Huxley here we come

(from Time magazine) While the headline-grabbing weapons in this war have been high-tech wonders, like unmanned drones that drop Hellfire missiles on the enemy below, troops like LeJeune are going into battle with a different kind of weapon, one so stealthy that few Americans even know of its deployment. 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. (go to article)

This is a sticky problem, isn't it? Leaving one's opinions about the wars in Iraq or Afganistan aside...and leaving aside as well my own strong bias against the overuse of medication in psychiatry, what IS the problem here? Soldiers are a resource that need to be managed; their returning home exhausted and traumatized serves nobody's interest, right?

Here is some research on a drug, known commercially as Inderal:

[Pitman] and his colleagues tested a tongue-twister of a drug called propranolol on 41 people who had experienced automobile accidents, assaults, and other traumas serious enough for them to be treated at the emergency room of Massachusetts General Hospital in Boston. The goal was to see if this drug, given within six hours of their mishaps, would prevent terrifying, indelible memories.

Tested three months after an auto accident, one young man, who took a dummy pill as part of the experiment, was still wary about getting into a car. He had nightmares. He sweated, his heart rate jumped, and he felt nervous anytime he got behind the wheel, especially in the area where the accident occurred.

In contrast, others who survived similar accidents and took propranolol had significantly fewer problems.

The most revealing tests were done three months after the traumas, when 22 of the victims returned to Mass General Hospital for evaluation. Eight of these people took propranolol four times a day for 10 days, but had been off the drug for more than two months when tested. Fourteen of the 22 had taken dummy pills, or placebos.

All of them listened to audiotapes on which they had described the incidents that brought them to the emergency room. None of those who took propranolol showed strong responses to the tapes. But eight of the placebo patients were obviously shaken by reliving their traumas. Their heart rates increased, their palms sweated, their muscles twitched - all signs of PTSD.

From 1988 to around 1994 I worked in a somewhat innovative program in Boston that treated young children (6-12) who suffered from a wide range of abuse. Violence was the texture of much of their young lives, and of course there was a great deal of sexual abuse. It was quite common for a kid to get really wound up and seek some sort of conflict; often it ended with the child being physically restrained. When I write "innovative" I mean for its time. It was a loving, caring place, but one that put far too much emphasis on such unbounded concepts as "cerebral dysfunction". Its strength was its staff, especially the nurses. But the conceptual framework was, to be sure, weak.

The kids were viewed, conceptually, as damaged. They certainly faced a myriad of extreme disadvantages, and these were compounded, I believe, by the behavioral scheme that attempted to reinforce and reward all kinds of actions, at the expense of a more natural, genuine setting. Once they left, it was likely that they moved into a world that responded to them in a totally different manner. What they learned they left behind, unless they wound up in a good school, with a good family, and a fierce advocate to protect them throughout the brutal foster care system.

But one thing that worked was Inderal. Inderal is a beta-blocker. More specifically, a beta-adrenergic antagonist that blocks the body's use of epinephrine. It puts a ceiling on how excited or overstimulated you can get. We used it to cut the cycle of violent outbursts that made any kind of therapeutic learning impossible. It was relatively safe- so long as the patient's blood pressure was monitored.

It was developed first from an anti-fungal compound that was shown to have these properties. The scientist who discovered it won a Nobel Prize. We valued it because it allowed very traumatized children to tolerate situations they found far too frightening and disorganizing.

In more recent times it is used for stagefright, agoraphobia, and such things. The above study sees it as a treatment for PTSD per se. That is what we used it for, and lo and behold, Harvard is catching up, some twenty years later. (link)

(more soon)