Treating PTSD: It's a maze of pills, possibilities for troops, vets

Former Army Sgt. Eric Terry returned from Iraq in 2007. Friends of his died during the yearlong deployment, and he experienced close calls with mortars and other attacks.

Working as a military police officer at Fort Hood during the next two years, he increasingly became anxious, especially in large crowds. He had trouble sleeping. He began drinking heavily. All the warning signs were there, and he suspected he had post-traumatic stress disorder.

By 2009, doctors confirmed the PTSD. His initial prescription: Klonopin, an anti-anxiety pill that’s part of the same group of drugs that includes Valium and Xanax. He later was diagnosed with bipolar disorder.

Terry’s mental wounds became deeper.

His prescriptions got stronger.

His drinking got worse.

The Army in 2010 stationed him in Korea, where “I drank to die,” Terry said. He got in trouble and was demoted in rank to specialist before being assigned to the Fort Hood’s Warrior Transition Brigade, a unit for wounded and ill soldiers.

Terry was medically retired in 2012 after 13 years in the Army. He continued his PTSD treatment at the Veterans Affairs hospital in Temple. There, the pill prescriptions continued.

“At one time, I was on Abilify, Topamax, Klonopin and a sleeping aid,” said Terry, now 35, of Temple. “I was on Abilify on the highest dosage.”

All told, Terry has been on about a dozen different medications.

Terry said Abilify gave him the unwanted side effect of fatty liver syndrome, which caused him to vomit frequently. And he had to take additional pills to thwart the side effects of the anti-anxiety pills.

“You can give somebody so much medication, they can forget life,” Terry said. Then, when the medication stops, memories and emotions can come flooding back. Last year, Terry stepped away from the pills, drawing on the support of his wife, friends and therapists to cope with those feelings.

Pill problems

For years, pills have been a go-to treatment option for service members and veterans trying to learn how to live with PTSD. But like Terry, many of them aren’t finding success with the medications prescribed to them, and are grasping for other options.

Doctors are moving more toward holistic approaches, and soldiers and veterans are seeking alternatives beyond what doctors can provide, such as medical marijuana.

On Veterans Day, about two dozen people marched to the White House and dumped a large box of empty pill containers, calling on the president and other federal officials to make medical marijuana accessible to veterans, according to a report in the Washington Post.

“Here’s what the over-medication of our veterans looks like,” they said as they spilled the canisters on the floor. “We don’t want it.”

According to the VA, the prevalence of PTSD among veterans varies by service era. In the most recent conflicts, Operations Iraqi Freedom and Enduring Freedom, “about 11-20 out of every 100 veterans who served in OIF or OEF have PTSD in a given year.”

Fort Hood

In fiscal year 2015, about 2,500 Fort Hood soldiers have been given the PTSD diagnosis, said Col. Sharette K. Gray, chief of behavioral health at Fort Hood’s Carl R. Darnall Army Medical Center.

The number is not surprising, she said.

“Definitely, it’s an issue at Fort Hood, because we’re the largest deployment projection platform, so more soldiers deploy out of Fort Hood than any other Army post.

“We have a lot of soldiers who are coming back and forth from the combat zones, and doing excellent work there, and I think that’s why you’re going to see (PTSD) more here than you would at a training post where all they do is training,” she said.

Treatment Options

After diagnosis, the problem becomes how to treat the individual, keeping in mind that each soldier will respond to various treatments in unique ways. What might work for one, won’t necessarily work for someone else.

With close proximity to Fort Hood, Dr. Stacy Gwynn, a psychologist at the VA hospitals in Waco and Temple, said local veterans hospitals see a high volume of PTSD patients, who also are treated using medicines and therapy.

According to a 2008 report by the Department of Veterans Affairs, 80 percent of veterans diagnosed with PTSD received psychotropic medication, which alter chemicals in the brain, to treat the disorder, and 89 percent of those individuals were prescribed antidepressants.

“I would say, of the (PTSD patients) in our clinics ... a great majority of them are probably on some sort of medication. That could be an antidepressant, or something to help them sleep. Generally speaking, an antidepressant, of some sort, can be very effective and also a sleep aide is commonly provided as well,” Gwynn said

Most commonly, medicinal PTSD prescriptions include selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors, Gray said.

Both are commonly used in treating depression, and in the case of PTSD patients, help ease the high levels of anxiety closely associated with the disorder.

Gray said these types of medications have “relatively few side effects.”

“Every medicine has side effects but those tend to be fairly well-tolerated, and generally tend not to have any severe adverse or dangerous side effects, so that’s a good thing. They tend to be relatively safe,” she said.

Risks

Some of these potential “side effects” are controversial.

An April 2014 report from the Citizens Commission on Human Rights International outlines some of the serious risks associated with the use of psychiatric medications among soldiers and veterans, including violence and suicide.

