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The war, on drugs 

A suicide surge puts Army mental health practices in the crosshairs

Upon returning from Iraq, 23-year-old Marine Lance Cpl. Jeffrey Michael Lucey suffered episodes of such intense war-induced rage that they often led to him needing to be consoled by his parents, who would rock him back to normalcy in their laps. On June 22, 2004, unable to handle the intensity anymore the daily vomiting, the feeling that he was a murderer, the fear that none of his military higher-ups even cared Lucey wrapped a garden hose around his neck in the basement of his family's Belchertown, Mass., home and hanged himself.

During his last visit to the Northampton VA Medical Center in Leeds, Mass., for post-traumatic stress disorder (PTSD) a three-day stint in the hospital's psychiatric ward almost six weeks before he killed himself Lucey had been prescribed a number of antipsychotic drugs, including Klonopin, Ativan and Haldol. He was also given warnings that they not be taken with alcohol.

Two days after his release, he destroyed his parents' car in an apparent suicide attempt. A little more than a month before he killed himself, say his parents, Kevin and Joyce Lucey, he was refused mental health treatment by the Department of Veterans Affairs (known as the Veterans Administration until the late 1980s, but still commonly referred to as the VA) because he'd been drinking heavily. The Luceys insist that the VA focused on a symptom (the drinking) instead of the actual cause of his mental deterioration (PTSD).

In January 2008, the Luceys were awarded a $350,000 settlement from the VA, which admitted no wrongdoing in their son's suicide. This past Thanksgiving, the Luceys were once again left with an empty seat at the table and emptiness in their hearts. A few days before the holiday, they distributed a letter through the nonprofit organization Veterans For Common Sense, which used Lucey's story as a cautionary tale for other veterans and their families (veteransforcommonsense.org/articleid/11721).

Another front has opened in the wars being fought by the U.S military, and it is one for which the Pentagon was as unprepared as it was for the conflicts in Iraq and Afghanistan. The primary (though not the only) enemy is PTSD, and to fight it, U.S. troops are desperately being prescribed a wide array of medicines, from anti-depressants to anti-anxieties. They are also self-medicating in numbers beyond the control of the Department of Defense (DoD) or the VA, and the military has failed to provide adequate long-term treatment and follow-up care.

As a result, as we recognize the sixth anniversary of the start of the war in Iraq, America's troops both in that conflict and in the one in Afghanistan are literally fighting their wars on drugs and a record number of both active troops and discharged veterans are committing suicide.

The RAND Center for Military Health Policy Research, a nonpartisan global-policy think tank, estimated this past year that 300,000 Iraq and Afghanistan veterans suffer from PTSD, or about 19 percent of all troops who have served in the two wars. The impact of that astonishing number is difficult to articulate (although Nobel Prizewinning economist Joseph E. Stiglitz has theorized that the true cost of the wars, including post-war veterans care, will reach nearly $3 trillion). Treatments are slow, expensive and highly individualized. So even when the Pentagon does diagnose traumatized personnel in time (that is, before they harm themselves or others), it merely doles out quick-and-dirty medications that may hide symptoms then too often redeploys those troops overseas, anyway.

Untold numbers of traumatized active-duty U.S. troops specifically, large numbers of those whom John McCain praised during his failed presidential campaign for manning the "surge" are taking prescription drugs with little or no medical supervision. Selective serotonin reuptake inhibitors (SSRIs), mood enhancers, painkillers, anti-anxiety medicines Xanax, Ativan, Klonopin, morphine, Valium, Ambien, Zoloft are ill-advisedly helping unfit-for-duty soldiers keep it together on the battlefield.

The DoD appears to be aware of this, but its policies allow for such drugs to be taken in combat, regardless of side effects. When the troops return home, doctors and vets say, the cash-strapped VA has little more to offer than further medication and group therapy, which hardly assuage a vet's trauma or curb his dependence on prescription drugs.

According to numbers obtained by the Boston Phoenix from the VA, of the 5,439 Iraq and Afghanistan vets treated (for any symptoms) in Massachusetts since 2003, 277 were treated for prescription-drug addiction.

"When we started out in 2004, we thought [soldiers' families] would need us a lot more when individuals were deployed, and [figured that] then the guys would come home and, in a couple of months, everybody would be fine," says Dr. Jaine Darwin, co-director of Needham-based nonprofit group Strategic Outreach to Families of All Reservists (SOFAR), which gives free psychological care to families of reservists and National Guardsmen deployed in Iraq and Afghanistan. "That's just not what has happened."

