After a rather intense two months of long-form work, I'm so far behind on blogging I don't know where to start. Forget the last two months and move on? Probably the best move. But beforehand, I want to note a few developments along major lines of interest. I'll start with PTSD.
Amid the stagnation on combat PTSD, the summer brought news of new programs from the UK and US militaries aimed to answer the call for more effective treatment for rising rates reported in vets of the wars in Iraq and Afghanistan. Mind Hacks was one of several blogs to report and comment on a new Royal Marine program called TRiM, or Trauma Risk Management. The Times and other outlets covered a program being launched this October by the US Dept of Defense.
I'm not sure how much I have to add to these, other than noting (as others have) that neither of these programs is peer-reviewed (though they're based roughly on peer-reviewed methods), and neither should be seen as anything approaching a full solution. I'm glad to see these programs and expect they'll help some soldiers. But not many, I fear, at least in the US, for the program proposed has no real hope of overcoming the other problem with our response to war-related distress here.
And that problem (again, in the US) is that neither the PTSD establishment nor the VA is seriously trying to answer -- and indeed, they are trying to ignore -- the two obvious questions that should be asked:
1. Why are rates in US soldiers and vets higher than in other countries?
2. Why is the US combat vet population the only one in which PTSD rates and diagnoses increase as time passes after service? (Civilians studies have repeatedly shown that likelihood of developing PTSD decreases steadily and significantly as time passes after the traumatic event. Only in US combat veterans does likelihood of reported symptoms and diagnosis increase with time.)
Those are the two great anomalies of the US experience -- and they scarcely go examined in most papers and statements, much less VA or DOD policy or practice. (A recent paper out of the UK does look at these issues.) Sometimes the researchers do backflips to try to try to answer those questions without mentioning the possibility that something in our culture or the VA's response could be contributing to the problem. Here's Karen Seal, lead author on a study published in the Am J of Public Health a few weeks ago that found rates increasing with time in vets of our wars in Iraq & Afghanistan:
Dr. Seal attributed the rising number of diagnoses to several factors: repeat deployments; the perilous and confusing nature of war in Iraq and Afghanistan, where there are no defined front lines; growing public awareness of PTSD; unsteady public support for the wars; and reduced troop morale. She said that "waning public support and lower morale among troops may predispose returning veterans to mental health problems, as occurred during the Vietnam era."
Dr. Seal said often it takes more than a year for symptoms of PTSD to appear and diagnosis to be made. She said, "The longer we can work with a veteran in the system, the more likely there will be more diagnoses over time. It sometimes takes time, given the stigma associated with mental illness, before we are able to break through the barriers and have patients tell us what is happening."
The key sentence here is ""The longer we can work with a veteran in the system, the more likely there will be more diagnoses over time.'" The many ways in which the VA's response -- both in the clinic and in its absurd disability structure -- can discourage healing and encourage a faulty diagnosis of PTSD are well-documented. I recently had an Army captain buttonhole me and volunteer that the entire response to returning soldiers feeling any sort of distress all but begs them to declare themselves traumatized rather than troubled. A leading Australian PTSD researcher who worked for 6 weeks with returning US vets at Walter Reed said essentially the same thing. Yet the iatrogenic powers of such a response go ignored in Seal's attempt to explain why a vet's chance of diagnosis increases with time spent in the care of the VA.
Meanwhile, as I've noted before, both the press and the military continue to ignore a study suggesting that we could cut PTSD rates in half by simply not deploying the 15% of soldiers who score lowest on measure of overall health we're already giving them.
We can throw all the money we want at PTSD and continue to hire lots of therapists at the VA. But we won't get anywhere until we start asking why the PTSD problem takes such a unique course here in the U.S.
Update 9/3/09: The speculative answers to these questions (i.e., why rates apparently so uniquely high in US soldiers) in the comments make me fear I was too subtle. Much of the answer is in the way this country, and the VA, responds to combat-related stress. For an exploration of that answer, see my Scientific American story "The PTSD Trap" looks at the issue in depth. I'll soon be posting a longer version here.
What nations is the US being compared to in its incidence of PTSD? Clearly one can estimate the morale of a nation's soldier from the morale of a nation.
How much difference is there between the definitions used to diagnose PTSD in different nations?
If there's any truth to the claim that PTSD varies less by what the victim experiences than by what the victim does, then part of the US anomaly may derive from the US military committing more atrocities, and/or preparing soldiers more poorly for combat (in terms of expectations, training in how not to do the wrong things, and recovery afterwards).
