Hidden Combat Wounds: Extensive, Deadly, Costly

Psychiatric TimesPsychiatric Times Vol 25 No 1
Volume 25
Issue 1

The U.S. Departments of Defense and Veterans Affairs have developed protocols for assessing soldiers returning from combat operations in Iraq and Afghanistan. With data showing that many veterans do not show psychiatric symptoms until three to six months after returning home, a new post-deployment assessment was created and is ready to roll out. In the meantime, a jump in PTSD cases led to an internal review at the VA.

No Purple Hearts are awarded for the often hidden wounds of posttraumaticstress disorder, but ultimately those wounds can be deadly--linked to suicides, accidentsand, over the long term, increased risk of death from cardiovascular diseasesand cancer (Boscarino, 2005). Aware of the risks,government agencies, veterans groups and the U.S. Congress in recent monthshave grabbled with identification, treatment and benefit issues for the growingnumber 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 sinceVietnam," according to one report (Robinson, 2004). The National VietnamVeterans' Readjustment Survey (from 1986 to 1988) found that 15.2% of male and8.5% of female Vietnam War veterans suffered from current PTSD (Schlenger et al., 1992).

In Iraq and Afghanistan, the visible manifestations of themental health toll of U.S.combat operations include suicides and medical evacuations. Official Armystatistics from March 19, 2003, through July 31, 2005, indicated that 6.4% ofthe 19,801 soldiers evacuated from Iraqand 7.2% of the 1,733 evacuated from Afghanistan had psychiatricproblems. Among the 1,275 psychiatric disorder evacuations from Iraq, 596 werefor depression, 109 for suicidal ideation and 91 for PTSD. There have been 53suicides among service members fighting in Iraq and nine among those fightingin 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, occurafter troops return home. One highly publicized case was that of Marinereservist Jeffrey Lucey, deployed to Iraq for fivemonths. When he returned home to Belchertown, Mass., he began drinking heavilyand suffering from insomnia, night sweats, hallucinations and panic attacks. Hereceived treatment at a Veterans Affairs facility, where he was described byone physician as having PTSD, depression with psychotic features, suicidalideation and acute alcohol intoxication. One day, Lucey'sfather came home to find his son had hung himself in the cellar. On Lucey's bed were the dog tags of two unarmed Iraqiprisoners 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 Iraqreturned home and committed suicide shortly thereafter.

Other statistics and surveys are equally revealing. The Figure illustrates medical surveillance data obtained from the Army's Center for Health Promotion and Preventive Medicine on health assessmentresponses completed between January and August of 2005 by 193,131 troopsreturning from Operation Iraqi Freedom (OIF). Col. Charles Hoge, M.D., chief of psychiatry and behavior services at the Walter Reed ArmyInstitute of Research, told the U.S. House Committee on Veterans Affairs' Health Subcommittee last July that 19% to 21% of troops who have returned fromcombat deployments meet criteria for PTSD, depression or anxiety. Of these, 15%to 17% of troops who served in Iraqand 6% of those who served in Afghanistanhad PTSD symptoms when surveyed three to 12 months after their deployments. Ingeneral, PTSD rates were highest among units that served deployments of 12months 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 ofmental health problems among members of three Army units and one Marine Corpsunit before deployment or three to four months after returning from deploymentto Iraq or Afghanistan.The rates of PTSD were significantly higher after combat duty in Iraq (18.0% forArmy units and 19.9% for the Marine group) than before deployment (9.4%). Therewas 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 dutypersonnel from seeking mental health care even when they recognized theseverity of their psychiatric problems.

A survey of 1,300 paratroopers three months after they had returned to Fort Bragg, N.C., afterspending a year in Iraqfound that 17.4% of the soldiers had PTSD symptoms (Associated Press, 2004). Inanother study comparing the mental health of men and women in violence-pronejobs (e.g., medics, mechanics, drivers) in Iraq, researchers found that 11% ofthe men and 12% of the women had PTSD symptoms when they were screened threemonths 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 theirfamilies testified before Congress in July 2005 about efforts to identify andtreat service members experiencing mental health problems. Every year, servicepersonnel are screened for mental health problems during a preventive healthassessment. Prior to deployment, they receive another screening. Those withunremitting mental health disorders are not deployed, William Winkenwerder Jr., M.D., M.B.A., assistant secretary of defensefor health affairs, told the House Subcommittee on Military Personnel. Thosefor whom a mental health condition has resolved are permitted to stay onmaintenance 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 mayalso 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'sDeployment Health Support, explained that just as service members are leavingthe 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 "thatasks them about a full spectrum of medical symptomatology,both physical and mental health, as well as environmental concerns they mayhave." That assessment includes a face-to-face discussion with a medicalprovider in the military (e.g., physician, nurse practitioner or physicianassistant) and documentation of the individual's responses to the healthassessment questions.

