Supporting the Policy, Not the Troops

Cernig points to an article in Time magazine about the growing use of anti-depressants among U.S. troops on active duty in Iraq as well as those who have returned home.

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.”

Cernig rightly takes note of the courage it took for Sgt. LeJeune to go public with his story, given the stigma surrounding mental health problems in the military, and in American society in general.

I want to zero in here on that last thing LeJeune said: “If they do admit it, then the only solution given is pills.” The use of medication to treat depression is still controversial, although perhaps less so than it used to be. I happen to be a strong believer in the effectiveness of anti-depressants, especially when combined with psychotherapy. How could I not be? I have been diagnosed with major depression — I’ve struggled with depression most of my life — and I’ve been taking Zoloft for years now. It’s not a magic happy pill, but it does keep me stable and able to function reasonably well in my daily life.

However, there are very significant differences between anti-depressant use in society at large, and its use in the military, to treat depression among troops in combat situations. As I indicated above, the purpose of anti-depressants is to ameliorate the symptoms of depression — profound sadness that doesn’t go away, irritability, lack of energy, sleep disturbances, inability to focus and concentrate, memory problems (like “zoning out,” when the mind goes blank and you lose your train of thought or cannot remember what you were about to do) — so that depressed individuals can function effectively in their daily lives and in their relationships with others. This is normally a good thing — you want to be able to go back to work, to take care of your family, to enjoy your social relationships. But for soldiers on active duty, the daily reality that anti-depressants are enabling them to handle is combat, death, grievous injury, losing your friends in unimaginably horrible ways. Pragmatically, if your daily reality is filled with terror, grief, and sudden, unpredictable death, then anti-depressant medication can only go so far, and ultimately it will not be as effective. Consider the metaphor of an air conditioner cooling a hot room. If it’s over 100 degrees outside, that air conditioner is not going to cool the room as much as if it’s 85 degrees. Air conditioners are awesome tools, but they can only do so much. And ethically, the use of anti-depressants to help soldiers feel better emotionally so they can wage war more effectively is problematic, to say the least:

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.

A few more differences between treating depression in normal life (such as that is) and treating depression suffered by U.S. troops deployed in Iraq:

  • Medication supply problems — it’s hard to refill prescriptions.
  • Privacy issues: you’re getting your medication from the same people who employ you.
  • Lack of access to therapy, which is essential to treating depression in the same way that the combination of diet and exercise is essential to weight management.
  • Lack of medical personnel to monitor anti-depressant usage, adjust dosages, and deal with possible side effects.

Chris LeJeune again:

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.”

4 Responses to “Supporting the Policy, Not the Troops”

  1. Chief says:

    It seems to me that in your case, Kathy, the cause of your need for meds is beyond anyones control. You take meds so you can function as a regular person.

    The combat soldier has a cause that is not beyond anyones control. I would think that the medically ethical thing to do is to remove the soldier from the cause of needing meds.

    Pretty obvious, I suppose. Some medical people have as much morals as some politicians.

  2. Kathy says:

    I understand your point, Chief, but depression is a medical condition regardless of what triggers it. Every soldier who sees combat gets stressed and upset and sad, some extremely so. But that is not what major depression is. A smaller subset of soldiers (in this example) who experience combat for prolonged periods of time will develop the symptoms of major depression: severe sadness *that does not go away,* inability to sleep or inability to get out of bed, loss of interest in things the person used to enjoy, inability to concentrate, etc. This is a disease. It’s a disease of the brain. It’s not “the blues.” And without treatment (medication, therapy, or usually both) it *will not go away and it will not get better,* even after the soldier comes home.

  3. Kathy says:

    I should have added that I do absolutely agree soldiers with symptoms of clinical depression should be removed from combat, but even after being removed from what caused the depression to develop, they will still need medication and therapy. With the appropriate treatment, clinical depression will ease up and even end after a few weeks or months, depending on the person. But there is a smaller subset of clinically depressed people who will *not* be cured of their depression. Clinical depression that lasts for a longer period of time or that does not go away at all even after significant time has passed is called major depression. That’s my diagnosis. Medication and therapy help me manage this illness, but I’ve had it for years and it’s possible I’ll have it for the rest of my life. Clinically depressed soldiers are just as much at risk of developing major depression as anyone else. The difference is that the fact they are in a war zone adds a level of stress that just makes everything worse.

  4. Chief says:

    “The difference is that the fact they are in a war zone adds a level of stress that just makes everything worse.”

    This is where I was trying to go. Most of them probably would not have any depression if they were not in a prolonged combat situation.

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