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Veterans' Mental Healthcare: Epidemic of Denial

[commentary - Kat]

It's not often that you go to war with your own kind. In this I mean "milbloggers". We don't all speak with one voice exactly, but we do have a major focus: supporting our troops. It's over this one issue that I feel strong enough about to declare a kind of war on our own politicization of these numbers.

As I wrote yesterday about Veterans' Suicides, we in the milblog community spend an awful lot of time disputing numbers and defending the people that need no defense: those in the military who do not suffer from any mental health disorder. Just cruising around the net yesterday (and many days before as the subject has come up), most of the response go along the line of "those anti-war people using our veterans to score political points" and "hey, they're trying to make us/soldiers look bad".

I noticed that Mudville Gazette linked to Jules refutation of these numbers and Blackfive had their own post up on it and it got the same responses.

(continued in Flash Traffic)

I understand we want to defend all of our troops. Jules wanted to know where the reports are the show all of the veterans who either do not suffer the after effects or that go on to cope with their symptoms, living productive, fairly normal lives. Well, if we reverse this study information on the fact sheet, if 18% develop PTS or the more chronic PTSD, that means at least 82% of all troops come home to healthy, productive lives. With over 1 million already having served in Iraq and Afghanistan, that's approximately 820,000 troops. With 11% of the 18% that goes on to have the more chronic "disorder", that means another 70,000 who have the "acute", short term PTS and go on to live fairly healthy lives.

That is good news. Especially for our troops who may be concerned that they will be part of some overwhelming number of troops who will not be able to return to "normal". However, that's really not the point. These troops, by and far, do not need our "defense". They know they are fine and going on with their lives.

There are still 11%, over 110, 000 troops, who will struggle with PTSD. Some of the 70,000 with the "acute" variety, will not receive treatment, will stop treatment or will refuse treatment and may go on to develop the chronic disorder. Then, there are the unknown numbers who will not report any symptoms, not seek treatment and be below the radar, with both soldier and family suffering. These are the people that we need to worry about, that we need to "defend".

I don't know exactly how many visits all of the "big" milblogs get. Based on some reported numbers, places like Blackfive get about 10k visits a day. My guess is, somewhere in there, there are deployed or recently returned troops. Out of these, my guess is there are some troops who might be experiencing either the "acute" or short term conditions of PTS and some might have the chronic disorder: Post Traumatic Stress Disorder. They might need a little "acceptance" and "encouragement".

The best way to mitigate stigmatization of these conditions, improve acceptance, increase treatment and reduce the chances of PTS becoming "chronic" or even PTSD turning into suicidal tendencies, is to accept it ourselves.

Isn't it time we milblogs stopped worrying about "the politics" started having a real conversation?

25 Comments

My impression is that PTS and PTSD are going from an undiagnosed or underdiagnosed problem to an overdiagnosed and overtreated problem. The problem of institutionalization of the people suffering for this problem, when the best way to treat this and many other mental disease is to try hard to reinsert the person in his/her family/workplace. People need to be given help there, not in hospitals away from their home. Hospitalizing people for long terms (weeks, months) have a grave risk to make them dependent from the institution. They start behaving like the institution expect they will behave. In the rush to help and protect, people sometimes do more damage than good. The problem is that the good done is seen, but the damage is not.
 
My impression is that PTS and PTSD are going from an undiagnosed or underdiagnosed problem to an overdiagnosed and overtreated problem.
Actually, that can occur for any mental health problem. It's really up to the patient to work with the doctor and for family members to make themselves cognizant. In regards to the hospitalization, that is an issue, but that is actually pretty limited. Most are "voluntary" not "involuntary" inpatient stays. Thus, I have to assume that there is a great risk to the patient or others. also, the beds for "inpatient" are limited. I mean , very limited, so it seems a little overstated to claim that hospitalization happens "too much". Most clinicians also believe that patients are better off either at home or in a setting that is open and includes compatriots. which is why a lot of PTSD programs are group therapy with similar troops. Although, I did hear a complaint from a combat soldier about having to share his issues with "pogs" who hadn't seen half of what he did, but part of that is really anger about talking about it at all. One thing I would like to see a lot more of is peer oriented therapy. People are less afraid to share things with their peers. Particularly ones that are in the same boat with them. everyone else they think is judging them even if it is a sincere desire to help.
 
