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Wednesday, May 17, 2006

IRAQ: MENTALLY UNFIT, FORCED TO FIGHT---PART V..........................................


POTENT MIXTURE: ZOLOFT & A RIFLE

The military told Congress that medications aren't used to keep soldiers with serious mental illnesses in combat. But a Courant investigation reveals that drugs are increasingly being handed out.


When Army Sgt. 1st Class Mark C. Warren was diagnosed with depression soon after his deployment to Iraq, a military doctor handed him a supply of the mood-altering drug Effexor.

Marine Pfc. Robert Allen Guy was given Zoloft to relieve the depression he felt in Iraq.

And Army Pfc. Melissa Hobart was dutifully taking the Celexa she was prescribed to ease the anxiety of being seperated from her young daughter while in Baghdad.

All three were given antidepressants to help them make it through their tours in Iraq---and all came home in coffins.

Warren, 44, and Guy, 26, committed suicide last year, according to the military; Hobart, 22, collapsed in June 2004, of a still undetermined cause.

The three are young among a growing group of mentally troubled service members who are being kept in combat and treated with potent psychotropic medications---a little-examined practice driven in part by a need to maintain troop strength.

Interviews with troops, families and medical experts, as well as autopsy and investigative reports obtained by The Courant, reveal that the emphasis on retention has had dangerous, and sometimes tragic, consequences.

Among The Courant's findings:

* Antidepressant medications with potentially serious side effects are being dispensed with little or no monitoring and sometimes minimal counseling, despite FDA warnings that the drugs can increase suicidal thoughts.

* Military doctors treating combat stress symptoms are sending some soldiers back to the front lines after rest and a three-day regimen of drugs-even though experts say the drugs typically take two to six weeks to begin working.

* The emphasis on maintaining troops numbers has led some military doctors to misjudge the severity of mental health symptoms.

Some of the practices are at odds with the military's own medical guidelines, which state that certain mental illnesses are incompatible with military service, and some medications are not suited for combat deployments. The practices also conflict with statements by top military health officials, who have indicated to Congress that psychiatric drugs are not being used to keep service members with serious disorders in combat.

In an interview Monday, Army Surgeon General Lt. Gen. Kevin C. Kiley insisted that the military uses psychiatric medications cautiously in the war zone, saying that medical professionals may prescribe them at low doses, "for very mild symptoms that might assist soldiers in transitioning through an event." He said the emphasis on keeping troubled troops close to the front lines is in the service members' best interests, because it helps them recover and avoid the stigma of abandoning their duties.

But many outside the chain of command see it differently.

"It's best-for the Army," said Paul Rieckhoff, a former platoon leader in Iraq who said he was overruled when he tried to have a mentally ill soldier evacuated. "But find me an independent mental health expert who thinks that there's a proper course of action."

Vera Sharav, president of the Alliance for Human Research Protection, a patient advocacy group, said retaining troops with mental disorders serious enough to require medications is "completely irresponsible."

"It's really just plain dehumanizing. They are denying these guys a humane treatment, which is to get out of the battle," she said. "The best kind of thereapy for someone in that kind of stress is to get them out of the stress. The worst things is to add a drug to this."


DISTRIBUTING DRUGS

Some soldiers' advocates and medical experts criticize the military for taking an overly pharmacological approach to mental illness in an effort to retain troops, without proper oversight.

Autopsies and investigative reports show that at least three service members who killed themselves in 2005, including Warren and Guy, were taking antidepressants.

Warren intentionally overdosed on his heart medication, the military ruled, and a medical examiner concluded he died of "mixed drug intoxication," finding that the combination of the heart drug and the Effexor, an antidepressant, had a "synergistic" effect that led to his death.

Guy was placed on Zoloft by a military doctor one month before he locked himself in a portable toilet and shot himself in the head, according to military reports. An investigator concluded that Guy's suicide was caused in part by the effects of Zoloft---a conclusion later rejected by a commanding general.

Zoloft, and other drugs in a class known as SSRIs, such as Prozac, Paxil and Celexa, are the most commonly prescribed antidepressants. But they can worsen depression and increase suicidal thinking, and the FDA says patients taking any antidepressant medication should be monitored carefully when the drugs are first prescribed---a task that can be difficult to accomplish in a war zone.

