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Potent Mixture: Zoloft & A Rifle
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 developed in Iraq.
And Army Pfc. Melissa Hobart was dutifully taking the Celexa she was prescribed to ease the anxiety of being separated from her young daughter while in Baghdad.
All three were given antidepressants to help them make it through their tours of duty 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 among a growing number 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 troop 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 duty.
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 that'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 medication 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 therapy for someone in that kind of stress is to get them out of the stress. The worst thing is to add a drug to this.''
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.
Autopsy 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 Cpl. Nickolas D. Schiavoni, 26, of Haverhill, 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 occurred after the driver of the car ignored demands from his son's unit to stop.
"A lot of things go through my mind,'' the father said. "Maybe I'd rather him 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 days' rest, allowing them 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 often 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 post-traumatic stress disorder 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.
"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 aids were relatively easy to obtain, with no requirement for regular counseling or follow-up care.
Paul Scaglione, 23, an 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 was 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 mental 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.''
Exactly how many troops are taking psychiatric drugs remains unclear. In response to a 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 Gilberd, 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. But 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 everybody'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 has labeled "natural'' causes. The autopsy report lists the cause of death as "undetermined.''
The report notes that the only medication 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 explore 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, with a mental condition that was not "fully resolved.'' He was diagnosed with depression about 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.
Emphasis On Retention
The use of medications is just one aspect of the military's emphasis on treating psychologically wounded troops close to the front and returning them to duty quickly.
Military combat-stress teams pride themselves on high "return to duty'' rates, which are also touted in reports by a team of military mental health experts who were sent to Iraq after a spate of suicides in 2003.
But in 2004, top military health officials acknowledged shortcomings with a key principle of modern combat psychiatry, known as "PIES,'' which emphasizes treating troops who exhibit problems as close to the front lines as possible, with the expectation that they will return to duty.
"Unfortunately, the validity of these concepts has never been demonstrated in clinical trials,'' the group of officials acknowledged in a written report. They also said proponents of the principle frequently leave out its most important element -- "respite.'' They said relief from stress "is the primary principle of acute combat-related behavioral and mental health [care] in theater.''
Still, military leaders maintain faith in their decision to treat psychiatric wounds in the field, arguing that the approach is better for service members than "pathologizing'' their stress by evacuating them to a hospital.
Col. Elspeth Ritchie, the psychiatric consultant to the Army surgeon general, acknowledged that the practice also serves the military.
"Historically, we've found patients evacuated out of theater don't return,'' said Ritchie. "In time of great difficulty -- and there's no question the war over there is very difficult -- sometimes anxiety and depression may overwhelm a soldier, and they feel like they've just got to get out of this place.
"But if they are evacuated out, they tend to have the stigma of leaving as a psychiatric case -- and then it's a loss of manpower for the service.''
Throughout the war, the military has evaluated the success of its mental health programs primarily on the basis of how many troops are retained in combat.
While Winkenwerder had assured Congress last summer that troops with severe mental illnesses were being sent out of the war zone, the Army's own reports indicate that the number of soldiers evacuated from Iraq for psychiatric problems has dropped steeply since the first year of the war, as combat-stress teams and medications have become more accessible.
Mental health evacuations have fallen from an average of 75 a month in 2003 to 46 a month in 2005, according to Army statistics. Overall, barely more than one-tenth of 1 percent of the 1.3 million troops who have been deployed to Iraq and Afghanistan have been evacuated because of psychiatric problems. Meanwhile, the mental health teams close to the front lines pride themselves on return-to-duty rates that typically exceed 90 percent.
But in some cases, the troubled troops who remain in the war zone never make it home.
Army Spec. Joshua T. Brazee, 25, of Sand Creek, Mich., had been in Iraq for less than three months when the military says he shot himself with his rifle in May 2005. According to his autopsy report, he had "talked with other soldiers about death and killing, and also about the idea of suicide.''
His mother, Teresa Brazee, said she still has questions about how he died, and believes there were conflicts within his unit. She said one of Joshua's superiors told her that his death taught him to pay closer attention to his soldiers.
"It's a little too late for that,'' she said.
In another case, Pfc. David L. Potter was kept in the war zone despite a diagnosis of anxiety and depression, a suicide attempt and a psychiatrist's recommendation that he be separated from the Army.
Potter, 22, told friends that he believed the recommendation had been overruled, leading to a deepening of his depression, a fellow soldier said. On Aug 7, 2004 -- 10 days after the psychiatrist recommended he be sent home -- Potter took a gun from under another soldier's bed and killed himself.
The fellow soldier, who did not want his name used because he is still in the military, said Potter was clearly having trouble dealing with the stress of deployment, but wasn't getting the help he needed.
"We saw what was going on,'' he said, "but we couldn't do anything about it.''
Ann Scheuerman knew her son Jason was having a rough time in Iraq, but she didn't know the depth of his despair until she awoke to a short e-mail from him last July that left her shaking with fear.
"I'm sorry, mom, but I just can't deal with this anymore,'' he wrote from his base in Muqdadiyah. "I love you, but goodbye.''
