The nation has a huge challenge and obligation regarding the soldiers and airmen, Marines and sailors, who are lucky enough to come home alive from Iraq and Afghanistan.

Battlefield medics and medicine, in-country surgeons and speedy airlift to hospitals in Germany and then the United States all contribute to service members surviving physical wounds that would have meant death in previous wars.

However, the psychological injuries, including post-traumatic stress disorder (PTSD), can also be severe and are often not as identifiable as a broken bone.

"As the tide of war recedes, we have the opportunity, and the responsibility, to anticipate the needs of returning Veterans," Secretary of Veterans Affairs Eric K. Shinseki said in April. "History shows that the costs of war will continue to grow for a decade or more after the operational missions in Iraq and Afghanistan have ended. As more veterans return home, we must ensure that all veterans have access to quality mental health care."

Shinseki's comments came as the VA announced it was hiring about 1900 psychiatrists, psychologists, social workers and support staff to help in the existing mental health staff of 20,590.

How pharmaceuticals - specifically, antipsychotic drugs - fit into treatment are part of the discussion.

In the last few weeks, the Pentagon has started to tighten the limits on antipsychotics use.

On Feb. 22, Assistant Secretary of Defense Dr. Jonathan Woodson sent a memo on PTSD to all branches of the military, expressing that "the greatest concern is the suspicion of the over-prescription of antipsychotic medications for PTSD."

Sunday's Inquirer story on the topic is here.

Woodson noted that military-wide antidepressant use had changed little between 2002 and 2009, but prescription rates for atypical antipsychotics increased 10 times during that period, from 0.1 percent to 1 percent. AstraZeneca's Seroquel was prescribed to 1.4 percent of the Army and 0.7 percent of the Marines in fiscal year 2010.

On April 10, the Army's Office of the Surgeon General issued a guidance memo for PTSD, including caution about antipsychotic drugs. "There are numerous concerns with potential long-term adverse health effects," the memo said, "and these medications have shown disappointing results in clinical trials in the treatment of PTSD."

Versions of Seroquel brought AstraZeneca nearly $6 billion in revenue last year.

IMS Health, a healthcare information and services company, said that in the 12 months ending in February of this year, 14.1 million Seroquel prescriptions were written, more than any other antipsychotic. IMS said the $4.7 billion in revenue over the period, was exceeded only by the $5.3 billion spent on Abilify, which belongs to Bristol-Myers Squibb and Otsuka America Pharmaceutical, Inc. The revenue numbers were based on the invoice price for wholesalers. Seroquel XR brought in another $1.1 billion with 2.9 million scripts, IMS said.

Risperidone, the generic that spun out of Johnson & Johnson's Risperdal was the second-most prescribed antipsychotic during that period with 12.2 million scripts written.

"Seroquel is not approved for the treatment of PTSD or indicated for use as a sleep aid," an AstraZeneca spokesman said in a statement. "Atypical antipsychotics, like many other medications, are often prescribed by mental-health professionals for indications beyond those set forth in the FDA-approved label. Like patients, we trust doctors to use their medical judgment to determine when it is appropriate to prescribe medications. Patient safety is a core priority for AstraZeneca, and we believe that Seroquel is a safe and effective medication when used as recommended in the prescribing information."

Dr. Elspeth Cameron Ritchie recently retired from the U.S. Army as a colonel and she now is the chief clinical officer for the District of Columbia's department of mental health. She organized several panel discussions on care of troops and veterans at last week's American Psychiatric Association convention in Philadelphia. She also contributes to Time magazine's Battleland blog, which can be found here.

Ritchie said some clinicians had success with antipsychotics when used with antidepressants for "trauma-induced nightmares," but the dosing was closely watched and used only for a short time. Those sleep-aid situations will now need approval from the Central Command surgeon general.

Beyond the use of drugs, Ritchie urges counseling in several forms and consideration for such things as acupuncture, yoga and therapy dogs to help veterans adjust.

"Sometimes people ask me if the Army is doing all it should be doing and my response is that the Army is doing all it can," Ritchie said. "They are flat-out stretched. They've been at war for 10 years. They have put a lot of money and energy into it, but it is more than an Army problem. It's more than a military problem. It's more than a VA problem. Only about 50 percent of vets go to VA facilities.

"I would encourage every community and every state to talk about what they are doing in the community and the state, and say, 'Can we do more to take care of veterans?' "