Daunting Disability: PTSD, Commentary

Up to 29 percent of Iraq veterans will likely suffer from PTSD.

BY CECILIA CAPUZZI SIMON, The Philadelphia Inquirer, February 19, 2007

Missing legs, arms, multiple amputations. These injuries are the visual emblems of the war in Iraq. But it is the invisible psychological harm--primarily post-traumatic stress disorder--that is the most pervasive and pernicious injury from this war and that is emerging as its signature disability. Veterans' advocates say it is the number-one issue facing soldiers returning from Iraq and Afghanistan.

The scope of the problem is daunting: 35 percent of Iraq veterans sought psychological counseling within a year of coming home, according to the Department of Defense. If the trend continues, half a million could need mental-health services by 2008. The Defense Department estimates that between 15 percent and 29 percent of Iraq veterans will suffer from PTSD, characterized by flashbacks of the traumatic event, nightmares, anxiety, and social withdrawal.  It often takes months or years to manifest. Meanwhile, it takes a physical toll: diarrhea, vomiting, sleeplessness, panic attacks and substance abuse. A new study shows that veterans with PTSD are at a greater risk of heart attack. Research had already concluded they suffer more autoimmune diseases.

Are we prepared for what Charles Figley of the Traumatology Institute at Florida State University calls a "tsunami" of mental-health problems "headed our way" as a result of the war? He and other trauma experts say "no."

Consider the situation at the Veterans Administration, one of the largest providers of PTSD treatment: 20,000 cases of post-combat stress last year--more than six times the number expected (despite possible shortfalls in screening). Many VA PTSD programs are too full to accept new patients.

Veterans are advocating for improved screening--including a face-to-face interview with a mental-health professional for every returning troop, to reduce stigma and catch more at risk.

The military appears to be trying. Every returning service member must fill out a health assessment, which screens for risk of PTSD. But studies cast doubt on the efficacy of such screens, and the military doesn't put much stock in their results. Neither do many soldiers take them seriously, fearing that a positive PTSD screen will hold them up in Iraq for evaluation. Of the 5 percent of troops who did screen positive, just 22 percent were referred for mental-health consultation, says a government report.

For those identified, what treatment can they expect? It depends. The Defense Department and VA have no standardized treatments. They do recommend four evidence-based psychotherapies, but providers are not required to use them. A survey of VA and Defense mental-health providers conducted by VA psychologist Steven Silver found that 90 percent had no training in the four therapies. Many said they did not treat PTSD at all because they did not know how.

The obstacles are not only institutional. Veterans with PTSD typically don't seek help until 10 years after their war. Meanwhile, the condition becomes chronic and resistant to treatment. Many prefer to avoid therapy that is difficult, requires recounting the trauma, or risks personal judgment of wartime acts for which they feel ashamed.

Fear of being treated differently by leaders, worry that military careers will be compromised, negative perceptions about the efficacy of treatment, distrust of providers, and difficulty scheduling appointments are all key reasons service members avoid mental-health assistance from government institutions, according to Defense Department research. Of 13 percent of Iraq soldiers diagnosed with PTSD in one study, 80 percent recognized their problem, but only 40 percent said they wanted help--a little more than half of those got it.

Iraq veterans are not different from other veterans in their emotional reaction to war, but the war in Iraq is unique in the environmental, political and cultural factors that, as one veteran says, "makes it the perfect festering pot for psychological damage."

Many factors--guerrilla warfare, contentious domestic politics, eroded public support for the war, lack of clear mission, and the resulting lack of meaning in soldiers' wartime sacrifices--are reminiscent of Vietnam, in which nearly a third suffered PTSD, according to  1998 study.

We've advanced greatly since the 1970s in understanding mental illness and have broken down much of its stigma. Still, PTSD numbers from Iraq seem headed in the direction of those from Vietnam. PTSD can be staved off if trauma is treated early; for those who suffer full-blown PTSD, effective therapies can mitigate its symptoms or cure it. It takes training, funding and openness to the mind's healing potential. We may have been surprised by the number of PTSD cases that came out of Vietnam; we will have no excuse if it happens again.

"Fear of being treated differently by leaders, worry that military careers will be compromised, and distrust of providers are key reasons service members avoid mental health assistance."