Soldiers drink alcohol.
They have for thousands of years – to celebrate, to forget, to fortify themselves for the next day’s battle. In the Iliad, Homer recounted feasts and games flowing with wine and spirits. Indeed, for most young people, whether in or out of uniform, alcohol is a drug of choice. So it should be no surprise that some men and women fighting in Iraq and Afghanistan for the past eight years come home and use alcohol, marijuana, and any other drug that they can get their hands on. What is surprising is what we do about it.
Last month, The American Journal of Psychiatry published an article that could change our minds. The study involved 300 women suffering from both PTSD and drug abuse. The time-honored approach for such a combination of problems has been to treat the alcohol abuse first, and then cope with the trauma. The line of reasoning – erroneous as it turns out—was that the emotional turmoil of treating the PTSD would only aggravate the drug and alcohol abuse. Surprisingly, the reverse turned out to be true. Researchers found that, contrary to current practices, intense treatment of PTSD helped to sober up the subjects.
Sounds like common sense, but lots of common sense has been marginalized by academic medicine and the hunt for hard facts. The old approach had a certain kind of logic, but it was the logic of something mechanistic, rather than psychologically nuanced. Extrapolate from these 300 women to literally thousands of soldiers, suffering from PTSD and self-medicating with drugs or alcohol (or both). By adhering rigidly to their ideas about “best medicine,” and in fact working in best practices, clinicians may have caused more harm than good.
The soldiers talk straight about their combat experiences and how hard it is to pull themselves together when they come home to their families and friends. At least 25% of them report suffering with feeling edgy, nightmares, headaches, pain, guilt, and sadness. All the side effects from the hardships of war that often and inevitably lead to the collateral damage of troubled families or divorce.
These men and women will tell you that they drink alcohol – often too much — as the cheapest, over-the-counter medication they can find in order to simply live with themselves and their loved ones. Alcohol is a drug they know. It is legal and it has had proven efficacy since high school. Less than half of those who need treatment actually get it because, despite genuine efforts to destigmatize mental health problems, the military reflects society at large when it comes to handling psychological issues. Add to that – shortages, and shortcomings in the availability of treatment. Often, mental health professionals cannot get hired, or when soldiers do see psychiatrists, they are often just prescribed antidepressants. These medications work some times, but many young people find the side effects unacceptable. The medicines cause problems with sexual functioning, sleep, and not feeling “like yourself.” What these men and women want is a chance to talk, and time to adjust. And often a stiff drink will make the nights easier and the intrusive thoughts more manageable.
Military medicine conforms to the best practices in civilian and academic health care, and often leads in developing and promoting new treatments. Current practice involves what is referred to as “partitioning” the treatments for psychological problems, substance abuse, and associated medical conditions like blast concussion and pain. What that means is that each practitioner—the neurologist, the psychologist, the psychiatrist, the addiction counselor– work in their separate silos. Patients shuttle from therapists to drug counselors to physician specialists who prescribe medicines for multiple problems. Only rarely, are the treatments and the patient all brought together under one roof. Only rarely is the whole human being appreciated and understood not as a collection of symptoms and problems, but as a complex individual who has faced unbelievably difficult challenges.
That’s the hidden lesson in this study of PTSD and substance abuse. The treatments and the patients do better when there is a team approach and everyone is working together. There are no silver bullets for most neurobehavioral conditions, including substance abuse. These problems don’t respond to highly technical interventions like putting stents in coronary blood vessels because we are more than a collection of our diagnoses, more than a list of specialists’ problems.
Ironically, we have been through all this before. After Vietnam, thousands of soldiers came back with PTSD, which wasn’t even a recognized condition then, and many were abusing all sorts of drugs and alcohol. With the Reagan build-up in the 1980s, we started aggressive and broad programs across all the Services to educate soldiers and leaders, and identify and treat problems with drugs and alcohol. We had almost a dozen residential centers, and numerous intensive outpatient programs. Then along came managed care and the super-specialization of medicine that has brought us to our current state of fragmented treatments. The casualties of those treatments, like the casualties of our wars, often appear in VA hospitals, homeless shelters, and unemployment lines.
The best thing we could do for the thousands of Americans in uniform now, who often return troubled by their experiences, is to apply some common sense to their healing, common sense that has been given medical legitimacy by a randomized controlled study and peer reviewed article in a prestigious professional journal. The message, however, is simple: put a human face to the itemized list of medical conditions and build up lots of multidisciplinary, integrated care programs that get to the heart and soul of where these soldiers live. Soldiers will drink when they return from combat. They are likely to drink even more when they must wrestle with memories and troubling emotions. They will do “dumb stuff and get into trouble.” Let’s not be judgmental about what happens. Let’s not cling to the old orthodoxies of how to provide help. But let’s address the underlying trauma first, and then see if other problems don’t get resolved more quickly.
Stephen N. Xenakis, M.D. is a practicing psychiatrist, who retired from the Army as a Brigadier General after 28 years of active service.