Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
Although the pace of deployment has decreased in recent years, military members continue to deploy to combat zones and other areas around the globe. Behavioral health providers who serve a military population are well aware of the ebbs and flows of stresses on military members and their families around deployment cycles. Modern evidence-based care includes use of appropriate psychotherapies and medications to treat major depressive disorder, PTSD, and other deployment-related conditions. In addition to providing good care, it is important to consider the compatibility of treatments with future deployments. The following article will discuss the concepts of deployment-limiting conditions and the impact of psychotropic medications on deploy ability.
The Department of Defense offers broad guidance on deployments and medical conditions in DoD Instruction 6490.07, entitled “Deployment Limiting Medical Conditions for Service Members and DoD Civilian Employees.” The purpose of this instruction is to ensure that Service members and civilians are medically able to accomplish their duties in deployed environments. Defining medical standards for deployment ensures individual safety and reduces disruption due to preventable illness and injury. An example is the exclusion of pregnant Service members from deploying. The risks to a pregnant woman and fetus are amplified in remote locations with limited access to health care. The DoD instruction places limits for deployment on individuals with acute or unstable illnesses, chronic illnesses requiring frequent visits or monitoring, and illnesses likely to be aggravated by the deployed environment.
The Assistant Secretary of Defense for Health Affairs Policy Memorandum, entitled “Clinical Practice Guidelines for Deployment-Limiting Mental Disorders and Psychotropic Medications,” offers additional guidance specifically pertaining to mental health conditions and medications used to treat them. Specifically, this guidance requires that individuals must demonstrate a minimum of three months stability on their current treatment. It also identifies specific classes of medications and their suitability in deployed settings. Operational commanders issue additional guidance on medical standards for personnel deploying to their geographic region. US Central Command (CENTCOM), which encompasses Syria, Iraq, and Afghanistan, issues guidance for deployment to the region that amplifies DoD requirements and identifies specific limitations on medical conditions and medications. Commanders update this guidance frequently, so it is best to check with unit medical providers for the most up to date limitations.
As providers treating Service members with mental health conditions, there are several situations to be alert for that may limit a Service member’s deploy ability:
1. Residual symptoms or medication side effects which impair performance
2. Fewer than three months of stability from the last change in treatment
3. Substantial risk for deterioration or recurrence of impairing symptoms in the deployed environment.
4. Need for frequent follow up or monitoring to ensure stability
For most individuals, mental illnesses can be effectively treated, but successful treatment does not necessarily render them suitable for deployment. Consider an individual taking lithium to treat Bipolar Disorder. The person may be completely asymptomatic and reliable in their follow up and medication compliance. However, putting them in a setting with limited medical resources and environmental extremes could expose them to toxic complications of their medication without access to rapid medical response. Thus, an individual on lithium treatment would be excluded from deployment. Another circumstance to consider is a patient who shows significant improvement with weekly psychotherapy visits, but has been unable to taper back the frequency of visits due to recurrence of symptoms with longer intervals. The following paragraphs will discuss some commonly used psychiatric medications and their impact on deployable Service members.
Antidepressant medications are commonly prescribed and generally do not limit deployability. Selective serotonin reuptake inhibitors (SSRIs) are effective in treating depression and anxiety with very limited side effects. Patients who take them are unlikely to develop toxicity in the deployed environment, thus they are relatively safe. Providers should consider the implications of a Service member abruptly stopping medication due to inability to refill, loss or damage to the medication. An individual likely to become impaired after abruptly stopping an SSRI may not be suitable for deployment. Also, providers need to adhere to the general guidance of three months of stability from the last dose change.
Sleep medications have recently become an area of concern. Medications commonly used for sleep include sedative-hypnotic medications and older antidepressants that have sedative side effects. A provider inside the United States may find it completely safe to prescribe a sedative-hypnotic medication such as zolpidem (Ambien) for a Service member with chronic insomnia. However, using this medication could put a Service member at risk if placed in a situation where they are roused from sleep after taking medication. The Service member could act inappropriately or have amnesia for actions taken while under the influence of medication. Some operational commanders have placed restrictions on deployment of individuals taking sedative-hypnotic medications for greater that three months to treat insomnia.
Stimulant medications are effective in treatment of Attention Deficit Hyperactivity Disorder (ADHD). However, their use in deployed settings requires some caution. First, consider the level of impairment of the patient with ADHD when they are off of their stimulant medication. Severe inattention or impulsivity can put an individual at risk should they run out, lose or damage their medication. Stimulants also have a high potential for diversion. As controlled substances with abuse potential, they can be stolen or sold. Patients should be instructed explicitly to protect their medication and not share it with other Service members.
Some classes of medications present significant risk in deployed settings. Benzodiazepines are effective in treatment of anxiety, but the potential for withdrawal or diversion generally makes their use incompatible in deploying Service members. Antipsychotic and anticonvulsant medications are also generally non-deployable. This has more to do with the conditions they treat – bipolar and psychotic disorders – and the risk to individuals with these illnesses in deployed settings.
Individuals with psychiatric illnesses and treated with psychotropic medications can deploy if they meet criteria outlined in DoD and theater policies. Deploying typically requires a waiver requested by the individual’s commander. Doing so demonstrates to the theater commander that the service member has been medically examined, is aware of the risks of deployment with their condition, and that the unit is prepared to provide necessary support. It further gives the theater medical staff the opportunity to identify additional risks to the individual perhaps not immediately obvious to providers outside of the deployed area. Effective preparation for the deploying individual and their provider includes ensuring an adequate supply of medication for the anticipated deployment. Not only this, but the patient must have resources and a plan to obtain refills or replacement of medication.
The considerations above are not comprehensive, but cover the main concepts associated with mental health conditions and medications in deploying service members. Providers should periodically review and stay familiar with the most up to date DoD guidance on deployment-limiting medical conditions. As we continue to provide the best care for our service-members, considering the impact of treatment choices on deployment and deployability will ensure a ready force.
Department of Defense Instruction 6490.07, “Deployment Limiting Medical Conditions for Service Members and DoD Civilian Employees”, Feb 5, 2010
Assistant Secretary of Defense, Health Affairs Policy Memorandum, “Clinical Practice Guidelines for Deployment-Limiting Mental Disorders and Psychotropic Medications”, Oct 7, 2013
PPG-TAB A: Amplification of the Minimal Standards of Fitness for Deployment to the CENTCOM AOR; to Accompany MOD TWELVE to USCENTCOM Individual Protection and Individual/Unit Deployment Policy
CAPT West is Assistant Professor and Assistant Chair of Psychiatry at the Uniformed Services University of the Health Sciences. He has previously served as Operational Stress Control and Readiness (OSCAR) Psychiatrist to 1st Marine Division and deployed to Iraq and Afghanistan
Disclaimer: The views expressed above are those of the author and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense.