The ongoing conflict in Southwest Asia has garnered a number of distinctive markers. Its two signature medical outcomes are amputations (the result of an historically high battlefield survival rate) and traumatic brain injury (TBI). But the departments of Defense (DoD) and Veterans Affairs (VA) also have significantly increased their search for diagnoses of and development of new treatments for a variety of veterans behavioral health issues, from post-traumatic stress disorder (PTSD) to substance abuse, domestic violence, clinical depression, and suicide.
Both the extent of DoD and VA efforts on behavioral health issues – including their linkage to physical injuries – and the publicity those suffering from them have received have, in some ways, distorted the reality of such problems in the military and veteran populations, compared to those of previous wars or the general population.
“We know there is an increased rate of PTSD among those returning from combat. One of the criteria is exposure to a severely traumatic event, which most people living everyday lives in the U.S. don’t have, while someone on patrol in Iraq or Afghanistan may have multiple exposures. But we’ve also found people exposed to combat have a lower rate of PTSD than those who are raped or otherwise physically assaulted,” according to Capt. Edward Simmer, USN, senior executive for psychiatric health at the Defense Centers of Excellence for Psychological Health & TBI (DCoE).
“Substance abuse and depression seem to go up after deployment, but for most psychological illnesses, we find the rates are somewhat lower in the military population than in the civilian, probably in part because we do screen people when they first come in. Military personnel also are screened periodically and work closely with others every day, making the likelihood of detection more likely. And you also have good medical care, better than some civilians, so you may be more likely to seek help.”
The percentages may be somewhat different within the VA, which only tracks returning veterans from Iraq and Afghanistan who use the VA health care system – currently about 454,000, which is far below the total population of returning veterans.
“Within that population, using cumulative data from FY 02 through the second quarter of FY 09, the percentage of those with a possible diagnosis of PTSD is 24.5 percent, for a depressive disorder [clinical, not mild depression] 17 percent, drug abuse 7.5 percent, and alcohol dependence 4.4 percent,” said Dr. Bradley Karlin, the VA’s associate chief consultant for psychotherapy and psychogeriatrics.
“I don’t believe the percentage is substantially different from previous wars, although there are differences due to different types of conflict and the fact people are surviving wounds today they would not have survived before. In addition, the VA now routinely screens for PTSD, TBI, clinical depression, military sexual trauma, and alcohol abuse, which was not the case in the past. And research recently has indicated some important overlaps in symptoms between mild TBI and PTSD, something researchers are examining more and more.”
Karlin said hard data remain scarce because that relationship is still a new and innovative area.
“However, some of the new treatments – evidence-based psychometrics for PTSD, for example – are being made widely available and bridging the science-to-practice gap. While some of these have shown to be effective, they often are not seen as frequently in practice as you might think,” he added. “We’re seeing these treatments for PTSD are having some really nice gains in returning vets with TBI and PTSD.”
Two other problems that rarely get public mention also have increased to the point of concern for those deployed to Southwest Asia – the use of tobacco and inhalants.
“I don’t know the rate is higher than the general population [of the same age], but the rate of tobacco use among those deploying has gone up. And we are very concerned about that. When I was in Iraq, we had a stop smoking program and usually about a month or two before returning home, people would show up to take that program because they didn’t want their families to see them smoking,” Simmer recalled.
“Another is the rate of inhalants, which may not be higher than the general population, but is higher among those deploying than those not. Almost any kind of aerosol can be used, including canned air used to clean computer keyboards. What they get out of it, depending on who you ask, is a feeling of euphoria; it lets them forget stress for awhile and has a mild stimulus effect. But it can cause brain damage, depending on what is being inhaled. Most of all, however, inhalants can affect your judgment, which can be extremely risky in a war zone.”
While there are a number of potential behavioral health issues affecting military personnel – especially those who have served multiple deployments in Southwest Asia – some also overlap. Simply being away from home and family for 12 to 15 months, combined with the stress of war, can spark or worsen relationship and family problems.
Some health care professionals now believe a number of PTSD diagnoses, especially from previous wars, may actually have been mild TBI; symptoms of both include irritability and trouble sleeping. In addition, substance abuse may get its beginning with legitimate prescriptions or, all too often, self-medication for another problem.