Darwin says that, all too often, upon returning, the soldiers cannot relate to their wives, their kids, their parents. They are completely alienated from everything and everyone they knew before.

"The fact is that there is no normal," she says. "There's the new normal, and the new normal is how you negotiate relationships between separations and reunions."

Suicidal tendency

Tragic stories like Lucey's and like those of the veterans and families Darwin treats are becoming more commonplace. The journal Military Medicine found that, during an 11-month period in 2004, 30 percent of soldiers evaluated by mental health staff in Iraq said they had considered suicide within the past week. (A DoD intelligence-center report on psychotropic drugs acknowledges this finding.) Of those, almost 64 percent said they had specific plans to kill themselves.

Four years later, the situation has worsened. The Army announced in January 2009 that its suicide rate hit 138 or little more than 20 per 100,000 this past year, which surpassed previous highs of 115 in 2007 and 102 in 2006. (That's also higher than the suicide rate for the general population, which is 19.5 per 100,000.)

And earlier this month, the Army said it was investigating 24 potential suicides committed by troops in January and another 18 committed in February. If those numbers hold true, it will confirm what many have recently started to fear: that, for the first time since the wars began, U.S. troop deaths by suicide will have outpaced deaths in combat for two months in a row.

In February, the Army responded by ordering its first ever force-wide "stand-down," a month-long effort to get every soldier into suicide-prevention training. Last Tuesday morning, Fort Carson informed the media that all its soldiers, family members and civilian workers would be required to participate later that day in the first phase of a three-phase training session designed to help them "identify suicide signs and symptoms, risk factors and where they can escort a person to get help."

While such efforts seem honorable, they won't do much for many veterans, among whom suicides are exponentially more frequent. The VA announced in September that 46 out of every 100,000 male veterans between the ages of 18 and 29 killed themselves in 2006, compared with 27 the year before. (For women, there was improvement, as it was three in every 100,000, compared with eight in 100,000 the year before.)

Internal conversations at the VA suggest the situation is dire. According to court documents, when asked by the VA's media adviser in early 2008 whether it was true that 1,000 veterans a day were attempting suicide, VA director Ira Katz sent back an e-mail titled "Shhh," confirming the number, but suggesting it be kept under wraps until the VA figured out: "Is the fact that we're stopping them good news, or is the sheer number bad news?"

Other factors

Army Special Forces Staff Sgt. Andrew Pogany describes a young soldier's fatal overdose the way you might order soup at a deli: in plain English and without embellishment. "They labeled the kid a liar and a drug seeker, then he went home and overdosed, and now he's dead."

Such are the effects of half a decade of dealing with the military justice system. It's been that long since Pogany himself suffered hallucinations and panic attacks in September 2003 which he says are a result of taking Lariam, a mandatory anti-malaria medication issued by the military and just as long since military doctors prescribed sleeping pills to wash away Lariam's side effects. Pogany has seen 17 other servicemen from his former post at Fort Carson commit suicide during that same amount of time.

In early 2004, Pogany faced a court-martial (and a possible death sentence) for cowardice. Acquitted, he later that year was medically retired from the Army with an honorable discharge, at which point he moved to Washington, D.C., to become an investigator for the National Veterans Legal Services Program, an independent agency that provides legal assistance to veterans with difficulties similar to his own.

Throughout his ordeal, Pogany says, he has learned all too well what stress can do to a soldier, and says the military hasn't learned a thing. Troops who evidence symptoms of being what Pogany calls "suicides in the making," he claims, "are being overlooked and they are being ignored."

PTSD is just one root cause of the spike in suicides. Another may be Army-issued medication, such as Lariam.

No direct links have been drawn between either Lariam or increased use of psychotropic drugs and a growing military-suicide rate. But their parallel course is, at best, inconvenient. According to the U.S. Army Medical Department's 2008 mental health report, at least 13 percent of U.S. troops in Iraq and 17 percent in Afghanistan are taking antidepressants, anxiety medication or sleep aids.

This falls in line with the Armed Forces Health Surveillance Center's May 2008 report, which found that within a year of deploying, 11 percent of surveyed active-duty personnel had at least one prescription for psychotropic medication including common SSRIs (Paxil, Zoloft and Prozac), anti-anxiety medications (Valium, Ativan and Xanax), attention-deficit medication (Ritalin, Adderall), and antipsychotics (Seroquel), but not sleep medications, such as Ambien and Lunesta, or antidepressants used to stop smoking, such as Wellbutrin.