As I understand how the military does it - they are not taking the institutionalization approach. We learned the hard way as long ago as WWI that approach was one that actually made the problem worse. The French and German approach which mirrors what Mirco spoke of, was much more effective for treating what was then termed "battle fatigue".
 
Shipmates, Ah hell. I kept trying to write what i wanted to say, but no matter how hard I phrase it, it'll piss off someone for sure. Certainly there are times when suicide is the result of mental health issues, and those should, indeed, be assessed and discussed. However, there are other times when it is a viable and perhaps even desired form of death. I have known three veterans who killed themselves, including my grandfather. He was dying of cancer, in agony, and before he became unable to help himself anymore, he made peace with grandma, said goodby, and checked himself out. I see no mental health issues there, and I would hope that i could have the same courage were I faced with that sort of fate. However I certainly agree tyhat mental health issues are over-diagnosed. That's a function of both the health care industry having a financial stake in the matter, as well as from a liability angle. Good heaven's, even religion and government proscribe suicide because it deprives both of revenue from the deceased, although the IRS tries to still get a bite through the estate taxes. I am not suicidal, but I have thought often about this issue. In the end, my life is the ONE thing that I have control over, or at least should be allowed to have control over. I should be able to decide when it's time to leave, when I've had enough, when I've done all I can to help out the world. I'm NOT trying to be cold and cynical, although I am a tad bit jaded these days. Still and all, anytime there is money to be made, an industry will arise to take advantage of the situation, and that is where much of our mental-health and NGO's are headed: suicide-prevention. Respects,
 
Okay John, you asked for it, you got it. My maiden post. In the current health care environment, people with mental health issues are not hospitalized unless they are in severe crisis. Nor should they be. Kat has done a really fine job of outlining the difference between PTS and PTSD and the many issues surrounding these disorders. The standard of care for PTSD includes both individual and group therapy, as well as appropriate medications (antidepressants and anxiolytics) when they are necessary. The group component is very important in helping people understand that their experience is not unique and that they are *not* crazy. Others here have also mentioned the stigma surrounding mental health issues and this is something with which our culture struggles mightily. That is one reason we are beginning to see services labeled as behavioral health. I work in the field of health psychology, which didn't exist when I was an undergrad back in the dark ages. When I am working with people, I try to help them understand that it is impossible to separate the mind from the body. Is your brain not a part of your body? Depression and PTSD should carry no more stigma that diabetes or hypertension. They are problems that need to be dealt with to lead a healthy life.
 
I don't think your anymore jaded than I am Tim. As long as Illegal Aliens are getting better healthcare than Veterans, I don't have anything i can add to the context of this without the use of what my father labeled "sailor words"
 
Everybody, meet my sister. Keep that in mind, too. She's my sister. Pick on me, she'll kick your butt.
 
In case of death, I would suggest to try crionic conservation. It is probably a 1% bet. But the alternative is a 0% bet.
 
And welcome to our commenter from Italy... Mirco.
 
Kathy ~ nice to meet you! This is an incredibly interesting discussion. I want to focus on AW1 Tim's comments. The logical, practical side of my brain agrees wholeheartedly with the concept of assisted suicide and/or one's ability to determine at what point their life no longer contains the quality necessary to continue (how's that for a run-on sentence??). The Christian part of me says that only God has the power to decide when and where and why my life will end. Tough quandry.
 
Well, when we are talking about "suicide" here, we are not talking about "end of life" decisions regarding the terminally ill. Mental health is not a terminal condition unless someone absolutely chooses it. It is almost always something that can be addressed either through therapy and/or medications. Having dealt with several people with the chronic condition, usually the issue is that they either believe they are a burden on their family or they simply cannot deal with how they perceive their own behavior. Typically because it's extreme ups and downs, but also complicated by sleep deprivation, alcohol and drug abuse, family issues (which invariably occur as families try to deal with it). They can't see a way out though it is there. They can't see who they are going to be beyond what they are experiencing right that second. Most of our job is to assure them that this is not the end or the only thing they will ever experience. There is a future, even for those who experience chronic PTSD. The symptoms can be controlled and eventually recess to nothing or a minimum. There are a lot of coping skills that clinicians can teach and that people naturally have if they reach for them. Here's some thoughts on the "over diagnosed"...it happens in every medical condition, it can be "undiagnosed". Secondly, there was a time when it was "under diagnosed" and in reality, that happens today as many try to avoid the diagnosis and hide the symptoms. At this point, "over diagnosed" is not nearly the problem that "under diagnosed" is.
 