Alleged PTSD and suicide rates are linked in the media to OIF/OEF.
There all sorts of data issues to consider when talking about comparing population shifts.
1. 32,000 civilians commit suicide each year, while hundreds of thousands attempt it. Civilian suicide rates vary widely by age, gender, and race so population-level data is highly lumpy. 73% of suicides are Caucasian males (I'd have to check but this might be a bimodal distribution by age). Suicide is a close tie as 2nd cause of death with firearms for 18-24 y/o males (cars being #1).
2. The military is a demographically unique population with fairly significant shifts (% married, etc.). See 'Strengthening the Validity of Population-Based Suicide Rate Comparisons: An Illustration Using U.S. Military and Civilian Data'
Author(s): Karen M. Eaton, MS 1 | Stephen C. Messer, PhD 2 | Abigail L. Garvey Wilson, MPH 3 | Charles W. Hoge, MD 4
3. The military has close to real-time annual data. The CDC formal data lags well behind with latest being 2005. CDC was documenting annual increases in civilian suicide behaviors in prior years.
4. The military force structure has increased since 2001. Alleging increase in suicide numbers must be compared with population shifts. The military infrastructure is constantly evolving so what each of us believes to be true based on our experiences may have shifted. In RVN increasing the MWR resources dramatically affected the desertion rate, etc. which gets at traditional military issues of large young populations in isolated surroundings.
5. There is a lot of suicide research addressing risk taking, impulsiveness, and alcohol use.
6. The post-suicide 'psychological autopsy' based on verbal hx analyses identify traditional pre-suicide issues: relationship break-ups, money problems, job issues, etc. The AF decreased its suicide rate by maintaining its training program frequency (when the training stopped the rate returned)
7. We know several physiological things to be true:
a. Alcohol washes b vitamins out of the body and heavy drinkers may not eat a balanced diet. Pellagra, a severe b vitamin deficiency causing psychosis, still exists in alcoholic populations (it was rampant in the US in the 30-40s due to bad diets).
b. Other nutritional deficiencies affect thinking and mood (see McClung on iron deficiency in BCT).
c. Adverse Childhood Experiences (CDC ACE study; see also Harlow studies) literally affect brain development. This population is characterized by high-risk behaviors. This population may join the military at higher rates (see Resnick).
d. The extensive WRAIR sleep deprivation research shows how sleep loss seriously affects thinking and feeling (we know that alcohol abuse interferes with sleep as well) and the massive data re Combat Exhaustion in WWII (most got better after rest and food).
It might be interesting to see if the physical autopsy results are included in the psychological autopsy.
8. Therefore, I'm not sure that bad experiences or bad memories "cause" suicide/PTSD or whether a fifth of Jack at 0400 causes bad memories, PTSD, and suicide. Hard to point out which single event in a cascade of events in the downward spiral is the "cause."
9. We cannot ignore Compensation Neurosis. Folks in WWII who got to the disability system became untreatable. The same is true today in TDRL folks. Exactly how does money 'treat' PTSD? Does the VA independently verify claims? As one guy I was working with said:"This bad back earns me $700 a month and it's not getting any better."
10. Please be careful with screening data. Screening out 15% of approx 400,000 physicals would disqualify 60,000 applicants. Correlations like this lack specificity.
Analyses are one thing. Solutions are another.
1. The probability of getting the Army's small suicide numbers down to say the AF rate (11/100,000) is close to impossible, but can get closer. 120 in 1.1M is a needle-haystack.
2. It is worth exploring solutions or future directions:
a. The military has no equivalent of the CDC NAHANES health monitoring program. Give everybody, or a sample, at entry a comprehensive health assessment:
a1. A modified comprehensive blood chemistry. Should evaluate exactly what gets added: vit D, RBC exam, bone density, EPA/AA ratio, etc. Very high stress fracture rates are associated with entry osteopenia.
a2. Paper & Pencil instruments. The Success Profiler (they have a resilience module and a good research bibliography). Look at data mining to bring in psych treatment hx from insurance databases. Rather focus on skill sets than relatively rare pathology.
a3. Look at the Kaiser-Permanentee ACE screen (K-P reduced its healthcare costs by 30% by looking for ACE background)? Brain scans?
a4. This could be done as a pilot under a hybrid MEPCOM-DODMERB model (use local regional hospitals as contract physical givers with MEPCOM docs doing PUHLES; ASVAB to computer learning centers). Screen out or treat in? Collect data first then decide.
