The psychotropic drugs are a bow to a little-discussed truth fraught with implications: Mentally ill service mem-bers are being returned to combat.
The redeployments are legal, and the service members are often eager to go. But veterans groups, lawmakers and mental-health professionals fear that the practice lacks adequate civilian oversight. They also worry that such redeployments are becoming more frequent as multiple combat tours become the norm and traumatized service members are retained out of loyalty or wartime pressures to maintain troop numbers.
Sen. Barbara Boxer hopes to address the controversy through the Department of Defense Task Force on Mental Health, which is expected to start work next month. The California Democrat wrote the legislation that created the panel. She wants the task force to examine deployment policies and the quality and availability of mental-health care for the military.
“We've also heard reports that doctors are being encouraged not to identify mental-health illness in our troops. I am asking for a lot of answers,” Boxer said during a March 8 telephone interview. “If people are suffering from mental-health problems, they should not be sent on the battlefield.”
Stress reduces a person's chances of functioning well in combat, said Frank M. Ochberg, a psychiatrist for 40 years and a founding member of the International Society for Traumatic Stress Studies.
“I have not seen anything that says this is a good thing to use these drugs in high-stress situations. But if you are going to be going (into combat) anyway, you are better off on the meds,” said Ochberg, a former consultant to the Secret Service and the National Security Council. “I would hope that those with major depression would not be sent.”
About 25,000 Marines and sailors based in San Diego County are undergoing a major combat rotation that began in January. Their deployments are expected to last seven months.
Officials from the Defense Department and Camp Pendleton, where some units have been to Iraq three times, said they don't track personnel deployed while taking mental-health medication or the number diagnosed with mental illness.
But medical officers for the Army and Marine Corps acknowledge that medicated service members – and those suffering combat-induced psychological problems – are returning to war. And anecdotal evidence, bolstered by the government's own studies, suggest that the number could be significant.
A 2004 Army report found that up to 17 percent of combat-seasoned infantrymen experienced major depression, anxiety or post-traumatic stress disorder after one combat tour to Iraq. Less than 40 percent of them had sought mental-health care.
A Pentagon survey released last month found that 35 percent of the troops returning from Iraq had received psychological counseling during their first year home.
That survey echoed statistics collected by the San Diego Veterans Affairs Healthcare System. The system has found that about 33 percent of Iraq and Afghanistan veterans suffer from schizophrenia, depression and post-traumatic stress disorder.
The various studies apparently didn't consider the effects of multiple combat tours, though psychiatrists agree that the greater people's exposure to combat, generally the higher their risk of suffering mental illness.
More than 435,000 U.S. personnel have served in Iraq and Afghanistan combined. It is unclear how many have served in that region more than once.
Joe Costello, a mental-health counselor at the Vista Veterans Center, said emotionally scarred troops are routinely redeployed and that most want to go back to the war zone.
“I see it every day,” said Costello, who mainly treats reservists.
Buttressing the idea that large numbers of service members are medicated, more than 200,000 prescriptions for the most common types of antidepressants were written in the past 14 months for service members and their families, said Sydney Hickey, a spokeswoman for the National Military Family Association.
Hicks said a Defense Department official gave her the information during a December briefing. She said the official did not distinguish between prescriptions for the troops and those for their family members.
In addition, the Defense Department has not provided prescription totals for such antidepressants from before and after the United States invaded Iraq in 2003.
The prescriptions were for selective serotonin reuptake inhibitors, commonly called SSRIs. These drugs are used to treat depression, anxiety disorders, some personality disorders and post-traumatic stress disorder. They include brand names such as Paxil, Cymbalta and Wellbutrin.
The antidepressants work by elevating the level of the neurotransmitter serotonin. Researchers believe that low serotonin levels in the brain could be a biological cause of depression and certain anxiety disorders.
Mental-health care for service members and the Defense Department's efforts to keep the mentally ill in uniform are becoming national issues, said Steve Robinson, director of the National Gulf War Resource Center in Silver Spring, Md.
Robinson said three Army doctors have told him about being pressured by their commanders not to identify mental conditions that would prevent personnel from being deployed.
“They are being told to diagnose combat-stress reaction instead of PTSD,” he said. “That does two things: It keeps the troops deployable and it makes it hard for them to collect disability claims once they get out of the military.”
Robinson contends that the Pentagon is trying to control its spending on mental-health disabilities.
Between 1999 and 2004, disability payments to veterans with post-traumatic stress disorder rose to $4.3 billion from $1.7 billion nationwide, according to a report by the Department of Veterans Affairs' inspector general.
Overall, service members' mental health is a hot-button subject because it goes to the cost of the war in dollars and lives, said Joy Ilem, an assistant national legislative director for the organization Disabled American Veterans.
“The (Department of Veterans Affairs) is very worried about the political implications of PTSD and other mental issues arising from the war,” Ilem said. “They are talking about early outreach and treatment, but they are really trying to tamp down the discussion.”
Cmdr. Paul S. Hammer deals with such issues daily.
Hammer, a psychiatrist, is responsible for the Marine Corps' mental-health programs during this deployment rotation. He confirmed that Marines with post-traumatic stress disorder and combat stress are returning to Iraq, though he would not say how many.
Hammer said deciding who is deployed is often anguishing.
Sometimes he has to tell Marine commanders that personnel they had counted on will not be deploying. In other instances, he said, “We'll hold some guy's feet to the fire and say, 'This is what you signed up for, and you have to go.' ”
Marines are “amazingly resilient,” Hammer added. “You've got people exposed to incredible violence, but they do entirely well.”
It's the tough calls that worry Adrian Atizado, a legislative director for Disabled American Veterans.
“Currently, the services will deploy a service member if the person is medically stable and it is determined that the deployment won't aggravate (his) condition,” Atizado said. “How does one gauge that?
“This a gray area; this is asking a medical provider to make a decision based on the future. The medical providers are human beings. I have no doubt that they are looking out for the best interest of the service members, but they are under pressure to check off on their deployment.”
Ultimately, much is unknown about the rates of post-traumatic stress disorder among Iraq veterans, especially those who have been through more than one combat tour, said Matt Friedman, executive director of the U.S. Department of Veterans Affairs National Center for PTSD in White River Junction, Vt.
Friedman said that with time, “one of the things we are going to find out is how well people function who might have been on medication (during combat). This is a very important question and has all kinds of implications.
“But remember, they are all volunteers. This isn't Vietnam, where people were drafted and sent to fight. Think of the ethical questions that would arise from sending draftees back to war on medications.”
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