“We are concerned about individuals who have been prescribed narcotic pain medications; if they take them long enough, most people develop a physical dependence, which is not the same as addiction. Their body becomes used to the drug and they need more to achieve the same level of relief. They also may experience withdrawal symptoms,” Simmer said. “We’re also very concerned about alcohol, which is often used as self-medication for PTSD. Over the short term, it does reduce some of the symptoms, but the harm is greater than the benefit.”
The majority of service members are between 18 and 24, which is considered a prime age to fall victim to peer pressure. In the case of behavioral health issues and treatment, peer pressure can be both negative and positive, such as vocal non-smokers pressuring others not to smoke around them.
“There is peer pressure in terms of using tobacco and alcohol, perhaps less with others, but I’ve also seen peer pressure in the other direction, so it can be positive as well as negative,” Simmer said, but added there is one especially negative aspect. “Another area we’re worried about is stigma – peers pressuring you not to seek help. Some of that is perception – if you come into the military believing people with mental health problems are inherently weak and you are in a position to influence the behavior of others, that may come out.
“There also is a concern about what seeking help may do to your career. If there is a serious problem, you may be discharged and some problems may disqualify you for some duties. That said, we’ve worked very hard to reduce the number of cases where that might happen. We still have some work to do, but having a mental illness and not getting it treated can reduce your ability to do your job, and that certainly can have an impact on your career. The Marine Corps Commandant has put out a video saying getting help with mental health problems is a duty for Marines, which we believe is a helpful step.”
Under a program called the Real Warriors Campaign, both DoD and the VA have encouraged officers and non-commissioned officers (NCOs), active duty and retired, who have sought mental health treatment and succeeded to come forward with their stories, as both role models and inducements to get help.
“It’s one thing for me, as a psychiatrist, to get up and tell soldiers they can get help without hurting their careers; they may simply see me as a doctor with an agenda. But if a two-star general or senior NCO gets up and tells them how they have faced their problems and gotten help – and continued their careers – that is a powerful message,” Simmer said. “We also do a lot of education on what these things are and are not – and how certain reactions to some of the things they experience are perfectly normal. We’re starting to gain some traction with that.
“Another thing we’re doing to reduce stigma is make it easier to get care. One way is by screening everyone, both before deployment and three to six months later, so no one is being singled out. We also are moving behavioral health care to primary clinics, so no one knows if you are going there for mental health or some other problem. We also are making it easier to talk to counselors, such as chaplains. Ideally, our eventual goal is to make talking to a psychiatrist or psychologist no more stigmatic than going to an orthopedist for a broken arm. We’re making progress, but we’re not there yet.”
Increased cooperation between DoD and VA also is a major factor in dealing with mental health issues. By sharing information on both potential causes and treatments, and ensuring individual service members receive continuity of care as they transition from military to civilian life, they hope to improve not only diagnosis and treatment, but prevention.
From sharing information to developing complementary programs and increasing the number of trained staff on both sides, the two departments hope to make significant advances in mental health care. Karlin believes the creation of DCoE in November 2007 was a major assist, both in promoting cooperation across all branches of DoD and improving collaboration with the VA.
“We’ve trained more than 2,000 VA mental health staff, but also more than 800 DoD staff, so they will have the necessary training to deliver state-of-the-art therapies with high fidelity. We also have worked together on the development of and updates to the DoD/VA clinical practice guidelines for depression, substance disorder, and PTSD, which aid clinicians in providing appropriate treatments for those conditions,” he said.
“We have worked with DoD on the development of a number of resources related to suicide prevention, which has been an important focus for both VA and DoD. Also the VA ACE [Ask, Care, Escort] card, which provides family members with information on what to do if they believe a family member may be suicidal. It is based on a card developed by the Army for active-duty military peers. There also is a lot of high level coordination through a mental health work group, with a goal to develop collaboration and coordination across the agencies. We’ve cosponsored joint suicide prevention conferences and have worked closely with the DCoE on PTSD and TBI.”
Those efforts, combined with advancements by civilian researchers and clinicians across the globe, have created an increasingly positive view of the future of identifying and treating behavioral health issues. According to Simmer, knowledge is advancing so quickly that much of what is now known would have been inconceivable 20 years ago.