b. Conduct a research program to use a Warrior Bar or the Warrior Supplement Pak to fix identified malnutrition problems. USARIEM documents iron and b vitamin deficiencies in IET (see McClung). Lappe and others document calcium-D deficiencies. Nutritional deficiencies affect thinking and mood.
c. Add an alcohol screen into the Drug Screen program. Alcoholics have enlarged RBC, etc.
d. Ensure adequate MWR resources are up and running. Ensure some contact is made with both Soldiers and families at some frequency. Again could be a pilot. Boredom, loneliness, and booze are the enemy. Everybody (Soldiers and families) moving to a post has to take the bus tour taking them around to see Army resources. Include problem solving linked to Army resource agencies in the Army training-educations systems.
e. Implement combat-style Chaplain interventions in IET and in units. Chaplains are highly effective. Watch that USMC chaplain video; amazing. This silly rule about no mandatory religious services is crap; call it group values training. A little singing, rock & roll, expressing common feelings, expressing resilience and hope, etc. go a loong way.
f. Implement R&R policies in war zones. Sleep/CONOPS Risk Mgmt planning (shift work has well-known effects). Mini-local breaks at say 3 months. Mandatory 2 week break to Australia at 6 months. Pay for families to join them. Buy a hotel (Army already owns several). Whatever it takes. Mandatory 2 week end of tour break with comp blood chemistry. Sleep them, feed them, IV serum rebalancing, etc. It's Combat Exhaustion, not PTSD.
g. Implement a multi-disciplinary comprehensive rehabilitation doctrine ICW VA. Involve the families. Boredom, loneliness, and booze are the enemies. Nobody sits by themselves in a room for days waiting for an appointment. MWR, Education, Voc Rehab, Med, PT, OT, Psych/Soc Wk, etc. get aggressively engaged. Idle hands....
h. Never ever pay folks for PTSD. How does money fix a disease? Spend more money on rehab, education, job retraining, etc. Whatever. But NEVER pay folks to be sick; they'll never get better. Maybe put VA LNO at discharge/transfer points? Right now we discharge folks on a wing and a prayer.
i. Ensure a validated Battlemind/Resilience/Wellness/CONOPS program is in NCOES/WOES/OES as appropriate by level.
How about because the trauma doesn't end when you become a civilian and have health problems?
You are the guy who used a study of treatment seeking rich people at Mclean Hopsital to prove that treatment avoiding veterans are overdiagnosed with PTSD right?
All the studies are on treatment seeking people, vet or not.
The reason other countries don't have rising rates of PTSD is that they don't even look for it.
For instance anyone in the UK who was stationed in Northern Ireland gets short shrift from the government if he tries to get help for PTSD. They believe it doesn't exist. You can't find it if it doesn't exist. Or if you refuse to look.
"Why is the US combat vet population the only one in which PTSD rates and diagnoses increase as time passes after service?" Because we are the only ones who look for them, and even that was being massively underfunded as the length of time since the last war increased.
There are people who actually look at what is, and then there are people who can't face the reality of combat trauma and want to delude themselves into thinking that it doesn't exist. Too bad you are on that side.
The PTSD establishment... ha ha ha.
You do know about DSMII?
About psychiatrists who talked to veterans of Vietnam being told they were overly emotional and shouldn't get involved. No I don't think you do.
I forgot to mention one other concern of mine. Military psychiatrists have an inherent conflict of interest, since their job is to get the service members back to combat, which is not necessarily the best thing for the patient/person...
Israeli studies show that a soldier who has PTSD as the result of one war will get it faster and worse in the next war. I assume this applies to multiple deployments too.
I have been at conferences where the military programs are presented. They deal in denial, because, for the best of reasons, they want to believe that they can prevent, control and cure PTSD.
I've also seen presentations on "evidence-based" treatments which have nice high effectiveness rates with a one year follow up. Unfortunately they don't fix everyone, so do you just throw away the ones this treatment doesn't help, or do you search for what helps this individual? And a one year follow up proves that it worked for a year. I want to see 20 and 50 year follow ups.
Archibald and Tuddenham (1965) found that 20 years after WWII veterans were still experiencing nightmares, anxiety attacks, etc...
PTSD risk does not rise, but the army likes to pretend there is not a problem, and therefore order soldiers not to get treated. As such after they are out, they are then allowed access to possible treatment, but with the downside that the problems would likely be far more mild if they were not so often ordered to not get early treatment.
I say this as a veteran, my unit actually ordered me to not go to my mental health appointments after my PTSD caused a suicide attempt. The VA system is not much better, but at least there is no bullying involved.