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Psychiatric Medications in Military Operations

Chapter 10

psychiatric medications in 

military operations

BRETT J. SCHNEIDER, MD*; JOHN C. BRADLEY, MD†; CHRISTOPHER H. WARNER, MD‡; and DAVID M. 

BENEDEK, MD§

INTRODUCTION

HISTORY OF PSYCHOTROPIC MEDICATION USE IN DEPLOYMENT

DOCTRINE AND POLICY

PREDEPLOYMENT ACTIONS

Psychiatric Medication Clearance for Deployment

Psychopharmacologic Planning for Deployment

DISPENSING PSYCHIATRIC MEDICATION IN THEATER

PHARMACOLOGIC TREATMENT OF MENTAL HEALTH CONDITIONS DURING 

DEPLOYMENT

Mood Disorders

Anxiety Disorders

Psychotic Disorders and Acute Agitation

Insomnia

ETHICAL ISSUES

Summary

*Lieutenant Colonel, Medical Corps, US Army; Deputy Chief, Department of Psychiatry, Building 61, Child and Adolescent Psychiatry Clinic, Walter 

Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307 

†

Colonel, Medical Corps, US Army; Chair, Department of Psychiatry, Borden Pavilion, Room 2022, Walter Reed Army Medical Center, 6900 Georgia 

Avenue NW, Washington, DC 20307; Psychiatry Consultant, North Atlantic Regional Medical Command and Vice Chair, Department of Psychiatry, 

Uniformed Services University of the Health Sciences, Bethesda, Maryland 

‡

Major, Medical Corps, US Army; Chief, Department of Behavioral Medicine, Winn Army Community Hospital, Building 9242, Room 20, 1083 Worcester 

Drive, Fort Stewart, Georgia 31324; formerly, Division Psychiatrist, 3rd Infantry Division, Fort Stewart, Georgia

§

Colonel, Medical Corps, US Army; Professor and Deputy Chair, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814

A portion of this chapter has been published as: Benedek DM, Schneider BJ, Bradley JC. Psychiatric medications for deployment: an update. 

Mil Med. 2007;172:681–685.
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Combat and Operational Behavioral Health

INTRODUCTION

Until the mid-1990s, psychotropic medication use 

for the treatment of ongoing mental disorders during 

combat operations was uncommon. Stimulants and 

other psychotropic medications were used, at times, 

to enhance the vigilance and performance of fatigued 

service members. However, in the mid-1990s the introduction of medications with more favorable side-effect 

profiles—particularly the selective serotonin reuptake 

inhibitors (SSRIs)—revolutionized the role of medications in the practice of military operational psychiatry. 

The widespread incorporation of these medications 

into civilian and military garrison psychiatric practice 

has resulted in an evolution in operational practice 

such that medication use in combat operations now 

focuses on the capacity for soldiers with symptoms 

of psychiatric illness to return to their premorbid level 

of functioning, rather than on efforts to “enhance” 

baseline performance. 

Before the current conflicts in Iraq and Afghanistan, recent experiences either predated the current 

usage patterns of medications in psychiatric care, or 

were limited in duration (the Persian Gulf War) or 

scope (Bosnia, Kosovo, Somalia), so that few service 

members were affected. As a result, comprehensive 

experience and doctrine for the use of psychotropic 

medications consistent with current practice patterns 

in psychiatry were not feasible. This chapter will 

focus on the use of psychotropic medications during 

deployment. An overview of the history of the usage 

of medications will highlight the doctrinal evolution. 

Current practice guidance will be outlined and as yet 

unresolved questions addressed.

HISTORY OF PSYCHOTROPIC MEDICATION USE IN DEPLOYMENT

The ancient Assyrians, Egyptians, and Greeks 

reportedly used opiates before and during battles to 

sustain or enhance bravery and courage.1

 Other drugs 

studied or used to enhance combat performance include ergot alkaloids, cannabis, amphetamines, and 

other stimulants; Dramamine (McNeil-PPC Inc, Morris 

Plains, NJ) and other antihistamines; benzodiazepines; 

and l-tryptophan.1 The most extensive modern use of 

performance-enhancing drugs occurred during World 

War II by German, Japanese, and English soldiers.2 Amphetamines were noted to be useful not only to stave 

off fatigue and drowsiness but also to improve memory, 

concentration, physical strength, and endurance.3–5

During the Vietnam conflict, methylphenidate (Ritalin [Novartis AG, Basel, Switzerland]) and sometimes 

dextroamphetamine (Dexedrine [GlaxoSmithKline, 

Philadelphia, Pa]) were standard-issue drugs carried 

by long-range reconnaissance patrol soldiers, who 

reported the drugs’ usefulness when they developed 

fatigue at the end of missions and had to return rapidly 

to base camp. Mild rebound depression and fatigue 

after discontinuation were the only reported adverse 

effects.1

 Sedatives were also explored as a method to 

improve performance in anxiety-producing situations, 

such as paratroopers making low-altitude jumps, or to 

reduce the emotional tension of young soldiers when 

guns were fired.6

Although the concept of using medications for 

performance enhancement remains an area of ongoing research, the documented usage of psychotropic 

medications to treat symptoms associated with current 

psychiatric diagnoses in soldiers actively involved in 

combat is limited. In earlier conflicts, limited experience using psychotropic medications to treat anxiety 

symptoms has been reported. These conditions have 

been treated with sedatives ranging from chloral hydrate and bromides in World War I to barbiturates in 

World War II and self-prescribed alcohol, cannabis, 

and heroin in Vietnam.1

 However, discussions of usage commented mostly on the medications’ unwanted 

side effects, such as sedation, and the concern that their 

usage would lead to the fixation of a sickness role suggested by taking medication.

