America's Medicated Army
Thursday, Jun. 05, 2008
By MARK THOMPSON
http://www.time.com/time/nation/article/0,8599,1811858,00.html
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."