Lisa & Lori

Lorraine

1956-1981

Lori’s Story

“I always knew my sister’s sudden death that was labeled suicide was

suspicious” Nothing made sense until NOW!

After almost 3 decades of being kept in the dark, I have the answer I

searched for my entire life since that tragic morning I found her in

her 1977 Buick with our father’s handgun in her lap. I promised her

that morning I would not give up until I found t

he “truth” about what

really happened to her. My sister loved her family and knew we loved

her. She would not of taken her life. So why did she?

Summary of my story:

My sister moved home to file for divorce in 1980.

I am her younger sister Lisa, and we spent the most time together when

she moved back home. I was thrilled to have the time with her. We were

very close.

She was a strong, smart woman and was determined to make it on her own.

She worked for the county that we lived in and was very well liked.

They were shocked as everyone was to hear about her sudden death. So

out of character.

The time she lived with us she was fine. Going to work taking one day

at a time to rebuild her life. Until Suddenly the last month to weeks

she  changed.

I listened, and I watched her suddenly turn into someone I did not

know. I could not figure it out. Why was she acting like this? Saying

these things to me? Finding it funny to scare me?

She started to talk about death and dying, and included me in her ideas

on how I could help her end her life. (ways we could try)

Some examples: She would loop a belt around her neck and ask me to pull

as hard as I could until she stopped breathing, She would ask me to

come in the middle of the night and put a pillow over her face to

suffocate her in her sleep, she would lay still in her bed and when she

heard me coming she would pretend to be dead when I shook her to wake

her up… she would not move until she started to laugh hysterically, and

would say “I’m just joking Lisa..I just wanted to see what you would do

if I were really dead? and what it would really feel like to be dead? I

wouldn’t really do it …I’m too chicken!”

Soon another sudden change came about she started to say things like

“HE” is in your closet and going to get you. Will you sleep with me in

my room?! Never made sense. She also would go from laughing and joking

about something then it turned into anger and agitation and confusion

at times.

Something else happened shortly before she took her life. She was

very sick with the flu.  She lost a lot of weight, she could not eat,

drink, or get up out of bed she was very pale and fragile looking. I

felt so bad I could not help her feel better.

She often fell asleep with her bible on her face she looked like she

was searching for a answer to something that was happening inside her

she did not understand.

I had to take the bible of her face when she finally was able to sit

still and take a short nap. Her sleeping pattern was all off as well.

The night before she took her life I remember so clear all the details.

I remember everything.. from how she kept rocking in our rocking chair

we had in the living room. She would n

ot stop. She also was talking

much faster than usual and walking much faster as well. When I asked

her to stop rocking so fast she just looked at me like she couldn’t

stop, or didn’t want to. It was like someone was pushing her to rock. I

thought it very odd at the time but soon overlooked it because her

behavior had been so altered lately that I almost was getting use to it.

Lori came into my bedroom late that night and stood in my doorway. She

was talking to me.

The last thing she said was “Well I’ll see you in the morning!” and off

she went down the hallway and I heard the door slam as it always did

behind her. I did not know it then but that was the last time I would

see her alive.

On September 22 1981 I was getting ready for school. I went into her

room to borrow a shirt of hers and I quietly asked her if I could

borrow it.

She did not answer. So I took it and got ready to catch the bus.

As I walked out the front door down our driveway I had to pass her car.

From a distance all I could see was RED. My first thought was “here she

goes again,  She is trying to fool me again, and this time she used

Ketchup!

Well as I got closer..I saw my sister through the car window as she lay

on her side with her head on the headrest of the passenger side door. I

could see her face clearly. There was blood dripping from her bottom

lip onto the seat and still I was in disbelief.

Our father came out of the house broke the driver side window unlocked

the door got in the car reached across her body to unlock the passenger

side door ran around the car as fast as he could to then find out my

sister was not moving. She was not alive. She was gone.

My sister’s body lay across my fathers lap and he just kept repeating

Why?

My father’s spirit died at that moment he realized his daughter was

dead.

We had no answers, there was no evidence that somebody could of helped

her there was no clues left behind. So It appeared at the time

“suspicious”

Decades later the truth has surfaced. Finally I was able to put it all

together.   I was going through my sister’s box of things I packed almost 28 years

ago.  I came across many things I remembered from the time… Including a

medicine bottle. We knew my sister was put on a medicine to help her

with stress from the divorce so it was not a surprise that I packed the

bottle off her dresser.

However..the shock came to me when I typed the name of the drug into

the computer just months ago.

Slowly…it all came together..and I mean all of it. From the things she

said to the things she did. To the rocking in the chair to the things

she was seeing that were not there ..and finally to the flu like

symptoms that come with the Sudden withdrawal of the

medication!

The Black Box Warnings that today are on ALL antidepressant drugs says

it all.

My sister was put on this drug Aug. 18 1981.

She stopped taking it as many people did due to the side effects.

She was in bed with the flu which turned out to be not the flu at all

but the withdrawal from this prescription drug that in the end killed my

sister!

I WAS 13 YEARS OLD

LORI WAS 25

PEOPLE ASK ME WHY NOW DOES THIS MATTER?

MY ANSWER IS…BECAUSE NUMBER ONE MY SISTER IS DEAD.

NUMBER TWO I AT 13 HAD TO LIVE MY ENTIRE LIFE WITH SUSPICIAN ABOUT WHAT

HAD HAPPENED TO HER!

I HAD TO LIVE WITH THE NIGHTMARES, I COULD NOT WALK BY A PARKED CAR FOR

YEARS DUE TO THE FEAR OF SEEING HER INSIDE AGAIN,

I WOULD GO TO THE CEMETARY FOR THE FIRST FEW YEARS RIGHT FROM SCHOOL

AND JUST SIT AND ASK..WHY..HOW..SOMETHING IS MISSING. I KNOW YOU DID

NOT DO THIS. YOU WOULD NOT DO THIS.

I WAS TORMENTED BY HER BECAUSE OF A MIND ALTERING DRUG..THAT WAS AND

STILL IS LEGAL IN THIS COUNTRY.

I COULD NOT SAY GOODBYE TO HER WHEN SHE DIED BECAUSE I WAS AFRAID TO GO

UP TO THE COFFIN DUE TO THE FACT I THOUGHT SHE WOULD JUMP UP AT ME AND

LAUGH LIKE SHE DID BEFORE.

I HAVE BEEN THROUGH HELL BECAUSE OF THE DAMAGE THIS DRUG DID TO MY

SISTER..AND TO MY FAMILY.

AND I KNOW THERE ARE OTHER FAMILIES OUT THERE STILL IN THE DARK!!

I HOPE TO FIND THEM AND LET THEM KNOW WHAT REALLY HAPPENED TO THEIR

LOVED ONE IF OUR STORIES ARE SIMILAR..AND THIS RX DRUG WAS INVOLVED!

——————————————

THE DRUG WAS CALLED IMIPRAMINE. GENERIC FOR TOFRANIL

ALSO PRIOR TO THE SSRI THE CLASS OF DRUG LORI WAS ON WAS CALLED A TCA. TRICYCLIC 3 RING MAKE UP..THIS DRUG WAS THE FIRST ANTIDEPRESSANT INVENTED IN THE LATE 1950′S.

** MANY DID NOT LIKE THE DRUG DUE TO ALL THE SIDE EFFECTS/ADVERSE REACTIONS THAT CAME ALONG WITH IT.

MOST PEOPLE WHO TOOK THIS IN CLINICAL TRIALS OR STUDIES SHOWED THEY DROPPED OUT DUE TO THESE SIDE EFFECTS. NEVER GOT TO THE POINT WHERE IT WAS SUPPOSE TO TAKE EFFECT!

THAT IS WHAT MY RESEARCH SHOWED.. BUT YOU ASK ANN TRACY.

YOU MAY WANT TO ADD THIS TO LORI’S STORY SOMEWHERE IF YOU CAN:

WHEN WE TOLD HER DOCTOR SHE WAS ACTING LIKE SHE WAS ABOUT DEATH AND DYING..WE WERE TOLD NOT TO WORRY ABOUT IT THAT SHE WOULD NOT DO ANYTHING BECAUSE IT WAS NOT IN HER. SHE WOULD NOT REALLY HARM HERSELF OF ANYONE ELSE.

WELL…THAT WAS ANOTHER PIECE THAT DID NOT FIT.

THIS WAS TRUE.

**** THE DOCTOR BACK IN 1981 WHO GAVE HER THIS DRUG FOR MERE STRESS OF A DIVORCE…DID NOT KNOW..THE DRUG THEY GAVE HER WAS INDUCING HER BEHAVIOR.

THEY HAD NO IDEA..THEY WERE IN THE DARK JUST AS LORI WAS..AND US HER FAMILY WERE.

IT JUST SIMPLY LOOKED LIKE SHE WAS GOING CRAZY AND LOSING HER MIND!!

WHEN IN ACTUALITY SHE WASN’T..THE DRUG WAS INDUCING THIS REACTION!

but the one thing I wanted to make clear on the taking this drug Imipramine is that FROM START TO FINISH IT WAS ABOUT A MONTH. AUG 18 1981 SHE STARTED IT.

THEN STOPPED she told a friend I don’t like how this medicine is making me feel I’m not taking it anymore.

SEPT. 22 1981 SHE SHOT HERSELF IN THE HEAD AT 1AM.

FOUND AT 7AM PRONOUNCED DEAD AT 8:32AM

AND HER SUSPICIOUS SUICIDE WAS JUST RECENTLY SOLVED AS OF A FEW MONTHS AGO!

I AM OUTRAGED!

The Note she left behind said:  It’s Nobody’s fault I Just Flipped!!!

then drew a smiley face.”

She often drew smiley faces when she wrote things in general. but even the smiley face did not match her normal happy ones.

Lptpkp@aol.com

PLEASE SIGN Lori’s Petition to help me find others: :http://tinyurl.com/mt63tp

Part of the Warning on this drug today:

patients should be carefully supervised during the early phase of treatment with imipramine, and may require hospitalization. Prescriptions should be written for the smallest amount feasible.

Hypomanic or manic episodes may occur,  Such reactions may necessitate discontinuation of the drug. If needed, imipramine may be resumed in lower dosage when these episodes are relieved.

All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and non-psychiatric. Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.

Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, OR who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidally, especially if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms.

Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and non-psychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidally, and to report such symptoms immediately to health care providers. Such monitoring should include daily observation by families and caregivers.

patients should be carefully supervised during the early phase of treatment with imipramine, and may require hospitalization. Prescriptions should be written for the smallest amount feasible.

Hypomanic or manic episodes may occur,  Such reactions may necessitate discontinuation of the drug. If needed, imipramine may be resumed in lower dosage when these episodes are relieved.

Comments are coming in since my story posted:

I’m 48 years old and my introduction to Zoloft began when I was 34. I’ve since learned that the symptoms of fatigue and difficulty sleeping and concentrating that I was having at that time were due to over-work and adrenal exhaustion. That doctor had me fill out a questionnaire and then spent maybe 10 minutes with me before giving me free samples of Zoloft.   Had I known then, what I know now?… And I must forgive the past and not dwell on it in order to heal.

In June of 2008, my nutritionist who was treating me with amino acid therapy took me off Zoloft abruptly.  This caused me to go into a manic state, which I had never experienced before.  It also brought up a lot of anger.  After about a ten days, my wife and I figured out it was the discontinuation of Zoloft that was causing all these problems, so I went back on it.

Because of all my weird behavior, I had left the house and was staying at a hotel.  My wife got my sister involved and she stayed with me for a couple of days but didn’t bring along her bi-polar medications.  I remember distinctly the night of July 13th:  I slept from about 9pm to 5am, went for a work out and did my meditation.  I was definitely stabilizing.

Then my sister took me into town, my wife and I had another fight and, in my anger and frustration, I broke the rear view mirror off my sister’s car.  This caused her to freak out.  We had picked up her meds and agreed to go back to the hotel and take a nap.  I later learned that she had already called the police.

When we arrived at the hotel, the cops came to my door (hands on their holstered guns) and ordered me out of the car.  They hand cuffed me, searched me and put me in the squad car.  Then, as I later learned, my sister and wife had a discussion about “wether or not to tell the police that I had threatened her.”  My sister told the police a lie, that I had threatened her with a gun and I was hauled off to the ER where I was doped up with an injection.

Later I was taken to the psychiatric hospital where I was asked to sign a bunch of forms and “releases.”  How absurd!  I was only semi-consicouss at the time.

At the hospital I was taken off the Zoloft and diagnosed as bi-polar.  Of course, this through me into another withdrawal episode and made me manic and aggressive again.

I want to point out that I have no history of violence, have never been in any sort of brawl, have never been arrested, have never before been put in handcuffs, no DUI tickets and even a clean driving record.

The hospital changed my drugs every few days.  Zyprexa, Lithium, Depakote, Abilify, etc.  After 20 days, I was discharged. The insurance and family money was expended, so I was well, right?

Far from it:  My wife filed for divorce.  I lost access to my home, which was also my office.  She cleaned out the company bank account, etc.

Eventually, I lost pretty much everything and got saddled with all our debt and received none of the assets due to a waiver of “appearance” I signed 3 days out of the hospital.  We had agreed on a negotiated, one lawyer divorce, but I ended up getting totally screwed.

Over the past 12 months, I’ve lived in 5 states.  I’ve had a couple of “room and board” jobs and stayed with friends.  Fortunately, my mother has been able to give me some financial support, so I haven’t been without the basic necessities of life.  Through a friend, I found Dr. Tracy and she helped me understand what happened to me and gave me phone support while I finished the detox from the Zoloft these past few months.

Now, I’m well enough that I’m looking for  a job again so I can restart my life.

I’m certainly not bipolar.  What a bunch of total bullshit.  All I’m taking right now is 0.5 mg of Klonopin (Clonazepam) twice a day to help with anxiety and sleep.

I used to have a pretty normal life.  I made a six figure income.  My wife (18 years of marriage) didn’t have to work. We had a nice house and the swimming pool I had wanted since I was a child.  Now, all that’s gone.  All because of a stupid little pill and all the people that don’t know what the hell their doing with all these powerful drugs.

During the 13 years I was on SSRI Antidepressants, I saw several different psychiatrists and doctors.  They experimented on me with many different drugs: Effexor, Celexa, Abilify, Alprazolam, Clonazepam (Klonopin), Depakote, Lunesta, Trazodone, Xanax, Zyprexa and of course Zoloft (Sertraline).

Of all the drugs, Lamictal was the worst.  Once the doctor increased the dose from 50 mg a day to 200 mg a day (I’ve since found out that is NOT an increase in accordance with the manufacturers instructions) I had horrible, disgusting nightmares every single night and became highly suicidal.  This happened in October of 2008, and freaked me out so much that I went back on Zoloft and some other drugs so that I could get my sleep.

During all these crazy times, I have survived because of my spiritual faith, the generosity of my mother and some good friends and Divine Grace.  Also, because of the various nutritionists I’ve had over the years, I’ve learned how to eat well and take the right supplements.  Cenitol by metagenics is magnesium supplement that has been especially helpful with relaxing me and helping me sleep.  I order that online at:  http://www.janethumphrey.meta-ehealth.com.

Lastly, I would like to mention that none of these doctors I saw gave me any sort of what I would call informed consent.  I was never informed about all the adverse reactions and side-effects that I’ve now learned were well known back then.  None of the doctors explained that, according to their view of brain chemical imbalance, I would need to stay on these SSRI Antidepressants for the rest of my life.  None of the doctors EVER explained discontinuation syndrome etc, etc, etc.

These drugs manufactures and the doctors that push these drugs are all involved in a horrible scam, the tragic consequences of which yet to become fully manifest.

My intense gratitude to Dr. Tracy and the good work she is doing!

