The guidelines call on clinicians to ... follow up with the patient weekly, during the first weeks of treatment, "to monitor for emerging side effects, including the potential risk for increased suicidality."
Military Sets New Rules On MedsGuidelines Aimed At Troops' Mental Health
June 6, 2007
By LISA CHEDEKEL, Courant Staff Writer
The military has adopted detailed guidelines for dispensing psychotropic drugs to combat troops in Iraq, calling on mental health providers to have weekly contact with patients, ensure that troops receive therapy along with the medications, and prescribe only a small supply at a time.
The guidelines, released at The Courant's request, have been distributed to mental health specialists in Iraq in recent months, but have not been publicly disclosed. The use of psychotropic drugs in the war zone has been an issue of concern among civilian mental health specialists, who say proper monitoring is essential to safeguard troops' safety.
Although the guidelines include strict cautions on use of the medications, some soldiers' advocates worry that the recommendations will be difficult to follow as the number of psychiatric professionals in Iraq falls and mental health needs climb. A recent study by a team of Pentagon mental health experts found that one in eight soldiers in Iraq was taking medication for a mental health, combat stress or sleep problem - but that the number of behavioral health providers treating deployed service members had dropped to one for every 668, compared with one for every 387 in 2004.
"It's a paper tiger. Until there is accountability in the medical community, all the policies you can think of don't mean anything," said Steve Robinson, director of veterans affairs for Veterans for America, an advocacy group.
In a series last year, The Courant reported that the military was dispensing potent antidepressants to troops in Iraq with little or no monitoring or counseling, despite FDA warnings that the drugs can increase suicidal thoughts. In some cases detailed by The Courant, service members who were placed on the medications ended up committing suicide.
Those findings conflicted with the Army's own regulations, adopted in 2005, that cautioned against the use of antidepressants for cases of moderate or severe depression during combat deployments.
Last year, top military officials insisted that the use of such medications in the war zone was minimal. But the recent Pentagon survey found that 12 percent of soldiers, or nearly one in eight, were taking medications for a mental health or sleep problem.
Robinson questioned whether the military was able to provide the extensive monitoring prescribed in the new guidelines, saying a shortage of mental health providers caring for troops in Iraq and for those returning home had reached a crisis.
"I've had no indication that mental health care in [the combat] theater has gotten better. I still hear the bag-of-meds stories," he said, referring to deployed troops who are given psychiatric medications without therapy or monitoring.
But Army medical officials said they have confidence that the cautions contained in the new guidelines, dated August 2006, are being heeded. The guidelines were published by the Multi-National Corps-Iraq, the tactical unit responsible for command and control of operations throughout Iraq.
The guidelines call on clinicians to take a "comprehensive history" of a service member before prescribing a psychotropic medication, and to follow up with the patient weekly, during the first weeks of treatment, "to monitor for emerging side effects, including the potential risk for increased suicidality." They also instruct providers to encourage patients to tell others that they are starting a new medication "so that they have an extra set of eyes to watch for any potential side effects."
The guidelines recommend that troops be given "only a small quantity of drugs at a time, usually 1-2 week's supply" at first, in part to guard against overdoses. They encourage providers to offer therapy to troops in conjunction with the drugs, saying: "It cannot be emphasized enough that the most efficacious treatment for moderate to severe depression is combined treatment, including both psychotherapy and antidepressant medication."
An accompanying instruction to commanders encourages them to pay attention to any changes in a service member's work performance and make sure that troubled troops get help.
"If you learn that one of your [service members] is seeing a mental health professional, don't panic," it says. "This isn't necessarily a bad thing because it means a professional set of eyes is checking out your [service member]."
Commanders are cautioned not to force troops to disclose information about their mental health treatment. But the recommendations say that mental health providers will encourage service members who are placed on antidepressants to share that information with commanders.
Last year, in response to The Courant's series, Congress passed legislation directing the Department of Defense to expand mental health screenings for combat troops and to establish clear mental fitness standards for deployment to war. Included in the legislation was a requirement that the military establish programs for monitoring the mental health of deployed personnel receiving psychotropic medications.
In November, in response to that legislation, the Pentagon did adopt new mental health guidelines that expand screening for troops and set limits on when service members with psychiatric problems can be kept in combat. Those rules include a provision urging military clinicians to regularly evaluate troops who are taking psychotropic medications, and to use "caution ... in beginning, changing, stopping and/or continuing psychotropic medication."
The congressional legislation directed the secretary of defense to submit to the Senate and House armed service committees, by June 1, a progress report on actions taken to enhance mental health care. Cynthia Smith, a Pentagon spokeswoman, said the progress report is still being prepared and has not been submitted yet.
The team of military mental health experts who surveyed soldiers and health professionals serving in Iraq last year found that only about half, or 53 percent, of behavioral health providers reported that their higher command had provided them with adequate resources needed to perform their duties.
The majority of psychiatrists surveyed by the team said there was adequate availability of psychiatric medications in Iraq. But fewer than half reported that the procedures for ordering and replenishing psychiatric medications in Iraq were clear.