In 1978 Datel and Johnson7 reviewed the usage of 

psychotropic medications by physicians deployed to 

Vietnam in 1967. They surveyed a group of mostly 

primary care physicians about how they prescribed 28 

different psychotropic medications, including “major 

tranquilizers,” “minor tranquilizers,” antidepressants, stimulants, and sedatives for a 30-day period 

during the summer of that year. The most commonly 

utilized “psychotropic medication” was Compazine 

(GlaxoSmithKline) for gastroenteritis, and anxiety 

and insomnia were the most frequent mental health 

reasons for prescribing medications. Minor tranquilizers such as Equanil (Wyeth, Madison, NJ); Librium 

(Hoffman-LaRoche Inc, Nutley, NJ); Valium (HoffmanLaRoche Inc); and Vistaril (Pfizer Inc, New York, NY) 

were most frequently prescribed for symptoms of 

anxiety, with Librium accounting for the majority of 

prescriptions (65%) and Thorazine (GlaxoSmithKline) 

accounting for most of the major tranquilizer prescriptions (86%).The authors noted that a “surprisingly low 

frequency” of depression was an indication for the usage of psychotropic medications. In general, the drugs 

that were utilized were perceived by the prescribing 

physicians as being quite efficacious.7 Six medications (Prolixin [Bristol-Myers Squibb, Princeton, NJ]; 
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Psychiatric Medications in Military Operations

Vesprin [Bristol-Myers Squibb]; Nardil [Pfizer]; Parnate [GlaxoSmithKline], Taractan [Hoffman-LaRoche 

Inc]; and desipramine) were not prescribed by any of 

the reporting physicians.

The first Israeli reports of operational use of tricyclic 

antidepressants in combat soldiers occurred during the 

1982 war with Lebanon. Belenky noted that in 1973 

the Israelis created a policy prohibiting forward use 

of medications and even hypnosis, expressing concern about the potential effect of this policy on battle 

fatigue return-to-duty rates.8,9 Belenky advocated for 

longer-term military treatment facilities in theater, but 

cautioned against placing soldiers on psychotropic 

medications in forward deployed areas because of 

the possibility of side effects that might interfere with 

psychomotor performance or impair judgment in 

dangerous situations. He also noted potential medical 

risks from side effects in the field environment and 

problems with resupply.8

No reports have been published on the utilization 

rates or rationale for usage of psychotropic medications during the Persian Gulf War (1991), possibly 

because of the lack of prolonged combat exposure, or 

possibly because the military stress control doctrine 

at the time emphasized triage and normalization, 

discussing the use of psychotropic medications only 

in emergency situations. Staudenmeier and Bacon10

reviewed the history and role of combat stress units 

during deployments and noted that one unit, the 

528th, conducted 514 psychiatric evaluations during 

the Persian Gulf War. Of those evaluated, 24% were 

held for treatment and 3.5% were evacuated. Although 

this information demonstrated that combat stress units 

were being utilized, no data were given on the usage 

of medications among service members identified for 

treatment or evacuation.10

Ritchie11 described a decision-making process for 

choosing which psychotropic medications to bring 

and use in Somalia during Operation Restore Hope 

(1993). Ritchie recommended considering two broad 

categories: emergency and maintenance medications. The former group included benzodiazepines 

(diazepam and lorazepam) and neuroleptics (haloperidol). The latter included antidepressants (“one 

tricyclic antidepressant and one SSRI”); anxiolytics 

(buspirone, benzodiazepines, or antidepressants); and 

sedatives (temazepam, triazolam, and trazodone). The 

rationale for bringing just one tricyclic antidepressant 

and one SSRI mirrored clinical practice at the time, 

which suggested that patients being treated by one 

antidepressant could be switched to another with little 

problem. Subsequently, practitioners have recognized 

that frequently patients only respond to a particular 

antidepressant or have side effects with one SSRI but 

not another. Ritchie recommended that medications 

such as lithium, carbamazepine, valproic acid, and 

all monoamine oxidase inhibitors be avoided during 

deployment because of problems with safety and 

monitoring.11

Pincus and Benedek12 summarized the integrated 

use of combat stress detachments and division mental 

health (DMH) assets during Operation Joint Endeavor 

in Bosnia during 1995. The article does not specifically 

discuss medication usage in detail, but it considered 

the mission, a year-long peacekeeping operation, as 

more similar to the practice of garrison mental health 

than to other deployment environments.12 Garrison 

mental health in 1995 typically consisted of a DMH 

team providing routine outpatient mental healthcare, 

including using psychotropic medications as indicated 

for the treatment of disorders seen in routine outpatient 

clinics. This practice suggests that mental health assets 

deployed during Operation Joint Endeavor utilized 

psychotropic medications routinely during the more 

than 3,000 outpatient contacts made over the year-long 

deployment. The authors acknowledged use consistent with garrison psychiatric practice in subsequent 

