8 June 2008

Pathogenic War Environment

Filed under: Culture, Psychology — ktismatics @ 7:28 am

Sam recently made a comment on my Wartime Reality post from about a year ago, linking to this TIME article which discusses the use of antidepressants to treat American soldiers in Afghanistan and Iraq for stress-related psychological disorders. In his comment Sam remarks:

What’s your take on ‘helping’ soldiers to cope with the war zone in this way? It strikes me that the use of these drugs in this situation is ethically ridiculous given the fact that it is not based on any scientific studies, not even short term ones. Experimenting on the troops in the name of expediency is really the pits!

I don’t think the use of psychotropic medications is particularly experimental. There’s nothing out of the ordinary in medicating the effects of pathogenic situations — this is pretty much status quo in the civilian world as well. Soldiering is a job; usually it’s a rather mundane, repetitive and boring sort of job. Put the soldier in occupied territory and the job changes drastically: danger induces fear and anxiety, aggression and anger and guilt, loss and depression, hypervigilance and psychic numbing. The diagnosticians might want to assign a separate diagnosis to each of these psychological reactions, or to roll them all together into one catch-all category like “combat stress disorder.” The medications aren’t specific in their effects: they serve to modulate neural reactions to chronically pathogenic situations, letting people tolerate these situations.

The issue is this: anxiety and depression are normal psychological responses to stressful and depressing circumstances. Overriding these responses by medication tricks the brain into regarding the circumstances as less traumatic than they really are. Also, the whole protocol of diagnosis and treatment shifts the locus of pathology from the environment to the individual. Instead of focusing on the toxicity of the militarized zone and figuring out either how to change the environmental toxicity level or to escape the environment altogether, the soldier starts thinking of himself as mentally ill.

The Time article says that soldiers — who are younger and healthier on average than the general population — have been prescreened for mental illnesses before enlisting. Doesn’t this strongly imply that the syndrome isn’t caused by abnormal brains but by exposing normal brains to abnormal situations? The article continues:

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.”

This three-tiered categorization scheme is almost certainly not a true reflection of qualitative differences in psychopathology, but rather a statistical artifact. Let’s say the Pentagon’s psychologists come up with a diagnostic checklist. “In the past month have you felt downhearted and blue most of the time?” “In the past month have you ever felt intensely angry, to the point where you were afraid you might hurt someone?” And so on. Let’s say there are 25 items on this checklist. The military administers the questionnaire to a few hundred soldiers. The results are fed into a computer, and in the output you get the aggregate distribution of “yes” responses. Some will have none; others will acknowledge 1 stress-related response, etc. Let’s further speculate that the Pentagon is prepared to acknowledge that 20% of the soldiers have “moderate stress disorder,” while another 10% have “severe stress disorder.” What the statisticians have to do is find the break points in the distribution. Maybe 30% of respondents have 5 or more “yes” responses and 10% have 8 or more “yeses.” Those statistically determined break points become the gold standard for clinicians diagnosing individual soldiers. It looks scientific, but it’s a cooked-up scheme. If over time the statistical distribution shifts, so that a higher percentage of soldiers are 5+ on the checklist, the diagnostic manual can just shift the break points: now instead of 5 “yes” responses you now need 6 in order to get the “moderate stress disorder” diagnosis. It’s like the American football commissioner moving the goal posts back 10 yards if the kickers get too accurate and change the dynamic of the game.

This isn’t just my antiwar cynicism talking (although it’s partly that). I don’t doubt that soldiers in the occupation experience all manner of anxiety, depression, rage, risk-seeking, etc. As I said, it’s a normal response to a pathogenic environment. I question the management, the spin, the official explanations for what’s happening. In Creating Mental Illness, sociologist Allan Horwitz describes how the American Psychiatric Association vastly expanded the number of discrete diagnoses included in its Diagnostic and Statistical Manual of Mental Disorders. The process works just the way I’ve described it here: a panel of clinicians names a mental illness; psychological researchers devise a diagnostic questionnaire based on clinical consensus about what characterizes this mental illness; based on statistical distributions on the questionnaire as well as current treatment practices among clinicians, the researchers “set up the goal posts” for assigning an individual the diagnosis based on his or her score on the questionnaire. Clinicians and pharmaceutical companies are united in their motivation to move the goal posts in, making the diagnosis more inclusive so practitioners have more potential clients to treat, more potential income to be generated. The Pentagon has different variables to factor into their cost-benefit analyses, though I suspect that in their deliberations they’re not immune to the influence of Big Pharma.

The Time article goes on:

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.