B
Beneficat, Bimaran, Bioperidolo, Biston, Brotopon, Bespar, Bupropion, Buspar, Buspimen, Buspinol, Buspirone, Buspisal

C
Calepsin, Calcium carbonate, Calcium carbimide, Calmax, Carbamazepine, Carbatrol, Carbolith, Celexa, Chlordiazepoxide, Chlorpromazine, Cibalith-S, Cipralex, Citalopram, Clomipramine, Clonazepam, Clozapine, Clozaril, Concerta, Constan, Convulex, Cylert

D
Dalmane, Dapotum, Defanyl, Demolox, Depakene, Depakote, Deprax, Deprilept, Deroxat, Desipramine, Desirel, Desoxyn, Desyrel, Dexedrine, Dextroamphetamine, Dextrostat, Diapam, Diazepam, Dilantin, Disulfiram, Divalproex, Dogmatil, Doxepin, Dozic, Duralith

E
Edronax, Efectin, Effexor (Efexor), Eglonyl, Einalon S, Elavil, Endep, Epanutin, Epitol, Equetro, Escitalopram, Eskalith, Eskazinyl, Eskazine, Etrafon, Eukystol

F
Faverin, Fazaclo, Fevarin, Finlepsin, Fludecate, Flunanthate, Fluoxetine, Fluphenazine, Flurazepam, Fluvoxamine, Focalin

G
Geodon, Gladem

H
Halcion, Halomonth, Haldol, Haloperidol, Halosten

I
Imipramine, Imovane

J
Janimine, Jatroneural

K
Kalma, Keselan, Klonopin

L
Lamotrigine, Largactil, Levomepromazine, Levoprome, Leponex, Lexapro, Libritabs, Librium, Linton, Liskantin, Lithane, Lithium, Lithizine, Lithobid, Lithonate, Lithotabs, Lorazepam, Loxapac, Loxapine, Loxitane, Ludiomil, Lunesta, Lustral, Luvox, Lyogen, Lecital

M
Manegan, Manerix, Maprotiline, Mellaril, Melleretten, Melleril, Meresa, Mesoridazine, Metadate, Methamphetamine, Methotrimeprazine, Methylin, Methylphenidate, Minitran, Moclobemide, Modafinil, Modalina, Modecate, Moditen, Molipaxin, Moxadil, Murelax, Myidone, Mylepsinum, Mysoline

N
Nardil, Narol, Navane, Nefazodone, Neoperidol, Norebox, Normison, Norpramine, Nortriptyline, Novodorm

O
Olanzapine, Omca, Orap, Oxazepam

P
Pamelor, Parnate, Paroxetine, Paxil, Peluces, Pemoline, Permitil, Perphenazine, Pertofrane, Phenelzine, Phenytoin, Pimozide, Piportil, Pipotiazine, Pragmarel, Primidone, Prolift, Prolixin, Protriptyline, Provigil, Prozac, Prysoline, Psymion

Q
Quetiapine

R
Ralozam, Reboxetine, Resimatil, Restoril, Restyl, Rhotrimine, Risperdal, Risperidone, Rispolept, Ritalin, Rivotril, Rubifen, Rozerem

S
Sediten, Seduxen, Selecten, Serax, Serenace, Serepax, Serenase, Serentil, Seresta, Serlain, Serlift, Seroquel, Seroxat, Sertan, Sertraline, Serzone, Sevinol, Sideril, Sigaperidol, Sinequan, Sinqualone, Sinquan, Sirtal, Solanax, Solian, Solvex, Songar, Stazepin, Stelazine, Stilnox, Stimuloton, Strattera, Sulpiride, Sulpiride Ratiopharm, Sulpiride Neurazpharm, Surmontil, Symbyax, Symmetrel

T
Tafil, Tavor, Taxagon, Tegretol, Telesmin, Temazepam, Temesta, Temposil, Terfluzine, Thioridazine, Thiothixene, Thombran, Thorazine, Timonil, Tofranil, Trancin, Tranax, Trankimazin, Tranquinal, Tranylcypromine, Trazalon, Trazodone, Trazonil, Trialodine, Triazolam, Trifluoperazine, Trihexane, Trihexyphenidyl, Trilafon, Trimipramine, Triptil, Trittico, Tryptanol

U
V
Valium, Valproate, Valproic acid, Valrelease, Venlafaxine, Vestra, Vigicer, Vivactil

W
Wellbutrin

X
Xanax, Xanor, Xydep

Z
Zamhexal, Zeldox, Zimovane, Zispin, Ziprasidone, Zolarem, Zoldac, Zoloft, Zolpidem, Zonalon, Zopiclone, Zydis, Zyprexa

Also keep in mind that antidepressants affect memory so strongly that “amnesia” is listed as a “frequent” side effect. Combine that with the information we have that Alzheimer’s is a condition of elevated serotonin levels and antidepressants are designed to specifically increase serotonin levels and you can see how many of the problems Ray was dealing with we being caused by the medication he was being given.

Dr. Ann Blake-Tracy, Executive Director, International Coalition for Drug Awareness, www.drugawareness.org
____________________________________________________________________________________

In the very hours we were celebrating Andrew in Washington, tragedy was unfolding in Texas. Lt. Col. Raymond Rivas, a 53-year old civil affairs officer who had dedicated his career to rebuilding war torn countries, was found dead in his car in the parking lot of Brooke Army Medical Center in San Antonio Texas.

Colleagues of Ray’s said prescription pills and notes he wrote to his family and wife, Colleen, were found. A military source told me all indications are Ray took his own life.

His devastated family understandably declined to talk publicly, and the military won’t discuss the case citing privacy concerns. But friends and colleagues I spoke to confirmed that Ray had suffered multiple blast injuries to his brain from bomb attacks during several deployments over the years.

In October 2006, Ray survived an attack in Iraq that rendered him briefly unconscious. He was transferred to Europe but somehow talked the doctors into sending him back to the war zone. A week later, ill and confused, he was sent back to the United States.

A close associate tells me that at first, despite being diagnosed with traumatic brain injury in Iraq, some doctors thought Ray might be suffering from post-traumatic stress disorder. They didn’t realize he had all the symptoms of traumatic brain injury. He had trouble talking, reasoning and remembering.

He was sent to Brooke Army Medical Center in San Antonio so he could be near his family, but for the first few months he just sat in his room. Fellow soldiers helped him with his bathing, dressing and eating.

Finally, Ray was assigned a case manager, and things began to move rapidly. He got therapy and was able to go home.

But by all accounts from his friends, Ray had become seriously debilitated by the injuries to his brain. A private email shown to CNN revealed that Ray had been diagnosed with rapidly emerging Alzheimer’s disease. The cumulative impact of all those bomb blasts were destroying his brain. Colleagues say Ray knew he might have to move to an assisted living facility.

Ray’s doctors are not discussing his treatment because of privacy concerns.

A colleague told me Ray was tired and in pain on the night of July 15. He was found in his car in the parking lot at the army hospital where he had spent so long trying to get better.

http://www.cnn.com/2009/US/07/27/starr.extraordinary/index.html?iref=24hours

Behind the Scenes: Triumph and tragedy for two wounded soldiers

* Story Highlights
* CNN’s Barbara Starr celebrated a victory and mourned a loss on July 15
* An injured Marine was celebrating getting into Harvard Law School
* On same night, a warrior with a traumatic brain injury was found dead in his car
* Men’s stories are linked — both pleaded with the government to aid injured soldiers

By Barbara Starr
CNN Pentagon Correspondent

WASHINGTON (CNN) — Where were you on the night of July 15? You may not even remember, but for me it was an extraordinary evening, an evening of unimaginable triumph and unbearable tragedy.

But I would not actually know everything that happened until the night was long over.

A couple of weeks before July 15, a friend who works with injured troops emailed me to say it was time for Andrew’s going away party.

Andrew Kinard is a young Marine I first met a few years ago at Walter Reed Army Medical Center in Washington where he was recovering from a devastating IED attack in Iraq. He had stepped on the roadside bomb and lost his entire body below the hips.

The party being arranged was Andrew’s farewell to D.C. Andrew is off to the rigors of Harvard Law School. He’s says he’s itching to get into a courtroom.

You need to remember the name Andrew Kinard. Many of his friends believe Andrew is such an amazing man that he will become president of the United States. If I had to bet, I’d say it could happen.

I wouldn’t have missed the party for the world. I was touched that this tight-knit community of wounded warriors had included me in this very special, very intimate evening.

There was a display of photos of Andrew serving in Iraq. I suddenly realized I never knew how tall he was before the war. There were a few sniffles and wiping of eyes in the room for a Marine whose dream of service to his country ended within a few months of getting to Iraq. But sniffles didn’t last long and the evening became one of hugs, laughter and good wishes (and more than a few beers) for a young Marine who had triumphed over what the war had dealt him.

But my warm feelings didn’t last long. The next day another source in the wounded troop community came to me in the Pentagon hallway with another tale.

“You have to do something about the story of Ray Rivas,” he said.

In the very hours we were celebrating Andrew in Washington, tragedy was unfolding in Texas. Lt. Col. Raymond Rivas, a 53-year old civil affairs officer who had dedicated his career to rebuilding war torn countries, was found dead in his car in the parking lot of Brooke Army Medical Center in San Antonio Texas.

Colleagues of Ray’s said prescription pills and notes he wrote to his family and wife, Colleen, were found. A military source told me all indications are Ray took his own life.

His devastated family understandably declined to talk publicly, and the military won’t discuss the case citing privacy concerns. But friends and colleagues I spoke to confirmed that Ray had suffered multiple blast injuries to his brain from bomb attacks during several deployments over the years.

In October 2006, Ray survived an attack in Iraq that rendered him briefly unconscious. He was transferred to Europe but somehow talked the doctors into sending him back to the war zone. A week later, ill and confused, he was sent back to the United States.

A close associate tells me that at first, despite being diagnosed with traumatic brain injury in Iraq, some doctors thought Ray might be suffering from post-traumatic stress disorder. They didn’t realize he had all the symptoms of traumatic brain injury. He had trouble talking, reasoning and remembering.

He was sent to Brooke Army Medical Center in San Antonio so he could be near his family, but for the first few months he just sat in his room. Fellow soldiers helped him with his bathing, dressing and eating.

Finally, Ray was assigned a case manager, and things began to move rapidly. He got therapy and was able to go home.

But by all accounts from his friends, Ray had become seriously debilitated by the injuries to his brain. A private email shown to CNN revealed that Ray had been diagnosed with rapidly emerging Alzheimer’s disease. The cumulative impact of all those bomb blasts were destroying his brain. Colleagues say Ray knew he might have to move to an assisted living facility.

Ray’s doctors are not discussing his treatment because of privacy concerns.

A colleague told me Ray was tired and in pain on the night of July 15. He was found in his car in the parking lot at the army hospital where he had spent so long trying to get better.

But Ray will be remembered for all he did for others. Even with all his suffering, he wanted to make sure other injured troops were helped. In April he and his wife Colleen went to Capitol Hill to testify with other wounded warriors about their needs.

Sitting on that panel with Ray was Andrew Kinard.

All AboutBrooke Army Medical Center

“On May 11, after a dispute at the center, Russell was ordered to leave. Outside, he allegedly grabbed a gun from his escort, burst into the center and started firing. He submitted to arrest minutes later.”

Dead were Navy Cmdr. Charles Springle, 52, of Wilmington, N.C.; Maj. Matthew Philip Houseal, 54, of Amarillo; Staff Sgt. Christian Enrique Bueno-Galdos, 25, of Paterson, N.J.; Spc. Jacob David Barton, 20, of Lenox, Mo., and Pfc. Michael Edward Yates Jr., 19, of Federalsburg, Md.

http://www.amarillo.com/stories/072809/new_news8.shtml

Web-posted Tuesday, July 28, 2009

Soldiers’ families await hearing
Los Angeles Times

SHERMAN – Tears come to Elizabeth Russell’s eyes when she thinks of the five American soldiers her son is accused of gunning down in a moment of rage in Iraq.

She prays for them: the Navy officer, the Army psychiatrist, and three enlisted men, and their widows, parents and children.

She also prays for her son, Army Sgt. John Russell, who faces five counts of premeditated murder for what happened May 11 at a combat stress center near Baghdad.

Russell, 44, is in custody in Kuwait, awaiting an Article 32 hearing, the military equivalent of a preliminary hearing. Under military law, a conviction can carry a death sentence; the minimum is life in prison.

In more than seven years of war in Afghanistan and Iraq, there have been cases of alleged attacks among U.S. troops, but never one in which a soldier stands accused of killing five colleagues.

The Russell case also brings up issues of how the Army evaluates the mental health of troops in combat zones, many of whom, like Russell, have endured repeated deployments. The Army is now studying the psychological services available to soldiers in Iraq.

Russell had been a competent communications technician but hardly a stellar performer. After 16 years, he was still a sergeant. He had lost a stripe earlier for unauthorized absence.

Russell went to the combat stress center at Camp Liberty where mental-health workers evaluate soldiers for post-traumatic stress disorder and depression. Russell was close to the end of his deployment. He was given medication and his sidearm was taken away, a routine precaution for soldiers receiving counseling.

On May 11, after a dispute at the center, Russell was ordered to leave. Outside, he allegedly grabbed a gun from his escort, burst into the center and started firing. He submitted to arrest minutes later.

Dead were Navy Cmdr. Charles Springle, 52, of Wilmington, N.C.; Maj. Matthew Philip Houseal, 54, of Amarillo; Staff Sgt. Christian Enrique Bueno-Galdos, 25, of Paterson, N.J.; Spc. Jacob David Barton, 20, of Lenox, Mo., and Pfc. Michael Edward Yates Jr., 19, of Federalsburg, Md.

Paragraph 8 reads: “Sanchez and Buchholtz lived together during the pregnancy and the first two weeks after their son was born, Buchholtz told the Express-News. The paper reported that an infection complicated Sanchez’s recovery from giving birth, and she was required to use a catheter for about a week. That setback darkened her mood, and she was soon diagnosed with postpartum depression.”

Paragraphs 9 & 10 read: “She moved out of the couple’s shared home July 20. On Saturday, she showed up to see Buchholtz at his parents’ house. She became agitated when he told her he needed a copy of the baby’s birth certificate and Social Security card, Buchholtz told the paper.

Sanchez ran out of the home with her son in a car seat, threw the car seat into the front passenger seat of her car and sped away without buckling him in, the paper said. She left behind a diaper bag, her purse and her medication.

http://www.google.com/hostednews/ap/article/ALeqM5j65NeeVH5ihfMyvu7qiBZWQBV-kgD99NHC180

By PAUL J. WEBER (AP) – 1 hour ago

SAN ANTONIO ­ Relatives of the Texas mother of a 3 1/2-week-old boy found dismembered in his bedroom said she was diagnosed with schizophrenia and postpartum psychosis, and the father of the slain baby said he wants the woman executed.

Otty Sanchez, 33, is charged with capital murder in the death of Scott Wesley Buchholtz-Sanchez. When authorities found the infant’s body Sunday, Sanchez told officers the devil made her do it, police said.

“She was a sweet person and I still love her, but she needs to pay the ultimate price for what she has done,” the baby’s father, Scott W. Buchholtz, told the San Antonio Express-News Monday. “She needs to be put to death for what she has done.”

Relatives and Buchholtz told the newspaper Sanchez’s mental health deteriorated in the week before her son’s death. Buchholtz, who called his son “baby Scotty,” said she often talked about how she needed to see a counselor. Sanchez told detectives she had been hearing voices.

Otty Sanchez’s aunt, Gloria Sanchez, told The Associated Press that her niece had been “in and out” of a psychiatric ward, and that the hospital called several months ago to check up on her.

Sanchez was hospitalized Tuesday with self-inflicted stab wounds and was being held on $1 million bail. Police have said she does not have an attorney. Authorities found the baby with three of his toes chewed off, his face torn away and his head was severed.

Otty Sanchez’s sister and her sister’s two children, ages 5 and 7, were in the house at the time, but none were harmed.

Sanchez and Buchholtz lived together during the pregnancy and the first two weeks after their son was born, Buchholtz told the Express-News. The paper reported that an infection complicated Sanchez’s recovery from giving birth, and she was required to use a catheter for about a week. That setback darkened her mood, and she was soon diagnosed with postpartum depression.

She moved out of the couple’s shared home July 20. On Saturday, she showed up to see Buchholtz at his parents’ house. She became agitated when he told her he needed a copy of the baby’s birth certificate and Social Security card, Buchholtz told the paper.

Sanchez ran out of the home with her son in a car seat, threw the car seat into the front passenger seat of her car and sped away without buckling him in, the paper said. She left behind a diaper bag, her purse and her medication.

Buchholtz’s mother called 911, and a sheriff’s deputy investigated the incident as a disturbance, according to court records. The next day, authorities said, she killed her son.

Officers called to Sanchez’s house at about 5 a.m. Sunday found her sitting on the couch screaming “I killed my baby! I killed my baby!” San Antonio Police Chief William McManus said.

McManus described the crime scene as so grisly that police officers barely spoke to each other while looking through the house.

Copyright © 2009 The Associated Press. All rights reserved.

Dr. Ann Blake-Tracy, Executive Director, International Coalition For Drug Awareness

Paragraph four reads: “The jury inquest at Nottingham Coroner’s Court heard Mr Brown had been at the prison for five weeks and was four days away from being released when he was seen by a psychiatrist and given anti-depressants.”

SSRI Stories note: The most likely time for suicidal behaviors and SSRI antidepressants are: 1. When first starting the drugs: 2. When stopping the drugs. 3. While increasing the dose: 4. While decreasing the dose. 5. When switching from one SSRI to another antidepressant.

http://www.thisisnottingham.co.uk/homenews/Coroner-criticises-healthcare-Nottingham-Prison/article-1196220-detail/article.html

Coroner criticises healthcare at Nottingham Prison
Monday, July 27, 2009, 07:00

1 reader has commented on this story.
Click here to read their views.

A CORONER has criticised health services at Nottingham Prison after an inmate committed suicide hours after his release.

Gary Brown, 39, of Cranwell Road, Strelley, drowned on December 24, 2007.

He was seen jumping off Trent Bridge less than three hours after he was released from the prison.

The jury inquest at Nottingham Coroner’s Court heard Mr Brown had been at the prison for five weeks and was four days away from being released when he was seen by a psychiatrist and given anti-depressants.

Notts coroner Dr Nigel Chapman said there was a “huge gap” between Mr Brown seeing a GP on his arrival at the prison and seeing a psychiatrist.

The inquest heard there was a lack of communication between health workers, and one doctor at the prison called it “an entirely haphazard system”.

Mr Brown arrived at Nottingham Prison on November 15, 2007. He saw a GP, Dr Lloyd, the next day, who said Mr Brown was not showing symptoms of mental health problems.

