Tuesday, July 14, 2009

Pharmaceuticals in Direct Support

Originally published in Blog Them Out of the Stone Age on June 9, 2008

The current Time magazine features a cover story entitled "A Medicated Army," discussing the practice of prescribing antidepressants and antianxiety meds to soldiers in combat environments:
For the first time in history, a sizable and growing number of U.S. combat troops are taking daily doses of antidepressants to calm nerves strained by repeated and lengthy tours in Iraq and Afghanistan. The medicines are intended not only to help troops keep their cool but also to enable the already strapped Army to preserve its most precious resource: soldiers on the front lines. Data contained in the Army's fifth Mental Health Advisory Team report indicate that, according to an anonymous survey of U.S. troops taken last fall, about 12% of combat troops in Iraq and 17% of those in Afghanistan are taking prescription antidepressants or sleeping pills to help them cope. Escalating violence in Afghanistan and the more isolated mission have driven troops to rely more on medication there than in Iraq, military officials say.

As many readers know, I have bipolar disorder, and consequently have a long acquaintance with many of the meds being prescribed. At the moment, for instance, I take Lamictal on a daily basis and clonazepam (the generic equivalent of klonopin) as needed. The former operates as an antidepressant. It has mood stabilizing properties that make it a reasonably good prophylactic against mania -- in fact I've had no trouble with incipient "highs" since I began taking Lamictal about two years ago. The latter is a mood stabilizer and anti-anxiety med. The biochemical manifestations of bipolar disorder are more complex than most people suppose. I have had days when I felt neither up nor down, but had such an insistent sense of generalized anxiety that I had to cancel class because I felt too light-headed to responsibly drive down to campus. Once I grasped its beneficial properties, clonazepam has done a lot to alleviate that problem. I also take the generic form of Ambien on a fairly regular basis in order to make sure I get a good night's rest. Regular sleep -- what's known as "good sleep hygiene" -- is a bedrock element in managing the illness.

The situation of a college professor in the midwest is obviously dissimilar from that of a combat soldier in Iraq or Afghanistan, but I think my experience can contribute a degree of insight. To begin with, I think it's important to regard the meds as simply a tool to assist with the overall task of maintaining good health. There's a tendency for those who take them to regard them as a sort of query against their character: that if they were somehow stronger they wouldn't need to take the meds. That leads to problems. First, it reduces self-confidence and self-esteem. Second, it often creates a state of partial denial in which a person may take the med, but does not acquaint himself closely with the medication's properties. He may not follow the guidelines for taking the med responsibly and when he feels better may quit taking the meds entirely. (Medication noncompliance is the single biggest problem among those with bipolar disorder.)

Third, there can be a tendency to regard the meds as shouldering the whole burden of managing the problem, whereas I have found it helpful to take an active role in managing the disorder rather than just passively taking the pills. I monitor myself for symptoms, even subtle ones that no one around me would recognize. I try to exercise on a regular basis. I make use of as many other tools as I can gather to help with the job: a psychiatrist, a therapist, and also the support of friends. There's too much tendency to let fears of the stigma prevent a person from letting others know about one's situation. But I've found that for every jerk there are many people who welcome the opportunity to be of assistance.

Finally, I have made a personal commitment to be public about having bipolar disorder. In each course I teach, I find a topic that lends itself to disclosure that I have the illness (in the U.S. history survey, for instance, the work of 19th century reformer Dorothea Dix provides a good opportunity). In a class of 200 students, statistically two students have been or will be diagnosed with bipolar disorder. I have never yet disclosed the illness and not received subsequent contact from a student who has the same diagnosis. They express appreciation for my candor and particularly a sense of relief in realizing that they are not alone, and that someone they regard as highly functional can have the disorder and lead a reasonably normal life. I often wind up meeting with them to discuss the illness and how best to manage it. Students usually have a lot of concerns: What will their life be like? what degree of stigma will they face? Frequently they do not yet have in place a good support system for managing the disorder. I recently spoke with a student who has no psychiatrist and therapist; her prescriptions are written by a general practitioner. I've been able to assist with referrals to good psychiatrists and therapists within her health care network.

How does this relate to military personnel who take psychotropic meds? First, I wonder how many officers and NCOs self-disclose that they are taking the same meds. If they keep this info away from their soldiers, they send a double message: overtly it's OK for you to take these meds, but tacitly it's really not because I wouldn't be caught dead letting you know that I take them myself. It would require real moral courage, but an officer willing to talk matter of factly about taking these meds, and at the same time functioning effectively as an officer, would serve as a powerful role model. (I find that's the role I often play with my students.) Such an officer's example could not only reassure the soldiers who take the meds, but would also help shift the military culture toward one in which other soldiers would find it easier to trust and support their comrades in arms.

Second, I think it's important to de-mystify these drugs as much as possible, so that the fact of taking them does not, in its own way, add to the issues that soldiers must face. To repeat, taking a med to assist with a problem is not a confession of weakness or bad character. On the contrary, it takes strength and maturity to face up to a problem squarely and do what it takes to accomplish the mission -- whether that mission is to maintain one's health as a civilian or one's effectiveness as a soldier.

Third (and as a corollary), I have found it useful to apply, metaphorically, the warrior ethos to the task of managing the illness. I conceptualize bipolar disorder as an enemy that will never cease in its efforts to destroy me -- either outright or by destroying my quality of life -- and that consequently I have to work conscientiously and intelligently to keep it in check. I've found that my military training and my familiarity with strategic studies have come into play, in various, sometimes unexpected ways, to help me do this.

It would be wrong to create a sunny picture. Even in my safe suburban life, the task of managing bipolar disorder requires a lot of vigilance and is not without its setbacks. For obvious reasons the problem is compounded for those in combat zones, and the last thing I would ever want to suggest is some sort of situational equivalence. At the end of the day, shorter tours of duty and regular rotation into safe areas (such as they are) is a better solution to the problem. But until then, if the Army is going to pursue what I regard as a sensible 21st century policy -- to treat issues of depression, stress and anxiety as problems to be solved rather than defects to be scorned -- then it needs to shift the military culture to conform with the policy. I hope these insights from my own situation, however modest, may be of some help.

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