Also of note: The New England Journal of Medicine found in 2004 that 11 percent of military recruits had psychiatric histories before entering the military. No more recent information on that is available. But we do know that since 2004, the military has seen an increase in "waivers" OKs given to recruits who committed acts that under previous conditions would have precluded military service, including marijuana possession and DUI, misdemeanors and felonies. Waivers jumped from nearly five percent in 2004 to 11 percent leading up to the surge, and the number of Army recruits who graduated high school fell from 91 percent in 2001 to 79 percent this past year.

One final point: Despite the increase in medications and in troops and certainly in troops suffering from PTSD the number of Army mental health personnel on the ground in Iraq remains disturbingly the same: 215.

According to the Army Mental Health Advisory Team's survey of military medical personnel included in its mental health report this past February, those in Iraq treating soldiers with mental health issues say they prescribe depression, sleep-deprivation and anti-anxiety medications 64, 52 and 60 percent of the time, respectively, a significant increase compared with the 45, 30 and 42 percent of the time a year earlier. Doctors say side effects including depression and manic episodes are being ignored.

"If someone has not had a thorough diagnosis and there's really not time for that on the front lines a lot of the time and a doc on the front lines is thinking, 'This isn't an acute-stress reaction, this is just someone who was shaken up,' [he may] give them an SSRI, [which] can induce a manic episode in some people," says Dr. Chad S. Peterson, former medical director of the San Francisco VA Medical Center's PTSD clinical team and its primary contact for returning Iraq and Afghanistan veterans. "If the follow-up isn't good and you get a soldier who becomes manic, then manic people are notoriously not good judges of behavior. Their judgment is poor and that could really be a problem with someone carrying a weapon."

Bad medicine

The rise in use of such medications is the symptom of a much larger concern. Nearly 40 percent of military doctors in Iraq say they helped a service member with a mental health problem on a weekly basis this past year, as opposed to 25 percent a year earlier, according to the Army's mental health report. Also, 26 percent referred patients to mental health care this past year, as opposed to 15 percent a year earlier.

Concerns about the use of drugs deemed "clinically and operationally problematic" on the battlefield led to the passage, in October 2006, of a federal law that required the military to state which conditions and ensuing use of psychotropic drugs would "preclude deployment." The office of the secretary of defense (at that time, Donald Rumsfeld) responded that only psychotic and bipolar disorders could prevent someone from serving, and that using medications for other mental health conditions such as PTSD is "compatible with deployment."

That's all well and good, but military officials make tracking potentially disqualifying medical histories difficult if not impossible by failing to use all the resources at their disposal. The DoD keeps a pharmacy database for military personnel and their families (through its TRICARE health care program), but doesn't use it to identify deploying service members who are using medications that would disqualify them from service a practice that's been criticized by medics and field doctors.

In addition, the Army's combat health-support management system, MC4 (Medical Communications for Combat Casualty Care), was designed to harness a state-of-the-art network of handheld devices, laptops and software, and to share medical information in the field. Yet while MC4 could, in the event of an emergency, be used to alert field commanders and medical personnel to a soldier's pre-existing conditions such as PTSD this isn't being done with any consistency. As a result, many combat troops are being unnecessarily mis-prescribed at the worst of all possible times during battle.

Complicating matters further is the assortment of mandatory medications including the anthrax vaccine ABthrax, as well as other drugs to fight off local ailments given to all military personnel serving in Iraq. Drugs used to treat mental conditions aren't necessarily problematic on their own, but when combined with one of these mandatory medications, they can be dangerous, even fatal.

In Pogany's case, for example, the problem wasn't the Ambien he was given as a sleep aid, but his acute reaction to the Army-issued Lariam. While effective in treating malaria American tourists often take a dose before traveling to Third World countries it can have severe repercussions when used as a preventative measure by people with depression, anxiety disorder, psychosis or schizophrenia. Consider that it can present hazards to a backpacker who takes it just once or twice while on vacation, then imagine how it can have exponentially more severe consequences for a soldier who takes it once a week (or more) for years at a time.

Four years ago, Dr. Geoffrey Dow and his team at Walter Reed Army Institute of Research in Rockville, Md., found that not only is Lariam a neurotoxin that ate away the brain stems of test creatures, but that it causes psychiatric effects including dizziness, depression, acute anxiety, mania, aggression, rage, psychosis, confusion and memory loss in nearly a quarter of the people who take it, as the World Health Organization asserted in 1995.

