Friday, June 06, 2008 13:16
In 1994 then Major E. Cameron Ritchie, an Army psychiatrist, was among
the first to suggest that SSRIs should deploy with Army combat units. In
a paper written and published after she returned from a combat
deployment to Somalia, Ritchie noted that the sick-call chests used by
military doctors "contain either outdated or no psychiatric
medications." She concluded, "If depressive symptoms are moderate and
manageable, medication may be preferable to medical evacuation."
Time Magazine By MARK THOMPSON
Seven months after Sergeant Christopher LeJeune started scouting
Baghdad's dangerous roads - acting as bait to lure insurgents into the
open so his Army unit could kill them - he found himself growing
increasingly despondent.
"We'd been doing some heavy missions, and
things were starting to bother me," LeJeune says. His unit had been
protecting Iraqi police stations targeted by rocket-propelled grenades,
hunting down mortars hidden in dark Baghdad basements and cleaning up
its own messes. He recalls the order his unit got after a nighttime
firefight to roll back out and collect the enemy dead. When LeJeune and
his buddies arrived, they discovered that some of the bodies were still
alive.
"You don't always know who the bad guys are," he says. "When you
search someone's house, you have it built up in your mind that these
guys are terrorists, but when you go in, there's little bitty tiny shoes
and toys on the floor - things like that started affecting me a lot more
than I thought they would." So LeJeune visited a military doctor in Iraq, who, after a quick
session, diagnosed depression. The doctor sent him back to war armed
with the antidepressant Zoloft and the antianxiety drug clonazepam.
"It's not easy for soldiers to admit the problems that they're having
over there for a variety of reasons," LeJeune says. "If they do admit
it, then the only solution given is pills." While the headline-grabbing weapons in this war have been high-tech
wonders, like unmanned drones that drop Hellfire missiles on the enemy
below, troops like LeJeune are going into battle with a different kind
of weapon, one so stealthy that few Americans even know of its
deployment. For the first time in history, a sizable and growing number
of U.S. combat troops are taking daily doses of antidepressants to calm
nerves strained by repeated and lengthy tours in Iraq and Afghanistan.
The medicines are intended not only to help troops keep their cool but
also to enable the already strapped Army to preserve its most precious
resource: soldiers on the front lines. Data contained in the Army's
fifth Mental Health Advisory Team report indicate that, according to an
anonymous survey of U.S. troops taken last fall, about 12% of combat
troops in Iraq and 17% of those in Afghanistan are taking prescription
antidepressants or sleeping pills to help them cope. Escalating violence
in Afghanistan and the more isolated mission have driven troops to rely
more on medication there than in Iraq, military officials say.
At a Pentagon that keeps statistics on just about everything, there is
no central clearinghouse for this kind of data, and the Army hasn't
consistently asked about prescription-drug use, which makes it difficult
to track.
Given the traditional stigma associated with soldiers seeking
mental help, the survey, released in March, probably underestimates
antidepressant use. But if the Army numbers reflect those of other
services - the Army has by far the most troops deployed to the war zones
- about 20,000 troops in Afghanistan and Iraq were on such medications
last fall. The Army estimates that authorized drug use splits roughly
fifty-fifty between troops taking antidepressants - largely the class of
drugs that includes Prozac and Zoloft - and those taking prescription
sleeping pills like Ambien.
In some ways, the prescriptions may seem unremarkable. Generals, history
shows, have plied their troops with medicinal palliatives at least since
George Washington ordered rum rations at Valley Forge. During World War
II, the Nazis fueled their blitzkrieg into France and Poland with the
help of an amphetamine known as Pervitin. The U.S. Army also used
amphetamines during the Vietnam War. The military's rising use of antidepressants also reflects their
prevalence in the civilian population. In 2004, the last year for which
complete data for the U.S. are available, doctors wrote 147 million
prescriptions for antidepressants, according to IMS Health, a
pharmaceutical-market-research firm.
