Service members are not allowed to deploy on certain medications [1]. These include: (1) antipsychotics; (2) mood stabilizers that require therapeutic monitoring, such as lithium and valproic acid; and (3) medications like coumadin which could be dangerous if one were shot or injured. Thus, the clinician needs to realize that putting service members on these medications will limit their deployments , and could thereby end their careers, if they will need the medications for an extended period.

The restrictions on certain medications during deployment are borne out of the realities of the austere conditions of many operations, be they combat or humanitarian assistance missions. For example, one cannot get lithium or valproic acid levels at a field hospital, and it is easy to get dehydrated in a desert.

Another dimension is the public appearance of deploying service members on antipsychotic medications. However, many atypical psychotics are used “off-label,” especially to augment antidepressants or to decrease trauma-induced nightmares. While clinicians and patients find them very useful, there are vocal anti-medication elements in society who highlight what they consider “overuse” of medication, especially antipsychotics. This is a very controversial area [2].

There is a rich literature on evidence-based treatment of PTSD , developed by the American Psychiatric Association, the Department of Defense (DoD), the Department of Veterans Affairs (VA), and others [3–6]. These include: (1) pharmacotherapy or medication, and (2) psychotherapy. However, these guidelines do not take into account the deployment restrictions for active duty troops, discussed above. This chapter will highlight special considerations for active duty military troops.

Thirty years ago, chlorpromazine (Thorazine) and diazepam (Valium) were the only psychiatric medications in a deployed pharmacy. Beginning in the early 1990s, the services gradually increased the availability of medications allowed in the field environment.

Selective serotonin reuptake inhibitors (SSRIs) were developed for treatment of depression , with the first one, fluoxetine (Prozac), released in the early 1990s. Since then, many have been FDA approved for depression. Only two, paroxetine (Paxil) and sertraline (Zoloft), have been FDA approved for PTSD. Not surprisingly, clinicians use a wide range of SSRIs for PTSD. Usually the choice of SSRI is based on the side-effect profile.

Some SSRIs/serotonin–norepinephrine reuptake inhibitors (SNRIs) are equally effective, and may be helpful for other conditions. For example, Cymbalta (duloxetine) has been proven effective for some forms of concurrent neuropathic pain, and Effexor (venlafaxine) is established as useful for the prevention of migraine headache.

In general, service members may deploy on an SSRI, although certain military occupations, such as aviators, may not be allowed to take them. The clinically most important side effects in a military population are: (1) sedation, (2) weight gain, and (3) sexual side effects.

Other medications are also used for PTSD and related conditions, including second-generation antipsychotics, mood stabilizers, and medications for sleep. This chapter will cover the so-called “off-label” uses of other medications for PTSD. However, service members are not supposed to deploy on antipsychotics or mood stabilizers. Infrequent use of sleeping aids is permissible.

Sedation may either be useful or a problem, depending on whether the service member is suffering from insomnia, and what their job/life requirements are. Paroxetine is often considered the most sedating antidepressant, and fluoxetine the most activating. Sertraline (Zoloft) is usually considered neutral, although the side-effect profile varies based on the service member. Other middle-of-the-road choices include Celexa (citalopram) and Lexapro (escitalopram). However, sedating side effects vary in individuals.

Many service members and veterans with PTSD and/or traumatic brain injury (TBI) suffer from insomnia and PTSD-related nightmares. In that case, their insomnia should be treated. Standard sleeping aids may be used. Trazodone at low doses (50–100 mg) is often used with good effect. The antidepressant effect of trazodone may also augment their other medications. Although rare, priapism can still occur even in this relatively young population, so the male service member being prescribed trazodone should be warned to seek help in the emergency department if he should develop a painful erection which does not subside .

Other sleeping aids should be used with caution. Diphenhydramine (Benadryl) is often used, but the anticholinergic properties may be problematic. Benadryl is very dangerous in overdose. Ambien (zolpidem) and Lunesta (eszopiclone) are useful if prescribed sparingly as they can be habit forming. There are new FDA warnings regarding the dosage of Ambien, recommending that dosages should be significantly reduced, especially in women, to avoid excessive morning sedation.