Mr Brown said he had previously been prescribed anti-depressants but Dr Lloyd did not renew the prescription as he could not obtain any previous medical records.

Other members of the health team said they tried to get hold of Mr Brown’s medical records but were unable to trace them.

Dr Julian Kenneth Henry, who also saw Mr Brown, told the inquest the amount of time between the prisoner arriving and seeing a psychiatrist was “unprecedented”.

He said: “Unfortunately, in a prison setting there are an awful lot of people involved and there are failures of communication on a daily basis.

“It’s an entirely haphazard system. It’s a very disjointed system and there is not an excuse for it.”

Mr Brown saw psychiatrist Dr Trevor Boughton on December 20 and was given a prescription for anti-depressants.

Dr Boughton said Mr Brown seemed anxious but not psychotic or suicidal.

He said: “He seemed very eager to be released from prison. He spoke very fondly of his brother, whom he was hoping to spend Christmas with.”

The inquest heard the medication was not likely to have had any effect on Mr Brown by the time he was released four days later.

Senior prison officer Vince McGonigle said Mr Brown was released between 9am and 9.30am on December 24 and seemed “in an agitated state”.

Less than three hours later, at around 11.45am, a member of the public saw him jump from Trent Bridge into the River Trent.

Kyle Charles told the inquest: “I saw a person in the water and tried shouting at him. I managed to get the orange ring off the wall and threw that into the water but he swam away from it.

“When he saw me taking my jacket off he held his nose and then started to push himself under the water. He went down, came back up, went down and never came back up again.”

Mr Brown’s body was pulled from the water at 2.55pm. There was no evidence of any violence and no alcohol found in his system.

The jury returned a verdict of suicide, with a majority of six to two. They said there had been a “severe breakdown” of communication during Mr Brown’s care.

Coroner Dr Chapman said: “Clearly there have been difficulties here and the prison has taken those on board.”

But he said Mr Brown’s time in prison would have been a good opportunity to put him on medication and monitor him.

He added “a simple phone number” for a crisis team would be beneficial for people leaving prison.

samantha.hughes@nottinghameveningpost.co.uk

“That study is expected to take two years. In the meantime, Cardin’s amendment also would require a report every June from 2010 through 2015 giving the number and percentages of troops who are serving or have served in Iraq or Afghanistan who had prescriptions for antidepressants or similar drugs.”

http://www.airforcetimes.com/news/2009/07/military_suicides_antidepressants_072309w/

Senator: Study prescriptions-suicide link
By Rick Maze – Staff writer
Posted : Thursday Jul 23, 2009 11:32:42 EDT

The Senate on Wednesday ordered an independent study to determine whether an increase in military suicides could be the result of sending troops into combat while they are taking antidepressants or sleeping pills.

Sen. Benjamin Cardin, D-Md., who pushed for the study, said he does not know whether there is a link, but he believes prescription drug use, especially when it is not closely supervised by medical personnel, needs a closer look.

“One thing we should all be concerned about is that there are more and more of our soldiers who are using prescription antidepressant drugs … and we are not clear as to whether they are under appropriate medical supervision,” Cardin said.

The problem, he said, is that some antidepressants “take several weeks before they reach their full potential,” and during that time there is a risk of increased suicidal thoughts among 18- to 24-year-olds ­ an age group that includes many service members.

When people taking antidepressants are deployed, they may not be under close medical supervision, especially if they are in a unit that is on the move in combat, Cardin said.

“Surveys … have shown that as many as 12 percent of those who are serving in Iraq and 17 percent of those who are serving in Afghanistan are using some form of prescribed antidepressant or sleeping pills,” Cardin said. “That would equal 20,000 of our service members.”

By voice vote, the Senate approved a Cardin-sponsored amendment to the 2010 defense authorization bill that would order an independent study by the National Institute of Mental Health on the potential relationship between suicide or suicide attempts and the use of antidepressants, anti-anxiety and other behavior-modifying prescription drugs.

That study is expected to take two years. In the meantime, Cardin’s amendment also would require a report every June from 2010 through 2015 giving the number and percentages of troops who are serving or have served in Iraq or Afghanistan who had prescriptions for antidepressants or similar drugs.

The reports would not include names or any specifics that would identify the service members, Cardin said. “We protect their individual privacy,” he said. “There is no stigma attached at all to this survey.”

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———- Forwarded message ———-
From: Atracyphd1@aol.com
To: post@drugawareness.org, DCKCCPAS@aol.com, Atracyphd2@aol.com
Date: Fri, 24 Jul 2009 03:08:48 EDT
Subject: ANTIDEPRESSANTS: Senate Orders Study on Military Suicides
Paragraphs 7 & 8 read: “By voice vote, the Senate approved a Cardin-sponsored amendment to the 2010 defense authorization bill that would order an independent study by the National Institute of Mental Health on the potential relationship between suicide or suicide attempts and the use of antidepressants, anti-anxiety and other behavior-modifying prescription drugs.”

“That study is expected to take two years. In the meantime, Cardin’s amendment also would require a report every June from 2010 through 2015 giving the number and percentages of troops who are serving or have served in Iraq or Afghanistan who had prescriptions for antidepressants or similar drugs.”

http://www.airforcetimes.com/news/2009/07/military_suicides_antidepressants_072309w/

Senator: Study prescriptions-suicide link
By Rick Maze – Staff writer
Posted : Thursday Jul 23, 2009 11:32:42 EDT

The Senate on Wednesday ordered an independent study to determine whether an increase in military suicides could be the result of sending troops into combat while they are taking antidepressants or sleeping pills.

Sen. Benjamin Cardin, D-Md., who pushed for the study, said he does not know whether there is a link, but he believes prescription drug use, especially when it is not closely supervised by medical personnel, needs a closer look.

“One thing we should all be concerned about is that there are more and more of our soldiers who are using prescription antidepressant drugs … and we are not clear as to whether they are under appropriate medical supervision,” Cardin said.

The problem, he said, is that some antidepressants “take several weeks before they reach their full potential,” and during that time there is a risk of increased suicidal thoughts among 18- to 24-year-olds ­ an age group that includes many service members.

When people taking antidepressants are deployed, they may not be under close medical supervision, especially if they are in a unit that is on the move in combat, Cardin said.

“Surveys … have shown that as many as 12 percent of those who are serving in Iraq and 17 percent of those who are serving in Afghanistan are using some form of prescribed antidepressant or sleeping pills,” Cardin said. “That would equal 20,000 of our service members.”

By voice vote, the Senate approved a Cardin-sponsored amendment to the 2010 defense authorization bill that would order an independent study by the National Institute of Mental Health on the potential relationship between suicide or suicide attempts and the use of antidepressants, anti-anxiety and other behavior-modifying prescription drugs.

That study is expected to take two years. In the meantime, Cardin’s amendment also would require a report every June from 2010 through 2015 giving the number and percentages of troops who are serving or have served in Iraq or Afghanistan who had prescriptions for antidepressants or similar drugs.

The reports would not include names or any specifics that would identify the service members, Cardin said. “We protect their individual privacy,” he said. “There is no stigma attached at all to this survey.”

“Detective Senior Sergeant Mark Fyfe said prescription drugs for the woman were found alongside the unconscious mother and her seven-month-old twins, who media reports have named as Sophie and Lachlan.”

“Police believe the woman may have killed her son and daughter before attempting to take her own life.”

“Det Sen Sgt Fyfe said family members had told police the mother had been suffering postnatal depression and been prescribed drugs for treatment.”

http://news.theage.com.au/breaking-news-national/dead-twins-mother-was-depressed-report-20090707-dakd.html

Dead twins’ mother was depressed: report

Aleisha Preedy
July 7, 2009 – 1:49PM

Police are investigating reports the mother of twins found dead inside a Perth home was suffering depression.

Detective Senior Sergeant Mark Fyfe said prescription drugs for the woman were found alongside the unconscious mother and her seven-month-old twins, who media reports have named as Sophie and Lachlan.

Police believe the woman may have killed her son and daughter before attempting to take her own life.

Det Sen Sgt Fyfe said family members had told police the mother had been suffering postnatal depression and been prescribed drugs for treatment.

He said police had ruled that no one had forced entry into the house and the incident was being investigated as an apparent murder suicide.

“We are investigating reports the mother was suffering postnatal depression,” Det Sen Sgt Fyfe told reporters on Tuesday.

“We have been unable to confirm that at the moment.

“It appears she may have taken an overdose of prescription drugs but until later today when the toxicology reports are out, I can’t confirm that.”

He said the distraught father had been sedated and police hoped to speak to him later in the day.

The mother remained in a critical but stable condition in Royal Perth Hospital.

Major crime squad detectives were called to the home at the end of a cul-de-sac in Flintlock Street, Cloverdale about 3.30pm (WST) on Monday.

The twins were the couple’s only children.

© 2009 AAP

http://www.tampabay.com/news/publicsafety/crime/article1015369.ece

Spa manager believes she is a victim of the Botox Bandit
By Justin George, Times Staff Writer
In Print: Friday, July 3, 2009

TAMPA ­ The woman came in looking to peel off her past.

Blond hair, blue eyes, gym shorts. Like the girl next door, thought the manager of Skin NV, a med spa that opened in May.

The client said her 10-year high school reunion was around the corner and she wanted to be the envy of everyone else.

The spa obliged.

Chemical peel: $50. Laser treatment: $348. A protein-rich recovery cream: $155. Clarisonic Skin Care Brush: $195. Prescription-grade Vitamin A: $74.

Then came the bill: $851.68, not uncommon in South Tampa, where looks matter and women have the means, said Anne Nelson, Skin NV’s manager.

The client wrote a check and signed it Jaimie Merk.

Five days later, on June 15, the check bounced. It bounced again on repeat tries. Nelson has the bank paperwork to prove it.

That’s when she learned the story of the Botox Bandit.

“What kind of girl does this?” she asks now. “I just don’t understand.”

• • •

On Jaimie Merk’s Facebook page, her profile photo flashes an even, bright white smile.

She’s single, 32, and says she works as a weight-loss clinic director.

She majored in psychology at the University of North Florida.

Yoga is her new obsession, she notes on Facebook. She loves lying in the sun, hearing a baby laugh and getting facials.

She has nearly 400 friends. Some write her daily.

She doesn’t like to be called “ma’am.”

Elsewhere, a different picture of Merk appears.

Once, in a courtroom, a doctor testified that her self-esteem was so low that she resorts to stealing Botox to feel better, according to an attorney who was part of the proceedings.

In April, Tampa police reported they took Merk into protective custody for mental evaluation after she sent her ex-boyfriend a text message indicating she was suicidal. Police noted she was taking medication for depression.

People victimized by Merk do not have much sympathy.

Their names show up in lawsuits and court judgments.

• • •

In August 2007, the Hillsborough County Sheriff’s Office asked the public for help catching the “Botox Bandit.”

A woman had shown up at Rejuva Plastic Surgery Center and Medi-Spa, received a facial and cosmetic procedures, and then disappeared leaving an $850 bill. She used an alias.

The Sheriff’s Office had a picture of the suspect ­ made possible because the plastic surgeon had taken a “before” photo.

A tip led deputies to Jaimie Merk, Hillsborough County Sheriff’s officials said at the time.

It was just one of several cases that landed her on probation until 2012 for several convictions of grand theft and worthless checks in Hillsborough and Pinellas counties, according to the state Department of Corrections.

Her civil court and probation files contain claims from pet supply stores, renters and even an adoption agency saying she owes them money.

Those who have dealt with Merk wonder whether there are other victims.

• • •

Pregnant in 2004, Merk agreed to turn over her unborn child to adoptive parents through Heart of Adoptions of Tampa, according to a lawsuit the agency filed.

She told the adoption agency that she had no idea who the father was, the lawsuit stated. She said she met him at a bar.

Medical records stated that Joshua Sean Squires was the father. But Merk signed a notarized statement disputing that, the lawsuit said.

The adoptive parents and the agency paid her more than $5,000 for living expenses, attorney fees and other costs.

A few weeks later, the agency heard from Squires.

In an interview with the Times, he said he was in a weeks-­long relationship with Merk when she became pregnant.

“She knew she was pregnant with my child,” he said. “There was no one-night stand with anyone, and I was in the delivery room on Dec. 23, 2004.”

Squires, 30, now has custody of the 4½-year-old girl.

In 2006, a judge ordered Merk to pay the agency $6,113, court records show.

The agency’s executive director, Brigette Barno, said Monday that Merk has paid nothing.

• • •

In January 2008, prospective renters responded to an ad on Craigslist advertising a Seminole Heights house that belongs to Merk’s mother, according to Hillsborough property records.

Two of them, Angela Hart and Eric Younghans, wound up suing Merk in small claims court. Hart also sued Merk’s mother.

They say Jaimie Merk showed them a house and collected $1,900 from each of them.

Hart, suspicious after Merk delayed the move-in date, looked her up on Google and learned of her Botox Bandit past. She asked for her money back. In a court document, she said Merk agreed.

Younghans, meanwhile, learned from Merk that the house wouldn’t be available. Merk told him she would refund his money, he said.

Neither got a refund. Merk made excuses, they said. Sometimes she didn’t return calls.

In 2008, a judge ordered her to pay each $2,075. In Hart’s case, Merk’s mother was also held responsible, according to the final judgment.

So far, Hart, 30, has received $150, she said.

“She’s never going to learn her lesson,” Hart said of Merk. “People say people change. They don’t.”

Younghans, 56, has received $150, he said.

“She seemed very believable,” he said. “She’s very good at it.”

• • •

Merk did not respond to a voice mail message from the Times for this story. A note was left at her door seeking comment. An attorney who represented her did not call back.

“I’m not giving any comments,” said her mother, Debra Merk, who owns a $1.1 million waterfront house in Clearwater Beach. “As far as I know, what you’re saying is not true.”

• • •

In hindsight, the Skin NV manager said she felt a little wary about Merk’s June 10 check when she noticed the address in a neighborhood of rentals.

After the check bounced, she tried to call Merk. The phone numbers Merk left didn’t work.

Nelson sent her business partner to Merk’s stated address, a pink apartment building. The partner left a note.

No one called back.

Nelson contacted the Hillsborough County Victims Assistance program. A counselor helped her start the process of filing a bad check complaint. That process is now under way. No charges have been filed.

Nelson even tried to connect with Merk by inviting her to be a “friend” on Facebook.

Merk didn’t respond.

On June 25, after a Times reporter left messages for Merk, she sent an e-mail to the spa.

“I’m very sorry I did not contact you sooner,” she wrote. “I have not had a phone since you left that letter at my apartment, and I just received another letter in the mail today.

“I just want you to know that I am very sorry for this, and of course I’m going to pay for the services I received,” she wrote. “I am just not sure why you have chosen to take this further without even giving me the opportunity to rectify the situation.”

Merk said she would bring the money in this week.

Nelson told her the spa would be closed Friday.

By the end of the day Thursday, Merk hadn’t paid.

• • •

On a Facebook quiz, Merk writes that she loves the smell of flowers and wants to meet the man of her dreams.

Two things she is proud of? Her daughter and family.

Two things she is not proud of? “Let’s keep those in the closet,” she wrote.

Times researcher Shirl Kennedy contributed to this report. Justin George can be reached at (813) 226-3368.

“They say he sought help from the military to battle depression and PTSD and was on medication.”

http://www.wmur.com/news/19934903/detail.html

Full Military Honors Planned For Marine

Family Questions Whether He Should Have Been Given More Help
POSTED: 11:19 pm EDT July 2, 2009
UPDATED: 11:43 pm EDT July 2, 2009

AUBURN, N.H. — New Hampshire is preparing to lay a Marine to rest with full military honors.

Staff Sgt. Charles Edward Dane, known as Eddie to family and friends, served six combat tours, dedicating 15 years in service to the country.

Last week, 37-year-old Dane took his life in California where he was stationed. His family in Auburn questions if more could have been done to prevent his death.

They say he sought help from the military to battle depression and PTSD and was on medication.

After two DUIs, Dane was being processed out of the service he loved.

A funeral with full military honors will be held Monday at noon at the New Hampshire State Veterans Cemetery in Boscawen.
Tell Us More: E-mail WMUR your tips and story ideas.

Copyright 2009 by WMUR. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Paragraph 7 reads: “Fessenden disputes reports that his son was taking multiple prescription drugs. He said his son recently went off anti-depressants.”

Relatives remember Oceana man as generous person

by Chad D. Lerch | The Muskegon Chronicle
Friday July 03, 2009, 6:41 AM

Roger Fessenden

OCEANA COUNTY — Dale Fessenden says his son, who was found dead June 25 in an Oceana County pond, will be remembered as a caring person who always put others first.

His son, Roger Dale Fessenden, 40, of Rothbury suffered a back injury at work earlier this year when he fell 20 feet while cleaning a storage tank. He underwent back surgery in February, family members said.

Roger Fessenden was reported missing June 23 and was found dead two days later in a pond known by locals as Oceana Lake in Grant Township.

Dale Fessenden said his son often had a difficult time sleeping because of back pain. He said Roger would take prescription sleeping pills and then go for drives in his car. He suspects the sleeping pills affected his son’s judgment.

On the night he went missing, Roger Fessenden likely took sleeping pills before venturing out, his father said.

