course of treatment, those soldiers are back in Iraq."
Collins, an associate medical director at Las Vegas' Montevista Hospital, which treats the mentally ill and chemically dependent, said Prozac has been studied intensely for suicide risk.
"There are very strict guidelines for Prozac's use, including extremely close monitoring of the patient for side effects," Collins said. "It really takes four to six weeks on Prozac to see improvement , and its full benefits can take up to three months."
Collins emphasized that he is not a military psychiatrist. But he said that with the information so far available of Virgadamo's situation , "there appears to be a substandard of care. It's not what we would have done in private practice."
The Pentagon, along with a peer-reviewed military medical journal and researchers from across the country, question the use of Prozac for combat soldiers.
In a July 1 article in Military Medicine, a peer-reviewed military medical journal published since 1892, a history of current use of anti depressants does not mention any treatments beyond acute care of those suffering combat stress.
Prozac, the article says, "might offer some advantages, but its tendency to be more activating makes its use for both anxiety and depressive disorders less favorable."
A military doctrine, written during the Cold War when few antidepressants existed, recommends 72 hours of rest as intervention for combat stress - not the use of drugs.
Virgadamo's father and grandmother Katie O'Brien on Wednesday said the soldier suffered from bouts of anxiety and depression dating to boot camp in 2005.
Robert Virgadamo said that although it was his son's lifelong dream to be a soldier, he had problems adjusting to that job from the start.
He said it was his understanding that his son was first prescribed a drug of some kind for anxiety attacks in July 2006, about seven months after basic training. He started seeing a military psychiatrist while stationed in Georgia at that time.
He was first deployed to Iraq in May.
"When he came home on leave in July he told me he had only recently been switched from Zoloft to Prozac," said family friend Marcy Kallick, who also takes Prozac in the same dosage Virgadamo did . "I was constantly reminding him every day to take his Prozac."
"He did not want to go back," Kallick said.
After leaving Las Vegas in late July, Virgadamo returned to Georgia and then to Kuwait before reentering Iraq in August, his family said. While he was stationed in Georgia and Kuwait, military officials placed him on suicide watch, O'Brien said, noting that Virgadamo also was put on the antidepressant Paxil when he returned to Iraq. Psychiatrists often adjust dosages and drugs to find a combination that is best for patients.
"They took his gun away from him," she said, not knowing exactly when he got it back.
Kallick said that in one of her final phone conversations with Virgadamo from Iraq he lamented that the chaplain he had been seeing prior to his coming home was not available to talk with him.
Virgadamo's family thinks he was granted military leave this summer specifically to help him briefly escape the problems he was having dealing with the war, including a rollover accident in which he was involved in May.
On the My Space Web site, Virgadamo described that ordeal, writing on May 13: "After driving all day coming back to the base in a little SUV I was told to make my way up from a long-ass convoy and to pass them on the right side Long story short, I hit a decent sized rock doing 60 mph, blew my rear tire, fish-tailed across both lanes of traffic, missing both my own convoy and on-coming traffic I'm happy to say I had a lot of luck that night."
Virgadamo bought a car during his July visit and talked about his future , including getting out of the Army in a year and joining his father in starting a security business in the Philippines. His father said he did not appear suicidal at the time.
Combat doctors' complaints about the lack of drugs to treat patients like Virgadamo led to the prescribing of Prozac and similar medications to soldiers in Iraq after 2004. Prozac had entered pharmacies in December 1987, the first in a class of drugs called selective serotonin reuptake inhibitors, which now includes Zoloft, Paxil, Effexor, Luvox, Celexa and Lexapro.
The Army reports that 59 soldiers had killed themselves in Iraq by the end of 2006. A dozen Marines have died of self-inflicted gunshot wounds, the Pentagon reports.
Guidelines drawn up in August 2006 by the Multi-National Corps-Iraq, the tactical unit responsible for command and control of Iraq operations, said mental health providers in Iraq are to have weekly contact with patients, ensure that troops receive therapy along with medications and prescribe only small amounts of medications at a time.
Congress passed legislation last year directing the Department of Defense to expand mental health screenings for combat troops and to establish clear mental fitness standards for deployment to war.
That program included a requirement that the military establish programs for monitoring the mental health of deployed personnel receiving psychotropic drugs.
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