“Between 2001 and 2009, orders for psychiatric drugs for the military increased sevenfold,” the report states. It goes on to say, “Psychologists have blamed the surge in random acts of violence among U.S. military on the heavy use of prescribed drugs.”

But instead of laying all blame on the drugs, Gwynn said, it’s important to consider the reasons why the pills are prescribed in the first place.

“Certainly, we need to be mindful of having access to certain medications that they can actually use to attempt suicide, but the risk factors really, primarily lie within their original diagnosis to begin with,” Gwynn said.

Prevention

A concern with some medications is a high risk of dependence. The Defense Department is monitoring this.

The department warns against the use of benzodiazepines, a family of anti-anxiety medications that includes Xanax and Valium, and the same kind Terry was prescribed when he was diagnosed.

“We advise our providers to utilize the VA-DOD clinical practice guidelines for the treatment of PTSD, and part of those guidelines basically steer people away from utilizing the benzodiazepines because they’ve been found to actually potentially worsen the person’s ability to improve from PTSD, and actually it potentiates the fear response,” Gray said.

The class of medications is also highly addictive. Gray said such medications “hit the same receptors in the brain as alcohol.”

Soldiers at Fort Hood, as well as patients at the VA, return to a doctor within the first two weeks of using a psychiatric medication “to make sure that they’re tolerating it well,” Gray said.

Patients are also warned not to combine the use of other substances, including alcohol, when taking psychiatric medications. Educating both patients and providers is key in preventing the harmful consequences of having the wrong cocktail of pills in the hands of a soldier or veteran, Gwynn said.

Unfortunately, there is no recipe or magic pill or combination of medications to instantly remove the symptoms of PTSD.

“It would be nice if a pill cured everything, but that’s generally not the way it works, so we really encourage people to think about therapy as an option,” Gwynn said.

Both the VA and Fort Hood focus primarily on trauma-focused therapies. They include cognitive restructuring to help patients think differently about the traumatic event they experienced, and exposure therapies, which gradually introduce situations to trigger the fear reactions and make those scenarios less anxiety-inducing.

“Those have a tremendous amount of research to support their effectiveness, and treating PTSD relating to various kinds of trauma, and they’ve both been demonstrated strong research support with veterans specifically,” Gwynn said.

Holistic approach

Along with medications and therapy, Gray said it’s important when treating PTSD to look at all aspects of a patient’s health, including diet, exercise and sleep. She suggests trying alternative approaches to treatment, such as yoga or relaxation techniques, in conjunction with the mainstream therapies.

“It’s really important for our clinicians to really make sure that we educate our patients about the importance of all of those aspects of their life, and not neglecting those as well. And then, as they become more educated and enlightened about it, the patients they are more interested, and then they find it’s not all one thing or another, but they all work together in conjunction,” Gray said.

“We have a lot of really dedicated providers that really love the fact that they are able to help soldiers and are dedicated to what they do. I’m very happy about that and I think we’re providing good treatment,” she added.

Dropping the pills

In 2010, Terry stopped drinking. In 2014, against his VA doctors orders, he stopped taking the pills. Now, his main treatment for dealing with PTSD is talking about it.

“The easiest way to deal with PTSD is to talk about it,” he said.

Terry still gets emotional when he talks about his battle buddies who died in Iraq, but he’s decided to deal with his PTSD without the use of pills.

He said he started smoking marijuana last year and that helps with his anxiety. He smokes about five times a day.

A green approach

Medical marijuana is increasingly being discussed as a viable PTSD treatment.

On Tuesday, the U.S. Senate passed a bill that will allow veterans who use VA hospitals in states where medical marijuana is already legal, to be prescribed medicinal marijuana. Currently, VA doctors in all states are prohibited from doing so.

And in Austin on Wednesday, a group of Texas veterans and supporters gathered outside the state Capitol to announce the launch of a campaign advocating for comprehensive medical marijuana legislation. They want veterans to have access to medical marijuana — which they say is a safer alternative to prescription drugs — for treatment of PTSD, traumatic brain injuries, chronic pain and other service-related conditions.

“Veterans have sacrificed greatly to serve and protect our nation,” said David Bass, a Killeen resident and Army veteran involved in the campaign. “It’s time to serve and protect the many soldiers who have returned home with debilitating conditions that would benefit greatly from medical marijuana. The goal of this campaign is to give those veterans a voice and get Texas legislators to listen.”

As research into current and future PTSD treatments continues, new medicinal and non-medicinal approaches are likely to develop.

Terry said it’s not the medicine itself that’s the most important part of the process. “It’s not the medication. It’s the mentality behind the medication.”

And like the doctors who treat PTSD, Terry said strong, individualistic care and understanding between the patient and the physician are key to a successful outcome.