title: Prevalence of Central Nervous System Polypharmacy and Associations with Overdose and Suicide-Related Behaviors in Iraq and Afghanistan War Veterans in VA Care 2010-2011.
abstract: BACKGROUND
  The increase in the quantities of central nervous system (CNS)-acting medications prescribed has coincided with increases in overdose mortality, suicide-related behaviors, and unintentional deaths in military personnel deployed in support of the wars in Iraq and Afghanistan. Data on the extent and impact of prescribing multiple CNS drugs among Iraq and Afghanistan Veterans (IAVs) are sparse.
  
  
  OBJECTIVE
  We sought to identify the characteristics of IAVs with CNS polypharmacy and examine the association of CNS polypharmacy with drug overdose and suicide-related behaviors controlling for known risk factors.
  
  
  METHODS
  This cross-sectional cohort study examined national data of Iraq and Afghanistan Veterans (N = 311,400) who used the Veterans Health Administration (VHA) during the fiscal year 2011. CNS polypharmacy was defined as five or more CNS-acting medications; drug/alcohol overdose and suicide-related behaviors were identified using ICD-9-CM codes. Demographic and clinical characteristics associated with CNS polypharmacy were identified using a multivariable logistic regression model.
  
  
  RESULTS
  We found that 25,546 (8.4 %) of Iraq and Afghanistan Veterans had CNS polypharmacy. Those with only post-traumatic stress disorder (PTSD) (adjusted odds ratio (AOR) 6.50, 99 % confidence interval (CI) 5.96-7.10), only depression (AOR 6.42, 99 % CI 5.86-7.04), co-morbid PTSD and depression (AOR 12.98, 99 % CI 11.97-14.07), and co-morbid traumatic brain injury (TBI), PTSD, and depression (AOR 15.30, 99 % CI 14.00-16.73) had the highest odds of CNS polypharmacy. After controlling for these co-morbid conditions, CNS polypharmacy was significantly associated with drug/alcohol overdose and suicide-related behavior.
  
  
  CONCLUSIONS
  CNS polypharmacy was most strongly associated with PTSD, depression, and TBI, and independently associated with overdose and suicide-related behavior after controlling for known risk factors. These findings suggest that CNS polypharmacy may be used as an indicator of risk for adverse outcomes. Further research should evaluate whether CNS polypharmacy may be used as a trigger for evaluation of the current care provided to these individuals.
authors.affiliation: Departments of Epidemiology and Biostatistics, Medicine, Psychiatry, Anesthesiology, and Rehabilitation Medicine, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
authors.forename: Garen A
authors.initials: GA
authors.lastname: Collett
authors.affiliation: Research, and Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton Minter BLVD, San Antonio, TX, USA.|Departments of Epidemiology and Biostatistics, Medicine, Psychiatry, Anesthesiology, and Rehabilitation Medicine, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.|College of Pharmacy, University of Texas, Austin, TX, USA.
authors.forename: Kangwon
authors.initials: K
authors.lastname: Song
authors.affiliation: Research, and Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton Minter BLVD, San Antonio, TX, USA.|Departments of Epidemiology and Biostatistics, Medicine, Psychiatry, Anesthesiology, and Rehabilitation Medicine, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Jaramillo
authors.affiliation: Departments of Epidemiology and Biostatistics, Medicine, Psychiatry, Anesthesiology, and Rehabilitation Medicine, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Potter
authors.affiliation: Research, and Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton Minter BLVD, San Antonio, TX, USA.|Departments of Epidemiology and Biostatistics, Medicine, Psychiatry, Anesthesiology, and Rehabilitation Medicine, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
authors.forename: Erin P
authors.initials: EP
authors.lastname: Finley
authors.affiliation: Research, and Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton Minter BLVD, San Antonio, TX, USA. pughm@uthscsa.edu.|Departments of Epidemiology and Biostatistics, Medicine, Psychiatry, Anesthesiology, and Rehabilitation Medicine, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA. pughm@uthscsa.edu.
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Pugh