Kathy! Nice post. Thanks for being a part of all this. KAT: I hope you understand that I support fully the VA mental health programs, both inpatient and outreach. My big gripe (and not with you, mind you) is the perception by so many that someone who chooses suicide is, by default, mentally ill, depressed, whatever. It's to the point where nearly every state has laws that DEMAND that physicians report anyone who talks about it to them. Seriously, how many folks have given up on talking about the subject with their own doctor, or anyone else because they fear being reported and detained against their will? That sort of legislation, the one that requires doctors to report such comments and individuals, is to my mind the real illness. respects,
 
I know that there is the distinction to be made between PTS and PTSD, but to those affected it is a moot point if there are long waits for assistance and lack of facilities in addition to the stigma. Unfortunately, in my experience, the stigma is most fostered by the NCOs with interference, intimidation, threats and punishment. Whether this was (is) ignorance on their part or the pressures top down to train up and have sufficient personnel mission ready.... it exists. Only those [soldiers] in crisis mode (they must tell someone they are considering or have attempted suicide or violnce) are seen on an emergency basis. If a soldier is then determined to be a threat to himself or to others he is hospitalized -- but typically in a civilian facility because the services cannot afford to spend capital dollars on "housing" for mental health conditions. If they are not in crisis, they have to call and get an appointment and wait for weeks to be seen. If they are experiencing crisis symptoms (extreme anxiety, aggitation, severe depression, suicidal urges) they must go to the medical ER where they might sit for 6, 8, 10 hours before they are seen... and most soldiers in crisis leave in frustration. Self medication -- alcohol, drugs and "cutting" (self-mutilation) -- are big time among returning troops... and little is done to discover or discourage such behavior: so long as you show up at formation and pass the occasinal urine screening (and your Sgt. isn't called out to bail you out or break up a fight) -- you're good. I know that they are trying to change the culture within the services and that efforts are underway to up treatment availability in the VA system... but it's going to be a long, difficult and costly process. But it all starts with truthful answers when asked, "Have you ever ______" and the willingness to speak up and/or seek treatment when the answer is "yes".
 
Kat - I hear you, but there's a political dimension to this that can't be ignored, and that has to be countered at every turn. You can separate the personal coping and support for treatment from that political dimension, but it's something that can't go unaddressed. The public has to understand both sides. The politicization of this condition by some quarters has forced the issue. Some media outlets use health data to support a political agenda, and have the side effect of even further stigmatizing of vets. Of course, the bulk of them, that 80%, don't need defending. It's not so much in defense of the vets per se as it is a stop sign to put up against the exploitation of PTSD and it's sufferers -- under the pretense of compassion -- to serve other agendas. When it comes to familial coping, we get an email on what to say, what not to say, how to act, what questions not to ask, etc...But it can't be denied that high political emotion surrounds this publically, and will, if allowed to continue, come back around and aggravate things further on a personal level. The hysterical waving of PTSD by some groups does have an effect, even on those who understand it. And I see the effect of this reckless use of the problem when I get a frantic call from my sister that, "He was scanning for targets the whole drive to the hotel! Oh my God! It's PTSD!"
 
Heh. That last part is good training. I still do that now and then. And watch for good ambush positions along the highways. It's how you *react* that matters. What's going on inside the head that matters. Good perspective, though. It's one of the things I've actually been hammering Gun Owners of America about - their major argument against the NICs change for Brady Checks has been that vets with PTSD will get denied. Aside from being misleading - it's damn dangerous among the vets who need help.
 
