The VA Office of Inspector General (OIG) was asked by Senator Rockefeller to review the care of two West Virginia combat veterans who were being treated for severe post-traumatic stress disorder (PTSD) and who died in their sleep. The Senator asked that the review take into account the medications prescribed and explore the possibility of any pattern in these tragic deaths.

We reviewed these patients’ medical records and visited the Huntington VA Medical Center (VAMC), Charleston Community Based Outpatient Clinic and Vet Center, and the Cincinnati VAMC PTSD Residential Program. We interviewed the families of the patients and the providers at each site who had been involved in the care of these patients. We reviewed the autopsy and toxicology reports for both patients and discussed the findings with the Chief Medical Examiner for the State of West Virginia. We concluded that the care provided for these patients at the Charleston community based outpatient clinic, and the VA facilities in Huntington and Cincinnati met community standards of care.

VA’s Pharmacy Benefits Management Services program and its Center for Medication Safety (VAMedSAFE) conducted a nationwide data pull of all-cause mortality during 1998–2008 for patients prescribed the combination of quetiapine, paroxetine, and clonazepam. Additional analyses examined other combinations of mental health medications, including an analysis by age of patients with and without PTSD. There was no apparent signal to indicate increased mortality for patients taking the combination of quetiapine, paroxetine, and clonazepam when compared with patients taking other similar combinations of psychotropic medications. The direct impact of non-prescribed medications in these patient deaths cannot be determined. VA mental health providers describe the use of non-prescription medications as growing area of concern in the treatment of young veterans.

Returning war veterans may have multiple mental health conditions in addition to PTSD. Restriction of admission to the Clarksburg Residential PTSD Program for patients taking clonazepam and related medications may decrease access to appropriate treatment. We recommended that management evaluate exclusion criteria for admission related to medications for newly-diagnosed patients to the Residential PTSD Program.

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These two Iraqi war veterans served honorably in Iraq. After returning from the Middle East they suffered with symptoms of PTSD and other mental health conditions. Their deaths are tragic.

The health care provided for these patients met community standards of care.

VHA’s Pharmacy Benefits Management Services program and its Center for Medication Safety (VAMedSAFE) conducted a nationwide data pull of all-cause mortality during 1998–2008 for patients prescribed the combination of quetiapine, paroxetine, and clonazepam. Additional analyses examined other combinations of mental health medications, including an analysis by age of patients with and without PTSD. There was no apparent signal to indicate increased mortality for patients taking the combination of quetiapine, paroxetine, and clonazepam when compared with patients taking other similar combinations of psychotropic medications. The direct impact of non-prescribed medications in these patient deaths cannot be determined.

Returning war veterans may have multiple mental health conditions in addition to PTSD. Restriction of admission to the Clarksburg Residential PTSD Program for patients taking clonazepam and related medications may decrease access to appropriate treatment.

VA mental health providers describe the use of non-prescription medications as growing area of concern in the treatment of young veterans.