This number reflects in part the
common practice of cycling through different medications to find the
most effective drug. A 2006 federally funded study found that 70% of
those taking antidepressants along with therapy experience some
improvement in mood. When it comes to fighting wars, though, troops have historically been
barred from using such drugs in combat. And soldiers - who are younger
and healthier on average than the general population - have been
prescreened for mental illnesses before enlisting.
The increase in the use of medication among U.S. troops suggests the
heavy mental and psychological price being paid by soldiers fighting in
Iraq and Afghanistan. Pentagon surveys show that while all soldiers
deployed to a war zone will feel stressed, 70% will manage to bounce
back to normalcy. But about 20% will suffer from what the military calls
"temporary stress injuries," and 10% will be afflicted with "stress
illnesses."
Such ailments, according to briefings commanders get before
deploying, begin with mild anxiety and irritability, difficulty
sleeping, and growing feelings of apathy and pessimism. As the condition
worsens, the feelings last longer and can come to include panic, rage,
uncontrolled shaking and temporary paralysis.
The symptoms often
continue back home, playing a key role in broken marriages, suicides and
psychiatric breakdowns. The mental trauma has become so common that the
Pentagon may expand the list of "qualifying wounds" for a Purple Heart -
historically limited to those physically injured on the battlefield - to
include posttraumatic stress disorder (PTSD). Defense Secretary Robert
Gates said on May 2 that it's "clearly something" that needs to be
considered, and the Pentagon is weighing the change.
Using drugs to cope with battlefield traumas is not discussed much
outside the Army, but inside the service it has been the subject of
debate for years. "No magic pill can erase the image of a best friend's
shattered body or assuage the guilt from having traded duty with him
that day," says Combat Stress Injury, a 2006 medical book edited by
Charles Figley and William Nash that details how troops can be helped by
such drugs. "Medication can, however, alleviate some debilitating and
nearly intolerable symptoms of combat and operational stress injuries"
and "help restore personnel to full functioning capacity." Which means that any drug that keeps a soldier deployed and fighting
also saves money on training and deploying replacements.
But there is a
downside: the number of soldiers requiring long-term mental-health
services soars with repeated deployments and lengthy combat tours. If
troops do not get sufficient time away from combat - both while in
theater and during the "dwell time" at home before they go back to war -
it's possible that antidepressants and sleeping aids will be used to
stretch an already taut force even tighter. "This is what happens when
you try to fight a long war with an army that wasn't designed for a long
war," says Lawrence Korb, Pentagon personnel chief during the Reagan
Administration.
Military families wonder about the change, according to Joyce Raezer of
the private National Military Family Association. "Boy, it's really nice
to have these drugs," she recalls a military doctor saying, "so we can
keep people deployed." And professionals have their doubts. "Are we
trying to bandage up what is essentially an insufficient fighting
force?" asks Dr. Frank Ochberg, a veteran psychiatrist and founding
board member of the International Society for Traumatic Stress Studies. Such questions have assumed greater urgency as more is revealed about
the side effects of some mental-health medications.
Last year the U.S.
Food and Drug Administration (FDA) urged the makers of antidepressants
to expand a 2004 "black box" warning that the drugs may increase the
risk of suicide in children and adolescents. The agency asked for - and
got - an expanded warning that included young adults ages 18 to 24, the
age group at the heart of the Army. The question now is whether there is
a link between the increased use of the drugs in the Iraqi and Afghan
theaters and the rising suicide rate in those places.
There have been
164 Army suicides in Afghanistan and Iraq from the wars' start through
2007, and the annual rate there is now double the service's 2001 rate. At least 115 soldiers killed themselves last year, including 36 in Iraq
and Afghanistan, the Army said on May 29. That's the highest toll since
it started keeping such records in 1980. Nearly 40% of Army suicide
victims in 2006 and 2007 took psychotropic drugs - overwhelmingly,
selective serotonin reuptake inhibitors (SSRIs) like Prozac and Zoloft.
While the Army cites failed relationships as the primary cause, some
outside experts sense a link between suicides and prescription-drug use
- though there is also no way of knowing how many suicide attempts the
antidepressants may have prevented by improving a soldier's spirits.