In a prior exchange with Sam I had wondered why all of a sudden the Pentagon was acknowledging the prevalence of PTSD among soldiers and veterans, why in addition to the latest $126 billion requisitioned for continued funding of the occupation an additional $2 billion was stuck into the bill for psychological treatment. This might explain it: America needs more decorated war heroes. I doubt the recipients of these Purple Hearts will derive much comfort from the honor. But if it rallies the nation behind the war effort to pin more medals on more uniforms, if it induces more sympathy for the soldiers/vets, if it increases the public desire to justify our boys’ sacrifices by staying the course, then it’s a pragmatically sound strategy. I’m sure that even as we speak the Pentagon’s market researchers are investigating “what-if” scenarios, reading the tea leaves, running it up the flagpole…



  1. I know that the use of Tylenol/Motrin is very common and has been for a very long time. Beyond this, and alcohol off-duty, the standard has always been to avoid all other drugs. Vietnam was famous for the illicit (but winked at) use of all sorts of drugs including some real nasties. Now, it’s become official policy to encourage being drugged out – as long as the job gets done!

    I guess the main reason it seems like a fly-by-night experiment is not so much that the drugs are non-standard nor that their effects have not been fairly well quantified (tho I think there is reasonable doubt on a link between SSRI use and suicidal ideation) in civilian settings, so much as the fact that you are prescribing medication to soldiers who are in a war zone without knowing how it will affect combat readiness. In fact how would one scientifically study such a thing while in the war zone? The drugs are being prescribed and used while the prescribing physician will probably not even see the same soldier again. Even then is any track kept of performance before and after, other than perhaps some occasional self evaluation? It looks as though the criterion is not therapeutic effect but rather the soldier feeling that they don’t need to go back to the psychiatrist. Close your eyes and the problem disappears.

    Furthermore, I would think that such basic issues as whether any of this potpourri of medications could adversely affect say a sniper’s accuracy, judgment, or reaction time, or field of vision, or…

    The army specifically dislikes anti-psychotics (why?) and these are also just as well-studied medications. Why not just open the flood gates? The older way was to give the soldier a break, some R&R, a few nights off, send them to the back, or even homeside. Under intense pressure, with extended and repeated tours of duty, with ever reducing recruitment, and with a war that is getting worse rather than better, it looks to me as if the army just threw all their principles of caring for their own out the window and sold out – and most particularly the psychiatric part of the medical corps.

    And since this is the same extended organization that melds into the VA, I wonder how good the vets will feel about the care, concern and sincerity of their service providers here?

    Comment by samlcarr — 8 June 2008 @ 12:08 pm

  2. I’m not so sure that “drugged out” is the effect of these new SSRI-class medications, which aren’t narcotic (though they may induce withdrawal effects). My sense is that they give the brain more tolerance for repeated and chronic noxious overstimulation. Some people refer to these drugs as “psychic energizers,” which is why a lot of asymptomatic people take them. They give you confidence and enhance performance (or so I’m told). In other words, I think there’ll still be plenty of demand for alcohol in the occupation.

    Maybe eventually the Army will start issuing SSRIs to every soldier assigned overseas. There’s an experiment waiting to happen: next troop deployment to Iraq, have half the soldiers take SSRIs and the other half take placebo pills, then measure results (psychological symptoms, injuries or deaths, body counts, etc.).

    Comment by ktismatics — 8 June 2008 @ 1:58 pm

  3. I’m just wondering now whether the use of these medications may have played some role in facilitating things like Abughraib? If something as nasty as a war zone can be made to seem more homely, why not for torture or ‘collateral damage’?

    Quoting Time: “The trickle of new drugs became a flood after the invasion of Iraq in 2003.”

    Comment by samlcarr — 8 June 2008 @ 4:52 pm

  4. John, your comments on purple hearts being spun in new directions is absolutely spot-on according to a followup article in today’s Time: that’s almost prescient dude!

    Comment by samlcarr — 9 June 2008 @ 5:05 am

  5. Interesting. You’ve got the Pentagon trying to turn a sociological pathogen into warfare-inflicted brain damage, while the Order of the Purple Heart hardasses insist that PTSD is just a wussy mental illness and not a real war injury perpetrated on real men by real enemies. It’ll be curious to see how this plays out after the spinmeisters have vetted the idea thoroughly and settled on a PR campaign.

    Comment by ktismatics — 9 June 2008 @ 5:32 am

  6. I saw this article on Yahoo’s news and it looks like it came from AP. The description of the struggle that these soldiers have along with the inadequacy of current VA treatment modalities indicates that this is something that can’t be swept under the carpet for very long. As the main theater looks to shift from Iraq to Afghanistan, American soldiers and American society are going to end up paying a very high price indeed. These guys need something more than a purple heart to bring them back.

    Comment by samlcarr — 20 July 2008 @ 1:42 pm

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