"The health care provider who goes over the assessment with the individualdoes not make a diagnosis but refers the individual to clinical areas forfurther evaluation and workup to determine if, in fact, there is a diagnosisbecause of the symptoms or concerns," Kilpatrick continued. For examplesymptoms such as anxiety, sleep problems and anger management issues may beindicative of possible PTSD. In testimony before the House Veterans AffairsCommittee in July 2005, Kilpatrick noted, "Of the 138,000 troops who returnedin 2004 and received a post-deployment health assessment, 16% have beenreferred to mental health providers for further evaluation."

Individuals with mental health referrals have options. "They can go to thebase support area that may have counselors and chaplains to deal with it. Theycan also go to our primary care facilities, and many of those facilities areenhanced with behavioral health specialists, such as psychologists andpsychiatrists, working with a primary care physician," Kilpatrick said.Additionally, they could go to a mental health clinic, where they would see apsychologist or psychiatrist.

In testimony before the House Subcommittee on Military Personnel in October2005, Winkenwerder recognized that "no one who goesto war remains unchanged." In response, he announced that DoD is instituting a short interview questionnaire (Post-DeploymentHealth Reassessment [PDHRA]) to be filled out by all service members, includingthose serving in the Reserves or National Guard, three to six months after theyreturn home. The assessment is designed to identify health concerns and conditionsthat may have emerged following the service member's most recent deployment andto determine the types of information and assistance the individual would liketo have. A credentialed health care provider (e.g., physician, physicianassistant) reviews the assessment with the service member, discusses healthconcerns and makes referrals when needed. Active duty members can be referredto their primary care provider or mental health community support. Members ofthe Reserves or National Guard and separated veterans are referred to TRICARE,the DoD's worldwide healthcare program, or the VA.

The PDHRA is scheduled to be used broadly by January, according toKilpatrick. It was initiated because the Army looked at the mental healthstressors troops were experiencing while deployed and after they got home, andits research data indicated that "at the three- to six-month period people weresubscribing to more symptomatology than they hadeither 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 assessmentsused questions from standardized, validated survey instruments, Kilpatrick toldPT. The PDHRA includes screens foranxiety, PTSD symptoms, interpersonal conflict, alcohol abuse and depression.Implementation of the program also has involved leadership and clinicianeducation 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 Arkansasand for the Army Reserve with the 88th Regional Readiness Command with units insix states. In the preliminary trials at active duty sites, researchers foundthat the percentage of returning troops referred for follow-up medical ormental health treatment was between 30% and 35%, and "it is a 50/50 splitbetween mental/behavioral health and the physical health problems," accordingto Kilpatrick.

The goal of both the post-deployment assessment and reassessment is to getservice members early access to health care, Kilpatrick said, therebyeliminating the risk, for example, of PTSD symptoms developing into chronicPTSD. If care is needed, military and VA providers use jointly developedclinical practice guidelines for acute stress, PTSD, depression, substance usedisorders and other health concerns.

Importance of Early Intervention

Studies of Vietnam War veterans underscore the importance of early treatmentof PTSD symptoms to prevent emergence of other psychiatric and medicaldisorders. One recent study concluded that Vietnam War veterans with PTSD maybe at increased risk of death (Boscarino, 2005).

The national study examined the causes of death among 15,288 male U.S. Armyveterans 16 years after they had completed a telephone health survey, whichincluded questions related to PTSD symptoms and substance abuse, and 30 yearsafter their military service. The study confirmed that PTSD was associated withan adjusted all-cause mortality for both Vietnam Warera and theater veterans. For PTSD-positive theater vets, the postwar mortalityfor all-cause, cardiovascular, cancer and external causes (e.g., deaths fromsuicides, homicides, accidents) was about twice as high as that of Vietnam Warveterans without PTSD.

The study was not a sample of patients who show up at VA hospitals, "it wasa random sample of all U.S. Army veterans, some of whom got PTSD from Vietnamand some of whom got PTSD from life, and they die after a significant period oftime," the study's author, Joseph Boscarino, Ph.D.,told PT. The study results point tothe importance of prevention and treatment, Boscarinonoted.

"If we can prevent or reduce the anxiety levels, we can prevent thelong-term psychological sequelae ... and we can alsoreduce [physical] disease outcomes," he said. "We know there are effectivetreatments for PTSD, the combination therapies are effective and the drugtherapies are effective. Cognitive-behavioral therapy appears to be one of themost cost-effective methods, in my opinion, but there are other methods outthere that have been effective."

