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Hidden Combat Wounds: Extensive, Deadly, Costly
(January, 2006) -- No Purple Hearts are awarded for the often hidden wounds of posttraumatic stress disorder, but ultimately those wounds can be deadly--linked to suicides, accidents and, over the long term, increased risk of death from cardiovascular diseases and cancer (Boscarino, 2005). Aware of the risks, government agencies, veterans groups and the U.S. Congress in recent months have grabbled with identification, treatment and benefit issues for the growing number of troops and veterans afflicted with PTSD.
"Studies indicate that troops who serve in Iraq are suffering from [PTSD] and other problems brought on by their experiences on a scale not seen since Vietnam," according to one report (Robinson, 2004). The National Vietnam Veterans' Readjustment Survey (from 1986 to 1988) found that 15.2% of male and 8.5% of female Vietnam War veterans suffered from current PTSD (Schlenger et al., 1992).
In Iraq and Afghanistan, the visible manifestations of the mental health toll of U.S. combat operations include suicides and medical evacuations. Official Army statistics from March 19, 2003, through July 31, 2005, indicated that 6.4% of the 19,801 soldiers evacuated from Iraq and 7.2% of the 1,733 evacuated from Afghanistan had psychiatric problems. Among the 1,275 psychiatric disorder evacuations from Iraq, 596 were for depression, 109 for suicidal ideation and 91 for PTSD. There have been 53 suicides among service members fighting in Iraq and nine among those fighting in Afghanistan, as reported in a review of suicide data from 2003 to July 19, 2005 (Ireland, 2005).
Yet most suicides, according to veteran groups and media accounts, occur after troops return home. One highly publicized case was that of Marine reservist Jeffrey Lucey, deployed to Iraq for five months. When he returned home to Belchertown, Mass., he began drinking heavily and suffering from insomnia, night sweats, hallucinations and panic attacks. He received treatment at a Veterans Affairs facility, where he was described by one physician as having PTSD, depression with psychotic features, suicidal ideation and acute alcohol intoxication. One day, Lucey's father came home to find his son had hung himself in the cellar. On Lucey's bed were the dog tags of two unarmed Iraqi prisoners he said he had been forced to shoot (Srivastava, 2004). A recent Associated Press story (2005) reported that three men who had served with the Army's 10th Special Forces in Iraq returned home and committed suicide shortly thereafter.
Other statistics and surveys are equally revealing. Surveillance data obtained from the Army's Center for Health Promotion and Preventive Medicine on health assessment responses completed between January and August of 2005 by 193,131 troops returning from Operation Iraqi Freedom (OIF). Col. Charles Hoge, M.D., chief of psychiatry and behavior services at the Walter Reed Army Institute of Research, told the U.S. House Committee on Veterans Affairs' Health Subcommittee last July that 19% to 21% of troops who have returned from combat deployments meet criteria for PTSD, depression or anxiety. Of these, 15% to 17% of troops who served in Iraq and 6% of those who served in Afghanistan had PTSD symptoms when surveyed three to 12 months after their deployments. In general, PTSD rates were highest among units that served deployments of 12 months or more and had more exposure to combat.
The numbers are similar to those published in another study (Hoge et al., 2004). Researchers studied the prevalence of mental health problems among members of three Army units and one Marine Corps unit before deployment or three to four months after returning from deployment to Iraq or Afghanistan. The rates of PTSD were significantly higher after combat duty in Iraq (18.0% for Army units and 19.9% for the Marine group) than before deployment (9.4%). There was a strong relationship between combat experiences-such as being shot at, handling dead bodies or killing enemy combatants-and the prevalence of PTSD. The study also found that the fear of stigmatization deterred some active duty personnel from seeking mental health care even when they recognized the severity of their psychiatric problems.
A survey of 1,300 paratroopers three months after they had returned to Fort Bragg, N.C., after spending a year in Iraq found that 17.4% of the soldiers had PTSD symptoms (Associated Press, 2004). In another study comparing the mental health of men and women in violence-prone jobs (e.g., medics, mechanics, drivers) in Iraq, researchers found that 11% of the men and 12% of the women had PTSD symptoms when they were screened three months after their deployment ended (Elias, 2005).
What Is the DoD Doing?
The U.S. Department of Defense (DoD) officials in charge of mental health services for service personnel and their families testified before Congress in July 2005 about efforts to identify and treat service members experiencing mental health problems. Every year, service personnel are screened for mental health problems during a preventive health assessment. Prior to deployment, they receive another screening. Those with unremitting mental health disorders are not deployed, William Winkenwerder Jr., M.D., M.B.A., assistant secretary of defense for health affairs, told the House Subcommittee on Military Personnel. Those for whom a mental health condition has resolved are permitted to stay on maintenance medication during deployment.
