Treating the Mental Wounds of War

As troops come home, can the U.S. handle their psychological health?

Published on November 12, 2012by Elaine Meyer

As an influx of troops return home from the American Wars in Iraq and Afghanistan, the U.S. government is making an unprecedented effort to address their mental health needs, a dramatic shift from previous wars when the psychiatric fallout of combat was often unacknowledged or met with skepticism.

Of the over 2.6 million active-duty, National Guard, and reserve members who have been deployed in the wars in Iraq and Afghanistan, an estimated 13 to 20 percent have or might develop post-traumatic stress disorder (PTSD), the psychiatric condition most commonly associated with combat.

The wars in the Middle East mark the first time in the nation’s history that there has been a diagnosis of PTSD in place for troops returning from sustained ground combat. However, advocates and health experts warn that it still may be difficult to treat, pointing to a culture in which soldiers feel shame or embarrassment about seeking treatment and to a mental health infrastructure that is still struggling to meet troops’ needs.

PTSD is a “severe anxiety disorder” that is seen in people who have witnessed a traumatic event such as combat, a terrorist attack or sexual abuse. Those with PTSD often relive the event in nightmares or flashbacks while at the same time attempting to numb themselves emotionally to pain. They may react disproportionately to things that startle them and contend with uncontrolled outbursts of anger.

If left untreated, PTSD can take a significant toll on the lives of those with the disorder, their families, and their communities. In its worst forms, it can lead to alcoholism, marital strife, problems holding a job, and long term physical problems, including erectile dysfunction, unprovoked seizures, dementia and decline in neurocognitive function.

Although psychiatrists and others point to symptoms of the disorder in works as old as the Iliad and Shakespeare plays, PTSD was not officially recognized by “the bible of psychiatry,” the Diagnostic Statistics Manual of Mental Disorders, until the publication of its third edition in 1980.

“The diagnosis came to being in the Vietnam War,” says Dr. Bruce Dohrenwend, professor of epidemiology at Columbia University’s Mailman School of Public Health, who studies the prevalence of PTSD in wars.

It was during the war that returning troops began to agitate for an official psychiatric diagnosis and demand government-supported treatment for it, accusing society of turning a blind eye to their mental anguish from war. The symptoms that today comprise PTSD were then known by the much less serious term “combat fatigue.”

Even once it became official in the Diagnostic Statistics Manual many in and outside the military were skeptical of its legitimacy, pointing to conflicting reports from government agencies of PTSD’s prevalence and questioning whether veterans would make fraudulent claims for treatment.

The controversy was mostly settled in 2006, with the publication of a rigorous study by Dr. Dohrenwend and his colleagues, which found that about 19 percent of Vietnam veterans had at some point developed PTSD related to the war and few cases were fraudulent. Also bolstering the case for its legitimacy has been scientists’ identification of physiological reactions to trauma, including neuroanatomical and endocrinological changes.

The institutionalization of PTSD has changed how people are treated by society and mental health professionals, not as inherently weak but rather as marked by traumatic event.

Yet it has taken longer for this shift to happen in the military. Troops are often fearful of seeking help, according to a report released this past summer by the Institute of Medicine (IOM), which was commissioned by Congress to study the adequacy of mental health programs in the military and for veterans.

“Because of concerns about stigma and appearing weak, service members often ignore or self-manage their pain until their condition impairs their ability to function and puts others at risk,” the IOM report says.

Many veterans are also eager to avoid anything that would delay their returning home.

As one veteran quoted in the IOM report put it: “I lied on my post-deployment forms. Whatever got me back to my family quicker.”

Another fear is having to request time off for treatment.

“Although at the highest military level, the officers say, ‘we’re all for it, we’re supportive,’ at the NCO level, which is the commander level, it’s difficult because you’re losing one of your men or women to this treatment,” says Dr. Sandro Galea, chair of the Columbia University Department of Epidemiology and of the committee that published the IOM report.

Veterans and active duty members are also wary of being perceived as sick, disordered, and unstable.

Even referring to the experience of PTSD as a disorder is stigmatizing for veterans, says Dr. Charles Hoge a retired army colonel and former director of a Walter Reed Army Institute of Research program on the psychological and neurological consequences of the Iraq and Afghanistan wars.

To truly help members of the military deal with PTSD, society needs to re-think the way the disorder is perceived, he says.

“Virtually every reaction that mental health professionals label a ‘symptom,’ and which indeed can cause havoc in your life after returning home from combat, is an essential survival skill in the war zone. I don’t think that paradox has been sufficiently grappled with,” he says in his 2010 book Once a Warrior, Always a Warrior: Navigating the Transition from Combat to Home.

Acknowledging the toll of PTSD on members of the military and their families, the U.S. Congress has taken the unprecedented step of appropriating significant resources to improve mental health services, including increasing medical staff, instituting training programs, developing clinical practice guidelines, and increasing screening throughout a soldier’s career.

Some new models of care and treatment for PTSD have been developed to respond to the unique experience of soldiers.

Dr. Charles Engel, an army colonel and psychiatric epidemiologist has since 2004 directed the U.S. Department of Defense’s Re-Engineering Systems of Primary Care Treatment in the Military in response to research showing that veterans were not seeking out psychological care the way they might seek care for a broken ankle or chronic aches and pains.

The program is intended to train primary care providers to be on the look-out for signs of PTSD and then refer the individual to psychiatric care.

“We take away the stigma of soldiers having to go and see a psychologist or a behavioral health person,” Engel has said about the program.

The Veterans Administration has also tried to make care more available by mandating that all veterans treated for PTSD have access to either prolonged exposure therapy or cognitive processing therapy.

However, there are no treatments that have been proven overwhelmingly effective.

“The most effective treatment for PTSD—prolonged exposure—which is really effective, can help no more than half the population with PTSD. The problem with drugs like [selective serotonin reuptake inhibitors] is even worse. There are reports suggesting medications are not effective at all when taken by themselves,” says Dr. Yuval Neria, professor of clinical psychiatry and director of Columbia’s Trauma and PTSD program.

A combination of medication and therapy is more effective, he adds.

Available therapy, much of it untested, often varies from military base to military base, according to the IOM report. Many emerging treatments, such as couple and family therapy, animal-assisted therapy, and complementary and alternative medicine programs like yoga and acupuncture, do not have a “substantial evidence base by which to judge their efficacy,” according to the IOM report, though that does not mean they are not effective for some.

The IOM committee recommends studying these various forms of therapy to find out which are efficacious in order to standardize available treatment across bases.

Even with these therapies in place, people have a hard time seeking and remaining in treatment because of wait lists and difficulty fitting a treatment schedule around one’s job or other obligations. Of the 40 percent of those who screen positive for PTSD symptoms and have been referred to care, only 65 percent  get help.

“I think that the number one problem with treatment is not that we don’t have effective techniques. We have effective techniques,” says Dr. Hoge. “The number one problem is people not staying in treatment.”