Families of some troops report that their loved ones were readily prescribed SSRIs by military doctors in Iraq, with no requirement for regular monitoring or counseling.

Marine Lance Col. Nickolas D. Schiavoni, 26, of Havnhill, Mass., earned a Purple Heart during his first deployment to Iraq in 2004, but came home shaky and anxious after seeing heavy combat, his parents said. Soon after he was deployed back to Iraq for his second tour, in September of 2005, he told his father in an e-mail that he had been prescribed Zoloft.

"He said, 'I'm real angry. I can't take anything from anyone. They have me on Zoloft,'" David Schiavoni, of Ware, Mass., recalled. "I couldn't believe it---an antidepressant, while he's out there holding a gun? I told him, 'Get off the Zoloft because I hear bad things about it.'"

Two months after that exchange, Schiavoni, who was married with two small children, was killed by a car bomb. David Schiavoni said he has been told that the incident occured after the driver of the car ignored demands for his son's unit to stop.

"A lot of things go through my mind," the father said. "Maybe I'd rather be angry than medicated. Maybe if he's angry, he grabs his gun and shoots."

Shelly Grice said her husband, Chris, a Fort Riley soldier, was put on Zoloft and the sleep aid Ambien after surviving an incident in February 2005 in which his close friend was killed by an improvised explosive device. She spent the rest of her husband's yearlong tour worried about his mental well-being.

"His [commanding officer] said, 'If I could, I would ship you home right now,' but they lost two guys that day and five others were injured, so they needed him," Grice recounted. "It bothers me that these guys are just experiencing too much."

As part of an effort to avoid evacuations out of the war zone, the military's cadre of combat stress teams typically treat troubled troops with a 72-hour break from the front lines---three hots and a cot, in military parlance---sometimes with drugs prescribed. But medical experts and drug makers themselves say it often takes weeks for SSRIs to have any therapeutic value, while the side effects can kick in immediately.

"I have a fundamental problem with prescribing someone an SSRI and then, with a couple of days' rest, allowing then to return to duty," said Dr. Stefan Kruszewski, a Harvard-trained psychiatrist in Harrisburg, Pa. "If you're newly introducing a drug, the most problematic side effects occur right at the beginning. So at 72 hours or at 96 hours or at seven days, you may have more of a problem, not less, because of a drug-related side effect."

Dr. Jonathan Shay, an expert on combat stress who has served as a consultant to the military on ethics and personnel issues, said SSRIs generally do not impair a person's ability to think clearly or react to danger. But he said the use of such drugs should be accompanied by counseling, and patients should be monitored closely during the initial "window of danger," when they begin the medications.

Shay said there is no evidence that SSRIs such as Prozac or Paxil help with acute stress or would "protect someone in a traumatic situation" from developing PTSD or major depression.

"There's nothing to suppose that it helps with an immediate trauma," said Shay, a Boston area psychiatrist who counsels Vietnam veterans. "I would expect to see it used for a previously deployed service member who has been diagnosed with PTSD" or other disorders.

Kruszewski agreed.

"It's not even a Band-Aid," he said. "It might make the doctor feel better, but the patient's not going to benefit."

Some Iraq war veterans say antidepressants and sleep aides were relatively easy to obtain, with no requirement for regular counseling of follow-up care.

Paul Scaglione, 23, any Army mechanic from the Detroit area, said he was put on Wellbutrin in 2003 after telling a medical worker at Tallil Air Base, "I'm not feeling so hot," and asking for "something to keep my mind off everything."

"It's no big deal," he said. "They just talk to you a little and give it to you. They say you can come back if you want, but they don't follow up or anything."

Kiley insisted that troops receiving medications are afforded a balance of care, including counseling.

He characterized the use of medications in Iraq as limited, saying some troops were allowed to deploy "on a low-dose SSRI," while others who developed problems in the war zone were placed on "a little bit of medication for a relatively short period of time, to get them through something."

He acknowledged that giving mood-altering drugs to troops in combat could be controversial.