“He didn’t know what he was doing and just took off,” he said. “I’m convinced that’s what happened to him.”

Fessenden disputes reports that his son was taking multiple prescription drugs. He said his son recently went off anti-depressants.

Family members said they want Roger Fessenden to be remembered as someone with a generous heart.

Dale Fessenden said his son once went shopping for a stranger in the hospital — just because he wanted to help.

“That’s the kind of person my son was,” he said. “He was the most polite person in my life.”

Oceana County Sheriff Bob Farber said a toxicology report is pending in the investigation into Roger Fessenden’s death. The report could return from the lab in the next two weeks.

But in the meantime, the county coroner has ruled the cause of death as drowning. It remains unclear how Fessenden ended up in the pond.

Fessenden, a longtime resident of Ferry, is survived by his wife, Blanco Suarez, two stepchildren and his parents.

E-mail Chad D. Lerch at clerch@muskegonchronicle.com

Paragraphs 29 & 30 read: “He stopped going to school and began attending an outpatient program, seeing a therapist and a psychiatrist and taking medication for depression and anxiety. He tried returning to school on a half-day basis, but soon became overwhelmed with makeup work and inquiries from classmates who heard rumors he had tried to kill himself. After a few days in school, Iain asked to be readmitted to the hospital, where he stayed for a week, his parents said.”

“But as summer approached, he began showing signs of improvement. He was easier to communicate with, did his chores when asked and his doctors believed they had found the right balance in his medication, his father said.”

Paragraph 32 reads: “Lain’s parents and friends say they do not know of any incidents that might have triggered what happened June 3, when his father found him in the basement. His death was ruled a suicide by hanging, according to the Cook County Medical Examiner’s Office. He did not leave a note.”

http://www.azcentral.com/news/articles/2009/07/05/20090705bullying.html

Bullied boy’s short life ends in suicide
Jul. 5, 2009 08:20 AM
Associated Press

CHICAGO – The bullying seemed inescapable.

His family and friends say it followed Iain Steele from junior high to high school
- from hallways, where one tormentor shoved him into lockers, to cyberspace, where another posted a video on Facebook making fun of his taste for heavy metal music.

“At one point, (a bully) had told (Iain) he wished he would kill himself,” said Matt Sikora, Iain’s close friend.

Iain’s parents know their son had other problems, but they believe the harassment contributed to a deepening depression that hospitalized the 15-year-old twice this year. On June 3, while his classmates were taking final exams, he went to the basement of his home and hanged himself with a belt.

His death stunned his quiet suburb west of Chicago and unleashed an outpouring of support for his parents, William and Liz, who say greater attention should be paid to bullying and its connection to mental health.

“No kid should be afraid for himself to go to school,” his father said. “It should be a safe environment where they can intellectually thrive. And he was, literally, just frightened to go to school, fearing what he would have to deal with on that day. And it was day after day.”

A school spokeswoman said she did not believe Iain was bullied. Police are investigating the allegations.

Nearly 30 percent of American children are bullied or are bullies themselves, according to the National Youth Violence Prevention Resource Center. Bullying can be physical, verbal or psychological and is repetitive, intentional and creates a perceived imbalance of power, said Dr. Joseph Wright, senior vice president at Children’s National Medical Center in Washington.

Soon, the American Academy of Pediatrics will for the first time include a section on bullying in its official policy statement on the pediatrician’s role in preventing youth violence.

Wright, a lead author of the statement, said the decision to address the issue was due to a growing body of research over the last decade linking bullying to youth violence, depression and suicidal thoughts.

Last year, the Yale School of Medicine conducted analysis of the link between childhood bullying and suicide in 37 studies from 13 countries, finding both bullies and their victims were at high risk of contemplating suicide.

In March, the parents of a 17-year-old Ohio boy who committed suicide filed a lawsuit against his school alleging their son was bullied. Instead of seeking compensation, they are asking the school to put in place an anti-bullying program and to recognize their son’s death as a “bullicide.”

—

Iain Steele enjoyed riding his skateboard, his father said, but after hip surgery in 8th grade limited his mobility, he picked up the guitar and impressed an instructor with his musical talent.

He was revered by younger kids in the neighborhood, often fixing their skateboards, settling their disputes and including them in games. “He was a very gentle, kind kid, compassionate to a fault,” his father said. But Iain’s embrace of heavy metal set him apart from classmates. He let his hair grow to shoulder-length and wore mostly black clothing, including jeans with chains and T-shirts of heavy metal bands with dark, sometimes morbid lyrics.

For this, his classmates at McClure Junior High School often called him “emo” – a slang term for angst-ridden followers of a style of punk music, said Sikora, 15.

The bullying could also be physical, Iain’s friends and parents said. In 8th grade at McClure, one bully pushed Iain into a locker while he was on crutches and accused him of faking an injury to get out of gym class. Iain rarely shied away from his tormentors, however, and in this case, he punched the bully in the jaw, his father said.

“He was mainly bullied only because he was different, or hurt, or stupid things like that,” said Sikora. “He never bothered anybody. … It was all just because he was different and an easy target.”

William Steele said his son had trouble ignoring the bullying because it “was just sort of relentless.” It got to the point where the father sat down with the principal at McClure and with a bully’s mother. But the harassment did not subside.

Steele said, “(Iain) had a real trust issue because he felt like, particularly at McClure, the system let him down, that it didn’t deliver on its promise to protect him from bullying.”

McClure Principal Dan Chick said in an e-mail “the District 101 community is deeply saddened by this recent tragedy of losing one of our children.” Chick said he takes bullying very seriously but declined to discuss details of Iain’s case because of privacy issues.

“As with all situations, I investigated this specific matter and took appropriate actions within the limits of my authority,” Chick said.

After graduating from McClure in 2008, Iain began attending the south campus for freshmen and sophomores at Lyons Township High School, where he found new friends – and new tormentors. A new bully emerged who at first acted friendly but then posted a homemade video on Facebook pretending to be Iain playing heavy metal on guitar.

“It was like a public humiliation to (Iain),” Sikora said.

The family of the student did not respond to requests for comment.

Jennifer Bialobok, a spokeswoman for Lyons Township High School, said “bullying is obviously not tolerated at LT,” but added, “I don’t think we’re naive enough to think that bullying behavior doesn’t exist.”

Two years ago, Lyons Township created a “speak up line” in which students can anonymously report “inappropriate or unsafe behavior,” and the school hangs posters defining bullying and explaining how to report it, Bialobok said. If any student reported being bullied, a thorough investigation would take place, with consequences ranging from parental notification to out-of-school suspension, she said.

Bialobok said she could not discuss Iain’s case because of student privacy laws, but, “we don’t believe that bullying was an issue while Iain was attending LT. Counselors and a host of other support personnel worked routinely to make his experience at LT a positive one.”

Local police have not documented incidents of bullying involving Iain but are still conducting interviews, Deputy Chief Brian Budds said.

—

By this winter, Iain’s mental health had begun a downward spiral, his parents said. In February, he told them he was having suicidal thoughts and asked to be admitted to the hospital.

He stopped going to school and began attending an outpatient program, seeing a therapist and a psychiatrist and taking medication for depression and anxiety. He tried returning to school on a half-day basis, but soon became overwhelmed with makeup work and inquiries from classmates who heard rumors he had tried to kill himself. After a few days in school, Iain asked to be readmitted to the hospital, where he stayed for a week, his parents said.

But as summer approached, he began showing signs of improvement. He was easier to communicate with, did his chores when asked and his doctors believed they had found the right balance in his medication, his father said.

“He seemed to be in a calm, happy place,” he said.

Iain’s parents and friends say they do not know of any incidents that might have triggered what happened June 3, when his father found him in the basement. His death was ruled a suicide by hanging, according to the Cook County Medical Examiner’s Office. He did not leave a note.

Looking back, Iain’s parents wonder what factors besides bullying may have contributed to their son’s depression.

Iain’s favorite heavy metal bands, such as Lamb of God and Children of Bodem and Bullet for My Valentine, often have lyrics with dark messages. One Bullet for My Valentine song is about being bullied, and another song contains the refrain: “The only way out is to die.”

Also, Iain was deeply hurt this spring after a brief relationship with a girl he met in his outpatient program. The two exchanged text messages, but her parents and therapists advised against them dating and about two months ago barred her from having communication with him.

Still, Iain’s parents remain convinced bullying played a significant role in their son’s depression. As Iain’s story spread through the community, many people approached Liz Steele to describe their own experiences with bullying, depression or suicide, she said.

“A lot of people don’t want to talk about mental health or bullying because it’s a difficult thing to talk about, but we need to talk about it,” she said. “It shouldn’t be a stigma.”

Meanwhile, the community has rallied behind the Steeles. In Iain’s memory, his classmates tied white ribbons around hundreds of trees in the neighborhood. On June 10, about 500 people attended a memorial service at First Congregational Church of Western Springs.

Rich Kirchherr, senior minister at the church, said the community has felt a “deep and abiding sadness” since Iain’s death. Kirchherr said few people seemed aware that Iain was bullied.

“There is an acknowledgment now, as people have discovered that Iain might not always have been treated with the respect that every person deserves,” Kirchherr said. “Many people were surprised to hear that.”

Friends have established several Facebook groups in his memory, including the “Iain Steele Remembrance Group,” which has more than 700 members. The commentary on the group’s wall was summed up by a Lyons Township High School student who said she did not know Iain but had learned an important lesson from his death.

“I’m learning to treat everyone with respect, even people who I don’t know well or people who I might not get along with,” she wrote. “If there is anything good that can come out of this tragedy, the responsibility lies with us to live with kindness and be aware that life is fragile.”

http://blogs.dallasobserver.com/sportatorium/2009/07/breaking_news_greg_williams_ta.php

BREAKING NEWS: Greg Williams, Take III
By Richie Whitt in Radio, TV and that Damned Media
Thursday, Jul. 2 2009 @ 7:00AM

Welcome back.

If you were surprised by Greg Williams’ cameo on with Richard Hunter yesterday afternoon, you haven’t been paying attention.

The Hammer, sacked by ESPN Radio in May partly because of a couple of wacky nights he blamed on a change in depression medication, will sit in with Big Dick the next couple of afternoons 4-6 p.m. – today, Friday, Monday and Tuesday, to be exact – on Rational Radio KMNY 1360 AM’s and see where this thing goes.

No defined role, and the gig is somewhere comfortably between a tryout and full-time. It’s the Wild Ass Circus, so who knows?

“It’s the talk radio equivalent of a jam session,” Hunter told me last night. “We wanted to do it before he went to ESPN, but he had a contractual conflict.”

I know this: Williams should be – and is – thankful to have a friend like Richard Hunter.

First, BDH invited him to be a groomsman in his wedding at this jumpin’ joint in Las Vegas. And now – you listening, Ticket boys? – when Williams needs a friend in the business Hunter is doing the opposite of turning his back on an old buddy.

I know, what a concept.

“There are two guys that I owe for my break in radio, and I will always have a place for either one of them to join me on air,” says Hunter. “Hammer’s one of them, and the other one is his former partner. I owe both those guys big time.”

No, I don’t think he’s referring to RJ Choppy.
Tags: Big Dick Hunter, Greg Williams, radio

SRI Stories note: A second article follows and states that the girl was stabbed over 200 times.

http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10582076

Tutor had ‘nasty, mean side’ ex-girlfriend tells court
11:31AM Thursday Jul 02, 2009

Sophie Elliott was stabbed to death. Photo / Supplied
Living with Clayton Weatherston could be “a bit like walking on eggshells”, a former girlfriend of the 33-year-old former University economics tutor told the Christchurch High Court this morning.

The trial was later adjourned until tomorrow after a juror collapsed.It will reconvene at 10am tomorrow.

The young woman whose identity is suppressed was in a relationship with Weatherston for two to three years until 2007 when he became involved with Sophie Elliott, a 22-year-old Honours student.

Weatherston stabbed Miss Elliott to death at her Ravensbourne home on January 9 last year and is on trial for murder.

He has admitted manslaughter but denies the killing was murder. The defense says he was provoked by the pain of the tumultuous relationship with Miss Elliott and because she attacked him with a pair of scissors.

The young woman was giving evidence on the seventh day of Weatherston’s trial.

To defense counsel Judith Ablett-Kerr QC, she said she learned she had to be “quite careful” with Weatherston. If she said something that set him off he would “really go off”.

But she agreed their relationship was generally loving and kind although she found it really stressful when he came under stress “He had two sides, a loving and generous side and a nasty, mean side which he seldom showed in public,” the woman said.

During their time together, she had never challenged Weatherston nor questioned his sexual performance. And she would not have compared his sexual organs to anyone else’s although she did once “reluctantly” when he asked her directly.

She never implied he was “a retard” but Weatherston told her Sophie Elliott had called him that.

” I thought she was probably saying it in jest and I suggested that to him. I said I didn’t think it was directed to his intelligence or meant that way.

“But he took it differently, and referred to it several times,” the young woman said.

She knew he could be mean and nasty when he was under stress and that he had been seeing a psychotherapist for years. She also knew he was on the antidepressant drug known as prozac.

“You knew he was psychologically fragile?” Mrs Ablett-Kerr asked, and the witness agreed there was “an element of fragility” to his personality.

- OTAGO DAILY TIMES
——————————————————————————————————-
Second paragraph reads: “The university tutor is accused of killing Sophie Elliott by stabbing her more than 200 times.”

http://tvnz.co.nz/national-news/tears-flow-weatherston-trial-2824693

Tears flow at Weatherston trial
Published: 12:29PM Thursday July 02, 2009

Source: NZPA/ONE News

Emotions spilled over in the murder trial of Clayton Weatherston in Christchurch on Thursday as letters he wrote after his arrest were read to the court.

The university tutor is accused of killing Sophie Elliott by stabbing her more than 200 times.

A former girlfriend of the accused, who has name suppression, read a letter she sent him while he was in jail.

“This will be a rough ride, you’ll be ok,” she read.

As Weatherston’s ex-girlfriend began to cry, there were tears from Clayton Weatherston too. His lawyer had to take over reading a letter he had written back.

“I’m nervous about court on Thursday and I’m annoyed my side will not be made public,” the letter, from just days after he stabbed Elliott to death, read.

The woman, who had been Weatherston’s girlfriend for three years, said she had written to him before she knew the extent of Elliott’s injuries.

“When I found out what had gone on…I couldn’t believe it and I wouldn’t have written a letter,” she said.

She also told the defense about the night Weatherston attacked her and kicked her across a room.

“Just before he kicked me he said ‘you ungrateful bitch’.” t

She agreed he was stressed and on anti-depressants at the time.

Just after the court adjourned, one of the jurors collapsed in the jury room.

A doctor in the court’s public gallery gave the juror medical assistance before he was taken away by an ambulance.

“We will get a report from the hospital after they have been able to assess his condition,” Justice Potter said.

If he is too unwell to continue, the court will reconvene at 10am on Friday with a jury of just 11.

Here is the complete list of adverse reactions attributable to SSRI medications:

1. Insomnia

2. Vivid and violent dreams

3. Inability to detect dreams from reality (The world takes on an other-worldly aspect)

4. No emotions

5. Inability to feel guilt or cry

6. Nausea

7. Loss of appetite

8. Rash; Breathing or lung problems

9. Heart fluttering

10. Shaking – jitteriness

11. Unusual energy surges at times producing super human strength (adrenalin rushes)

12. Memory impairment

13. Hair loss

14. Blurred vision or pressure behind the eyes

15. Inability to discontinue use of drug and increasing own dose

16. Cravings for alcohol, sweets, and other substances or drinking large sums of alcohol, coffee or other caffeinated drinks, diet pop with NutraSweet, etc.

17. Headaches

18. Swelling and/or pain in joints

19. Burning or tingling in extremities

20. Muscle twitching or contractions

21. Tongue numbness and slurred speech

22. Sweating

23. Dizziness

24. Confusion

25. Chills or cold sweats

26. Muscle weakness

27. Extreme fatigue

28. Diabetes or hypoglycemia

29. Lowered immune system

30. Seizures or convulsions

31. Weight gain or weight loss

32. Mood swings

33. Altered personality

34. Symptoms of mania, ie., inability to sit still or restlessness, racing thoughts, acting silly or giddy (like a teenager again)

35. Sexual promiscuity leading to unwanted pregnancy or divorce

36. Irresponsibility, wild spending sprees, gambling, criminal behavior, shoplifting, embezzling, stealing, hostility, etc.

37. Deceitfulness

38. Blank staring

39. Inability to see any alternatives in situations

40. Hyperactivity

41. Aggressive or violent behavior

42. Wanting to ram other cars or driving irrationally

43. Impulsive behavior with no concern about consequences

44. Numbness in various body parts – legs go numb and right out from under patient

45. Sexual organs go numb making orgasm impossible

46. Pulling away from loved ones and others (isolating oneself)

47. Divorce

48. No desire to be touched

49. Paranoia

50. Falsely accusing others of abuse – family members or acquaintances

51. Loss of spirituality

52. Feeling “possessed” or that something evil is inside

53. Self destructive behavior and suicidal ideation

54. Suicide attempts

55. Muscle tremors

56. Loss of co-ordination

57. Mania

58. Psychosis

[SOURCE: PROZAC: PANACEA OR PANDORA?, BY ANN BLAKE TRACY, PH.D.]