"The high percentage of U.S. soldiers attempting suicide after taking
SSRIs should raise serious concerns," says Dr. Joseph Glenmullen, who
teaches psychiatry at Harvard Medical School. "And there's no question
they're using them to prop people up in difficult circumstances."
The Trauma of War
Before the advent of SSRIs - Lilly's Prozac was the first to be approved
by the FDA, in 1987, followed by Zoloft from Pfizer, Paxil from
GlaxoSmithKline, Celexa from Forest Pharmaceuticals and others -
existing antidepressants had many disabling side effects. Impaired
memory and judgment, dizziness, drowsiness and other complications made
them ill suited for troops in combat. The newer drugs have fewer side
effects and, unlike earlier drugs, are generally not addictive or toxic,
even when taken in large quantities.
They work by keeping neural
connections bathed in a brain chemical known as serotonin. That
amplifies serotonin's mood-brightening effect, at least for some people.
In 1994 then Major E. Cameron Ritchie, an Army psychiatrist, was among
the first to suggest that SSRIs should deploy with Army combat units. In
a paper written and published after she returned from a combat
deployment to Somalia, Ritchie noted that the sick-call chests used by
military doctors "contain either outdated or no psychiatric
medications." She concluded, "If depressive symptoms are moderate and
manageable, medication may be preferable to medical evacuation." By 1999, military docs were debating the matter among themselves. Nash,
a Navy psychiatrist, wrote that Navy doctors - who also provide Marines
with medical care - had "sharp differences of opinion" over letting
troops in war zones use SSRIs. Skeptics argued that their "real safety"
in combat had not been proved. Supporters countered that their use could"avoid depleting manpower resources and damaging individual careers
through unnecessary removals from operational duty." Nash reviewed the
medical literature and reported that SSRIs "can be safely administered
to deploying and deployed personnel."
The trickle of new drugs became a flood after the invasion of Iraq in
2003. Details of America's medicated wars come from the mental-health
surveys the Army has conducted each year since the war began. If the
surveys are right, many U.S. soldiers experience a common but haunting
mismatch in combat life: while nearly two-thirds of the soldiers
surveyed in Iraq in 2006 knew someone who had been killed or wounded,
fewer than 15% knew for certain that they had actually killed a member
of the enemy in return.
That imbalance between seeing the price of war
up close and yet not feeling able to do much about it, the survey
suggests, contributes to feelings of "intense fear, helplessness or
horror" that plant the seeds of mental distress. "A friend was liquefied
in the driver's position on a tank, and I saw everything," was a typical
comment. Another: "A huge f______ bomb blew my friend's head off like 50
meters from me."
Such indelible scenes - and wondering when and where
the next one will happen - are driving thousands of soldiers to take
antidepressants, military psychiatrists say. It's not hard to imagine
why. Repeated deployments to the war zones also contribute to the onset of
mental-health problems. Nearly 30% of troops on their third deployment
suffer from serious mental-health problems, a top Army psychiatrist told
Congress in March. The doctor, Colonel Charles Hoge, added that recent
research has shown the current 12 months between combat tours "is
insufficient time" for soldiers "to reset" and recover from the stress
of a combat tour before heading back to war.
Colonel Joseph Horam says antidepressants have made "a striking
difference" in the way troops are treated in war. A doctor in the
Wyoming Army National Guard, Horam served in Saudi Arabia during the
first Gulf War and has been deployed to Iraq twice during this war. "In
the Persian Gulf War, we didn't have these medications, so our basic
philosophy was 'three hots and a cot'" - giving stressed troops a little
rest and relaxation to see if they improved. "If they didn't get better
right away, they'd need to head to the rear and probably out of
theater."
But in his most recent stint in Baghdad in 2006, he treated a
soldier who guarded Iraqi detainees. "He was distraught while he was
having high-level interactions with detainees, having emotional
confrontations with them - and carrying weapons," Horam says. "But he
was part of a highly trained team, and we didn't want to lose him. So we
put him on an SSRI, and within a week, he was a new person, and we got
him back to full duty." It wasn't until November 2006 that the Pentagon set a uniform policy for
all the services. But the curious thing about it was that it didn't
mention the new antidepressants. Instead, it simply barred troops from
taking older drugs, including "lithium, anticonvulsants and
antipsychotics."