descriptions of their deployments.12

Warner et al13 reviewed the utilization of one DMH 

activity during deployment to Operation Iraqi Freedom (OIF) in 2005. The authors noted 5,542 clinical 

contacts, of which 29.8% were for psychiatric mental 

disorders and the other 70.2% were for combat operational stress reactions. The top two psychiatric mental 

disorders in theater were generalized anxiety disorder 

(42.4%) and major depressive disorder (33.4%). The 

authors defined a “mature theater” as permitting the 

ongoing management of psychiatric disorders with 

psychotropic medications, although personnel were 

generally restricted to the use of SSRIs and mild hypnotics in theater. The article did not report rates of how 

many soldiers were prescribed or took the medications in theater; however, the account demonstrated 

the incorporation of practice patterns established in 

more recent peacekeeping operations (Bosnia) into 

psychiatric practice in the combat environment, with 

service members receiving treatment for ongoing 

mental health issues beyond the scope of combat operational stress.13

In July 2007, Schneider, Bradley, and Benedek14

revisited the question of a rationale for choosing a 

psychotropic formulary for military operations. Recommendations were based on a combined 18 months of experience by the authors as psychiatrists deployed with 

combat stress control detachments during the first and 

third rotations to Iraq. The authors discussed the evolution of treatment of combat operational stress casualties 

from triage and nonpharmacologic, treatment-forward 

psychiatry principles to a role more consistent with 

contemporary outpatient psychiatric practices, noting 
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Combat and Operational Behavioral Health

some caveats related to environmental and operational 

concerns. From their perspective, the nature of combat 

had changed. The idea that soldiers could be removed 

from the front lines and treated in the rear echelons no 

longer worked, because no true rear echelons exist in 

Iraq. It was now important to treat some mood and 

anxiety disorders as far forward as possible.14

Schneider and colleagues also noted that the increased dependence on National Guard and Reserve 

soldiers meant that the Army was receiving personnel 

who were treated according to civilian community 

standards rather than military readiness standards 

concerning prescriptions for SSRIs, atypical antidepressants, and antianxiety medications. This resulted 

in an increased requirement for available medications 

in theater. They suggested that most routine outpatient psychiatric conditions might be managed with 

medications and therapy in the combat zone, with 

the caveat of factoring in the “limitations inherent in 

the operational environment,”14(p685) such as military 

occupation, travel limitations for follow-up, and the 

restricted ability to educate the soldier and command 

about the medications’ potential risks, benefits, side 

effects, and possible effect on mission requirements. 

They proposed a psychotropic formulary of at least 24 

medications under the categories of antidepressants/

antianxiety medications, benzodiazepines, antipsychotics/antimanics, sleep medications, adrenergic 

agents, and attention deficit hyperactivity disorder 

medications (Table 10-1).14

The level of comfort with the use of psychotropic 

medications in combat has mirrored trends in the 

larger US society. The change in psychotropic medication use from the last major extended US conflict (Vietnam) to current operations in Afghanistan and Iraq is 

well illustrated by a comparison between Datel and 

Johnson’s questionnaire and the recent recommended 

psychotropic formulary for OIF by Schneider, Bradley, 

and Benedek. The only medications common to both 

documents are Ritalin and Dexedrine.7,14

DOCTRINE AND POLICY

US Army doctrine on the use of psychotropic medication has evolved significantly in the last 20 years. The 

initial Army field manual (FM) on combat stress control, Combat Stress Control in a Theater of Operations (FM 

8-51),15 published in 1994 and updated in 1998, focused 

on triage and nonpharmacologic interventions aimed 

at normalizing and minimizing combat stress. Little 

guidance was provided on the role and usage of psychotropic medications. The word “medication” occurs 

25 times in this document, which contains 9 chapters. 

Most of these references discuss the use of medications 

in emergency situations when medication might be 

needed to calm an agitated service member. Chapter 

3, section 8, states that “medication is prescribed sparingly and only when needed to temporarily support 

sleep or manage disruptive symptoms.”15(p3-8) Chapter 

6, section 3, discusses how to manage a service member who deploys after having been “diagnosed with 

psychiatric disorders by a civilian physician,” advising 

the clinician as follows:

These soldiers may hide the fact that they are taking 

psychotherapeutic medication to keep the diagnosis 

off their military record. Once in the theater they may 

experience a relapse or self-refer themselves to an 

MTF [medical treatment facility] when their medication supply is exhausted. The evaluating psychiatrist 

must determine if the soldier can function without 

the medication. If the soldier requires medication, can 

he be re-stabilized on a drug which can be provided 

in the theater? Can the drug be given without risk of 

harmful side effects? If the alternatives are not feasible, 

the soldier must be evacuated out of the theater.15(p6-13)