Paragraphs 14 through 18 read: “Marcus, whose name has been changed for fear of reprisal from his former military leaders, sat in a worn easy chair in his Salem studio apartment sucking on his third Marlboro in less than 20 minutes and nervously twirling an ink pen from Salem Hospital. A tall bottle of a generic prescription antidepressant sat on the end table he crafted out of leftover two-by-fours from a fencing project he worked last year. The shades were pulled and the glimmer from his lamp highlighted beads of perspiration on his forehead in the warm room.”

“’Before I left, I never smoked, not once,’ he said, as he took another long drag, letting the smoke linger in his mouth before letting it loose with a slow exhale. ‘There were a lot of things I didn’t do, ‘ he said. ‘That tour f***ed me up. When I got back, they expected me to return to life like it was before. No s***, like nothing had ever changed’.”

“Things had changed for Marcus, who said he couldn’t manage to keep his job as a welder because he would get sudden flashbacks to that one day in the Afghan village.”

“Change had also occurred for his 26-year-old wife, whom he said left him shortly after he returned, adding additional stress for the veteran to overcome.”

“’I’m the one who drove her away,’ Marcus admitted, wiping away several tears. ‘I would yell at her constantly. I hit her. I was never, never like this before I went to Afghanistan, never’.”

http://willamettelive.com/story/Soldiers_return_from_the_frontlines_to_face_war_with_VA121.html

Soldiers return from the frontlines to face war with VA
By Sheldon Traver
from WillametteLive, Section News

Posted on Tue Jun 30, 2009 at 08:45:07 PM PDT

This year marks a milestone for the Oregon Army National Guard.

More than 3,000 soldiers have already left or are preparing for deployment to Iraq in 2009. It will be the largest deployment for the Oregon Army National Guard since World War II.

However, questions have recently been raised about the care veterans receive upon their return from war. Some Oregon weekend warriors are finding a Department of Veterans Affairs that is unwilling or unable to care for the long-term physical and mental disabilities they are now facing.

With little outside help, some have given up the fight and others continue to struggle for the benefits they say they deserve.

The Veterans Affairs office in Portland disputes these claims, saying it is doing more for veterans now than any time in the past, and points to increased services and a new processing facility in Hillsboro that has prepared the federal agency to aid all returning veterans.

Todd Marcus

In November 2006, then-23-year-old Army specialist Todd Marcus was on patrol in a small Afghan village outside of Kabul.

He carried his M-16 barrel down with his finger just inside the trigger housing. He sweltered under more than 50 pounds of combat gear, including body armor and a Kevlar helmet. Beads of perspiration trickled down to the palms of his gloved hands. Even with the fingertips cut off, the salty runoff made the cuts in his hands sting and itch.

Approximately 100 meters to his left, Marcus saw an Afghan police officer walking a few meters behind another police officer in patrol formation. The officer looked nervous as he scanned the rooftops, looking for those who might intend to kill him. Each little boy, each expectant mother could have been a suicide bomber, paid or extorted by insurgents to end their lives in a desperate bid to feed their families.

Suddenly, a bright flash of light filled Marcus’ peripheral vision, followed by a percussion of hot wind that knocked him aside. His sunglasses flew off and the smell of cordite wafted through the air with a cloud of concrete and dust. He looked toward the ground where the blast originated. The Afghan police officer that was walking just yards from him lay in a pool of blood along with two other officers. An improvised explosive device planted inside the corner of a bullet-riddled concrete home had taken their lives.

Once the carnage and chaos was over, all Marcus could do was cry.

Although it was the only combat action he saw, Marcus said he was severely wounded, not medically, but mentally. However, the same government that agreed to send hundreds of thousands to war is failing to provide veterans like Marcus with proper care upon their return.

Lack of funding, personnel, and an overtaxed veterans administrative system has left many without the care they were promised, according to a 2006 report by the General Accounting Office.

“(The) VA does not know the number of veterans it now treats for PTSD,” and more significantly, the “VA will be unable to estimate its capacity for treating additional veterans… and therefore, unable to plan for an increase in demand for these services,” it said in the report. Additionally, outdated procedures and processes have slowed ability to process veterans’ benefits significantly, said Troy Spurlock, a veteran who has dealt with the Veterans Benefits Administration for himself and others.

Marcus, whose name has been changed for fear of reprisal from his former military leaders, sat in a worn easy chair in his Salem studio apartment sucking on his third Marlboro in less than 20 minutes and nervously twirling an ink pen from Salem Hospital. A tall bottle of a generic prescription antidepressant sat on the end table he crafted out of leftover two-by-fours from a fencing project he worked last year. The shades were pulled and the glimmer from his lamp highlighted beads of perspiration on his forehead in the warm room.

“Before I left, I never smoked, not once,” he said, as he took another long drag, letting the smoke linger in his mouth before letting it loose with a slow exhale. “There were a lot of things I didn’t do,” he said. “That tour f***ed me up. When I got back, they expected me to return to life like it was before. No s***, like nothing had ever changed.”

Things had changed for Marcus, who said he couldn’t manage to keep his job as a welder because he would get sudden flashbacks to that one day in the Afghan village.

Change had also occurred for his 26-year-old wife, whom he said left him shortly after he returned, adding additional stress for the veteran to overcome.

“I’m the one who drove her away,” Marcus admitted, wiping away several tears. “I would yell at her constantly. I hit her. I was never, never like this before I went to Afghanistan, never.”

In 2008, Marcus called and made his first appointment with a Veterans Affairs specialist. It took months to get the initial appointment with the compensation and pension specialists and months more for the VBA to make a decision on his claim. His claim for benefits and treatment for post-traumatic stress disorder was denied.

“They said I was faking it,” he said. “Wel,l f*** them. If they can’t look me in the eye and see that I’m f***ed up, I don’t know what to do.”

Troy Spurlock

Spurlock, a Newberg resident and employee with the Yamhill County Sheriff’s Office knows the struggles veterans face as they attempt to get the care to which they believe they are entitled. As a military police officer and a private during the first Gulf War, he was exposed to unidentified chemicals that caused fibromyalgia.

He also has a host of other ailments, injuries and post-traumatic stress requiring ongoing care. Additionally, he was systematically harassed and threatened by soldiers in his own unit.

However, unlike Marcus, he fought the system and has seen some, though not total, success serving as his own advocate.

“As soon as I got out I started the process,” Spurlock said. “I immediately realized that it’s a typical government bureaucratic process that acts much like an insurance company does. When you do finally get to see someone, you get a quick five-minute ‘Hi, how are you, what’s your claim and thank you I’ll read your file.’ You really have to jump through hoops to substantiate your claim.

“It’s not an adequate medical exam and doesn’t even touch the complexities of issues soldiers go through,” he added.

Veterans Affairs

The Department of Veterans Affairs is divided into three unique parts: the National Cemetery Division, the Veterans Hospital Administration (VHA) and the Veterans Benefits Administration (VBA).

Portland VHA spokesman Mike McAleer works with Oregon’s returning soldiers who return from deployments overseas. He said more is being done now to help soldiers reintegrate and get the benefits they need than any time in the past.

“We send folks to where the soldiers are,” McAleer said. “We provide them with information for enrollment and try to get them into the medical system. We also try to get them information about the services we provide. We want them to be successful when they enter the civilian-warrior portion of their lives.”

There are currently more than 330,000 vets eligible for medical benefits in Oregon, although McAleer said only one-third are taking advantage of them. Oregon Guard men and women returning from active duty are entitled to full medical coverage for five years, including mental health services.

Returning veterans need to sign up, even if they aren’t ready to file a claim,” McAleer said. “They can even do it online. It will streamline the process when they are ready to file a claim.”

To file a claim, there are many hands in the process. Veterans can file medical disability claims themselves or with the help of a specialist. The claim is filed through the VBA. If accepted, a new compensation and pension processing center in Hillsboro conducts medical and psychiatric exams. More than 1,000 requests for examination from the VBA are processed at the Hillsboro facility.

“This is where we compile information and send it to the VBA for processing,” McAleer said. “I think we’re doing a good job of reaching out to veterans and want to do more to help them.”

Once exams are complete, the files return to the Veterans Benefits Administration for further processing.

“Our organization has established a strategic goal of completing a claim in 125 days,” said Lisa Pozzebon, Assistant Director of the VA Regional Office in Portland. “Currently we have an average of 146 days.”

Claims that require a highly specialized exam or ones in the appeals process take longer, she said.

Tim Wehr

Spurlock spends part of his off time trying to reach veterans and help them navigate the stormy VA paperwork waters. His MySpace web site, www.myspace.com/support4veterans, has links to nonprofits working to help vets. Additionally, he has made it his mission to help his colleague, Tim Wehr of Sheridan, receive benefits he initially applied for in 1970 after returning from Vietnam with a purple heart, bronze star and many other decorations and awards.

Wehr currently receives a small amount of money as disability payments for an injury to his ear and PTSD. The Yamhill County Sheriff’s deputy said he still has flashbacks, especially when he hears a helicopter. He said he used to compulsively drop and roll any time he heard a helicopter, but recently was able to overcome this behavior.

Most of his military and medical records were lost in a 1972 fire that destroyed a federal records building and left many vets unable to prove their service and disabilities. He reapplied for benefits in the early 1980s, this time for skin conditions, which later included skin cancer related to exposure to Agent Orange, an herbicide used extensively during the Vietnam War. While his claim for PTSD and hearing problems was accepted, it was denied for his chloracne (Agent Orange-related skin condition) and a knee injury. He gave up trying – until he met Spurlock through a mutual friend.

In 2007, Spurlock was given the power of attorney for Wehr’s VA claims. Spurlock has managed to pull together many of Wehr’s old records to justify claims; however, both men feel the VBA is impeding their efforts. Several of the letters to and from the VBA regarding Wehr’s claims are available at www.WillametteLive.com.

Veterans Service Center manager Kevin Kalama said claims for conditions related to Agent Orange exposure don’t require the same level of documentation as other service-related disabilities.

“We will presume he was exposed to Agent Orange because of where he was in Vietnam during that time,” he said. “If we can find a record that he stepped foot in Vietnam during that time period, it is presumed he had exposure.” Wehr said this has not been true with his case.

The most recent denial came when the VA claimed that Spurlock’s power of attorney privileges had ended, despite no paperwork showing a POA is appointed for a limited time.

“The VA is continuing to stonewall my claims any and every chance it gets without clear and legal justification,” Wehr said in a letter to the Veterans Affairs office in Portland dated June 15, 2009. “Meanwhile, I will be preparing to submit my entire file to Senator Wyden’s office and request a congressional investigation into this utter lack of professionalism and lack of attention to detail in this matter.”

Protecting Yourself

With the current deployments, Spurlock said troops need to take steps while in Iraq to reduce problems later.

“Keep a copy of all of your medical records,” he advised. “Any time you see a doctor for anything, you need to keep that. Don’t wait too long… and don’t be dismayed by any instant denial. That is just routine.”

Veterans should also research their own medical conditions and have the information on hand when talking to the VA.

“The biggest thing is not to give up,” Spurlock emphasized. “They will try to wear you down, but don’t let them.”

Making sure all medical records are available is crucial to avoid delays, McAleer acknowledged. Currently the VA is working with the Department of Defense for access to medical and personnel records. He said this will help veterans and the VBA to process claims more efficiently.

Although he couldn’t speak about any individual cases, he said Marcus must make every effort to go to a clinic and get screened for PTSD and any other ailments.

“We have a clinic in Salem,” he said. “We are trying to make it as easy as possible for our veterans to get the help and services they need.”

One of the biggest pieces of advice that was offered by McAleer is to file all the known claims at one time.

“The process can be really frustrating if you are doing it in bits and pieces,” he said.

He added that veterans should keep a call list of people they served with to verify claims if needed.

Despite efforts to treat returning troops, one thing is certain: many of these complexities are leading to tragic endings.

In 2008, the Army reported nearly 150 suicides within its ranks. Every military branch except the Coast Guard has seen an increase in suicide rates. However, steps are being taken to curb the rise.

Both the Joshua Omvig Suicide Prevention Act, increasing mental-health assessments, and the Wounded Warriors Act, designed to help soldiers transitioning from active-duty to veteran status, are intended to aid active duty and returning soldiers. Studies are under way at the Madigan Army Medical Center near Fort Lewis, Wash., to assist in this effort.

This is little consolation for veterans who don’t have a desire to kill themselves, but simply want care for physical and mental injuries and benefits they were promised upon enlistment.

Marcus said his experience with the VA has left him soured and he doesn’t have any immediate plans to return. He admits he occasionally daydreams about refilling his antidepressants and taking them in a one-night alcohol-induced party for one.

He said he won’t do it, because “God doesn’t accept cowards who take the easy way out.”

In the back of his mind, he believes he’ll get help one day, or simply be cured by a miracle.

“I don’t know what may change, tomorrow or next year,” he said. “F*** the VA. I don’t need ‘em. One of these days I’ll get my head straight and have a family. It’ll all be good.”

We have received a request from a German TV crew who is doing a special on Lilly’s newer ADHD medication, Stratera. These investigative reporters from Germany are doing a 45 minute piece and looking for experiences of tragedy /suicide or severe adverse reactions in children treated for ADHD with this drug. I know we have had reports, but I do not keep close track anymore of which drug is involved after so many cases because all these drugs work basically the same way. An antidepressant is an antidepressant no matter what you callmit or what you prescribe it for or how you explain its supposed uniqueness. So if you or someone you know has been through a Strattera-induced nightmareand would be willing to help get some exposure of this in the press, please get in touch with me so that I can put you in touch the reporters.

O nce you read the following article on Strattera deaths you will see how very important it is to get information about this drug out to the public -

especially throughout the UK and Europe. What is going on here IS CRIMINAL!!
And here is just one example out of the article below that is full of data on how
the government agency in the UK who oversees these drugs is ignoring
critical information – even fatalities, and doing NOTHING but making excuses
for their own behavior:

MHRA has for almost three years been in possession of data showing that
Strattera in many cases actually can cause or worsen the œcondition it is
claimed to alleviate. More than 700 reports were submitted to the manufacturer,
Eli Lilly, about Strattera inducing “œpsychomotor hyperactivity. Lilly called
this an exacerbation of the “œunderlying ADHD”. If we would apply this to
the area of real medicine and to diabetes we could say that the patient got a
diabetes medication with resulting heavy increase in blood sugar level. Such a
medication would probably be withdrawn very fast from the market. But the
MHRA has not yet, after three years, succeeded to get even a bad quality review
of these cases done not even from the manufacturer.

Do read the rest of the information because it is clearly eye opening!! This
newer ADHD drug, Strattera, which is really an SSRI antidepressant, is
getting away with murder right under everyone’s noses. So definitely if you
know someone who is willing to talk to this news crew about their experience with
this drug, please do let me know ASAP.

Thank you,

Ann Blake-Tracy, PhD, Executive Director,
International Coalition for Drug Awareness
_www.drugawareness.org_ (http://www.drugawareness.org/) &
_www.ssristories.org_ (http://www.ssristories.org/)
Author of Prozac: Panacea or Pandora? – Our
Serotonin Nightmare & the audio, Help! I Can’t
Get Off My Antidepressant!!! (800-280-0730)

E-mail: _atracyphd1@…_ (mailto:atracyphd1@…)

_http://www.newmediaexplorer.org/sepp/2008/10/20/strattera_adverse_effects_uk_
medicines_agency_refuses_to_act.htm#_
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dicines_agency_refuses_to_act.htm#)

October 20, 2008
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Strattera adverse effects: UK Medicines Agency refuses to act
By Sepp Hasslberger

Categories
_Pharma_ (http://www.newmediaexplorer.org/sepp/pharma.htm)

Janne Larsson, an investigator and reporter in Sweden, has obtained
information about adverse event reports on Eli Lilly’s ADHD drug Strattera,
using the Swedish freedom of information laws. The data, coming from both the FDA’s
adverse reaction database and from reports to the UK’s Medicines agency, shows
numerous adverse effects and scores of deaths by suicide.

Yet the agency, even after repeated prodding by Larsson to initiate action,
has refused to budge or even acknowledge that there is a problem. MHRA
apparently accepts the drug’s producer Eli Lilly’s data rather than its own and
the
FDA’s adverse event reports.

Image credit: _Monheit Law_
(http://www.monheit.com/strattera/contact_lawyer.asp)

Larsson says: An investigation of MHRA™s handling of the harmful effects of
the ADHD drug Strattera has proven the following:

MHRA has ignored data about instances of death among children in connection
with Strattera treatment. At least 41 children have died. The agency has not
investigated the reported cases and does not even have a compiled summary of
cases with fatal outcome. Further the agency has allowed the manufacturer Eli
Lilly to give false information about the number of fatal cases and has
taken no action against the company once the false information was revealed.

MHRA has for almost three years been in possession of data proving that
Strattera can cause agitation, mania and psychotic reactions with hallucinations
among children. Yet no warning has been issued to doctors and parents. The
agency has withheld these disastrous consequences despite clear evidence. Due
to bureaucratic procedures no warnings have been issued even if Eli Lilly reluc
tanly conceded to include these harmful reactions in its information to the
public almost a year ago.