"These are people running around with big guns who are supposed to be alert," says Jeanne Lese, co-director of nonprofit health organization Lariam Action USA. "They're supposed to be shooting people, but they're also supposed to be in control of their weapon. And if their brain has taken away their ability to control their balance, what's wrong with this picture?"

The military has stood by its assertion that weekly doses of Lariam are safe, and more effective at preventing malaria than daily doses of cheaper and less potent alternatives, such as doxycycline, which was suggested as a Lariam alternative by the Army Surgeon General this past month. However, Pogany and other military personnel interviewed for this story who have had acute reactions to Lariam say that it has made them feel suicidal, which should outweigh any potential benefit as a preventative medication.

"The troops are not being prescreened," says Lese. "They are not being given the medication guide that was required to be given with any medication in 2003 or the handy wallet card that says, 'If you have any symptoms, you are supposed to consult a doctor immediately and leave the area. It's pretty crazy to think that someone in combat can say, 'Oh no, I'm having hallucinations I think I should go home.'"

Back to the front

According to veterans and health experts interviewed for this story, increasing occurrences of PTSD can be blamed at least in part on yet another factor: multiple deployments. The DoD is in tacit agreement, as it acknowledged in the Army's mental health report that 11.9 percent of troops deployed to Iraq for the first time report experiencing mental health issues. The ranks swell to 18.5 percent reporting problems during their second deployment, and 27.2 percent during their third.

In Afghanistan, the number of troops raising mental health concerns rises from 9.8 percent on the first tour to 14.2 during the second tour or beyond.

"If you're exposed to one gruesome and horrible episode, like your buddy getting blown up beside you, you'll get some sort of post-traumatic stress disorder," says Arthur S. Blank, a psychiatrist and former head of the Department of Veterans Affairs Vet Centers, who actually helped define the diagnosis for PTSD after the Vietnam War. "If that happens five, 10, 20, or 30 times because of multiple tours, your chances of getting PTSD go up considerably."

As of mid-2007 when such figures were last available the military said 525,000 of nearly 1.6 million personnel who had been deployed to either Iraq and Afghanistan had been deployed more than once. Today, with the number of personnel that have served in the two theaters reaching nearly 1.8 million, critics estimate that one-third have served multiple deployments.

Many of these multiple-deployed personnel are actually going back to battle voluntarily despite either suffering from, or putting themselves at increased risk for suffering from, PTSD.

The Army's mental health team also reports that 21.8 percent of troops in Iraq and 33 percent in Afghanistan feel their leaders discourage mental health treatment. While doctors, veterans advocates and the Army acknowledge the stigma felt by troops who feel they look weak in front of comrades by seeking treatment, they also recognize that it's become easier for people with said problems to enlist and re-enlist.

Medics and vets who spoke with the Phoenix note that the military is a crutch for troubled recruits, providing them with needed structure, and empowers soldiers by helping them survive traumatic experiences. The unforeseen consequence, however, is war as therapy and an endless cycle of long deployments.

"Lots of soldiers that know better look at deployment as a form of treatment," says one medic. "No soldier wants to say, 'I'm a coward. I want to quit.'"

The war at home

Hardly all soldiers with PTSD want to go back to a war zone. But some are finding themselves on the front lines anyway, because of the utter lack of communication between the VA and the DoD, which often results in a veteran with PTSD being returned to active duty.

"If a service member had an honorable discharge and then is diagnosed with PTSD by Veterans Affairs, the VA doesn't share its records with the Department of Defense, so [the latter] is free to call those veterans up," says Paul Sullivan, an Army veteran, former VA project manager, and executive director of Veterans for Common Sense. "The veteran has two choices: tell them about the condition or not. Even then, you can say, 'I might have PTSD, but I want to go.'"

Those who get home and stay in the States are frequently met with a course of treatment that's more concerned with keeping costs down than working toward true mental and emotional stabilization.

"They're in the dark ages in a number of different areas," says Gordon Erspamer, the California-based lead attorney in a class-action lawsuit against the VA that attempted to get immediate treatment for all veterans with PTSD. "On the health care side, the veterans I've spoken to say that, even if you get in to see them, they give you four or five pills, [ask you to] come back, [then offer] group-therapy sessions one day a month and the health care is rationed."