The hysterical waving of PTSD by some groups does have an effect, even on those who understand it. And I see the effect of this reckless use of the problem when I get a frantic call from my sister that, "He was scanning for targets the whole drive to the hotel! Oh my God! It's PTSD!"
Well, as John notes, that's good training, but beyond that, it's part hysteria and ignorance. There is obviously a lot more to PTS and PTSD than that. A good place to start is by giving her simple advice: 1) They aren't going to be the same when they come back 2) they are going to be trying to fit that "other life" into "civilian life" 3) There are a lot more symptoms that would have to take place in order to be worried about the condition. 4) Tell her to go to the National Center for Post Traumatic Stress Disorder website. They have a lot more information on what is or isn't the "signs". Maybe knowing more and talking to you will help her adjust as well. You know, this isn't just about the soldier. It's their family, too. They are trying to adjust to the new person as well. You might want to give her a little sympathy, too.
 
Thanks for the above website -- very informative for the worried mother who thinks anything unusual means "my baby has PTSD". Said baby, 6 ft. tall and 200 lbs., doesn't welcome the mothering.
 
Yes. actually, the "worry" part is natural, but can also be a bit of an "enabler" either by said "baby" rejecting it and going completely introverted when he might need to talk about it or by over-stating the responses and ingraining them. Sad to say, there is no "right" response. It's all "feeling it out" as we go. Maybe give her the "spousebuzz.com" site for some sharing by people who do deal with the "normal" effects of separation and the "different" people they have to adjust to when they come back. I should have posted that site on the other websites as well.
 
"1) They aren't going to be the same when they come back" Might there be a different, better way to say this?
 
Well, I admit that is very general thought. We could break it out to say: They are not going to look at the world as the same. They will be more mature. They will think different things are funny. somethings they did as "fun loving young men" will not seem as important nor fun anymore. They may love more deeply and feel the need to be more protective of those people. They may be more outgoing or less so. They may be more introspective. They may be more independent or they may be likely to cleave to their families and friends. It can be a lot of different "not the same". But maybe the best is to say they will almost always be changed by their experiences in small and large ways.
 
I know that they are trying to change the culture within the services and that efforts are underway to up treatment availability in the VA system... but it's going to be a long, difficult and costly process. But it all starts with truthful answers when asked, "Have you ever ______" and the willingness to speak up and/or seek treatment when the answer is "yes".
Addressing the first part last, I would like to say that, beyond talking bout it as if it was a regular process that we need to discuss, it might be more easily acceptable if we put it in terms that our service members are familiar with. for instance: being mission ready. I had a similar, long conversation at Blackfive. Both soldiers, NCOs and officers need to be aware that being mission ready, in all respects, both physical and mental, are important in order to insure the safety of the soldier in question, the soldiers they serve with and the successful completion of mission. Unfortunately, as I noted there, being able to physically assess someone for mission readiness is easier than assessing their psychic readiness. You can use quantitative assessments for physical conditions. You can use your eyes to see. But the psychic evaluation of "mission readiness" is about paying attention, knowing the soldiers and using our intuition. And, being overly cautious in stating someone has it or doesn't could create a different risk. In regards to available services, upon reading information available, it is apparent that we are basing the funding and addition of services based on a study from 2005. Where this issue is coming to a head right now is that we have had over 175k troops serving in Iraq during some of the heaviest combat. That means that there is a greater number at risk than any 2005 study can assess and recommend for. that goes the same for Afghanistan where, right now, combat and attacks are up significantly for the year. Our problem lies in the several aspects: 1) No one could know in 2005 that more troops would be sent than have been sent on average. Thus, no one could no the added burden. The same goes for the post 2003 invasion. Who could know how long it would go on? but, you would think we had learned our lessons from the past (we're not really that good at it). 2) Our budgeting practices. In order for certain programs to be funded, there must be some very specific numbers and assessment tied to it. These take time and, of course, invariably are based on old data. We are not very quick or flexible with this process. It's meant to protect against abuse, but, based on our spending on this compared to other things, it does appear under represented and under appreciated. 3) Our budgeting practices based on number two and then being presented as the budget for the next year well in advance of that year, leaves little room for that flexibility. It is why we need to be more proactive in reviewing programs and requesting the passing of bills within the entire year to insure these services get proper attention and funding as they are needed, not somewhere down the road.
 