MHRA has for almost three years been in possession of data showing that
Strattera in many cases actually can cause or worsen the œcondition it is
claimed to alleviate. More than 700 reports were submitted to the manufacturer,
Eli Lilly, about Strattera inducing œpsychomotor hyperactivity. Lilly called
this an exacerbation of the œunderlying ADHD. If we would apply this to
the area of real medicine and to diabetes we could say that the patient got a
diabetes medication with resulting heavy increase in blood sugar level. Such a
medication would probably be withdrawn very fast from the market. But the
MHRA has not yet, after three years, succeeded to get even a bad quality review
of these cases done“ not even from the manufacturer.
The background data for these conclusions can be found in the following text
and in the linked documents. When reading the data below please remember the
promise from the MHRA: we take any necessary action to protect the public
promptly if there is a problem._MHRA, About us_
(http://www.mhra.gov.uk/Aboutus/index.htm) [1]

Note that the linked documents (within letters described below) in most
cases could not be obtained in UK where the issuance of them would be deemed as
prejudicing œthe ability of the Assessory body to offer impartial advice and
where the MHRA wants to allow marketing authorisation holders the chance to
respond to regulatory action and make commercial decisions before data are
in the public domain. (MHRA, e-mail about FOIA-request, 29th September,
2006). However the documents could be obtained in Sweden, even if the MHRA has
tried to stop the issuance of them by implying that publication could threaten
the relations between Sweden and UK.
Deaths among children in connection with Strattera treatment

In May I submitted detailed data about cases of Strattera death to the MHRA.
1st October I finally got an answer from the Scientific Assessor of the
Vigilance and Risk Management of Medicines (VRMM). 7th October I got an answer
from Professor Kent Woods, CEO of the MHRA, referring to the letter sent by the
Scientific Assessor.

My data about Strattera deaths can be found _in the letter_
(http://jannel.se/Strattera.death2.pdf) Strattera: Eli Lilly gave false
information about
deaths from Strattera treatment “ a request for full investigation from 15th
May. [2]
The answer from the Scientific Assessor shows that MHRA is continuing to
ignore data about instances of death among children and adults in connection
with Strattera treatment. Despite limited resources and having to rely on data
released by reluctant medical agencies I had been able to produce a summary of
reported cases of Strattera death. Thats much more than the MHRA, with its
immense resources, had been able to do.

The agency was provided with specific data about instances of death forming
an excellent starting point for a full investigation. But instead of using
the data the MHRA used its energy to explain why it is impossible to
investigate these cases further, and in doing so presents some remarkable
comments.

The Scientific Assessor states _in the letter 1st October_
(http://jannel.se/Reply.from%20MHRA.Assessor.October.pdf) [3]:

in order to calculate the total number of reports with a fatal outcome
it is not simply a case of adding up reports with a fatal outcome mentioned
in our assessment reports of the PSURs [Periodic Safety Update Reports] and
those available on the FDA website as these different sources may contain
duplicate information. [Emphasis added.]

I fully agree and it takes only a casual reading of my letter from 15th May
to find out that much care has been taken to exclude possible duplicates. It
is quite easy to see that the data presented about fatal cases in my letter
is NOT simply a case of adding up reports with a fatal outcome. The only
way to come to another conclusion would be not to look in the first place and
it is a condemnation of the effectiveness of the agency to state the following
in the letter:

We have looked at the data you have sent us to see if they can add insight
to the statutory sources of data we have received and do not think that they
are of benefit as we cannot verify their source or accuracy. (p. 3)
[Emphasis added.]

I must add to all the data provided in my letter 15th May that the our

of the information about fatal cases is FDA™s Medwatch system and the PSURs
(submitted directly to the MHRA). I must make it clear that is very easy for
a lay person to find out that almost all reports about fatal outcome from
Strattera treatment submitted to the FDA came from Eli Lilly!

Thus the our of the information about fatal cases was in most of the
cases the manufacturer itself“ Eli Lilly. And yet the MHRA has not been able
to verify the source or accuracy of the information. The MHRA Scientific
Assessor states in the letter:The sources of data that regulators use such
as company data, spontaneous adverse reaction reports and literature are set
out in European and national law.
My FOIA request earlier this year to get a compilation of fatal cases in
connection with Strattera treatment was answered 12th August:

Thats very good and now we know that the data I submitted to the MHRA about
all fatal cases from Strattera treatment “ in the absolute majority of cases
were known by and reported via the manufacturer Eli Lilly.
The MHRA holds no data other than that previously released to you [the
misleading data from Eli Lilly in November 2007, see my letter from 15th May
for
more data] which was the data provided by the company. If you have any
questions about FDA data or the data provided by the company, you should
contact those organisations.

In other words the MHRA didn’t have a compiled summary of cases with fatal
outcome in August and the agency has not to this point been able to compile
such a summary.

As the agency has not been capable of getting the data or not even been
capable of using the specific data submitted for its use in a full
investigation NO action is taken despite the many verified deaths among
children in connection with Strattera treatment. This disregard for the safety of children is a scandal which should lead to a full formal investigation by the
Department of Health.

Drug induced agitation, mania and psychosis with hallucinations

Ive been contacted by parents asking if Strattera can induce mania and
psychosis with hallucinations. Their children have had such symptoms. The
parents have not found any warnings about it and their childrens doctors don’t
think that the symptoms are caused by the drug. The parents were desperate.

However the MHRA has known for almost three years that Strattera can cause
agitation, mania and psychotic reactions with hallucinations among children,
but has refused to issue warnings about it.

The Scientific Assessor from the MHRA _in the letter of 1st October_
(http://jannel.se/Reply.from%20MHRA.Assessor.October.pdf) [3] now confirms my
earlier arguments that the agency had knowledge about these effects a long time ago:

following an initial request in the assessment report for the Periodic
Safety Update for the period (dates 27-05-2005 to 26-11-2005) we asked Eli
Lilly for more information to enable us to review this issue in more detail. (p. 2)

This means that in the period ending 26th November, 2005 at the time when
Strattera was approved only in UK and four other European countries, but not
in the 22 additional European countries where it is now approved Eli Lilly
and the MHRA had knowledge about these disastrous effects in children taking
Strattera. But neither the MHRA nor Eli Lilly told anything about it and
Strattera was approved in 20 additional European countries in April 2006.
Image credit: _Wikimedia Commons_
(http://commons.wikimedia.org/wiki/Image:Strattera_atomoxetin.jpg)

Professor Kent Woods, CEO of the MHRA seems to be very misinformed by his
staff when answering about Strattera in a recent _letter of 7th October, 2008_
(http://jannel.se/answer.kent.woods.pdf) . In the letter Professor Woods
states [4]:

The MHRA is committed to ensuring that all safety concerns are subject to
robust scientific assessment and the best possible regulatory action is taken
in a timely manner. We strive to maintain the highest standards of work and
review our practices to ensure these standards are maintained or improved
upon where necessary. (p. 1)

In their 3rd March, 2006 report Psychiatric Adverse Events Associated with
Drug Treatment of ADHD: Review of Postmarketing Safety Data [5], the FDA
stated that there was compelling evidence for a likely causal association
between [Strattera/amphetamine drugs] and treatment emergent onset of signs and/or
symptoms of psychosis or mania, notably hallucinations, in some patients.

(p. 17) 360 reports about the drug inducing these effects had been received
up to June 2005.

From this FDA report the MHRA had knowledge about the œcompelling evidence for Strattera causing these effects on or about 3rd March, 2006 but did nothing.

In August the same year (2006) the MHRA requested the same data set from Eli
Lilly that was submitted to the FDA and which formed the basis of the FDA
report for Strattera. The data was sent to the MHRA some days later. But the
agency then decided not to do anything with the information. Instead it was
decided that Eli Lilly the manufacturer should do an analysis of the data
and submit its conclusions to the agency.

Professor Kent Woods says in his letter: An important aspect to this [ robust scientific assessment, highest standards] is ensuring that data from all available sources have been consider This may be true in some other area but it is definitely not true for the
safety work around Strattera. A very good example of this is the complete
rejection of the robust scientific assessment of Strattera in the FDA report.
Answering the question why the agency did not use the compelling evidence for harm in the FDA report _an official at the MHRA declared in a letter_
(http://jannel.se/mhraanswer.pdf) [6]:

Changes to European product information are based on assessment by EU
regulators, agreement between member states and in line with legal requirements
about product information, not on conclusions of FDA assessors. (25th May,
2007) [Emphasis added.]

Responsible officials at the MHRA had instead decided to rely completely on
the analysis of the manufacturer of the drug Eli Lilly. (In an article in
the Daily Mail this summer, Andrew Herxheimer, editor of the Drug and
Therapeutics Bulletin, and emeritus fellow of the Cochrane Centre commented:
Asking a drug company to review its own product is crazy, but it goes on quite a lot.
) [7]

At the end of 2007/beginning 2008 Eli Lilly submitted its review of
Strattera induced agitation, mania and psychosis with hallucinations to the
MHRA. It was a complete whitewash.

In summary: FDA was very clear about the psychosis-inducing effects of
Strattera; the MHRA did not listen. Instead the MHRA turned to the
manufacturer. Eli Lilly tried to explain away all the bad results found in its review. For
the full history about MHRA’s failure in this area and for a comparison of
the FDA report with the Lilly report, please see the following letter: _The
ADHD drug Strattera“ actions needed now_
(http://jannel.se/letter.mhra.strattera.jan08.pdf) [8] from January 2008, and
the letter _The ADHD drug Strattera“
an analysis of reports of drug induced mania, psychosis and hallucinations_
(http://jannel.se/strattera.mhra.March.08.pdf) [9] from March 2008.

In the letter from March [9] Eli Lilly’s whitewash report for the period up
to November 2007 is presented. At the end of that report Lilly says [10]:

Nevertheless, Lilly will consider adding language regarding psychotic symptoms
including hallucinations to its product information sheet. (p. 1279)

Larsson – _Suicides & Psychiatric Drugs_
(http://www.newmediaexplorer.org/sepp/suicide.psychiatricdrugs.pdf)

And so we come to October 2008 and the letters from Professor Kent Woods and
from the Scientific Assessor for Strattera. We are reassured that the MHRA
is acting to ensure that Strattera is used as safely as possible that

all safety concerns are subject to robust scientific assessment and the best
possible regulatory action, that any new safety signals are evaluated in
an independent, scientifically robust manner (Woods); we are told that

discussions between European Member States and Eli Lilly are ongoing to agree
on the most appropriate information to be included in the product information
for patients and prescribers; we are told to be patient, to understand that
it takes time from the point where œupdates have been agreed for inclusion in
the product information to the point where these will appear in the packs
in the market place due to movement of stock in the supply chain, and that
the appearances are estimated to be within the next 6 months (Scientific
Assessor).

It is probably hard to find a more obvious violation of the promise¦ we
take any necessary action to protect the public promptly if there is a
problem than the case described above. The worried parents still have no answers if
Strattera can induce the symptoms they find in their children. And the MHRA
knew about it three years ago but withheld the data. This should be
included in the investigation of the agency by the Department of Health.

Strattera causing hyperactivity“ the condition it was supposed to alleviate In my earlier letter to the Department of Health (29th August) I took up the data about the 700 forgotten cases of hyperactivity. I referred to my _letter 2nd January to the MHRA_
(http://jannel.se/letter.mhra.strattera.jan08.pdf) [8] and gave data about the
fact that Eli Lilly had withheld sensitive information and classified harmful effects as an exacerbation of the underlying ADHD.

The logical solution would have been for the MHRA to request all data about
this security risk, followed by an independent review of the data. But this
was not done and as expected nothing is still done. MHRA asked Lilly for an
explanation about this signal stemming from Periodic Safety Update Report
5 (dates 27-05-2005 to 26-11-2005) but got no answer. Three years later the
Scientific Assessor from the MHRA writes in the letter from 1st October:

The information submitted by the MAH [Market Authorization Holder] has been
evaluated and the MAH will be requested to provide further detailed
information within the next 2 months to ensure the issue has been investigated
in a thorough and scientific manner. (p. 2) [3]

The MHRA got this safety signal almost three years ago and is still in
the process of getting some sensible answers from Eli Lilly.

————

I again request the Department of Health to take action. This does not
concern only the children in UK; it concerns the children in the whole of
Europe, indeed it concerns all the children of the world.

The failure of the agency will also mean that psychiatrists within The
Guideline Development Group in NICE can push through more treatment with
Strattera and other ADHD drugs. The MHRA is withholding the clear evidence for
harmful effects and the psychiatrists with close relations to the manufacturers
of the drugs can unimpeded recommend these medicines to unsuspecting
doctors and parents.

The answers given by Professor Kent Woods and the Scientific Assessor did
not in any way handle my concerns. On the contrary, they finally proved that a
full formal investigation of the matters raised above is needed.

Yours sincerely,

Janne Larsson

Reporter – investigating psychiatry
Sweden
_janne.olov.larsson@…_ (mailto:janne.olov.larsson@…)

[1] MHRA, About us, _http://www.mhra.gov.uk_ (http://www.mhra.gov.uk/)
[2] Larsson, Strattera: Eli Lilly gave false information about deaths from
Strattera treatment“ a request for full investigation, May 15, 2008,
_http://jannel.se/Strattera.death2.pdf_ (http://jannel.se/Strattera.death2.pdf)
[3] MHRA, Re: letter of 9th September 2008 to “Assessor responsible for
Strattera, October 1, 2008,
_http://jannel.se/Reply.from%20MHRA.Assessor.October.pdf_
(http://jannel.se/Reply.from%20MHRA.Assessor.October.pdf)
[4] MHRA, Re: Open letter to Pr. Kent Woods (10th August 2008), October 7,
2008
_http://jannel.se/answer.kent.woods.pdf_
(http://jannel.se/answer.kent.woods.pdf)
[5] FDA, Psychiatric Adverse Events Associated with Drug Treatment of ADHD:
Review of Postmarketing Safety Data, released March 3, 2006.
_http://www.fda.gov/ohrms/dockets_
(http://www.fda.gov/ohrms/dockets/AC/06/briefing/2006-4210b_11_01_AdverseEvents.\
pdf)
[6] MHRA, answer FOI request, May 25, 2007,
_http://jannel.se/mhraanswer.pdf_ (http://jannel.se/mhraanswer.pdf)
[7] Daily Mail, Heart attacks and suicides… yet the dangers were all kept
so quiet. So how CAN you trust your medicine? July 7, 2008,
_http://www.dailymail.co.uk/_
(http://www.dailymail.co.uk/health/article-1033132/Side-effects-include-suicide-\
heart-attacks-So-prescribed-drugs.html)
[8] Larsson, The ADHD drug Strattera – actions needed now, January 2, 2008,
_http://jannel.se/letter.mhra.strattera.jan08.pdf_
(http://jannel.se/letter.mhra.strattera.jan08.pdf)
[9] Larsson, The ADHD drug Strattera – an analysis of reports of drug
induced mania, psychosis and hallucinations, March 9, 2008,
_http://jannel.se/strattera.mhra.March.08.pdf_
(http://jannel.se/strattera.mhra.March.08.pdf)
[10] Eli Lilly, Cumulative review of Spontaneous Case Reports of Mania,
Psychotic Disorders, Hallucinations, and Agitation, Appendix 16 to Periodic
Safety Report 9 for Strattera, 2008,
_http://jannel.se/Lilly_psychosis_strattera.pdf_
(http://jannel.se/Lilly_psychosis_strattera.pdf)

See also:

_Doctors told to curb use of Ritalin in hyperactive children_
(http://www.timesonline.co.uk/tol/news/uk/science/article4813727.ece)
_Children’s suicide attempts raise concerns about ADHD medication_
(http://www.theglobeandmail.com/servlet/story/RTGAM.20080703.wadhd03/BNStory/spe\
cialScie
nceandHealth/home)
_The ADHD drug Strattera: Lilly to issue warnings about psychosis,
hallucinations, mania and agitation_ (http://jannel.se/strattera.psychosis.doc)
_Strattera side effects_ (http://www.bonkersinstitute.org/stratteraffex.html)

_Strattera – 10,988 adverse “psychiatric reactions” reported in less than
three years_ (http://www.24-7pressrelease.com/view_press_release.php?rID=16662)
_Attention Deficit Hyperactivity Disorder? No, they’re just naughty, say
experts_
(http://www.dailymail.co.uk/news/article-1031436/Attention-Deficit-Hyperactivity\
-Disorder-No-theyre-just-naughty-say-experts.html#)

“This Adverse Event Report, from a study appearing in the New England Journal of Medicine, shows that of 133 children 17 & under on Zoloft there were 2 who reported “Homicidal Ideation”. There were no reports of “Homicidal Ideation” in the placebo group.

“According to the Physicians Desk Reference, a Frequent adverse reaction is one that occurs in 100 people or less. Homicidal Ideation occurred in 1 in 66 children on Zoloft aged 17 and under.

“This Adverse Event Report was the appendix for this study in the New England Journal of Medicine.”

And with this new information from the New England Journal of Medicine I want to include information out of Australia which is that Pfizer, the maker of Zoloft, along with the Therapeutic Goods Administration (TGA similar to our FDA), recommends that any SSRI antidepressant should not be prescribed to
Australians under the age of 24. Funny, but I missed that warning from Pfizer for Americans under 24, didn’t you?