During the spring and summer of 2004, the Army 

mental health community recognized, based on experience in the first year of OIF, that the FM required 

some revisions based on the changes in overall Army 

doctrine and lessons learned from the first long-term 

sustained conflict in more than 30 years. In the new 

manual, Combat and Operational Stress Control (FM 

4-02.51),16 published in 2006, the word “medication” 

occurs 30 times in an 11-chapter manual. Although the 

overall number of times medication usage is discussed 

barely eclipses the number of times it was mentioned 

in the previous manual, a change in the accepted role 

of medications can be seen. Three sections in the new 

manual highlight the gradual move towards acceptance of psychotropic medication usage in a combat 

zone. Section 8-21 discusses how a service member 

may have both a combat stress reaction and a mental 

disorder, and directs clinicians to use clinical judgment 

and consultation to help “distinguish among these 

sometimes overlapping conditions.”16(p8-6) When a 

service member presents with reemerging symptoms 

of a previously diagnosed mental disorder or for refill 

of previously prescribed psychotropic medication, 

“deferral of diagnosis is preferred, but diagnosis can 

be considered.”16(p8-6) Sections 9-8 and 11-1 outline 

doctrinal changes in the role of medication in treating 

service members diagnosed with mental disorders 

while deployed. Section 9-8 states:

Ongoing treatment and/or therapeutic modalities are essential to improving a Soldier’s chances 

to RTD [return to duty] whether in theater or af-
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Table 10-1

Example Psychiatric Formulary for Deployment 

Medication Amount

Antidepressants/Antianxiety Medications

Citalopram 20 mg 15 bottles

Sertraline 100 mg 30 bottles

Prozac* 10 mg 5 bottles

Paroxetine 20 mg 5 bottles

Venlafaxine XR 37.5 mg 10 bottles (good for initiating treatment)

Venlafaxine XR 150 mg 10 bottles

Bupropion XL 150 mg 10 bottles (more if planning to do smoking cessation)

Bupropion XL 75 mg 10 bottles (good for initiating treatment)

Mirtazapine 20 mg 10 bottles

Benzodiazepines

Lorazepam 1 mg tablets 30 bottles

Clonazepam 1 mg tablets 30 bottles

Lorazepam 2 mg injectable 30 dosages (must be refrigerated)

Antipsychotics/Antimanics

Risperidone 1 mg tablets 10 bottles

Quetiapine 100 mg tablets 30 bottles (can be used off-label for PTSD, insomnia)

Olanzapine 5 mg tablets 10 bottles

Haloperidol injectable 30 dosages

Sleep Medications

Trazodone 100 mg tablets 30 bottles

Zolpidem 10 mg tablets 30 bottles

Adrenergic Agents

Clonidine 0.1 mg tablets 10 bottles (may be better for startle, flashbacks in PTSD)

Prazosin 1 mg tablets 10 bottles (may be better for nightmares in PTSD)

Propranolol 20 mg tablets 10 bottles

ADHD Medications

Atomoxetine 20 mg tablets 10 bottles

Methylphenidate or Dexedrine† 10 bottles (may want to have combination of long-/short-acting forms)

*Eli Lilly and Company, Indianapolis, Ind

†

GlaxoSmithKline, Philadelphia, Pa

ADHD: attention deficit hyperactivity disorder

PTSD: posttraumatic stress disorder

Reproduced from: Schneider BJ, Bradley JC, Benedek DM. Psychiatric medications for deployment: an update. Mil Med. 2007;172:683.

ter evacuation. Therapeutic modalities are similar 

to those used on inpatient units, but must remain 

consistent with COSC [combat operational stress 

control] principles. These modalities include medication, individual psychotherapy, group psychotherapy, and appropriate therapeutic occupations.16(p9)

Section 11-1 states:

Behavioral health treatment is provided for Soldiers with behavioral disorders to sustain them 

on duty or to stabilize them for referral/transfer. This is usually brief, time-limited treat-
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ment as dictated by the operational situation. 

Behavioral health treatment includes counseling, psychotherapy, behavior therapy, occupational therapy, and medication therapy.16(p11) 

Despite this subtle but real evolution of the role of 

psychotropic medications, in the fall of 2006—only 4 

months after the FM was released—the Department of 

Defense developed criteria for psychiatric medications 

use in deployment. The policy was initially released 

in November 2006 in a memorandum titled Policy 

Guidance for Deployment-Limiting Psychiatric Conditions 

and Medications,

17 in response to a congressional directive18 after several media reports of deployed mentally 

ill soldiers who were unstable or taking medications 

without follow-on care. The memorandum outlined 

the restrictions and minimum mental health deployment criteria for all soldiers. Exhibit 10-1 lists key 

factors related to medications in the policy. Although 

the policy does not address how long a soldier on a 

medication for anxiety, depression, or insomnia should 

be monitored, at least 1 month prior to deployment is 

a good time frame for consideration.