Deployed military units embed mental health teams, unique to each service, to support the needs of each service. Military members and their families may also use Military OneSource--a confidential, around-the-clock information, education, referral and counseling service.
In an interview with Psychiatric Times, Michael Kilpatrick, M.D., deputy director of the DoD's Deployment Health Support, explained that just as service members are leaving the Iraq or Afghanistan theaters, or within a few days of their returning home, they are asked to complete a four-page, post-deployment health assessment "that asks them about a full spectrum of medical symptomatology, both physical and mental health, as well as environmental concerns they may have." That assessment includes a face-to-face discussion with a medical provider in the military (e.g., physician, nurse practitioner or physician assistant) and documentation of the individual's responses to the health assessment questions.
"The health care provider who goes over the assessment with the individual does not make a diagnosis but refers the individual to clinical areas for further evaluation and workup to determine if, in fact, there is a diagnosis because of the symptoms or concerns," Kilpatrick continued. For example symptoms such as anxiety, sleep problems and anger management issues may be indicative of possible PTSD. In testimony before the House Veterans Affairs Committee in July 2005, Kilpatrick noted, "Of the 138,000 troops who returned in 2004 and received a post-deployment health assessment, 16% have been referred to mental health providers for further evaluation."
Individuals with mental health referrals have options. "They can go to the base support area that may have counselors and chaplains to deal with it. They can also go to our primary care facilities, and many of those facilities are enhanced with behavioral health specialists, such as psychologists and psychiatrists, working with a primary care physician," Kilpatrick said. Additionally, they could go to a mental health clinic, where they would see a psychologist or psychiatrist.
In testimony before the House Subcommittee on Military Personnel in October 2005, Winkenwerder recognized that "no one who goes to war remains unchanged." In response, he announced that DoD is instituting a short interview questionnaire (Post-Deployment Health Reassessment [PDHRA]) to be filled out by all service members, including those serving in the Reserves or National Guard, three to six months after they return home. The assessment is designed to identify health concerns and conditions that may have emerged following the service member's most recent deployment and to determine the types of information and assistance the individual would like to have. A credentialed health care provider (e.g., physician, physician assistant) reviews the assessment with the service member, discusses health concerns and makes referrals when needed. Active duty members can be referred to their primary care provider or mental health community support. Members of the Reserves or National Guard and separated veterans are referred to TRICARE, the DoD's worldwide health care program, or the VA.
The PDHRA is scheduled to be used broadly by January, according to Kilpatrick. It was initiated because the Army looked at the mental health stressors troops were experiencing while deployed and after they got home, and its research data indicated that "at the three- to six-month period people were subscribing to more symptomatology than they had either at the time they just came home or while they were in the theater."
To create the PDHRA, medical providers from DoD and VA with expertise in developing assessments used questions from standardized, validated survey instruments, Kilpatrick told PT. The PDHRA includes screens for anxiety, PTSD symptoms, interpersonal conflict, alcohol abuse and depression. Implementation of the program also has involved leadership and clinician education and training as well as outreach and education for service members.
The PDHRA is undergoing pilot-testing for active duty personnel at three locations, for the National Guard in Arkansas and for the Army Reserve with the 88th Regional Readiness Command with units in six states. In the preliminary trials at active duty sites, researchers found that the percentage of returning troops referred for follow-up medical or mental health treatment was between 30% and 35%, and "it is a 50/50 split between mental/behavioral health and the physical health problems," according to Kilpatrick.
The goal of both the post-deployment assessment and reassessment is to get service members early access to health care, Kilpatrick said, thereby eliminating the risk, for example, of PTSD symptoms developing into chronic PTSD. If care is needed, military and VA providers use jointly developed clinical practice guidelines for acute stress, PTSD, depression, substance use disorders and other health concerns.
Importance of Early Intervention
Studies of Vietnam War veterans underscore the importance of early treatment of PTSD symptoms to prevent emergence of other psychiatric and medical disorders. One recent study concluded that Vietnam War veterans with PTSD may be at increased risk of death (Boscarino, 2005).
The national study examined the causes of death among 15,288 male U.S. Army veterans 16 years after they had completed a telephone health survey, which included questions related to PTSD symptoms and substance abuse, and 30 years after their military service. The study confirmed that PTSD was associated with an adjusted all-cause mortality for both Vietnam War era and theater veterans. For PTSD-positive theater vets, the postwar mortality for all-cause, cardiovascular, cancer and external causes (e.g., deaths from suicides, homicides, accidents) was about twice as high as that of Vietnam War veterans without PTSD.
The study was not a sample of patients who show up at VA hospitals, "it was a random sample of all U.S. Army veterans, some of whom got PTSD from Vietnam and some of whom got PTSD from life, and they die after a significant period of time," the study's author, Joseph Boscarino, Ph.D., told PT. The study results point to the importance of prevention and treatment, Boscarino noted.