Next I will send that article that just came out over the weekend because it ties in so closely with this new information on Zoloft. And because there is so much to read in this article alone I am going to cut my comments at this point and let the article speak for itself.

Ann Blake-Tracy, PhD, Executive Director,
International Coalition for Drug Awareness
_www.drugawareness.org_ (http://www.drugawareness.org/) &
_www.ssristories.org_ (http://www.ssristories.org/)
Author of Prozac: Panacea or Pandora? – Our
Serotonin Nightmare & the audio, Help! I Can’t
Get Off My Antidepressant!!! (800-280-0730)

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_http://content.nejm.org/cgi/content/full/NEJMoa0804633_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633)

Published at www.nejm.org October 30, 2008 (10.1056/NEJMoa0804633)
Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood
Anxiety

John T. Walkup, M.D., Anne Marie Albano, Ph.D., John Piacentini, Ph.D.,
Boris Birmaher, M.D., Scott N. Compton, Ph.D., Joel T. Sherrill, Ph.D., Golda
S. Ginsburg, Ph.D., Moira A. Rynn, M.D., James McCracken, M.D., Bruce Waslick,
M.D., Satish Iyengar, Ph.D., John S. March, M.D., M.P.H., and Philip C. Kendall, Ph.D.

ABSTRACT
Background Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy.

Methods In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at
weeks 4, 8, and 12.

Results The percentages of children who were rated as very much or much improved on the Clinician Global Impression “Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo
(23.7%). Combination therapy was superior to both monotherapies (P<0.001).

Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal
ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline.

Conclusions
Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate.

(ClinicalTrials.gov number,
NCT00052078 _[ClinicalTrials.gov]_
(http://content.nejm.org/cgi/external_ref?access_num=NCT00052078&link_type=CLINT\
RIALGOV) .)

____________________________________
Anxiety disorders are common in children and cause substantial impairment in
school, in family relationships, and in social functioning._1_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R1) ,_2_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R2) Such disorders
also predict adult anxiety disorders and major depression._3_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R3) ,_4_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R4) ,_5_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R5) ,_6_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R6) Despite a high
prevalence (10 to 20%_3_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R3)
,_7_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R7) ,_8_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R8) ) and substantial
morbidity, anxiety disorders in childhood remain underrecognized and
undertreated._1_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R1)
,_9_

(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R9)

An improvement in outcomes for children with anxiety disorders would have important public health
implications.In clinical trials, separation and generalized anxiety disorders and social
phobia are often grouped together because of the high degree of overlap in
symptoms and the distinction from other anxiety disorders (e.g., obsessive compulsive disorder). Efficacious treatments for these disorders include cognitive behavioral therapy_10_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R10) ,_11_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R11) and
the use of selective serotonin-reuptake inhibitors (SSRIs)._12_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R12) ,_13_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R13)

However, randomized, controlled trials comparing cognitive behavioral therapy, the use of an SSRI, or the combination of both therapies with a control are lacking. The evaluation of combination therapy is particularly important because approximately 40 to 50% of children with these disorders do not have a response to short-term treatment with either monotherapy.
_14_(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R14) ,_15_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R15)

Our study, called the Child “Adolescent Anxiety Multimodal Study, was designed to address the current gaps in the treatment literature by evaluating the relative efficacy of cognitive behavioral therapy, sertraline, a combination of the two therapies, and a placebo drug. This article reports the results of short-term treatment.

Methods
Study Design and Implementation

This study was designed as a two-phase, multicenter, randomized, controlled trial for children and adolescents between the ages of 7 and 17 years who had separation or generalized anxiety disorder or social phobia. Phase 1 was a 12-week trial of short-term treatment comparing cognitive behavioral therapy, sertraline, and their combination with a placebo drug. Phase 2 is a 6-month open extension for patients who had a response in phase 1.

The authors designed the study, wrote the manuscript, and vouch for the data gathering and analysis. Pfizer provided sertraline and matching placebo free of charge but was not involved in the design or implementation of the study, the analysis or interpretation of data, the preparation or review of the manuscript, or the decision to publish the results of the study.

Study Subjects

Children between the ages of 7 and 17 years with a primary diagnosis of separation or generalized anxiety disorder or social phobia (according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision
[DSM-IV-TR]_16_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R16) ),
substantial impairment, and an IQ of 80 or more were eligible to participate. Children with coexisting psychiatric diagnoses of lesser severity than the three target disorders were also allowed to participate;
such diagnoses included attention deficit–hyperactivity disorder (ADHD) whilereceiving stable doses of stimulant and obsessive compulsive, post-traumatic stress, oppositional defiant, and conduct disorders. Children were excluded if they had an unstable medical condition, were refusing to attend school
because of anxiety, or had not had a response to two adequate trials of SSRIs or an adequate trial of cognitive behavioral therapy.

Girls who were pregnant or were sexually active and were not using an effective method of birth control
were also excluded. Children who were receiving psychoactive medications other than stable doses of stimulants and who had psychiatric diagnoses that made participation in the study clinically inappropriate (i.e., current majordepressive or substance-use disorder; type ADHD; or a lifetime history of bipolar, psychotic, or pervasive developmental disorders) or who presented an acute risk to themselves or others were also excluded.

Recruitment occurred from December 2002 through May 2007 at Duke University Medical Center, New York State Psychiatric Institute Columbia University Medical Center New York University, Johns Hopkins Medical Institutions, Temple University University of Pennsylvania, University of California, Los Angeles,and
Western Psychiatric Institute and Clinic University of Pittsburgh Medical Center. The protocol was approved and monitored by institutional review boards at each center and by the data and safety monitoring board of the National Institute of Mental Health. Subjects and at least one parent provided written informed consent.

Interventions

Cognitive behavioral therapy involved fourteen 60-minute sessions, which included review and ratings of the severity of subjects’ anxiety, response to treatment, and adverse events. Therapy was based on the Coping Cat program,_17_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R17) ,_18_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R18) which was adapted for the
subjects’ age and the duration of the study._19_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R19)

Each subject who was assigned to receive cognitive behavioral therapy received training in anxiety-management skills, followed by behavioral exposure to anxiety-provoking situations. Parents
attended weekly check-ins and two parent-only sessions. Experienced psychotherapists, certified in the Coping Cat protocol, received regular site-level and cross-site supervision.

Pharmacotherapy involved eight sessions of 30 to 60 minutes each that included review and ratings of the severity of subjects’ anxiety, their response to treatment, and adverse events. Sertraline (Zoloft) and matching placebo were administered on a fixed flexible schedule beginning with 25 mg per day and adjusted up to 200 mg per day by week 8. Through week 8, subjects who were considered to be mildly ill or worse and who had minimal side effects were eligible for dose increases.

Psychiatrists and nurse clinicians with experience in medicating children with anxiety disorders were certified in the study pharmacotherapy protocol and received regular site-level and cross-site supervision.
Pill counts and medication diaries were used to facilitate and document adherence. Combination therapy consisted of the administration of sertraline and cognitive behavioral therapy. Whenever possible, therapy and medication sessions occurred on the same day for the convenience of subjects.

Objectives
Study objectives were, first, to compare the relative efficacy of the three active treatments with placebo; second, to compare combination therapy with either sertraline or cognitive behavioral therapy alone; and third, to assess the safety and tolerability of sertraline, as compared with placebo. We hypothesized that all three active treatments would be superior to placebo and that combination therapy would be superior to either sertraline or cognitive behavioral therapy alone.

Outcome Assessments
We obtained demographic information, information on symptoms of anxiety, and data on coexisting disorders and psychosocial functioning using reports from both the subjects and their parents and from interviews of subjects and parents at the time of screening, at baseline, and at weeks 4, 8, and 12.

The interviews were administered by independent evaluators who were unaware of study-group assignments.
We used the Anxiety Disorders Interview Schedule for DSM-IV-TR, Child Version,_20_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R20) to establish diagnostic eligibility. The categorical primary outcome was the treatment response at week 12, which was defined as a score of 1 (very much improved) or 2 (much improved) on the Clinical Global Impression Improvement scale,_21_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R21) which ranges from 1 to 7, with lower scores indicating more improvement, as compared with baseline. A score of 1 or 2 reflects a substantial, clinically meaningful improvement in anxiety severity and normal functioning. The dimensional primary
outcome was anxiety severity as measured on the Pediatric Anxiety Rating Scale, computed by the summation of six items assessing anxiety severity, frequency, distress, avoidance, and interference during the previous week._22_(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R22)

Total scores on this scale range from 0 to 30, with scores above 13 indicating clinically meaningful anxiety. The Children’s Global Assessment Scale_23_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R23) was used to rate
overall impairment.

Scores on this scale range from 1 to 100; scores of 60 or lower are considered to indicate a need for treatment, and a score of 50 corresponds to moderate impairment that affects most life situations and is readily observable. Agreement among the raters was high for anxiety severity (r=0.85) and diagnostic
status (intraclass correlation coefficient= 0.82 to 0.88) on the basis of a videotaped review of 10% of assessments by independent evaluators that were performed at baseline and at week 12.

Adverse Events
Adverse events were defined as any unfavorable change in the subjects’ pretreatment condition, regardless of its relationship to a particular therapy. Serious adverse events were life-threatening events, hospitalization, or events leading to major incapacity. Harm-related adverse events were defined as thoughts of harm to self or others or related behaviors. All subjects were interviewed at the start of each visit by the study coordinator with the use of a standardized script. Identified adverse events and harm-related events were then evaluated and rated by each subject’s study clinician.

This report presents data on all serious adverse events, all harm-related adverse events, andmoderate and severe (i.e., functionally impairing) adverse events that occurred in 3% or more of subjects in any study group. The data and safety monitoring board of the National Institute of Mental Health performed a quarterly review
of reported adverse events. Given the greater number of study visits (and hence more reporting
opportunities) and the unblinded administration of sertraline in the combination-therapy group, the test of the adverse-event profile of sertraline focused on statistical comparisons between sertraline and placebo and sertraline and cognitive behavioral therapy.

Randomization and Masking
The randomization sequence in a 2:2:2:1 ratio was determined by a computer-generated algorithm and maintained by the central pharmacy, with stratification according to age, sex, and study center. Subjects were assigned to study groups after being deemed eligible and undergoing verbal reconsent with a study investigator. Subjects in the sertraline and placebo groups did not know whether they were receiving active therapy, nor did their clinicians. However, subjects who received combination therapy knew they were receiving active sertraline. The study protocol called for independent evaluators who completed assessments to be unaware of all treatment assignments.

Statistical Analysis
On the basis of previous studies,_10_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R10) ,_11_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R11) ,_12_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R12)
,_13_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R13) ,_14_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R14) ,_15_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R15)
we hypothesized that 80% of children in the combination-therapy group, 60% in either the sertraline group
or the cognitive-behavioral-therapy group, and 30% in the placebo group would be considered to have had a response to treatment at week 12. We determined that we needed to enroll 136 subjects in each active-treatment group and 70 subjects in the placebo group for the study to have a power of 80% to detect a minimum difference of 17% between any two study groups in the rate of response, assuming an alpha of 0.05 and a two-tailed test with no adjustment for multiple comparisons.

Analyses were performed with the use of SAS software, version 9.1.3 (SAS Institute). For categorical outcomes (including data regarding adverse events), treatments were compared with the use of Pearson’s chi-square test, Fisher’s exact test, or logistic regression, as appropriate. Logistic-regression models included the study center as a covariate. For dimensional outcomes, linear mixed-effects models (implemented with the use of PROC MIXED) were used to determine predicted mean values at each assessment point (weeks 4, 8, and 12)
and to test the study hypotheses with respect to between-group differences at week 12.

In each linear mixed-effects model, time and study group were included as fixed effects, with linear and quadratic time and time-by-treatment group interaction terms. Each model also began with a limited number of covariates (e.g., age, sex, and race), followed by backward stepping to identify thebest-fitting and most parsimonious model. In all models, random effects included intercept and linear slope terms, and an unstructured covariance was used to account for within-subject correlation over time. All comparisons were planned and tests were two-sided. A P value of less than 0.05 was considered to indicate statistical significance. The sequential Dunnett test was used to control the overall (familywise) error rate._24_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R24)

We analyzed data from all subjects according to study group. Sensitivity analyses were performed with the last observation carried forward (LOCF) and multiple imputation assuming missingness at random. Results were similar for the two missing-data methods. We report the results of the LOCF analysis because the
response rates were lower and hence provide a more conservative estimate of outcomes.

Results
Subjects
A total of 3066 potentially eligible subjects were screened by telephone
(_Figure 1_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#F1) ). Of these subjects, 761 signed consent forms and completed the inclusion and exclusion evaluation, 524 were deemed to be eligible and completed the baseline assessment, and 488 underwent randomization. Eleven subjects (2.3%) stopped
treatment but were included in the assessment (treatment withdrawals); 46 subjects (9.4%) stopped both treatment and assessment (study withdrawals).

On the basis of logistic-regression analyses, pairwise comparisons indicated that subjects in the cognitive-behavioral-therapy group were significantly less likely to withdraw from treatment than were those in the sertraline group (odds ratio, 0.33; 95% confidence interval [CI], 0.13 to 0.87; P=0.03) or the placebo
group (odds ratio, 0.24; 95% CI; 0.09 to 0.67; P=0.006). Of the 488 subjects who underwent randomization, 459 (94.1%) completed at least one postbaseline assessment, 396 (81.1%) completed all four assessments, and 440 (90.2%) completed the assessment at week 12. Subjects were recruited primarily through advertisements (52.2%) or clinical referrals (44.1%).
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Figure 1. Enrollment and Outcomes.
Subjects who are shown as having withdrawn from treatment discontinued their assigned therapy but continued to undergo study assessment. Subjects who are shown as having withdrawn from the study discontinued both therapy and assessment. CBT denotes cognitive behavioral therapy.

Of 14 possible sessions of cognitive behavioral therapy, the mean (±SD) number of sessions completed was 12.7±2.8 in the combination-therapy group and 13.2±2.0 in the cognitive-behavioral-therapy group. The mean dose of sertraline at the final visit was 133.7±59.8 mg per day (range, 25 to 200) in the combination-therapy group, 146.0±60.8 mg per day (range, 25 to 200) in the sertraline group, and 175.8±43.7 mg per day (range, 50 to 200) in the placebo group.

Demographic and Clinical Characteristics
There were no significant differences among study groups with respect to baseline demographic and clinical characteristics (_Table 1_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#T1) ). The mean age of participants was 10.7±2.8 years, with 74.2% under the age of 13 years.

There were nearly equal numbers of male and female subjects. Most subjects were white (78.9%), with
other racial and ethnic groups represented. Subjects came from predominantly middle-class and upper-middle-class families (74.6%) and lived with both biologic parents (70.3%). Most subjects had received the diagnosis of two or more primary anxiety disorders (78.7%) and one or more secondary disorders
(55.3%). At baseline, subjects had moderate-to-severe anxiety and impairment (_Table
2_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#T2) ).

Given the geographic diversity among study centers, there were significant differences among sites on several baseline demographic variables (e.g., race and socioeconomic status). Overall, these variables were equally distributed among study groups within each center; however, three centers had one instance each of
unequal distribution for sex, race, or socioeconomic status.

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Table 1. Baseline Characteristics of the Subjects and Recruitment According
to Study Center.

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Table 2. Key Outcomes at 12 Weeks.

Clinical Response
In the intention-to-treat analysis, the percentages of children who were rated as 1 (very much improved) or 2 (much improved) on the Clinical Global Impression–Improvement scale at 12 weeks were 80.7% (95% CI, 73.3 to 86.4) in the combination-therapy group, 59.7% (95% CI, 51.4 to 67.5) in the cognitive-behavioral-therapy group, 54.9% (95% CI, 46.4 to 63.1) in the sertraline group, and
23.7% (95% CI, 15.5 to 34.5) in the placebo group (_Table 2_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#T2) ).

With the study center as a covariate, planned pairwise comparisons from a logistic-regression model showed
that each active treatment was superior to placebo as follows: combination therapy versus placebo, P<0.001 (odds ratio, 13.6; 95% CI, 6.9 to 26.8); cognitive behavioral therapy versus placebo, P<0.001 (odds ratio, 4.8; 95% CI, 2.6 to 9.0); and sertraline versus placebo, P<0.001 (odds ratio, 3.9; 95% CI, 2.1 to 7.4). Similar pairwise comparisons revealed that combination therapy was superior to either sertraline alone (odds ratio, 3.4; 95% CI, 2.0 to 5.9; P<0.001) or cognitive behavioral therapy alone (odds ratio, 2.8; 95% CI, 1.6 to 4.8; P=0.001). However, there was no significant difference between sertraline and cognitive behavioral therapy (P=0.41).

There was no main effect for center (P=0.69); however, a comparison among centers according to study group revealed a significant difference in response to combination therapy but no differences with respect to the response to sertraline alone (P=0.15) or cognitive behavioral therapy alone (P=0.25).

Further evaluation of response rates revealed that the average response rate for combination therapy at one center was significantly lower than at the other centers (P=0.002). A sensitivity analysis of site response rates showed that when data from the one site were removed, the average response rate of the other sites was consistent with that of the full sample.

