Bragg PTSD diagnoses low, but anti-depressant use up
By John Ramsey
Fort Bragg soldiers are being diagnosed with post-traumatic stress disorder less than half as often as soldiers Armywide.
Figures provided by the Army also show that Fort Bragg soldiers are medically retired or discharged for PTSD far less often than soldiers as a whole.
Yet the number of soldiers meeting with psychological counselors at Fort Bragg is similar to the overall Army rate in each of the past three years.
Meanwhile, the figures show prescriptions for anti-depressants and other drugs have grown tremendously at Fort Bragg since 2004. More than one in three soldiers on post – 17,594 – took some form of opiate last year, mostly for pain relief. One in 10 took an anti-depressant, according to statistics from Womack Army Medical Center.
Officials with Womack and PTSD experts say the numbers are intriguing, but there is no way to single out one factor to explain them.
Fort Bragg soldiers could be less prone to develop PTSD, or they may be less willing to fully reveal their symptoms when speaking to a counselor, said Lt. Col. Jay Earles, behavioral health director at Womack.
Or maybe, Earles said, they are more frequently using anonymous forms of counseling, such as chaplains or Military OneSource, that would not show up in Army data.
"It's interesting enough to probably look into what we're doing here," Earles said. "Is it a population issue? Is it somehow a practice issue?
"Is it good news or bad news?"
Earles and Col. Ed Crandell, the behavioral health director at Womack for six years before he retired in August, said the difference in PTSD numbers can't be attributed to a difference in the way PTSD is diagnosed at Fort Bragg.
Doctors there follow the same screening procedures as at other installations and use the same diagnostic criteria, they said.
"I don't think there's an under-diagnosis issue," Crandell said.
PTSD diagnoses and discharges have risen at Fort Bragg, just not at the same pace as at other posts across the Army.
PTSD is the only diagnosis with an automatic disability rating, said David Turban, an operations officer with the Army Physical Disability Agency. Turban created the discharge database that was given to the Observer.
A soldier determined unfit for duty because of PTSD automatically gets an initial disability rating of 50 percent, Turban said.
"The analyst in me would say that clearly shows a pattern of lower incidence of unfit soldiers at Fort Bragg. Why? I couldn't tell you," he said. "There are a lot of soldiers who have been diagnosed with PTSD who continue to serve. It has to be severe enough that either he's a danger to himself or others or he's unable to perform his duties."
The figures show that Fort Bragg discharged two soldiers per thousand for PTSD last year, while Fort Hood discharged almost nine soldiers per thousand.
Earles said he has worked on Fort Hood and that the practices for treating and diagnosing PTSD are basically the same at both posts.
Crandell said it is difficult to make comparisons across Army installations. Any meaningful study of the numbers would have to take into account the demographics and combat-exposure levels of the soldiers, he said.
Part of Fort Bragg's population includes Special Forces soldiers. Their training could be a factor that makes them more mentally resilient or less willing to open up to a psychologist, Earles said.
"The population of Fort Bragg, there might be another post of 50,000, but it's not quite the same population," Earles said. "These are not your average 18- or 19-year-olds straight out of individual training."
The number of combat exposures a soldier had during a deployment is the best predictor for whether he will develop PTSD, according to research by the Rand Corp.
Terri Tanielian, a mental health researcher at Rand, said the PTSD numbers merit further study. But there are too many variables – including the resources available or the differences in policies and practices at other installations – that haven't been accounted for to draw a conclusion, she said.
As mental health problems have grown in the Army since the wars in Iraq and Afghanistan began, so has the number of soldiers taking prescription medications.
At Fort Bragg, the number of soldiers on anti-depressants more than doubled between 2004 and 2009 – from 2,230 to 4,994.
Soldiers taking anti-psychotics increased from 127 in 2004 to 664 in 2009. Many soldiers take more than one type of medication.
Lt. Col. Andrew Vitt, assistant chief of the Department of Pharmacy at Womack, said anti-psychotics and anti-depressants are commonly used to treat conditions other than psychosis or depression, such as insomnia. Such off-label use is common in both the military and civilian populations, Vitt said.
An Army study published this summer said 14 percent of soldiers are taking some form of opiate medication. At Fort Bragg, records show, 36 percent of soldiers were prescribed opiates in 2009.
The numbers don't include prescriptions written while soldiers are deployed.
Seventeen percent of active-duty soldiers Armywide take anti-depressants, according to congressional testimony in February by Brig. Gen. Loree Sutton, then the director of the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury. Ten percent of Fort Bragg soldiers took anti-depressants last year.
The vast majority of the prescriptions are written by primary care physicians, not psychiatrists, said Crandell, Womack's former behavioral health director.
Crandell said it's long been the case that soldiers are more willing to visit a doctor than a therapist. That's why Womack began putting behavioral health providers in doctor's offices, so soldiers complaining of pain could also be screened for behavioral health problems.
Ron Acierno is a professor of psychiatry at the Medical University of South Carolina and the PTSD clinic director at the Charleston Veterans Affairs Medical Center. He said it's often more convenient just to get a prescription than to get counseling.
"Many people find it easier to take a pill and hope the symptoms go away than to engage in what is not always easy or comfortable evidence-based interventions for mental health problems," Acierno said. "They're not always the most effective, but they're most certainly the least difficult and require the least amount of time on the part of the patient."
Larry Clubine, a drug and alcohol counselor in Fayetteville, said soldiers and former soldiers tell him opiates are the easiest medication to get doctors to prescribe. Opiates such as oxycodone are used to treat pain. Because of the nature of their jobs, which on Fort Bragg often includes jumping out of airplanes, soldiers are often legitimately in pain, Clubine said.
Opiates produce a e
uphoria and can be habit-forming. Because of the potential for addiction, the average supply of an opiates prescription from Womack is 10 days.
Clubine said getting pills is not only easier for the patients, it is cheaper for the government. He said he sees the Army moving in the right direction by putting more resources into behavioral health services, but it's expensive and difficult. There's a national shortage of trained clinicians, he said.
"I think a lot of doctors, including Army doctors, are just squeezed for time. … They're trying to make people feel better," Clubine said. "If we're not careful, we're creating a bunch of addicts."
Some congressmen have questioned the side effects of the military's increased use of anti-depressants and other prescription drugs.
Sen. Ben Cardin, a Democrat from Maryland, has asked the Department of Defense to study whether increased prescription drug use is linked to the spike in military suicides in recent years.
Cardin said it's unclear whether soldiers are receiving the proper supervision while taking medications while deployed. He said he worries that some anti-depressants come with warnings that they could increase the risk of suicide.
"Yes, it is very alarming to me," Cardin said of the increases. "We're expecting the protocols to be reviewed."
A task force studying a record number of suicides in the Army released a report in July that said the increase in prescription drug use is "a growing national crisis," not just a military issue.
The increased number of soldiers prescribed opiates also makes it harder to test for illegal drugs, the report states. Any soldier who tests positive for opiates can be cleared if he previously had a prescription for them, the report says.
Staff writer John Ramsey can be reached at firstname.lastname@example.org or 486-3574.