Current military operations in war zones such as 

Iraq or Afghanistan no longer have true “rear” areas 

to which soldiers can be evacuated and treated away 

from the threat of attack. The ability to provide more 

definitive treatment to soldiers with certain mood or 

anxiety disorders as far forward as possible is increasingly important in these operations. For most soldiers, 

this means that a battalion aid station, DMH element, 

or a combat stress team is the most easily accessible 

location for treatment that could allow the soldier to 

remain mission capable. 

EXHIBIT 10-1

KEy POints in the NOvember 2006 

Policy Guidance for deploymentlimiting psychiatric conditions 

and medications

•	 Soldiers currently being treated for psychosis or

bipolar disorder are not deployable. 

	 •	 Soldiers who are taking medications that require

laboratory monitoring, such as lithium or valproic 

acid, are not deployable.

	 •	 Soldiers who are taking antipsychotic medications

to control psychotic, bipolar, or chronic insomnia 

conditions are not deployable. 

	 •	 The continued use of psychotropic medications

that are clinically and operationally problematic 

during deployments, including short half-life benzodiazepines and stimulants, should be balanced 

between the necessity for successful functioning in 

the theater of operations and the ability to obtain 

the medication, the potential for withdrawal, and 

the potential for abuse. 

	 •	 If a soldieris placed on a psychotropic medication

within 3 months of deployment, then he/she must 

be improving, stable, and tolerating the medication 

without significant side effect to deploy.

Data source: Assistant Secretary of Defense. Policy Guidance 

for Deployment-Limiting Psychiatric Conditions and Medications. 

Washington, DC: Department of the Army; 2006.

PREDEPLOYMENT ACTIONS

It is imperative that all military primary care and 

mental health providers know where a soldier under 

treatment is in the deployment cycle. The stage of the 

deployment cycle can play a major role in the selection of particular medication choices. Communication 

among the soldier, medical and mental health providers, and the brigade surgeon and brigade behavioral 

health officer is essential to ensure that treatment plans 

are developed without creating additional unnecessary 

limitations for the soldier. Two key actions required 

before deployment are (1) determining if soldiers currently taking psychotropic medications meet the minimum mental health fitness standards for deployment, 

and (2) choosing the medications to make available 

during deployment. 

Psychiatric Medication Clearance for Deployment

To determine if soldiers meet the minimum mental 

health standards for deployment outlined in Exhibit 

10-1, units have added mental health medication 

screening to the predeployment medical screening 

process. In one recently deploying brigade combat 

team, screening questions were added to the face-toface interview by a primary care provider; all soldiers 

taking psychotropic medications were required to meet 

with a behavioral health provider to ensure they met 

deployment requirements. 

Case Study 10-1: A deploying brigade combat team of 

3,312 soldiers implemented the process described above. 

The brigade identified 143 soldiers (4.3%) who were or had 

recently been under the care of a mental health provider, 

and 86 (2.6%) who were currently taking a psychotropic 

medication. Of those taking psychotropic medications, 53 

(1.6%) used antidepressant medications; 11 (0.3%) used 

medications other than antipsychotics for chronic insomnia 

or sleep disturbances; 11 (0.3%) used stimulants for attention 

deficit problems; 8 (0.2%) used antipsychotic medications 
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Psychiatric Medications in Military Operations

for chronic insomnia; 2 (0.06%) used benzodiazepines for 

chronic anxiety symptoms; and 1 (0.03%) used Depakote 

(Abbott Laboratories, Abbott Park, Ill) for bipolar disorder. Of 

the group on medication, 68 (2.1%) required mental health 

clearance for deployment; of the 68, 4 (0.1%) were delayed 

1 to 2 months before deploying for medication stabilization, 

and 3 (0.09%) were not cleared for deployment because of 

their medications (a tricyclic antidepressant, an antipsychotic, 

and a mood stabilizer). An additional 19 soldiers (0.6%) were 

deemed unqualified for deployment because of their current 

medication even though they were stable and performing 

required duties without impairment.19

For soldiers who are stable but on medications that 

disqualify them from deployment, such as a stimulant 

for attention deficit hyperactivity disorder or a lowdose antipsychotic for chronic insomnia, a waiver 

may be requested. The process is instituted through 

unit medical channels and is requested through the 

combatant command surgeon—the senior ranking 

command surgeon in theater. In most cases, if a unit 

provides a justification, plan for continuation of treatment, and safety assessment, the waiver is likely to be 

granted. Medications generally eligible for a waiver 

are benzodiazepines used for anxiety, stimulants for 

treatment of attention deficit disorder, nonlaboratory 

monitoring mood stabilizing agents for impulse control and nonbipolar mood management, and low-dose 

antipsychotics for sleep and anxiety symptoms. In 

deciding whether to request a waiver, a unit should 

consider the duties and responsibilities the soldiers 

will hold and ensure that they will have ongoing access to mental healthcare throughout deployment. The 

final decision on the waiver is at the discretion of the 

combatant command surgeon. 

