America's Medicated Army

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."

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.

At a Pentagon that keeps statistics on just about everything, there is no central clearinghouse for this kind of data, and the Army hasn't consistently asked about prescription-drug use, which makes it difficult to track. Given the traditional stigma associated with soldiers seeking mental help, the survey, released in March, probably underestimates antidepressant use. But if the Army numbers reflect those of other services — the Army has by far the most troops deployed to the war zones — about 20,000 troops in Afghanistan and Iraq were on such medications last fall. The Army estimates that authorized drug use splits roughly fifty-fifty between troops taking antidepressants — largely the class of drugs that includes Prozac and Zoloft — and those taking prescription sleeping pills like Ambien.

In some ways, the prescriptions may seem unremarkable. Generals, history shows, have plied their troops with medicinal palliatives at least since George Washington ordered rum rations at Valley Forge. During World War II, the Nazis fueled their blitzkrieg into France and Poland with the help of an amphetamine known as Pervitin. The U.S. Army also used amphetamines during the Vietnam War.

The military's rising use of antidepressants also reflects their prevalence in the civilian population. In 2004, the last year for which complete data for the U.S. are available, doctors wrote 147 million prescriptions for antidepressants, according to IMS Health, a pharmaceutical-market-research firm. This number reflects in part the common practice of cycling through different medications to find the most effective drug. A 2006 federally funded study found that 70% of those taking antidepressants along with therapy experience some improvement in mood.

When it comes to fighting wars, though, troops have historically been barred from using such drugs in combat. And soldiers — who are younger and healthier on average than the general population — have been prescreened for mental illnesses before enlisting.

The increase in the use of medication among U.S. troops suggests the heavy mental and psychological price being paid by soldiers fighting in Iraq and Afghanistan. Pentagon surveys show that while all soldiers deployed to a war zone will feel stressed, 70% will manage to bounce back to normalcy. But about 20% will suffer from what the military calls "temporary stress injuries," and 10% will be afflicted with "stress illnesses." Such ailments, according to briefings commanders get before deploying, begin with mild anxiety and irritability, difficulty sleeping, and growing feelings of apathy and pessimism. As the condition worsens, the feelings last longer and can come to include panic, rage, uncontrolled shaking and temporary paralysis. The symptoms often continue back home, playing a key role in broken marriages, suicides and psychiatric breakdowns. The mental trauma has become so common that the Pentagon may expand the list of "qualifying wounds" for a Purple Heart — historically limited to those physically injured on the battlefield — to include posttraumatic stress disorder (PTSD). Defense Secretary Robert Gates said on May 2 that it's "clearly something" that needs to be considered, and the Pentagon is weighing the change.

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.

Such questions have assumed greater urgency as more is revealed about the side effects of some mental-health medications. Last year the U.S. Food and Drug Administration (FDA) urged the makers of antidepressants to expand a 2004 "black box" warning that the drugs may increase the risk of suicide in children and adolescents. The agency asked for — and got — an expanded warning that included young adults ages 18 to 24, the age group at the heart of the Army. The question now is whether there is a link between the increased use of the drugs in the Iraqi and Afghan theaters and the rising suicide rate in those places. There have been 164 Army suicides in Afghanistan and Iraq from the wars' start through 2007, and the annual rate there is now double the service's 2001 rate.

At least 115 soldiers killed themselves last year, including 36 in Iraq and Afghanistan, the Army said on May 29. That's the highest toll since it started keeping such records in 1980. Nearly 40% of Army suicide victims in 2006 and 2007 took psychotropic drugs — overwhelmingly, selective serotonin reuptake inhibitors (SSRIs) like Prozac and Zoloft. While the Army cites failed relationships as the primary cause, some outside experts sense a link between suicides and prescription-drug use — though there is also no way of knowing how many suicide attempts the antidepressants may have prevented by improving a soldier's spirits. "The high percentage of U.S. soldiers attempting suicide after taking SSRIs should raise serious concerns," 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."

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