Nearly everyone contacted for this story agreed with Erspamer (whose federal lawsuit failed this past year and is heading into appeals) that group therapy (which by admitting to a weakness in front of your peers is anathema to those in the military culture) and medication are seemingly the VA's only means of dealing with mental health issues.

Failed communications are more troublesome when trying to identify past medications taken on the battlefield. Where a combat soldier could procure meds in the field with few repercussions, that same soldier returns home a veteran with no proof of his prescription record. This could lead to complications or downturns from coming off the medication, or having to deal with the stigma of re-diagnosis, especially if it's done at a VA center or in group therapy, where other veterans are present. Health experts say many veterans struggling with reintegration into civilian life would rather stop treatment than feel reduced in the eyes of their peers.

With nearly 150,000 mental health patients in the VA system, lack of communication between the VA and DoD increases the risk that a vet with medication-dependency problems will fall through the cracks into full-fledged abuse. In response to an information request by the Phoenix, the VA says it has treated 7,112 veterans from Iraq and Afghanistan for addiction to prescription drugs from 2003 through November 2008.

If veterans aren't getting prescriptions filled, or are too ashamed to seek proper treatment, both doctors and veterans say they may turn to the next-best thing. Whether it be cocaine or methamphetamine to simulate the rush of combat, or heroin to satiate an opiate addiction brought on by painkillers, substitutes are plentiful.

"If you get a vet who is addicted to a substance, because maybe they were getting benzodiazepine [Klonopin] in combat and really liked it and became dependent on it, and they return and are unable to go to the VA, they're going to find a suitable substitute," says Peterson. "The closest to benzodiazepine is alcohol. Benzos are kind of like prescription alcohol."

At the very least, abusing drugs can result in dishonorable-conduct charges for military personnel and, arguably more important in this wretched economy, the loss of VA benefits. Many of the doctors interviewed expressed a desire to avoid such scenarios by treating PTSD and other mental ailments through individual psychotherapy and drug treatment with proper follow-up, but the VA is sticking to its guns ... and missing the point.

Individual therapy is resource-intensive, yes: more money, more training and more treatment time. But medication and group therapy, though cheap at first, hold hidden costs not the least of which are too many unhealed soldiers with broken minds and lifetime drug dependencies, some haunted to the point of suicide for a VA system that has treated 402,872 patients from Iraq and Afghanistan alone since 2003, according to numbers obtained for this story.

"If they're just medicating away a feeling, the whole experience isn't going to go away," says Peterson. "They're still going to have guilt and shame and anger and all of the feelings they had, but they're just going to be numb to those feelings."

Losing battle

The military and its personnel are trapped between schools of thought when it comes to prescription drugs and a soaring suicide rate. Many military health experts applaud the use of psychotropic medications in the field and believe they are valuable in preserving troops' mental well-being. The lack of effective prescription and monitoring, however, has led Darwin, Pogany and others to say that medication alone won't solve the military's problems.

"The way medications are being dispensed to people in theater," says Pogany, "the underlying behavior modification is that you're teaching people to deal with their problems through medication. When I sit down and interview people, they say that 90 percent of their battlefield treatment is medication. We're talking heavy-duty anti-psychotic drugs without follow up or close monitoring."

Critics compare the failure to monitor prescription-drug use to general failures within the Iraq war. Yes, the drop in troop deaths in combat during this past year can be attributed to the surge and its attendant increased number of doctors (medics and field surgeons, not mental health personnel) in the field, as well as proximity of aid stations to the front lines, and the gradual handover of security duties to Iraqi troops. But, these critics note, the surge may not be worth the multiple deployments and medications used to fuel it.

"Are U.S. fatalities down?" asks Sullivan of the benefits of the surge. "Yes. Are U.S. casualties in Iraq down? No. Is the Iraqi government in control of its own laws? No, because U.S. military and contractors have immunity. Does the Iraqi government have control of its military? No. Does the Iraqi government have control of its entire country? No. Do the Iraqi people have water, power, jobs? All of those are no. So, in fact, the surge is a complete failure, except for the one variable of U.S. servicemember deaths."

And as suicides among active personnel and veterans increase, even that one beneficial variable may diminish. After going through his own battle with the military hierarchy and helping countless others do the same, Pogany says that more suicides will occur if the military does little more than medicate away the problems of troops like Lucey.

"What I have dealt with and what I encounter on a regular basis is professional arrogance," says Pogany, "and people are dying on a regular basis for professional arrogance because they are refused help."

Jason Notte is a freelancer who wrote this story for the Boston Phoenix, where it first appeared.

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