Wednesday, June 11, 2008

This is your Army on drugs 
Remember back in January of 2007 - a year and a half ago - when I wrote that I always thought someone should do a story on the use of Prozac and other anti-anxiety meds in the ranks?

Well, someone finally did. This week's cover story at Time Magazine.

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.

It's an important and interesting story, I think. Few civilians will ever have an appreciation of what it feels like to pull the lever on the slot machine every time you roll out of the gate - while rolling out of the gate several times per day in many cases.

While many people from all walks of life have experienced close calls - with criminals, accidents, dangerous jobs, etc., few can appreciate how that anxiety is cumulative over a tour. How it builds and builds, without anything like a weekend, without a 'mental health day,' without vacation, etc., in a combat zone. Combine the relentless effect of the daily stressors of the battlefield with the reality of close friends - closer than brothers - having been severely wounded or killed before your very eyes, and - and you can't underestimate this - the helplessness in the face of family problems at home, and the stress is an order of magnitude greater and longer lasting and more relentless than those faced by all but a few civilians.

I think anyone who's been deployed to a combat zone will back me up on this - particularly those who've had to suit up and roll out the gate on a daily or near daily basis for weeks or months at a time.

I knew there was some anti-anxiety meds being prescribed...and having had the benefit of a few years working as a behavioral health technician (read, a glorified psych-ward orderly), I had zero problem with it. If it helps a few guys cope without blowing up, and doesn't degrade their mission effectiveness, well, let me help you open that cap, soldier! (Oh, shit! It's lieutenant-proof!)

That said, Time's condescending and ignorant cover copy pissed me off.

"Is this any way to fight a war?"

Just what the f--- do you know, Time? Does the side that takes the least Prozac win, or something? Is someone keeping score?

Get your heads out of your asses.

Time's cover stupidity, though, shouldn't detract from the story itself - which is pretty good, and even-handed and balanced.

The reporter briefly surveys the medical literature, which establishes the effectiveness of Prozac and other anti-anxiety and anti-depressants in the civilian context - and like any reporter should, gives voice to those airing concerns:

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.

Well, it IS nice that we have these drugs, both in military and civilian contexts. But let me offer a reality check: These drugs were available and prescribed by military doctors in Iraq during OIF I and OIF II as well - when the relentless rotations were not a factor, and before many (stupid) people even realized a lengthy, sustained effort of 130,000+ troops would be necessary over a period of over five years and counting.

They aren't being prescribed to stretch an army beyond its capacity. They are being prescribed, one soldier at a time, to help that soldier make it through the mission, day, month, week, year.

Or, as one of the critics of the use of these drugs, Harvard psychiatry professor Dr. Joseph Glenmullin, puts it: 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."\

Gee, Doc! It took a Harvard prof to figure that out? Give that man a f-cking medal! You're a g-d d-mned genius, Gump!

Unfortunately, I won't be able to sort through the garbage statistics at this sitting. Maybe someone else will be able to. But let's take a look at the fact that some 40% of military suicides of late have involved soldiers taking pyschiatric drugs. This is a classic case of confusing correlation with causality, with disastrous results as far as the article's conclusions are concerned. Consider this: The more efficient the Army is at identifying soldiers with serious deppressive or anxiety disorders that could potentially lead to suicide, and getting help to these soldiers, the higher that correlation is going to be. And the leadership of the military, both the medical docs and the green tabbers, ought to be striving to get that number to close to 100%. After if 100% of soldiers who commit suicide are on prescription psychiatric drugs, or under the care of a psychiatrist, that means that the Army is getting some form of help to all of them. So a high percentage here is GOOD, not bad, if you accept that the military doctors are going to be prescribing the latest and best treatments available. (Hint: These would include the newer SSRIs.)

Garbage statistic point number 2:

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.

Well, again, no shit, sherlock! That's because every fobbit KNOWS a fighter - and fobbits are occasionally the unlucky victims of mortar shells and RPG attacks - only a small fraction of those deployed at any one time are professional trigger-pullers in trigger-pulling slots (that is, other than drivers, RTOs, pistol-wielding company commanders, and the like.)

But consider this: if 15% of every soldier deployed had scored a personal kill on a known insurgent, then with 120,000 soldiers deployed over five years, we've killed 90,000 confirmed moojies with small-arms fire alone.

Sorry. If you believe that I've got some beach front property in Najaf to sell you.

The article concludes on a favorable note, listing a number of success stories and positive initial data. But then here are some more dumbass statistics:

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.

Well, yeah. That's because it's not an Army of fobbits, hunkering inside the wire on large bases. The more we adopt effective counterinsurgent tactics, the more we will be pushing small units - battalions, companies, platoons, squads - into combat outposts, separate from the larger units. If we're doing our jobs right, that number will go UP, not down. It's a wholly inappropriate statistic for use in a combat zone. In the short run, combat stress for soldiers in these isolated units will go UP, not down - and the need for effective anti-anxiety meds increases. Readers should bear in mind that there are no Battalion surgeons at many of these posts. It's the green tabbers, and it's the guys platoon leader, platoon sergeant, First Sergeant and CO monitoring the soldier and his or her work load and stress levels. Many of them are superb counselors in any setting. But there are few alternative courses of treatment. Green tab leaders are not qualified to put soldiers through an extensive and time-consuming cognitive therapy process. There's a war on. That leaves meds, or medical evacuation.

In a world in which you need every man, and when someone gets medically evaced for combat stress, anxiety or depression, someone else needs to cover that shift, and take on ALL that stress. And some people have a problem with deploying SSRIs?


Here's another one:

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."

Well, they're referring to Post Traumatic Stress Disorder. But that's not the immediate concern on the battlefield, most of the time. When you've got a mission coming up in an hour, and two more that day beyond that, and three more tomorrow, and 21 this week, we're not talking about post-traumatic stress. It's PRE-traumatic stress. And that's a totally different treatment milieu than most Stateside clinicians can comprehend. And if anti-anxiety meds works, and help soldiers make it through the day, without negative side effects, I'm all for it.

Splash, out


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