March 11, 2009 – Upon returning from Iraq, 23-year-old Marine Lance Corporal Jeffrey Michael Lucey suffered episodes of such intense war-induced rage that he’d often need to be consoled by his parents, who would rock him back to normalcy in their laps. On July 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, Massachusetts, home and hanged himself.
During his last visit to the Northampton VA Medical Center in Leeds 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 non-profit organization Veterans for Common Sense, which used Lucey’s story as a cautionary tale for other veterans and their families (www.veteransforcommonsense.org/articleid/11721).
Another front has opened in the wars being fought by the US 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, US 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 this week 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.
Tragic stories like Lucey’s 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 just this past week, the Army said it was investigating 24 potential suicides committed by troops in January and another 18 committed in February, up from 11 suicides in February 2008. If those numbers hold true, it will confirm what many have recently started to fear: that, for the first time since the wars began, monthly US troop deaths by suicide will have outpaced deaths in combat, and for two months in a row.
Among veterans, 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 a slight 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 1000 veterans a day were attempting suicide, VA Director Ira Katz sent back an e-mail entitled “Shhh,” confirming the number, but suggesting it be kept under wraps until the VA figured out the answer to this question: “Is the fact that we’re stopping them good news, or is the sheer number bad news?”
PTSD is the acknowledged root cause of most of the suicides. 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 Prize–winning economist Joseph E. Stiglitz has theorized that the true cost of the wars, including post-war veterans care, will reach nearly $3 trillion — see “Iraq: Five Years Later,” March 12, 2008, at thePhoenix.com). 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 US troops — specifically large numbers of those that 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, and 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 Phoenix from the VA via a Freedom of Information Act (FOIA) request, of the 5439 Iraq and Afghanistan vets treated (for any symptoms) in Massachusetts since 2003, 277 were treated for prescription-drug addiction. That includes 147 treated in Boston.
“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 families — 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.”
Army Special Forces Staff Sergeant 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 claims are a result of taking Lariam, an anti-malaria medication that the military orders troops to take — 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 base in Fort Carson, Colorado, commit suicide during that same 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, DC, 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 US troop suicides. Other theories finger such suspects as, among others, Army-issued medicines (such as Lariam), lowered recruiting standards, and multiple deployments for troops.
While no direct links have been drawn between either Lariam or increased use of psychotropic drugs and a growing military-suicide rate, their parallel course is, at best, inconvenient. Also eye-opening on the medicinal front, according to the US Army Medical Department’s 2008 mental-health report, at least 13 percent of US troops in Iraq and 17 percent of US troops in Afghanistan are taking antidepressants, anxiety medication, or sleep aids. This adds to the New England Journal of Medicine’s 2004 finding (the most recent statistics available) that 11 percent of military recruits had psychiatric histories before entering the military and the Armed Forces Health Surveillance Center’s May report, which found that the same percentage of surveyed active-duty personnel had at least one prescription for psychotropic medication within a year of deploying.
The increase in medications was parallel with an increase in the number of the military’s “waivers” (a military-recruiting term describing a recruit who has committed acts that under previous conditions would have disqualified him from 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. The Armed Forces Health Surveillance Center’s May report did not even include sleep medications, such as Ambien and Lunesta, and antidepressants used to stop smoking, such as Wellbutrin, but did include common SSRIs (Paxil, Zoloft, and Prozac), anti-anxiety medications (Valium, Ativan, and Xanax), attention-deficit medication (Ritalin, Adderall), and antipsychotics (Seroquel).
Concurrently, distribution of medications by military mental-health personnel has increased, especially in post-surge Iraq. Despite increases in medications and in troops — and certainly in troops suffering from PTSD — the number of Army mental-health personnel on the ground in Iraq has remained 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.”
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” — that is, keep a soldier from being sent to a war zone. 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 disturbing enough, but military officials make even 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 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 too 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 — and even fatal.
In Pogany’s case, for example, the problem wasn’t the Ambien he was given as a sleep aid, but, he says, 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, Maryland, 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 non-profit 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 who have had acute reactions to Lariam to whom the Phoenix spoke 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 by the Phoenix, 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 say they experience 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. Almost two years later, 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 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 often 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 frontlines 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 VA course of treatment that’s more concerned with keeping costs down than working toward true mental and emotional stabilization.
“They’re [the VA] 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.
The Pentagon’s inadequate internal communications are more troublesome when trying to identify the medications a soldier has 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 altogether 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 a FOIA request by the Phoenix, the VA says it has seen the number of veterans from Iraq and Afghanistan treated for addiction to prescription drugs annually rise from 961 in 2005 to 1865 in 2006, 2996 in 2007, and 4646 in 2008. Military medical experts and veterans say that underreporting by embarrassed or ashamed vets may be keeping those numbers from rising further.
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 for this story 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 by the Phoenix. “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.”
A 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 Pogany, Darwin, 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. While recognizing that the drop in troop deaths in combat during this past year can be attributed to the surge — and its attendant increased number of doctors in the field, proximity of aid stations to the front lines, and the gradual handover of security duties to Iraqi troops — these critics note that the surge may not be worth the multiple deployments and medications used to fuel it.
“Are US fatalities down?” asks Sullivan of the benefits of the surge. “Yes. Are US casualties in Iraq down? No. Is the Iraqi government in control of its own laws? No, because US 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 US service member 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 has no other plan than to 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 freelance writer from Roxbury. He can be reached at firstname.lastname@example.org.