"There are those out in the community who would be very concerned about that, as though you've altered the capacities of a soldier by putting them on those medications," he said. "My understanding...is that, in fact, is not what happens. When properly managed and properly dosed, with evidence that the soldiers are...doing well, there's no reason why they can't do their soldierly duties."


FULLY RESOLVED?

Exactly how many troops are taking psychiatric drugs remains unclear. In response to Freedom of Information Act request by The Courant for data on all prescriptions dispensed in Iraq, Defense Department officials were able to produce only limited records on medications.

Those records, as well as the Army's own reports, indicate that the availability and use of psychiatric drugs in Iraq has increased steadily. A 2004 report by a team of Army mental health professionals cited widespread complaints from combat doctors about a lack of psychotropic drugs, which prompted the military to approve making antidepressants including Prozac, Zoloft and Trazodone, and the sleep aid Ambien, more widely available. A follow-up report 13 months later cited far fewer complaints about access to drugs.

But in a little-noticed change a year ago, the Army revised its deployment guidelines to include a caution about deploying troops who are taking antidepressants for "moderate to severe" depression. The guidelines say such medications "are not usually suitable for extended deployments" and "could likely result in adverse health consequences."

Also, Dr. William Winkenwerder Jr., the assistant secretary of defense for health affairs, characterized the use of psychotropic drugs as limited when he testified before a congressional committee last summer that service members were being allowed to deploy on "maintenance medication" if their conditions had "fully resolved."

"For example, it is prudent to continue antidepressants six to 18 months after an episode of major depression has fully resolved, in order to prevent relapse," he said.

How the military interprets "fully resolved" is in question.

"We have seen people diagnosed within three to four weeks [before] deployment, put on medications like Paxil, and their deployment schedule rolls along," said Kathleen Gilbert, a San Diego legal counselor for service members who heads the Military Law Task Force of the National Lawyers Guild. "People are being deployed when there is no way to tell whether this potentially serious depression will have remitted or whether it will become a problem."

Melissa Hobart, the East Haven native who collapsed and died in June 2004, had enlisted in the Army in early 2003 after attending nursing school, and initially was told she would be stationed in Alaska, her mother, Connie Hobart said.

When her orders were changed to Iraq, Melissa, the mother of a 3-year-old daughter, fell into a depression and sought help at Fort Hood, Texas, according to her mother.

"Just before she got deployed, she said she was getting really depressed, so I told her to go talk to somebody," Connie Hobart recalled. "She said they put her on an antidepressant."

Melissa, a medic, accepted her obligation to serve, even as her mother urged her to "go AWOL" and come home to Ladson, S.C., where the family had moved. Three months into her tour in Baghdad---and a week before she died---she told Connie she was feeling lost.

"She wanted out of there. She said everyone's morale was low," Connie recalled. "She said the people over there would throw rocks at them, that they didn't want them there. It was making her sad."

Around the same time, Melissa fainted and fell in her room, she told Connie in an e-mail. She said she had been checked out by a military doctor.

The next week, while serving on guard duty in Baghdad, Melissa collapsed and died of what the Army labeled "natural" causes. The autopsy report lists the cause of death as "undetermined."

The reports notes that the only medications found in Melissa's system was the antidepressant citalopram, the generic name for Celexa, at what appears to be a normal dosage level. It also suggests that because all other causes were ruled out, a heartbeat irregularity is a possibility.

But the report does not explain whether the medication might have played a role in her death---something Connie finds troubling.

"Maybe they don't want to know how a healthy young woman died---but I do," Connie said.

Tomas Young, 26, an infantry soldier from Kansas City, Mo., also was sent to Iraq in early 2004, from Fort Hood, Texas, with a mental condition that was not "fully resolved." He was diagnosed with depression three months before he deployed, he said.

Young said a military doctor put him on Prozac and told him to continue the medication while in combat.

"It was, 'Here's the Prozac.' I didn't get counseling or anything," said Young.

Young ended up forgoing the pills during his brief deployment. He was shot within a week of arriving in Iraq and was evacuated. He is now paralyzed from the chest down.


Watch for PART VI





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