Case Study 10-2: The 19 soldiers deemed unqualified 

from the brigade combat team in Case Study 10-1 were 

eligible for waivers. Many were taking stimulants for attention 

deficit problems or low doses of atypical antipsychotics for 

chronic insomnia. The unit leadership deemed that most of 

the soldiers were critical to the mission, and waivers were 

requested for all of them. The waiver requests outlined 

length of time on the medication and how the soldier would 

be followed by mental health services during deployment. 

All soldiers received waivers and deployed. The DMH team 

and the brigade surgeon ensured that each of the soldiers 

was seen on a regular basis (monthly), and after 6 months of 

deployment, all remained in theater, stable, and functioning 

well in their duties.19

Psychopharmacologic Planning for Deployment

A psychiatrist assigned to a DMH or combat stress 

control (CSC) unit must determine what type of psychotropic medications, and how much of each, to obtain for use in a deployment. For most brigade combat 

teams, the individual who makes these decisions is the 

brigade surgeon; the surgeon often acts on the advice 

of the brigade behavioral health officer or the division 

psychiatrist. Factors to be considered are the current 

medications used by soldiers within the unit, the availability of medications in theater, and the maturity of 

the theater. Medications are class VIII in the military 

supply classification system, and most medical/mental 

health units deploy with an initial supply stock.

The brigade surgeon can determine which medications soldiers are currently taking by asking them 

during the predeployment screening program or consulting the local medical treatment facility pharmacist. 

Medication availability is determined by the local theater. The brigade medical supply officer can provide a 

standard formulary for the region in which the unit is 

deploying. For example, in the current conflicts in Iraq 

and Afghanistan, the medications available for resupply are determined by the central command pharmacy 

review committee. In preparation for deployments, 

brigade surgeons should ensure that local home station 

providers have the theater formulary, and that they 

utilize the listed medications as the first choice.

The maturity of theater plays a key role in the 

amount of medications a unit needs to take with it. 

An important finding of the original mental health 

assessment team (MHAT) in the first year of OIF was 

that psychotropic medications were not adequately 

available in theater and resupply was not effective.20

However, the theaters in Iraq and Afghanistan have 

now become more mature, and resupply channels are 

clearly established and effective. The formulary provided by Schneider et al14 (see Table 10-1) delineates 

initial planning guidance, but it should be modified 

based on the factors outlined above.

DISPENSING PSYCHIATRIC MEDICATION IN THEATER

Multiple factors affect the dispensing of medications 

in the deployed environment. Providers must be able 

to support follow up for individuals who are started 

on medications and ensure that resupply is available. 

A number of options for resupply of medications are 

available in theater. DMH units are generally located 

with Level-II aid stations, and CSC units may have 

relationships with local unit medical clinics. CSC units 

can also establish medication resupply channels with 

medical logistics units. Psychiatrists must maintain 

ongoing communication with their resupply sources 

to ensure availability as well as to report utilization 

trends, which allows medical supply officers to effectively maintain supplies.

Once medications have been obtained, their storage 

and security are the next consideration. Although most 
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Combat and Operational Behavioral Health

medications are stable compounds, checking package 

inserts or asking the pharmacist or pharmaceutical 

company about any problems with keeping the specific 

compounds in the deployment environment is advisable. Deploying behavioral health units that intend to 

maintain their own medication supply should consider 

obtaining a small refrigerator for storage, taking into 

account the availability and source of power in theater. 

Medications such as benzodiazepines and stimulants 

are controlled substances with the potential for abuse. 

These medications must be securely maintained under 

clear standard operating procedures that fall within 

military regulations for maintenance of controlled 

substances. 

Methods for dispensing psychotropic medications 

in theater will be determined by several factors, including the soldier’s access to mental health services, 

the soldier’s reliability, and the proximity of other 

pharmacy services. In current operations in Iraq, multiple methods have been utilized, including providing 

soldiers with a supply of medication, providing a 

starting dose and a prescription to take to the local aid 

station or pharmacy, or providing only a prescription 

for the patient to have filled locally. In general, soldiers 

should be provided no more than a 1-month supply of 

medication. Additionally, in 2006 the Army opened the 

TRICARE mail order pharmacy program, which allows 

soldiers to have refills shipped directly to them. 

PHARMACOLOGIC TREATMENT OF MENTAL HEALTH CONDITIONS DURING DEPLOYMENT

Clinicians must make decisions regarding the extent 

of services they can safely and effectively provide within their units. Potential pharmacological interventions, 

such as medication for posttraumatic stress disorder 

(PTSD), attention deficit hyperactivity disorder, or 

smoking cessation fall into a “gray area” of in-theater 

treatment considerations. The decision to continue 

treatment or evacuate patients with these conditions 

depends on which medications are available, how 

significant the symptoms are, how the soldier initially 

responds to treatment, and how significantly the symptoms interfere with the soldier’s assigned duties. 

Mood Disorders

Bipolar Disorder

Bipolar disorder requires evacuation from the 

combat zone, especially if the soldier presents in the 

midst of a manic or hypomanic episode. Because the 

number of manic or hypomanic patients likely to present during military operations is minimal, psychiatrists 

should select medications useful for multiple situations. Because only acute and emergent management 

are conducted in theater, the most practical course of 

action is to stock at least two atypical antipsychotic 

agents, such as olanzapine, quetiapine, risperidone, 

aripiprazole, and ziprasidone. All of these medications 

are effective in treating acute mania and have multiple additional indications (mood instability, anxiety, 

agitation, psychosis, and augmentation strategies for 

depression).