"If we can prevent or reduce the anxiety levels, we can prevent the long-term psychological sequelae … and we can also reduce [physical] disease outcomes," he said. "We know there are effective treatments for PTSD, the combination therapies are effective and the drug therapies are effective. Cognitive-behavioral therapy appears to be one of the most cost-effective methods, in my opinion, but there are other methods out there that have been effective."
Boscarino acknowledged that various institutions might be concerned about the cost, compensation and disability issues connected with PTSD's link to medical conditions. "I got a call from a military person who said this kind of study is going to affect the nation's defense budget. I responded that it might be the case, but we have an obligation to the men and women in the Armed Forces. We can prevent [PTSD] from happening and if we do so, we will have lower costs, better quality of life and more productivity."
Boscarino also believes that because of efforts by the DoD and VA, outcomes among troops experiencing PTSD who are returning from Iraq and Afghanistan may be much better than those for Vietnam War veterans. "When I was doing my postdoctoral fellowship at the West Haven [Connecticut] VA Hospital in the late 1970s, they were diagnosing many of the combat veterans as being alcoholic and psychotic. They probably were, but it likely had a lot to do with their undiagnosed PTSD," he said, explaining that the PTSD diagnosis was first included in the DSM-III in 1980. The VA, he said, now has the tools to screen, diagnose, refer and treat PTSD that it did not have 30 and 40 years ago.
Is the VA Ready?
In September 2004, the U.S. Government Accountability Office (GAO) raised questions as to whether the VA could meet an increase in demand for PTSD services at its facilities, emphasizing, "The VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers." It also pointed out that at six VA facilities investigators visited, the staff said they were able to keep up with current number of veterans seeking PTSD services, but might not be able to meet an increase in demand (GAO, 2004).
One year later, Gordon H. Mansfield, deputy secretary of the VA, testified before the House Committee on Veterans' Affairs, "The VA is aware that there has been particular interest about mental health issues among OEF [Operation Enduring Freedom, Afghanistan] and OIF veterans and VA's current and future capacity to treat these problems, in particular PTSD," he said. "First, I want to assure the Committee that VA has the programs and resources to meet the mental health needs of returning OEF and OIF veterans. Second, in regard to PTSD among OEF and OIF veterans, I want to assure you that the PTSD workload that we have seen in these veterans has been only a small percentage of our overall PTSD workload. In [fiscal year] 2004, we saw approximately 279,000 patients at VA health care facilities for PTSD and 63,000 in Vet Centers. Our latest data on OEF and OIF veterans indicate that as of February 2005, approximately 12,300 of these veterans seen as patients at [VA medical centers] VAMCs carried an ICD-9 code corresponding to PTSD. It is important to note, however, that this represents approximately 4.5% to 5% of VA's overall PTSD population. Additionally, more than 3,500 veterans received services for PTSD through our Vet Centers. Allowing for those who have received services at both VAMCs and Vet Centers, a total of approximately 14,600 individual OEF/OIF veterans had been seen with actual or potential PTSD at VA facilities following their return from Iraq or Afghanistan. This figure represents only about 3% of the PTSD patients VA saw in FY 2004."
PTSD Benefits Controversy
A controversy over benefits exploded last August when the VA, acting on its Inspector General (IG)'s report, said it would audit files of 72,000 veterans who were receiving full disability benefits for PTSD alone or in combination with other conditions. That announcement generated a widespread backlash. Some veterans groups protested that the review of PTSD cases was an excuse to cut benefits for older veterans and toughen qualifications for future ones. The Senate passed an amendment to a military/VA appropriation bill seeking to restrict the audit. Press reports linked one man's suicide to the impending review (Benjamin, 2005). In November 2005, the VA dropped its full-scale audit plans, stating that most of the problems came from administrative errors and not fraud.
The focus on VA benefits for PTSD originally grew out of complaints from veterans about regional inequities in disability ratings and payments. For example, less than 3% of Illinois' disabled veterans are rated 100% disabled for PTSD, as compared to almost 13% in New Mexico (VA Office of the IG, 2005). Because of those complaints, in May 2005 the VA Inspector General examined the files of 2,100 randomly selected veterans with PTSD disability ratings. It found that 527 (25%) lacked documents to verify that a traumatic service-connected incident occurred before compensation benefits were granted. That 25% error rate equates to $860.2 million in questionable compensation payments in FY 2004, the IG report said. The IG also cited a dramatic increase in veterans filing for disability compensation for PTSD since 1999.
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"Not all combat wounds are caused by bullets and shrapnel," Nicholson said. "We have a commitment to ensure veterans with PTSD receive compassionate, world-class health care and appropriate disability compensation determinations."
Source: Psychiatric Times
Last updated -01/06
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