The mixed-effects model for the Pediatric Anxiety Rating Scale revealed a significant quadratic effect for time (P<0.001) and a significant quadratic time-by-treatment interaction for cognitive behavioral therapy versus placebo (P=0.01) but not for either combination therapy or sertraline versus placebo. In other words, as compared with placebo, cognitive behavioral therapy had a linear mean trajectory (_Figure 2_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#F2) ). Planned pairwise comparisons of the expected mean scores on the Pediatric Anxiety Rating Scale at week 12 revealed a similar ordering of
outcomes, with all active treatments superior to placebo, according to the following comparisons: combination therapy versus placebo, t=–5.94 (P<0.001); cognitive behavioral therapy versus placebo, t=–2.11 (P=0.04); and sertraline versus placebo, t=–3.15 (P=0.002). In addition, combination therapy was
superior to both sertraline alone (t=–3.26, P=0.001) and cognitive behavioral therapy alone (t=–4.73, P<0.001). No significant difference was found between sertraline and cognitive behavioral therapy (t=1.32, P=0.19). The same magnitude and pattern of outcome was found for the Clinical Global Impressio Severity
scale and the Children’s Global Assessment Scale.
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Figure 2. Scores on the Pediatric Anxiety Rating Scale during the 12-Week
Study.

Scores on the Pediatric Anxiety Rating Scale range from 0 to 30, with scores higher than 13 consistent with moderate levels of anxiety and a diagnosis of an anxiety disorder. The expected mean score is the mean of the sampling distribution of the mean.

Estimates of the effect size (Hedges’ g) and the number needed to treatbetween the active-treatment groups and the placebo group were calculated. Effect sizes are based on the expected mean scores on the Pediatric Anxiety
Rating Scale, derived from the mixed-effects model. The number needed to treat is based on the dichotomized, end-of-treatment scores on the Clinical Global Impression–Improvement scale with the use of LOCF. The effect size was 0.86 (95% CI, 0.56 to 1.15) for combination therapy, 0.45 (95% CI, 0.17 to 0.74) for
sertraline, and 0.31 (95% CI, 0.02 to 0.59) for cognitive behavioral treatment.

The number needed to treat was 1.7 (95% CI, 1.7 to 1.9) for combination therapy, 3.2 (95% CI, 3.2 to 3.5) for sertraline, and 2.8 (95% CI, 2.7 to 3.0) for cognitive behavioral therapy. Treatment and Study Withdrawals
Most treatment and study withdrawals were attributed to reasons other than adverse events (43 of 57, 75.4%) (_Table 3_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#T3) ).

Of the 14 withdrawals that were attributed to an adverse event, 11 (78.6%) were in the groups receiving either sertraline alone or placebo and consisted of 3 physical events (headache, stomach pains, and tremor) and 8 psychiatric adverse events (worsening of symptoms, 3 subjects; agitation or disinhibition, 3; hyperactivity, 1; and nonsuicidal self-harm and homicidal ideation, 1).
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Table 3. Subjects Who Withdrew from Treatment or the Study.

Serious Adverse Events
Three subjects had serious adverse events during the study period. One child in the sertraline group had a worsening of behavior that was attributed to the parents’ increased limit setting on avoidance behavior; the event was considered to be possibly related to sertraline. A child in the combination-therapy
group had a worsening of preexisting oppositional defiant behavior that resulted in psychiatric hospitalization; this event was considered to be unrelated to a study treatment. The third subject was hospitalized for a tonsillectomy, which was also considered to be unrelated to a study treatment
(_Table
4_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#T4) ).
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Table 4. Moderate-to-Severe Adverse Events at 12 Weeks.

Adverse Events
Subjects in the combination-therapy group had a greater number of study visits and therefore significantly more opportunities for elicitation of adverse events than did those in the other study groups, with a mean of 12.8±4.0 opportunities (range, 1 to 22) in the combination-therapy group, as compared with 9.9±3.6 (range, 1 to 14) in the sertraline group, 10.6±2.0 (range, 1 to 14) in the cognitive-behavioral-therapy group, and 9.7±4.2 (range, 1 to 14) in the placebo group (P<0.001 for all comparisons). Rates of adverse events,
including suicidal and homicidal ideation, were not significantly greater in the sertraline group than in the placebo group. No child in the study attempted suicide. Among children in the cognitive-behavioral-therapy group, there were fewer reports of insomnia, fatigue, sedation, and restlessness or fidgeting than in the sertraline group (P<0.05 for all comparisons). For a list of mild adverse events that were not associated with functional impairment, as well as moderate and severe events, see the _Supplementary Appendix_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633/DC1) ,

available with the full text of this article at www.nejm.org.

Discussion
Our study examined therapies that many clinicians consider to be the most promising treatments for childhood anxiety disorders. Our findings indicate that as compared with placebo, the three active therapies combination therapy with both cognitive behavioral therapy and sertraline, cognitive behavioral therapy alone, and sertraline alone — are effective short-term treatments for children with separation and generalized anxiety disorders and social phobia, with combination treatment having superior response rates. No physical,psychiatric, or harm-related adverse events were reported more frequently in the sertraline group than in the placebo group, a finding similar to that for SSRIs, as identified in previous studies of anxious children._12_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R12) ,_13_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R13) ,_25_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R25)

Few withdrawals from either treatment or the study were attributed to adverse events. Suicidal ideation and homicidal ideation were uncommon. No child attempted suicide during the study period. Since they were recruited at multiple centers and locations, the study subjects were racially and ethnically diverse. However, despite intense outreach, the sample did not include the most socioeconomically disadvantaged children.
Subjects were predominantly younger children and included those with ADHD and other anxiety disorders, factors that allow for generalization of the results to these populations.

Conversely, the exclusion of children and teens with major depression and pervasive developmental disorders may have limited the generalizability of the results to these populations.The observed advantage of combination therapy over either cognitive behavioral therapy or sertraline alone during short-term treatment (an improvement of 21 to 25%) suggests that among these effective therapies, combination therapy
provides the best chance for a positive outcome. The superiority of combination therapy might be due to additive or synergistic effects of the two therapies. However, additional contact time in the combination-therapy group, which was unblinded, and expectancy effects on the part of both subjects and
clinicians cannot be ruled out as alternative explanations.

Nonetheless, the magnitude of the treatment effect in the combination-therapy group (with two
subjects as the number needed to treat to prevent one additional event) suggests that children with anxiety disorders who receive quality combination therapy can consistently expect a substantial reduction in the severity of anxiety. An increased number of visits in the combination-therapy group resulted in increased opportunities for elicitation of adverse events. Consequently, the potential for expectancies among subjects, parents, and clinicians regarding the side effects of medications in the context of more visits may have increased the rate of some adverse events in the combination-therapy group and may limit conclusions that can be drawn regarding the rates of adverse events in combination therapy.

The positive benefit of cognitive behavioral therapy, as compared with placebo, adds new information to the existing literature._26_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R26)
The number needed to treat for cognitive behavioral therapy in this study (three subjects) is the same as that
identified in a meta-analysis of studies comparing subjects who were assigned to cognitive behavioral therapy with those assigned to a waiting list for therapy or to sessions without active therapy._14_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R14)

Our study’s test of cognitive behavioral therapy included children with moderate-to-severe anxiety and addresses criticism of previous trials that included children with only mild-to-moderate
anxiety._14_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R14)
Before our study, cognitive behavioral therapy for childhood anxiety was considered to be
“probably efficacious.”_26_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R26)

This evaluation of cognitive behavioral therapy and other recent studies_27_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R27)
,_28_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R28) suggests that
such therapy for childhood anxiety is a well-established, evidenced-based treatment._29_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R29)

Given that the risk of some adverse events was lower in the behavioral-therapy group than in the sertraline group, some parents and their children may consider choosing cognitive behavioral therapy as their initial treatment.

The results of our study confirm the short-term efficacy of sertraline for children with generalized anxiety disorder_25_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R25) and show that
sertraline is effective for children with separation anxiety disorder and social phobia. The number needed
to treat for sertraline in our study (three subjects) was the same as that previously identified in a meta-analysis_15_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R15) of six
randomized, placebo-controlled trials of SSRIs for childhood anxiety disorders._12_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R12) ,_13_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R13) ,_25_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R25)
,_30_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R30) ,_31_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R31)

These studies and others_27_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R27)
suggest that SSRIs, as a class, are the medication of choice for these conditions. The titration schedule that we used, which emphasized upward dose adjustment in the absence of response and adverse events, suggests that the average end-point dose of sertraline in this study is the highest dose consistent with good outcome and tolerability. No adverse events were observed more frequently in the sertraline group than in the placebo group. In contrast to the apparent risk of suicidal ideation and behavior in studies of depression in children and
adolescents,_15_ (http://content.nejm.org/cgi/content/full/NEJMoa0804633#R15) our study did not demonstrate any increased risk for suicidal behavior in the sertraline group. Given the benefit of sertraline alone or in combination with cognitive behavioral therapy and the limited risk of adverse events associated with the drug in our study, the well-monitored use of sertraline and other SSRIs in the treatment of childhood anxiety disorders is indicated.

Cognitive behavioral therapy and sertraline either in combination or as monotherapies appear to be effective treatments for these commonly occurring childhood anxiety disorders. Results confirm those of previous studies of SSRIs and cognitive behavioral therapy and, most important, show that combination
therapy offers children the best chance for a positive outcome. Our findings indicate that all three of the treatment options may be recommended, taking into consideration the family’s treatment preferences, treatment availability, cost, and time burden. To inform more prescriptive selection of patients for
treatment, further analysis of predictors and moderators of treatment response may identify who is most likely to respond to which_32_
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#R32) of these
effective alternatives.
Supported by grants (U01 MH064089, to Dr. Walkup; U01 MH64092, to Dr.
Albano; U01 MH64003, to Dr. Birmaher; U01 MH63747, to Dr. Kendall; U01 MH64107,
to Dr. March; U01 MH64088, to Dr. Piacentini; and U01 MH064003, to Dr. Compton)
from the National Institute of Mental Health (NIMH).

Sertraline and matching placebo were supplied free of charge by Pfizer. Dr. Walkup reports receiving consulting fees from Eli Lilly and Jazz Pharmaceuticals and fees for legal consultation to defense counsel and
submission of written reports in litigation involving GlaxoSmithKline, receiving lecture fees from CMP Media, Medical Education Reviews, McMahon Group, and DiMedix, and receiving support in the form of free medication and matching placebo from Eli Lilly and free medication from Abbott for clinical trials funded by the NIMH; Dr. Albano, receiving royalties from Oxford University Press for the Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions, but not for interviews used in this study, and royalties from the Guilford Press; Dr. Piacentini, receiving royalties from Oxford University Press for treatmentmanuals on childhood obsessive compulsive disorder and tic disorders and from the Guilford Press and APA Books for other books on child mental health and receiving lecture fees from Janssen-Cilag; Dr. Birmaher, receiving consulting fees from Jazz Pharmaceuticals, Solvay Pharmaceuticals, and Abcomm, lecture fees from Solvay, and royalties from Random House for a book on children with bipolar disorder; Dr. Rynn, receiving grant support from Neuropharm, BoehringerIngelheim Pharmaceuticals, and Wyeth Pharmaceuticals, consulting fees from Wyeth, and royalties from APPI for a book chapter on pediatric anxiety disorders; Dr. McCracken, receiving consulting fees from Sanofi-Aventis and Wyeth, lecture fees from Shire and UCB, and grant support from Aspect, Johnson & Johnson, Bristol-Myers Squibb, and Eli Lilly; Dr. Waslick, receiving grant support from Baystate Health, Somerset Pharmaceuticals, and GlaxoSmithKline; Dr. Iyengar, receiving consulting fees from Westinghouse for statistical consultation; Dr. March, receiving study medications from Eli Lilly for an NIMH-funded clinical trial and receiving royalties from Pearson for being the author of the Multidimensional Anxiety Scale for Children, receiving consulting fees from Eli Lilly, Pfizer, Wyeth, and GlaxoSmithKline, having an equity interest in MedAvante, and serving on an advisory board for AstraZeneca and Johnson & Johnson; and Dr. Kendall, receiving royalties from Workbook Publishing for anxiety-treatment materials.

No other potential conflict of interest relevant to this article was reported.

The views expressed in this article are those of the authors and do not necessarily represent the official views of the NIMH, the National Institutes of Health, or the Department of Health and Human Services.
We thank the children and their families who made this study possible; and J. Chisar, J. Fried, R. Klein, E. Menvielle, S. Olin, J. Severe, D. Almirall, and members of NIMH’s data and safety monitoring board.
* The study investigators are listed in the Appendix.
(http://content.nejm.org/cgi/content/full/NEJMoa0804633#RFN1)

Source Information
From the Johns Hopkins Medical Institutions, Baltimore (J.T.W., G.S.G.); New York State Psychiatric Institute–Columbia University Medical Center, New York (A.M.A., M.A.R.); the University of California at Los Angeles, Los Angeles (J.P., J.M.); Western Psychiatric Institute and Clinic University of Pittsburgh Medical Center, Pittsburgh (B.B., S.I.); Duke University Medical Center, Durham, NC (S.N.C., J.S.M.); the Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, MD (J.T.S.); Baystate
Medical Center, Springfield, MA (B.W.); and Temple University, Philadelphia
(P.C.K.).

This article (10.1056/NEJMoa0804633) was published at www.nejm.org on
October 30, 2008. It will appear in the December 25 issue of the Journal.
Address reprint requests to Dr. Walkup at the Division of Child and
Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns
Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD 21287.
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Appendix
The following investigators participated in this study: Steering Committee:
J. Walkup (chair), A. Albano (cochair); Statistics–Experimental Design: S.
Compton, S. Iyengar, J. March; Cognitive Behavioral Therapy: P. Kendall, G.
Ginsburg; Pharmacotherapy: M. Rynn, J. McCracken; Assessment: J. Piacentini,
A. Albano; Study Coordinators: C. Keeton, H. Koo, S. Aschenbrand, L. Bardsley,
R. Beidas, J. Catena, K. Dever, K. Drake, R. Dublin, E. Fontaine, J. Furr, A.
Gonzalez, K. Hedtke, L. Hunt, M. Keller, J. Kingery, A. Krain, K. Miller, J.
Podell, P. Rentas, M. Rozenmann, C. Suveg, C. Weiner, M. Wilson, T. Zoulas;
Data Center: M. Fletcher, K. Sullivan; Cognitive Behavior Therapists: E.
Gosch, C. Alfano, A. Angelosante, S. Aschenbrand, A. Barmish, L. Bergman, S.
Best, J. Comer, S. Compton, W. Copeland, M. Cwik, M. Desari, K. Drake, E.
Fontaine, J. Furr, P. Gammon, C. Gaze, R. Grover, H. Harmon, A. Hughes, K.
Hutchinson, J. Jones, C. Keeton, H. Kepley, J. Kingery, A. Krain, A. Langley,
J. Lee, J. Levitt, J. Manetti-Cusa, E. Martin, C. Mauro, K. McKnight, T. Peris, K.
Poling, L. Preuss, A. Puliafico, J. Robin, T. Roblek, J. Samson, M.
Schlossberg, M. Sweeney, C. Suveg, O. Velting, T. Verduin; Pharmacotherapists:
M. Rynn, J. McCracken, A. Adegbola, P. Ambrosini, D. Axelson, S. Barnett, A. Baskina,
B. Birmaher, C. Cagande, A. Chrisman, B. Chung, H. Courvoisie, B. Dave, A.
Desai, K. Dever, M. Gazzola, E. Harris, G. Hirsh, V. Howells, L. Hsu, I.
Hypolite, F. Kampmeier, S. Khalid-Khan, B. Kim, D. Kondo, L. Kotler, M.
Krushelnycky, J. Larson, J. Lee, P. Lee, C. Lopez, L. Maayan, J. McCracken, R.
Means,L. Miller, A. Parr, C. Pataki, C. Peterson, P. Pilania, R. Pizarro, H. Ravi,
S. Reinblatt, M. Riddle, M. Rodowski, D. Sakolsky, A. Scharko, R. Suddath, C.
Suarez, J. Walkup, B. Waslick; Independent Evaluators: A. Albano, G.
Ginsburg, B. Asche, A. Barmish, M. Beaudry, S. Chang, M. Choudhury, B. Chu, S.
Crawley, J. Curry, G. Danner, N. Deily, R. Dingfelder, D. Fitzgerald, P.
Gammon, S. Hofflich, E. Kastelic, J. Keener, T. Lipani, K. Lukin, M. Masarik, T.
Peris, T. Piacentini, S. Pimentel, A. Puliafico, T. Roblek, M. Schlossberg, E.
Sood, S. Tiwari, J. Trachtenberg, P. van de Velde; Pharmacy: K. Truelove, H.
Kim; Research Assistants: S. Allard, S. Avny, D. Beckmann, C. Brice, B.
Buzzella, E. Capelli, A. Chiu, M. Coles, J. Freeman, M. Gringle, S. Hefton, D.
Hood, M. Jacoby, J. King, A. Kolos, B. Lourea-Wadell, L. Lu, J. Lusky, R. Maid, C.
Merolli, Y. Ojo, A. Pearlman, J. Regan, S. Rock, M. Rooney, N. Simone, S.
Tiwari, S. Yeager.

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