 Major Depressive Disorder and Dysthymic Disorder 

In planning for the treatment of new-onset depressive disorders, clinicians should request a considerable 

quantity of the SSRI they are most comfortable prescribing. They should request the largest amount of an 

SSRI that is also indicated for new-onset anxiety disorders. Zoloft (sertraline [Pfizer-Roerig, New York, NY]) 

and Celexa (citalopram [Forest Pharmaceuticals, Saint 

Louis, Mo]) are reasonable first choices because neither 

interacts significantly with other medications through 

the cytochrome P450 enzyme system, and both are 

usually well tolerated by both depressed and anxious 

patients.21,22 The long half-life of fluoxetine offers an 

advantage; however, its tendency to be more activating 

than other medications makes its use for both anxiety 

and depressive disorders less favorable.23 Paroxetine’s 

potential for a discontinuation syndrome if doses are 

missed could prove problematic in a combat zone.24

Additionally, paroxetine’s anticholinergic properties 

may prove problematic in Iraq, where temperatures 

often reach 140°F. Nonetheless, a small supply of all of 

the SSRIs mentioned above should be secured, because 

these medications are so commonly prescribed that 

clinicians will surely encounter patients who either are 

currently receiving them or have responded favorably 

to them in the past. 

Clinicians should also consider keeping at least two 

non-SSRI antidepressants in the formulary (see Table 

10-1). Some deployed psychiatrists have selected bupropion and venlafaxine because they have different 

mechanisms of action than the SSRIs and both can be 

used for more than treatment of depression (bupropion for attention deficit hyperactivity disorder and 

smoking cessation, and venlafaxine for generalized 

anxiety disorder), allowing for maximal flexibility and 

economy.25,26 Other potential choices include Cymbalta 

(duloxetine [Eli Lilly and Company, Indianapolis, 

Ind]) and Remeron (mirtazepine [Organon USA, West 

Orange, NJ]). The recently released Cymbalta has a 

mechanism of action similar to that of venlafaxine 

with less reported risk of causing hypertension, and 

Remeron treats insomnia, which is nearly ubiquitous 
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during deployments.27,28 Not recommended are tricyclic antidepressants, which have anticholinergic properties, and nefazadone, because of the potential need 

for laboratory monitoring with liver function tests. 

Anxiety Disorders

SSRIs are the mainstay of treatment for various anxiety disorders because they have demonstrated efficacy 

in panic disorder, PTSD, obsessive-compulsive disorder, and generalized anxiety disorder.29–31 Clinicians 

should consider having one SSRI in large quantities 

to be used for both depressive and anxiety disorders. 

Benzodiazepines may be helpful for panic disorder 

and acute stress disorder because they improve sleep 

and decrease general anxiety symptoms, although 

they may increase the severity of PTSD, especially if 

used for long periods.29 Venlafaxine may be useful in 

treating generalized anxiety disorder. A useful adjunct 

in the treatment of acute stress disorder and PTSD is 

an α-adrenergic or β-adrenergic receptor antagonist 

to target the autonomic symptoms and nightmares 

that may be associated with these disorders. Prazosin 

is a medication in this group with preliminary data 

supporting its usefulness in treating trauma-related 

nightmares.32

Psychotic Disorders and Acute Agitation

Injectable haloperidol and lorazepam remain excellent choices for management of acutely agitated, 

violent, or psychotic patients.33 Although injectable 

forms of both Geodon (ziprasidone [Pfizer-Roerig]) 

and Zyprexa (olanzapine [Eli Lilly and Company]) are 

now available that may have better side-effect profiles, 

including decreased risk of extrapyramidal symptoms, 

both require preparation (being mixed with sterile 

water for 1–5 minutes) before use.34,35 Additionally, 

DMH sections and CSC units have a limited number of 

psychiatrists and psychiatric clinical nurse specialists. 

Physician’s assistants, general medical officers, flight 

surgeons, and others who transport soldiers between 

echelons of care often have limited experience with 

these medications and may be more comfortable with 

Haldol (haloperidol [Ortho-McNeil Inc, Titusville, NJ]) 

as the antipsychotic agent for treating acute mania, 

agitation, or psychosis in a combat zone.33

The authors recommend that deploying psychiatrists’ formulary include two orally administered 

atypical neuroleptic agents, one injectable typical neuroleptic agent (most likely haloperidol), one injectable 

benzodiazepine (most likely lorazepam), and injectable 

Benadryl (diphenhydramine [Pfizer]). The latter is useful to treat agitation and some acute side effects (such 

as dystonic reactions) of neuroleptic agents. 