kat-missouri... as for the "mission ready" argument, that is all part of the current but we- hope-they-are-changing culture. Wars and readiness have to do with warm bodies; mental health status has never been a big component unless it's to bully and punish those who dare speak such heresy. as for anticipating the need for budgeting purposes, the services (and the VA) have always known what was down the pike and it is/was a matter of wilfully not budgeting or preparing for the mental health needs of service members and veterans. From the outset -- based on numbers of the National Vietnam Veterans' Readjustment Study conducted 20+ years ago -- everyone knew (or should have known) that at least 11% of combat veterans would develop a level of PTS/PTSD sufficient to require treatment (with 20% or more experiencing symptoms); with 1.7 million having served in OIF and OEF, that is more than 185,000 who will at some point require treatment (and 340,000 symptomatic)-- and if I can run those numbers, so can DoD and the VA and (hopefully) members of our illustrious Congress. The 2003 and 2005 study numbers were simply validation of what should have been easily identified as a budget need. It was/is the culture of denying the problem that has led to the current treatment morass. the perfect example is 3ID: on its third deployment to Iraq... 40,000 active duty troops and more counting NG & Res. units + 80,000 contract employees and family members. Martin Army Hosp. (Benning) has 13 in-patient psych beds. that is not a typo: 13. If only 11% of the soldiers require treatment that is at least 4,400 soldiers... and if even 1% require some form of intensive treatment, they need 44 beds. If those numbers are even reduced by half for argument's sake, that's still almost double the number of current beds. My reading and feedback tells me that the situation at other Army bases is comparable. IMO It's not the budgeting process: it's the refusal (not just a failure) to identify a need, plan for it and request the appropriate funding.
 
Unfortunately the numbers reported on PTSD are most likely very low as they rely on people seeking help. Men are far les likely to seek treatment for mental health issues than their female counterparts thus skewing the numbers. As far as the medical proof of PTSD, it is becoming irrefutable as pre-test, post test data of brain scans is conducted. We are seeing changes a decrease in the mass of the hippocampus post stressful event which leads to poor emotional regulation, memory difficulty, etc. Now that they are able to target how the brain is effected, the good news is that the guess work on treatment decreases and they should be able to create more effective interventions.
 
therapist, thank you for your input. I really do think this has spawned another whole list of posts that can be created on the subject. Causes and treatment can demystify the situation for all involved, soldiers and families alike. We definitely need to get past the "hocus pocus" aspect of the condition and into the biological reality. Some Soldiers' Mom...I understand estimations and projections, I just don't think the GOA, VA, budgeting processes is good at it unless they are basing it on what they feel are "real" numbers. For instance "these are actual percentages seen in this time frame" extrapolate to create expectations. I don't think they are working off of Vietnam period numbers at all, but numbers within the current war period. That is my expectation based on working with the government over Medicare and Medicaid projections, utilization and funds. They are hard wired for hard numbers and they do not like to deviate from that. Further, in 2005, they could not have known that we would surge another 30k plus rotations since it wasn't planned until 2006. Not that it is a defense, just working with the "hard number" aspects. Then they try to factor in that many who serve go more than once as if this reduces the number that might need services, when it actually increases the probability. As for the "inpatient" bed situation, I am torn over it. I think that some numbers do show that an increase is needed. yet, there is reluctance to make "inpatient" the basis for treatment when it is a lot about re-adjustment to the outside world. Some of this is twisted up with trying to create the right processes for treatment and therapy. But, I'll agree with you in the long run, it needs increased. It's why I am perturbed about the hold up on the VA budgeting. Many additional beds were going to be added and some more outside programs with this budget. No one can even begin to go forward without the budget approved. That's a problem.
 
kat-missouri... just by way of info, soldiers in excess of the 13 beds requiring intensive (in patient) hospital treatment at benning are sent to a civilian facility in columbus, ga... and there are anywhere from 50-75 soldiers at that facility 365 days a year with a constant population (which includes those soldiers who have found basic training too stressful)... and the rumor is that the cost is near $1000 PER DAY PER SOLDIER... but at least the approved "head count" and payroll for Martin Army Hosp. is on budget.