podesta-emails
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http://www.time.com/time/printout/0,8816,1811858,00.html
Thursday, Jun. 05, 2008
*America's Medicated Army*
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."
--
Jon Soltz
Iraq War Veteran
Chairman
VoteVets.org
646-415-8429
303 Park Ave. S., #1293
New York, NY 10010
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