Insomnia

Insomnia was the most common symptom reported 

by soldiers presenting for care at the 528th CSC during 

the first year of OIF.14 Clinicians treating soldiers with 

insomnia must initially decide whether the problem 

is part of a major psychiatric disorder, a symptom of 

operational stress, or an adjustment disorder. In the 

absence of other symptoms, behavioral interventions 

such as education on sleep hygiene may be the preferred initial intervention because of the possibility that 

prescribed medications will cause drowsiness during 

missions or difficulty awakening during times of peril. 

The decision to use medications should include consideration of the soldier’s military occupational specialty, 

current duties, comorbid symptoms, substance use 

history, and estimated ability to adhere to instructions 

and the recommended dosing schedule. Potential 

deployment formulary medications for the treatment 

of insomnia include trazodone, zolpidem, lorazepam, 

clonazepam, prazosin, and quetiapine.14

Trazodone is particularly useful for patients with 

difficulty staying asleep throughout the night.36 To 

maximize its successful use, clinicians must spend 

extra time educating patients about how to take this 

medication in a field environment. One disadvantage 

of trazodone is its tendency to cause morning sedation or sluggishness, particularly if the dose is too 

high. Frequently, the standard dosage (50 or 100 mg 

with subsequent 50- to 100-mg increments) leaves 

a patient either undermedicated or overmedicated. 

Because the 528th CSC prescribed this medication 

only for sleep, patients there were given a range of 

pill strengths (usually between 25 and 200 mg) and 

flexible dosing instructions. They were encouraged 

to take the initial moderate dose to assess their individual response and then titrate the dosage up or 

down within the predetermined dosage range until 

they could (a) fall asleep within 1 hour of taking 

the medication, (b) sleep all night, and (c) wake up 

without feeling groggy. 

Lorazepam and clonazepam proved most useful 

in treating patients at the 528th CSC with prominent 

anxiety symptoms in addition to insomnia. These 

medications were practical for patients who presented 

with panic attacks and insomnia because they could be 

taken in divided doses to treat both problems, sparing 

the soldier a more complicated treatment regimen. 

However, clinicians must carefully evaluate a patient’s 

need to take these medications for extended periods to 

prevent physiological dependence, which could lead 

to withdrawal if refills are unavailable. Patients who 

have a history of substance abuse or are thought to be 

at risk for abuse should generally not be prescribed 

benzodiazepines in theater. Clinicians must use care 
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to ensure that patients taking benzodiazepines are 

closely monitored. It is prudent to inform someone 

in the soldier’s chain of command (with the soldier’s 

consent) when sleep medications are prescribed because they may affect the soldier’s ability to perform 

duties during the first few days while the dosage is 

being adjusted. 

Ambien (zolpidem [Sanofi-Aventis, Bridgewater, 

NJ]) is particularly useful for treating patients with 

initial insomnia as an isolated symptom or in the 

context of a mood disorder.37 Prazosin, although not 

yet extensively studied, has received increasing attention for helping to alleviate nightmares brought 

on by traumatic experiences.32 Seroquel (quetiapine; 

AstraZeneca US, Wilmington, Del) may also be useful 

in this population, as well as for patients with bipolar 

II disorder, both as a treatment for insomnia and as a 

mood stabilizer. 

ETHICAL ISSUES

The conflicts in Iraq and Afghanistan present for 

the first time since the advent of “biological psychiatry” a situation in which a large part of the military is 

forward deployed for extended periods. In addition, 

many service members are returning to combat zones 

for second or third tours of duty. The risks of keeping 

service members diagnosed with psychological problems in theater, or redeploying these patients a second 

or third time, presents a worrisome ethical question. 

Medication use may inform this discussion. 

The most prevalent disorders in theater are anxiety and depressive disorders. Most of the disorders 

in these two categories respond to treatment with 

psychotropic medications. If a soldier has a mood or 

anxiety disorder and a desire or duty to deploy to a 

combat zone, and a provider believes medication will 

help resolve the symptoms and contribute to successful performance, then perhaps the ethical decision is 

to provide the treatment. Historically, large numbers 

of service members who required evacuation for psychiatric symptoms never returned to their units and, 

unfortunately, developed chronic dysfunction and 

guilt.38 Although mere presence in a combat zone is a 

risk factor for psychological sequelae, experience has 

shown that failing to successfully negotiate, process, 

and come to proper closure with an experience as 

emotional as a deployment may also present longterm challenges.6

 Modern psychotropic medications 

can clearly reduce psychiatric symptoms of many 

disorders in the combat theater. The extent to which 

medication and treatment may facilitate successful 

negotiation and processing of combat experience and 

thus reduce long-term morbidity, however, remains 

an open question. 

SUMMARY

The use of psychotropic medications in combat 

has evolved significantly, mirroring changes in 

psychiatric practice and use of these medications in 

the military garrison environment and the civilian 

sector. Many disorders are now being successfully 

treated with medications in theater. Psychiatrists must 

prepare a deployment formulary before departure, 

and consider the individual circumstances as well 

as guidelines for pharmaceutical usage in theater. 

Factors such as the nature of the conflict, duration of 

deployment, size of deploying force, and guidance of 

military doctrine and policy will continue to inform 

and shape the use of psychotropic medications in 

combat zones. 

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