The document discusses the historical use of psychotropic drugs by militaries to enhance performance and numb trauma, as well as the contemporary use of these drugs by the US military to treat mental health conditions. It notes that 20% of active duty troops surveyed in 2010 were taking psychotropic medications. The document outlines some of the bioethical concerns regarding conflicts between military needs and patient needs. It summarizes clinical practice guidelines from 2013 regarding deployment while taking these medications. A case study illustrates the risks of abruptly changing medications. The conclusion calls for continued research on safer drugs, improved formularies and supply chains, and regular updates to the clinical guidelines.

1. The Use of Psychotropic
Medications by the Military in
Combat Environments
Rachel Woodlee, RN
Wilmington University
MSN 6645: Bioethics in Nursing Practice

2. Overview
 Introduction
 Historical Precedent
 Contemporary Psychotropics
 Bioethical Concerns
 Case Study
 Future Implications
 Conclusion

3. Introduction
Definition:
Any chemical substance used medically or recreationally that acts on
the central nervous system to alter perceptions, consciousness,
mood, or behavior(Clark et al, 2011).
Examples: analgesics, antidepressants, anxiolytics, antipsychotics,
stimulants
“A June 2010 internal report from the Defense Department's
Pharmacoeconomic Center at Fort Sam Houston in San Antonio
showed that 213,972, or 20% active-duty troops surveyed, were
taking some form of psychotropic drug: antidepressants,
antipsychotics, sedative hypnotics, or other controlled substances”
(Baker, 2014).

4. Historical
Precedent
“The history of mind-altering substances is
as old as humanity” (Kamienski, 2016)
Use of psychotropic drug existed
in premodern times. Drugs were
used to help warriors fight harder,
endure more, and to numb the
subsequent distress from the
traumas of war.
• Opium used by Assyrians,
Sumerians, and Greek
• Coca (cocaine) was used by
Inca Warriors as stimulate
• Hallucinogenic mushrooms
may have been used by
Berserker Vikings
• Amphetamines used to replace
cocaine in WWII , and use
continues today

5. Contemporary
Psychotropics
Psychotropics have traditionally been used to
enhance fighter capabilities (e.g. stimulants).
Newer classes of psychotropics are used to
treat psychiatric illnesses and help patients
return to baseline levels of functioning. These
include antidepressants, anxiolytics, sedatives,
and antipsychotics.

6. Bioethical
Concerns
Conditions in which is safe to deploy military
personnel on psychotropic medications is still a
subject under investigation. One of the main
bioethical dilemmas concerns the conflicts of
interest arise when weighing the needs of the
military’s versus the needs of the patient.
“Half of those who committed suicide had visited a
medical program or clinic within 30 days of death
and 27% had a history of psychiatric medication
use” – DoD Suicide Event Report, 2012

7. Other ethical issues that should be considered:
Beneficence
Combat environments can exacerbate psychiatric illnesses,
increasing risk of PTSD, depression, and suicide.
Non-Maleficence
Some psychotropics increase the risks of suicide, and
studies have shown those deployed on them have greater
incidence of relapse and suicide. Side effects of some
psychotropic medications include erratic behavior, which
could endanger others
Fidelity
Current guidelines suggest to involvement of first-line
supervisor, compromising patient confidentiality
standards of practice.
Justice
Members on medication inevitably use more resources
than those who aren’t, a crucial point in an environment of
extremely limited resources
Bioethical
Concerns

8. A New Precedent:
Clinical Practice
Guidelines
In general, individuals with any of these mental health
disorders, based upon medical assessment, shall not
deploy without a waiver*:
 Psychotic and/or bipolar disorders
 Psychiatric disorders under treatment with fewer than
three months of demonstrated stability
 Clinical psychiatric disorders with residual symptoms
that impair duty performance
 Mental health conditions that pose a substantial risk for
deterioration and/or recurrence of impairing symptoms
in the deployed environment
 Chronic medical conditions that require ongoing
treatment with antipsychotics, lithium or
anticonvulsants
*While this memo provided guidelines for military doctors and
leadership, the authorities responsible (who may not be doctors)
for submitting and approving waivers in each branch ultimately
have the final say in who deploys.
In 2006, the Assistant
Secretary of Defense for
Health Affairs (DHA) released
a memorandum which
addressed deployment limiting
psychiatric conditions and
medicines for the first time. In
2013, the Assistant Secretary
released an updated
memorandum that provided
clarification on mental health
conditions.

9. Case Study
Incident in 2006 Invovling Marine Corporal
M. Cataldi
 Returned from first Iraq deployment and was placed
on antipsychotics and narcotics
 Reported feelings of disassociation and flashbacks to
a military psychiatrist, but said his concerns were
ignored.
 Was deployed in 2006 for his second tour.
 Only one month into his deployment, his supply of
Klonopin ran out. He was placed on an alternative
medication, Seroquel, which he reported made him
feel “loopy”
 One night he awoke lying facedown in the dirt with a
fully loaded rifle buried next to him and no
recollection of how he got there
 The incident was later linked to the abrupt change in
his medication.
Highlights of Relevant 2013 Clinical Practice
Guidelines for Deployment-Limiting Mental
Disorders and Psychotropic Medications
2.b. Individuals diagnosed with mental disorders (excluding those disorders
referenced in paragraph 2.a.) should demonstrate a pattern of stability without
significant symptoms or impairment for at least 3 months prior to deployment. These
individuals are eligible for a waiver as detailed in paragraph l .c.
2.d. In addition to the requirements in paragraph 2.b., individuals should not deploy
if they have been determined to be at risk for suicide or violence toward others.
3.b. Psychotropic medications may pose operational problems during deployments.
Important considerations in prescribing psychotropic medications are the clinical
presentation and the mitigation of functional impairment. Providers must take into
account potential medication side effects on a Service member's ability to function
effectively in the deployed environment. e. Medications that disqualify an individual for
deployment include:
(1) Antipsychotics….
The full memorandum can be found at: http://www.pdhealth.mil/clinical-
guidance/deployment-limiting-conditions

10. Future
Implications
“The murderous pace of an increasingly impulsive war
requires military personnel to function not only on the
verge of physiological capacity of the human body, but
also well beyond it” (Kamienski, 2016)
Use of psychotropics by the military has and
continues to give an advantage other the enemy.
Future use of newer classes of psychotropics will
continue, but there are several factors that
should be considered moving forward:
• As our understanding of the biochemical
pathophysiology of mental health disorders
evolves, so does our ability to treat it more
effectively. Military medical researchers
should continue to develop new drugs that
have fewer undesirable side effects.
• The deployed psychiatric medication
formulary should also be updated to capture
the broad range of medications members will
require on deployment, and supply chains
must be thoroughly planned so there are no
interruptions.
• The memorandum with Clinical Practice
Guidelines for Deployment-Limiting
conditions should continue to be developed
on regular intervals and be adopted into
official instructions by each branch of the
military, so that application is consistent and
fair.

11. Conclusion
A historical precedent exists for using psychotropic drugs in war.
However, changes in the nature of war and the types of psychotropic
drugs available has forced military leaders to reconsider guidelines and
limitations. The ethical problems are complicated by multiple ethical
standpoints; on one side, the rights and protection of the individual,
and on the other, protection of the larger society. In a military that is
already struggling to maintain manpower, placing limitations could
break their ability to fulfill their functions. Additional. The military
should continue to research and develop psychotropics that are more
effective with fewer side effects, make improvements to their deployed
formularies and supplies chains, and continue to develop and
institutionalize guidelines using best evidence-based practice.

12. REFERENCES
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