SSRI Stories has received confimation that this young woman was taking the antidepressant Celexa.

November 28, 2006
By LISA CHEDEKEL, And MATTHEW KAUFFMAN Courant Staff Writers

The U.S. military has issued sweeping new mental-health guidelines that expand screening for troops being sent to war and set limits on when service members with psychiatric problems can be kept in combat.

The changes include a directive that troops who develop mental health problems during deployments should be sent home if their conditions do not improve significantly within two weeks of treatment.

Also, service members who are prescribed psychiatric medications less than three months before deploying will be disqualified from being sent to war unless there is evidence the drugs are working and have no significant side effects.

The changes - issued by Dr. William Winkenwerder Jr., the assistant secretary of defense for health affairs - are aimed at meeting a congressional mandate prompted by a May series in The Courant that exposed gaps in the military's mental health care system. The series reported that mentally troubled troops were being sent to Iraq and kept there, in some cases with fatal consequences.

Winkenwerder had told The Courant last spring that he believed existing mental-health practices were adequate to meet the needs of deploying troops. But in an interview Monday, he said the new policy was an important improvement.

"The intent is to provide improved and more precise guidance to our clinicians, so that they can make the best possible medical decisions with respect to individuals who might have deployment-limiting psychiatric conditions," Winkenwerder said.

He said the policy had been developed by military medical and clinical experts over the past several months - work that began before Congress passed legislation in late September directing the military to expand mental health screenings and set clear mental-fitness standards for deployment.

Veterans' advocates said the policy was a significant advance, but that more attention to psychological screening and services, especially for returning troops, is needed.

"From my view, it's a step in the right direction, but the devil is in the details," said Sen. Barbara Boxer, D-Calif., who co-sponsored the congressional legislation with Sen. Joseph Lieberman, D-Conn.

Boxer said the changes do not "satisfy the full scope of our legislation, so there is more work left to be done, particularly in the area of [post-traumatic stress disorder], which plagues so many of our military men and women returning from war."

In some areas, the policy appears to go even further than what Congress instructed. It steps up pre-deployment screening by directing that service members with mental health disorders should be sent to war only if they demonstrate a "pattern of stability, without significant symptoms" for at least three months prior to deployment. The rules also prohibit deploying troops with psychotic or bipolar disorders.

Clinicians evaluating whether troops should be sent to combat areas also must review all relevant medical records and consider the impact that sleep deprivation and other "mission demands" would have on a service member. Troops with mental illnesses that are not expected to resolve within one year also should be considered unfit for military duty and evaluated for possible discharge, according to the policy.

The Courant had obtained Defense Department records indicating that service members' mental illnesses were being missed or ignored during pre-deployment screenings. Some of the troops who were deployed with psychological problems later committed suicide in Iraq.

The Courant also had reported that some deployed troops were being prescribed potent antidepressants without close monitoring or counseling, and that others who had exhibited clear signs of mental illness were retained in combat.

Some family members of soldiers who had psychiatric problems before or during tours in Iraq said they were pleased that the military was changing the way it deals with mental illness.

Connie Hobart's 22-year-old daughter, Army Pfc. Melissa Hobart, was put on an antidepressant shortly before deploying and had told her mother that she remained depressed while in Baghdad. Three months into her tour, in June 2004, the East Haven native collapsed and died of a still-undetermined cause.

Told of the policy changes Monday, Connie Hobart said, "I'm happy to hear about it. That's good news." Sobbing, she said her daughter might be alive today if the policy had been different at the time.

The directive also sets new standards for evacuating troops who develop mental health problems in the war zone. Troops with psychotic disorders will automatically be recommended for return home. Those with other mental health disorders should be sent home if they are at "significant risk for performing poorly or decompensating" in the war zone, or if their condition does not significantly improve within two weeks of treatment, according to the policy.

"Any health condition that limits the physical or psychological ability of a service member to plan, train or execute the mission represents a risk to that individual, the unit and mission success," the policy says.

Winkenwerder said that while each of the armed forces has some guidelines for addressing mental health issues, the new directive "is obviously clearer guidance - [and] the same guidance across all services."

While the policy allows for the use of psychotropic medications in the combat zone, it urges medical providers to use caution when "beginning, changing, stopping and/or continuing" such drugs during deployments. Antidepressants can worsen depression and increase suicidal thinking, and experts say patients taking such medications should be monitored carefully when the drugs are first prescribed.

"Any little thing they do is a help," said Ann Guy of Willards, Md., whose son, Marine Pfc. Robert A. Guy, killed himself in Iraq on April 21, 2005 - a month after he was prescribed the antidepressant Zoloft with no monitoring.

But while Guy applauded the change, she said it comes too late for her.

"It'll help save somebody else and keep another family from going through this," she said. "But I am still so angry."

Dr. Jonathan Shay, a Boston-based expert on combat stress, said the directives on medications - including the prohibition on deploying troops if the drugs are ineffective - "sounds like a reasonably sane policy. For one thing, implicit in this is that if you're treating someone for depression or post-traumatic stress disorder with an [antidepressant], you want to know the person is actually responding and they're getting better."

But, like others, he was unsure how the policies would be implemented in the field, where commanders want to preserve troop strength.

"It's a little murky in my mind whether the secretary of defense for health has anything more than preaching rights," he said.

The new policy also directs medical personnel to consider a number of factors when deciding whether to retain a service member in the war zone, including the risk that continued exposure to combat stress or trauma will worsen the member's mental condition, and the possibility that a soldier may be unable to "psychologically tolerate the rigors of the deployed environment."

Paul Rieckhoff, executive director of Iraq and Afghanistan Veterans of America, praised the policy, saying rules that will keep mentally troubled troops out of combat show that the military is beginning to recognize that mental injuries can be as debilitating for a soldier as physical injuries.

"This is a significant improvement," he said. "Even the language is showing an evolution in the thought process."

Contact Lisa Chedekel at lchedekel@courant.com

A discussion of this story with Courant Staff Writer Matthew Kauffman is scheduled to be shown on New England Cable News each hour today between 9 a.m. and noon.

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