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“It’s a serious concern because not all [recent combat veterans] are taking advantage of our services,” says Clay King, chief of the local VA facility’s social work service. “We’re only treating about 10 to 20 percent of eligible vets.”
The VA provides two years of free medical care for any combat-related condition if a veteran enrolls in its healthcare system. In addition to physical exams, vets are encouraged to meet with a mental health professional.
The number of PTSD diagnoses reflects what experts believe are significant differences for veterans of the war on terror. Unlike combatants of earlier wars, says King, more-recent vets are part of an all-volunteer army, a large percentage are reservists or members of the National Guard, a significant percentage are women (one in every seven in Iraq), and many have had multiple deployments to war zones.
The high percentage of PTSD cases may also reflect an unprecedented, aggressive outreach effort by the VA. The department was widely criticized for its lack of attention to the estimated 30 percent of Vietnam vets with PTSD. The disorder affects about 8 percent of the general population.
The initial numbers might be misleading. Research shows that early symptoms of PTSD are not very good predictors of a long-term prognosis, according to a report from the National Center for Post-Traumatic Stress Disorder, which was established by Congress in 1989 and operates within the Department of Veteran Affairs. “Studies suggest that in the face of severe military service demands, including combat, most men and women do remarkably well across [their] lifespan,” the report says, adding a caveat:
“On the other hand, if the mission is experienced as a failure, if soldiers deploy more than once, if new veterans who need services do not get the support they need, or if post-deployment demands and stressors mount, the lasting mental health toll of the wars in Afghanistan and Iraq may increase over time.”
FOR SEVERAL YEARS, the VA San Diego Healthcare System has operated a post-traumatic stress disorders program, and last August it launched the Primary Care Post Deployment Clinic, specifically designed to treat veterans who have served in Iraq and Afghanistan. In September, the program was designated by Congress a “mental health center of excellence,” one of only three such VA facilities in the United States.
Psychiatrist Dewleen Baker, director of the program, also is concerned that returning vets who need mental health treatment aren’t getting it.
“It can take a while for some vets to admit they need help,” she says. “They may stay isolated at home, or drink or drug to dampen some of the symptoms, or work themselves into the ground by putting in 18-hour days to avoid dealing with their symptoms.”
PTSD is an anxiety disorder resulting from exposure to an extreme traumatic stress involving direct or indirect threat of death, serious injury or a physical threat. Symptoms include flashbacks of the event, nightmares, inability to feel a range of emotions, sleep disturbances, difficulty concentrating, persistent anxiety and increased hypervigilance. Signs of PTSD appear more severe and long-lasting if the traumatic event is man-made, such as in combat or with a violent crime. Adjustment disorder is not as chronic or as disabling as PTSD.
The brain gets “revved up” at the time of the traumatic incident and is flooded with stress hormones, says Baker. In PTSD sufferers, the brain’s metabolism has been altered by the rush of hormones, and memories of the event are stored in a different way. Research shows the level of certain stress hormones in PTSD patients can remain much higher than normal for decades after the trauma.
It’s difficult to predict who will be afflicted by PTSD. “Not everyone who’s exposed to a bacterium will get pneumonia,” says Baker, explaining why many vets might experience the same traumatic event yet perhaps only one develops PTSD. “It depends on your vulnerabilities and genetic makeup.”
According to the National Center for PTSD, the likelihood of the disorder significantly increases if a person has previously experienced a trauma, has been the victim of childhood physical abuse or is repeatedly exposed to intense combat experiences. Guerrilla warfare and terrorist acts in an urban setting—such as troops are encountering in Iraq—also can undermine a person’s ability to cope. Often, the center says, “there is no safe place and no safe duty. . . . In Iraq, soldiers are required to maintain an unprecedented degree of vigilance and to respond cautiously to threats.”
If PTSD is detected and treated early, Baker says, the prognosis is reasonably good. A variety of evidence-based treatments may be employed, and especially positive results often come from Prolonged Exposure, a cognitive-behavioral program that involves nine to 12 individual 90-minute sessions. In addition to body-relaxing techniques, it involves the patient repeatedly describing the traumatic event, coupled with exposure to nondangerous, real-life situations the patient is avoiding because of the trauma-related fear.
“What’s being avoided has to be experienced,” Baker says. For the newly returned vets, she says, real-life exposure commonly entails trips to shopping malls, which the PTSD sufferer has avoided because of crowds, and driving. “Some of these people have a heck of a time on freeways. They’re not paying attention because they’re looking for bombs around underpasses or along the roadside.”
Any candid discussion of combat-related PTSD, especially among veterans, invariably evokes comments that some vets are malingerers—faking symptoms to receive VA disability benefits. Baker and others at the post-deployment clinic respond by citing the thoroughness of the testing used by clinicians before making diagnoses. As a psychiatrist who has dealt with PTSD for 15 years, and who experienced a trauma early in her life, Baker adds:
“You develop a nose for this stuff, what’s real and what’s not. PTSD is not easily faked. Someone who says it is hasn’t seen the emotional reactivity of these patients.”
“FOR TODAY’S COMBAT VET, there’s no slow boat back from Europe, where you at least have a little time to unwind,” says Michael Kilmer, a clinical social worker at the post-deployment clinic. “Today, you can literally go from the battlefield to the bedroom in 24 hours, and that’s just not normal.”
He estimates there are 8,000 to 10,000 local vets who have served in Iraq and Afghanistan. When they don’t enroll in the VA healthcare system, Kilmer contacts them by letter or phone. It’s part of Operation Seamless Transition, a program jointly administered by the VA and the Department of Defense to assist veterans returning to civilian life.
Despite the broad outreach and availability of effective mental-health programs, Kilmer also worries that new vets who need help the most aren’t seeking it. Early treatment is essential to prevent PTSD from becoming a lifelong disability.
“I’m most concerned about the reservists and National Guard members,” says Kilmer. “A lot of them feel guilty for even asking for time off to come in to see us. And I’m concerned for many of the young vets who aren’t from San Diego but stay here after they leave the service. They may not have the strong support system they do back home.”
NATIONALLY, the Department of Veterans Affairs says about 317,000 veterans, with service periods dating back to World War II, received treatment for PTSD at its medical centers and clinics in the fiscal year that ended last September. The VA says 244,846 vets in 2005 were listed as having PTSD as a service-connected disability. PTSD disability payments last year were in excess of $4 billion. Nearly 19,000 veterans of the Iraq and Afghanistan wars have been treated for PTSD at a VA facility from October 2001 through last September, according to the department, which has announced a $29 million expansion this year of its PTSD services for vets returning from Iraq and Afghanistan. The only comprehensive study of the mental health impact on active-duty service personnel, conducted in 2004, estimates the risk for PTSD from service in the Iraq war is 18 percent, and the risk from the Afghanistan conflict is 11 percent. Of troops who acknowledge having a mental health problem, the study finds, only about half say they would seek treatment, citing fear of stigmatization.
—M.F
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