Boscarino acknowledged that various institutionsmight be concerned about the cost, compensation and disability issues connectedwith PTSD's link to medical conditions. "I got a callfrom a military person who said this kind of study is going to affect thenation's defense budget. I responded that it might be the case, but we have anobligation to the men and women in the Armed Forces. We can prevent [PTSD] fromhappening and if we do so, we will have lower costs, better quality of life andmore productivity."

Boscarino also believes that because of efforts bythe DoD and VA, outcomesamong troops experiencing PTSD who are returning from Iraq and Afghanistan may be much better thanthose for Vietnam War veterans. "When I was doing my postdoctoral fellowship atthe West Haven [Connecticut] VA Hospital in the late 1970s,they were diagnosing many of the combat veterans as being alcoholic andpsychotic. They probably were, but it likely had a lot to do with theirundiagnosed PTSD," he said, explaining that the PTSD diagnosis was firstincluded in the DSM-IIIin 1980. TheVA, he said, now has the tools to screen, diagnose, refer and treat PTSD thatit did not have 30 and 40 years ago.

Is the VA Ready?

In September 2004, the U.S. Government Accountability Office (GAO) raisedquestions as to whether the VA could meet an increase in demand for PTSDservices at its facilities, emphasizing, "The VA does not have a count of the totalnumber of veterans currently receiving PTSD services at its medical facilitiesand Vet Centers." It also pointed out that at six VA facilities investigatorsvisited, the staff said they were able to keep up with current number ofveterans seeking PTSD services, but might not be able to meet an increase indemand (GAO, 2004).

One year later, Gordon H. Mansfield, deputy secretary of the VA, testifiedbefore the House Committee on Veterans' Affairs, "The VA is aware that therehas been particular interest about mental health issues among OEF [OperationEnduring 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 VAhas the programs and resources to meet the mental health needs of returning OEFand OIF veterans. Second, in regard to PTSD among OEF and OIF veterans, I wantto assure you that the PTSD workload that we have seen in these veterans hasbeen only a small percentage of our overall PTSD workload. In [fiscal year]2004, we saw approximately 279,000 patients at VA health care facilities forPTSD and 63,000 in Vet Centers. Our latest data on OEF and OIF veteransindicate that as of February 2005, approximately 12,300 of these veterans seenas patients at [VA medical centers] VAMCs carried anICD-9 code corresponding to PTSD. It is important to note, however, that thisrepresents approximately 4.5% to 5% of VA's overall PTSD population.Additionally, more than 3,500 veterans received services for PTSD through ourVet Centers. Allowing for those who have received services at both VAMCs and Vet Centers, a total of approximately 14,600 individualOEF/OIF veterans had been seen with actual or potential PTSD at VA facilitiesfollowing their return from Iraqor 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 itsInspector General (IG)'s report, said it would audit files of 72,000 veteranswho were receiving full disability benefits for PTSD alone or in combinationwith other conditions. That announcement generated a widespread backlash. Someveterans groups protested that the review of PTSD cases was an excuse to cutbenefits for older veterans and toughen qualifications for future ones. TheSenate passed an amendment to a military/VA appropriation bill seeking torestrict the audit. Press reports linked one man's suicide to the impendingreview (Benjamin, 2005). In November 2005, the VA dropped its full-scale auditplans, stating that most of the problems came from administrative errors andnot fraud.

The focus on VA benefits for PTSD originally grew out of complaints fromveterans about regional inequities in disability ratings and payments. Forexample, less than 3% of Illinois' disabledveterans are rated 100% disabled for PTSD, as compared to almost 13% in New Mexico (VA Office ofthe IG, 2005). Because of those complaints, in May 2005 the VA InspectorGeneral examined the files of 2,100 randomly selected veterans with PTSDdisability ratings. It found that 527 (25%) lacked documents to verify that atraumatic service-connected incident occurred before compensation benefits weregranted. That 25% error rate equates to $860.2 million in questionablecompensation payments in FY 2004, the IG report said. The IG also cited adramatic increase in veterans filing for disability compensation for PTSD since1999 (Table).

After the VA conducted its own review of the 2,100 cases cited in the IG's report, VA Secretary R. James Nicholson released astatement saying, "The problems with these files appear to be administrative innature, such as missing documents, and not fraud. In the absence of evidence offraud, we're not going to put our veterans through the anxiety of a widespreadreview of their disability claims." Instead, the VA plans to improve itstraining for personnel who handle disability claims and toughen administrativeoversight.

"Not all combat wounds are caused by bullets and shrapnel," Nicholson said. "Wehave a commitment to ensure veterans with PTSD receive compassionate,world-class health care and appropriate disability compensation determinations."




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