“We’re getting down to specific parts of the brain, how they are influenced, how they change in people with psychological problems. We know PTSD causes physical changes in the brain we can now detect. So we are still gaining information on the brain as well as on who is at greater risk. Therapy also can change things in the brain and has measurable, demonstrable effects, so therapy is effective – probably more so at affecting the multiple parts of the brain impacted than any medicine,” he said.
“And we’re putting a lot of our attention into prevention, where our knowledge is growing even faster than the treatment area. Does that mean we will eventually have magic pills? No. Because one thing we are learning is how incredibly complex not only the brain is, but how other conditions impact the brain. And having a single pill to deal with all those is not practical.”
Unlike the years following Vietnam, the first war in which PTSD became widely known, clinicians now have confirmed treatments that show significant progress.
“And we are working hard to expedite that process without the lag that all too often occurs between development of a treatment and getting it into the therapy process,” Karlin said. “The VA has been very active in trying to bring treatments shown to be effective in clinical research into the veterans’ therapy rooms. Specifically, evidence-based psychotherapies developed specifically for PTSD and other serious issues, such as depression.
“Two for PTSD are cognitive processing therapy [CPT] and prolonged exposure therapy [PET], which are recommended at the highest level of VA/DoD guidelines for PTSD. Recently, the Institute of Medicine did an extensive review of research literature to identify evidence for currently available treatments for PTSD and concluded that exposure-based psychotherapy, including CPT and PET, are the most effective of all the available treatments, both psychological and medicine-based.”
Another promising new approach in treating PTSD, Simmer added, is virtual reality, “especially in terms of safely exposing someone to a problem they faced in Iraq. If the reaction is too high, you can back down, but still expose them to what they faced over there in a much more realistic way.”
DoD and the VA also deal with other mental health issues that, while not necessarily induced by military service, may manifest themselves during service because they are most commonly found in the age groups common to the military. That covers the full spectrum of mental health conditions and disorders, including schizophrenia, bipolar disorder, suicide, and clinical depression.
The VA’s Mental Health Intensive Case Management Program sends teams to the homes of individuals with serious mental illnesses to provide them with the care they need to function in their daily lives. Services for Returning Veterans Mental Health Teams (SERV-MH) also go out into local communities to provide education and care for veterans; the VA’s Readjustment Counseling Centers also devote much of their time to community outreach programs. The Suicide Prevention Hotline is staffed by clinicians with direct access to the VA’s computerized medical record system and to suicide prevention coordinators at each VA facility, so anyone calling the hotline can be placed into care immediately.
“This has been a major focus on a number of levels. We have a range of new coordinators whose job is only to make sure veterans returning from Southwest Asia get the VA care they need. They interface with both VA and DoD, working closely with veterans, even before they become patients, to make sure no one slips through the cracks,” Karlin said.
“The VA has been in the process of transforming its mental health care delivery care system since 2005, including hiring more than 5,000 new mental health staff, bringing the total today to 19,000. That has been part of an overall effort to create a state-of-the-art mental health care system. In the process, we also have worked to increase mental health capabilities in primary care and other locations and create a treatment culture and clinical services available to all veterans.”
Another program just coming on line is the In-Transition Program, under which a licensed mental health professional is assigned, not to provide treatment, but as a coach. The coach’s role is to make contact with a patient before their last DoD appointment, maintain contact through their first few VA contacts, and make sure nothing goes wrong within the bureaucracy. This will be a much more extensive and coordinated effort than the current system, in which DoD care providers may lose track of a patient who enters the VA system.
All of the advancements in diagnoses, treatment, ensuring the patient receives all of the care available at each step of the process, from DoD through the VA, also have led to a degree of change in how both agencies now view problems of the brain and mind.
“We tend to use the term psychological rather than behavioral health, because focusing on behavior is too limited. We’re more interested in the entire person – their relationships, spiritual well-being, etc. Overall, I think the psychological health of our force is very good, but it takes constant vigilance and monitoring and constant efforts to improve to make it better. We have incredibly devoted and caring providers, although often stretched thin and also deploying multiple times, which has been stressful on them, as well, although I don’t think it has impacted the quality of care they are providing,” Simmer concluded.
“However, there is one important point that often gets missed as we focus on these problems – and that is we have a lot of service members who go out, do their jobs and manage what they experience without these problems. So given what they are facing and the challenges they are under, we have a military force that is doing incredibly well.”
This article was first published in The Year in Veterans Affairs and Military Medicine: 2009-2010 Edition.