After an agonizing morning of frantic phone calls, Scheuerman learned that officers and a chaplain had reached Jason in time, taking away his rifle, posting a guard and ordering a mental evaluation for the 20-year-old private first-class.
For the first time that day, Ann Scheuerman could breathe.
But her son's problems were just beginning.
Jason got a psychological evaluation, but afterward, he sent his mother another disturbing e-mail.
"He was very discouraged,'' said Scheuerman, of Lynchburg, Va. "He said, `Mom, they think that I'm making this up and that there was nothing wrong with me, that I needed to just be a man, be a soldier and quit wasting the Army's time.' He said they were going to court-martial him for treason, that sergeants said they were tired of people making up excuses to try to get out of combat and it wasn't fair to all the other real soldiers.''
Jason was pulled off missions with his fellow soldiers, assigned menial jobs around the barracks and given his gun back.
He used the weapon three weeks later to become the 1,797th U.S. military fatality of Operation Iraqi Freedom.
Ann Scheuerman, who, like Jason's father, is an Army veteran, strongly supports the military. But she wants to know how things could have gone so wrong in Jason's case.
"The enemy should not be dressed in a United States Army military uniform. That's not what the enemy looks like, and should never be what our soldiers see as the enemy,'' she said.
"If someone would have taken two or three days, if he would have just been in the hospital for a few days, where someone could have actually talked to him, I think that's all it would have taken,'' she said.
Kiley, the Army surgeon general, said he believes that mental-health professionals in Iraq are quick to evacuate troops who are at risk of hurting themselves or others, or who have "risen to the level of being moderately or severely depressed.''
Who's Helping The Troops
After the spike in suicides in 2003, military officials said they had faith that teams of mental health specialists deployed to Iraq and Kuwait would be able to provide needed care to troops, and help to break the stigma associated with mental health issues.
But with the 2005 suicide rate in Iraq climbing to the highest level since the war began, some soldiers' advocates are now questioning whether the specialists have become too reliant on short-term treatments and medications, and not enough on one-to-one counseling.
Sandy Moreno, a Sacramento, Calif.-based psychiatric technician in the Army Reserve, was among the first combat-stress team members in Iraq. While her team prided itself on a return-to-duty rate of about 95 percent, she said counseling and respite -- not medications -- were the focus in the early months of the war.
"You can't start someone on antidepressants and then not see them again because their unit is moving around,'' Moreno said. "When you put them on those kinds of meds, a lot of times it takes six weeks before they take effect, or they can cause side effects. We could never keep that good track of a soldier.''
The military has about 230 counselors dispatched in Iraq and Kuwait for about 100,000 troops, about the same number as in 2004, an Army spokesman said. But there are signs that the providers themselves are burning out.
A team of mental health experts reported in January 2005 that caregivers were experiencing "compassion fatigue,'' with one-third of behavioral health workers reporting high burnout, and one in six acknowledging that stress was hurting their ability to do their jobs.
"If our providers are impaired,'' the team wrote, "our ability to intervene early and assist Soldiers with their problems may be degraded.''
Beyond burnout, military documents and interviews reveal a culture in which mental health professionals are constantly on the alert for troops faking mental illness to get out of duty.
"Clinicians must always maintain a keen eye for potential malingerers,'' instructs the Iraq War Clinician Guide, a 200-page bible compiled by the Department of Veterans Affairs and the Walter Reed Army Medical Center. "Suspicions require close consultation with commanders to ensure proper diagnosis and disposition.''
Some Iraq veterans say the military is too quick to dismiss mental health complaints, and still has a problem treating injuries to the mind the way it treats injuries to the body.
"If you break your leg over there, you're going to get treatment,'' said Georg-Andreas Pogany. "When they go for mental health services, they are belittled, they are shoved aside, they are called malingerers. Their experiences are completely invalidated.''
In 2003, Pogany, a former Army interrogator, was charged with cowardice -- a crime punishable by death -- after suffering a panic attack and seeking counseling because he had seen the body of an Iraqi man who had been cut in half by American gunfire. The charge was later dropped.
Bob Johnson, former chief of combat stress control for an Army brigade of about 2,800 soldiers, said he would routinely review soldiers' work and disciplinary histories when they complained of serious mental problems. If a soldier with a history of antisocial behavior came in insisting he was going to shoot himself if he wasn't sent home, "then that's a pretty clear-cut case of malingering,'' he said.
Johnson said he took a punitive approach to dealing with those soldiers, taking away their guns -- which he compared to "losing your manhood'' -- and forcing them to sleep at the command point, in the line of sight of commanders.
He said he had treated one soldier who threatened to starve himself to death, and later swallowed a handful of pills -- both acts that Johnson deemed bogus attempts to get out of serving.
"There's no doubt about it, the guy had mental health issues,'' Johnson said. "But he wasn't going to get the treatment he wanted, which was to go home.''
"The question is, do we want to reward this behavior? Because if we reward this behavior, more soldiers are going to do it.''