The goal, a participant in crafting the policy said,
was to give SSRIs a "green light" without saying so. Last July, a paper
published by three military psychiatrists in Military Medicine, the
independent journal of the Association of Military Surgeons of the
United States, urged military doctors headed for Afghanistan and Iraq to"request a considerable quantity of the SSRI they are most comfortable
prescribing" for the "treatment of new-onset depressive disorders" once
in the war zones. The medications, the doctors concluded, help "to
'conserve the fighting strength,'" the motto of the Army Medical Corps.
These days Ritchie - now a colonel and a psychiatric consultant to the
Army surgeon general - thinks the military's use of SSRIs has helped
destigmatize mental problems. "What we're trying to do is make treating
depression and PTSD - especially PTSD, which is quite common for
soldiers now - fairly routine," she says. "We don't want to make it
harder for folks to do their job and their mission by saying they can't
use these medications." Ritchie, who communicates "six times a day" with
her colleagues in the war zones, says she is unaware of "any bad
outcomes" resulting from soldiers taking SSRIs.
William Winkenwerder Jr., who issued the 2006 policy as the Pentagon's
top doctor before stepping down last year, says the new medicines are
working well. "Combat presents some unique and important caveats -
obviously, those who are being treated have access to firearms, and they
may be under significant stress, so they need to be very carefully
evaluated, and good clinical decisions need to be made," Winkenwerder
tells TIME. "It's my belief that is happening."
"In a Total Daze"
And yet the battlefield seems an imperfect environment for widespread
prescription of these medicines. LeJeune, who spent 15 months in Iraq
before returning home in May 2004, says many more troops need help -
pharmaceutical or otherwise - but don't get it because of fears that it
will hurt their chance for promotion. "They don't want to destroy their
career or make everybody go in a convoy to pick up your prescription,"
says LeJeune, now 34 and living in Utah. "In the civilian world, when
you have a problem, you go to the doctor, and you have therapy followed
up by some medication. In Iraq, you see the doctor only once or twice,
but you continue to get drugs constantly."
LeJeune says the medications
- combined with the war's other stressors - created unfit soldiers."There were more than a few convoys going out in a total daze." About a third of soldiers in Afghanistan and Iraq say they can't see a
mental-health professional when they need to. When the number of troops
in Iraq surged by 30,000 last year, the number of Army mental-health
workers remained the same - about 200 - making counseling and care even
tougher to get.
"Burnout and compassion fatigue" are rising among such personnel, and
there have been "recent psychiatric evacuations" of Army mental-health
workers from Iraq, the 2007 survey says. Soldiers are often stationed at
outposts so isolated that follow-up visits with counselors are
difficult. "In a perfect world," admits Nash, who has just retired from
the Navy, "you would not want to rely on medications as your first-line
treatment, but in deployed settings, that is often all you have."
And just as more troops are taking these drugs, there are new doubts
about the drugs' effectiveness. A pair of recent reports from Rand and
the federal Institute of Medicine (iom) raise doubts about just how much
the new medicines can do to alleviate PTSD. The Rand study, released in
April, says the "overall effects for SSRIs, even in the largest clinical
trials, are modest." Last October the iom concluded, "The evidence is
inadequate to determine the efficacy of SSRIs in the treatment of PTSD."
Chris LeJeune could have told them that. When he returned home in May
2004, he remained on clonazepam and other drugs. He became one of
300,000 Americans who served in Iraq and Afghanistan and suffer from
PTSD or depression. "But PTSD isn't fixed by taking pills - it's just
numbed," he claims now. "And I felt like I was drugged all the time." So
a year ago, he simply stopped taking them. "I just started trying to
fight my demons myself," he says, with help from VA counseling. He
laughs when asked how he's doing. "I'd like to think," he says, "that
I'm really damn close back to normal."
