Females in Combat
America's Medicated ArmyThursday, Jun. 05, 2008 ~ 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."
The Trauma of WarBefore 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from a combat deployment to Somalia, Ritchie noted that the sick-call chests used by military doctors "contain either outdated or no psychiatric medications."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."
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