I recently received an article from my friend, Nick Warren, concerning a study of the mental health problems of returning Iraq War veterans, which goes a long way towards accounting for “why the Department of Defense’s mental health system is overwhelmed”. The article follows and is followed by my reflections on what it means about our treatment of veterans and about what our government wants to believe and wants us to believe about the effects of this horrendous war. It also inevitably brings up comparisons between the MIS-treatment of vets now and during the Vietnam War…
Mental Health Problems of Iraq Veterans May Be Delayed
By Neil Osterweil, Senior Associate Editor, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.
November 15, 2007
Charles Milliken, M.D.
Walter Reed Army Institute of Research
SILVER SPRING, Md., Nov. 15 — For soldiers returning from Iraq, the full extent of mental health problems may take six months or more to surface, Pentagon investigators reported.
This could explain, in part, why the Department of Defense’s mental health care system is overwhelmed, asserted Charles S. Milliken, M.D., and colleagues, of the Walter Reed Army Institute of Research here, in the Nov. 14 issue of the Journal of the American Medical Association.
Action Points
* Explain to those who ask that this study suggests that mental health problems among returning veterans may be more pervasive than originally thought, and that reservists seem to be affected in larger numbers than active-duty soldiers.
Among more than 88,000 U.S. soldiers back from Iraq who had an immediate post-deployment screening, a follow-up about six months later revealed a higher number of positives for posttraumatic stress disorder (PTSD), interpersonal conflicts, and referrals for mental health problems, they found.
In all, after the second screening, one-fifth of all active-duty soldiers back from Iraq and two-fifth of all reservists were found on screening to have a mental health concern requiring treatment.
“Reserve and active soldiers reported similar rates of potentially traumatic combat experiences (69.6% versus 66.5%), hospitalization during deployment (6% versus 5.3%), and overall mental health concerns on the post-deployment health assessment (17.5% versus 17%),” the investigators wrote.
“However, by the time of the post-deployment health reassessment, National Guard and Army Reserve soldiers reported substantially higher rates of interpersonal conflict, PTSD, depression, and overall mental health risk (35.5% versus 27.1%, odds ratio: 1.48; 95% CI: 1.44 to 1.53; P<0.001).”
Although the Walter Reed group reported 20 months ago that 19% of returning Iraq veterans had mental health problems, the same authors now say they may have seriously underestimated the scope of the problem.
The largest increase from one screening to the next was in concerns about interpersonal conflict, which went from 3.5% to 14% among active-duty personnel, and from 4.2% to 21.1% of reservists.
Similarly, PTSD-positive screens increased from 11.8% to 16.7% among regular forces. Among reserves, the PTSD-positive increase jumped from 12.7% to 24.5%.
Depression was seen in 4.7% of active-duty forces at the first assessment and 10.3% at the reassessment, with depression among reserves rising from 3.8% at screening 1 to 13% at screening 2.
“A recent congressionally mandated task force found the existing Department of Defense mental health system to be overburdened, understaffed, and underresourced,” the investigators wrote. “This study suggests that the mental health problems identified by VA clinicians in more than a quarter of recent combat veterans may have already been present within months of returning from war.”
Other investigators have found that a quarter of all veterans treated at VA hospitals after returning home from the wars in Iraq and Afghanistan brought mental health problems home. When psychosocial and behavioral problems were thrown into the mix, nearly a third of these veterans who sought care at aVA facility had a diagnosis of a mental health-related disorder.
Additionally, more than half the returning vets who had a mental health diagnosis were found to have two or more mental health disorders, wrote Karen H. Seal, M.D., M.P.H., of the University of California at San Francisco and the San Francisco VA, and colleagues in the March 12 issue of the Archives of Internal Medicine.
Another study showed that only one in five veterans returning from combat duty in Iraq or Afghanistan with signs of posttraumatic stress disorder is actually screened for it, the Government Accountability Office reported in May of 2006. (See: A Quarter of Iraq and Afghanistan Vets Show Mental Health Problems)
The Walter Reed investigators reported in JAMA in March of 2006 that 19.1% of soldiers and Marines who returned from Iraq met risk criteria for a mental health concern, compared with 11.3% for those deployed to Afghanistan and 8.5% for those sent to other locations. The adjusted odds ratio for service personnel sent to Iraq compared with other deployment locations was 2.72 (95% confidence interval: 2.63 to 2.80, P<0.001).
Now, these authors say, they may have seriously underestimated the size of the problem.
In the current study, the Walter Reed team reported on a population-based, longitudinal descriptive study of the initial large cohort of 8,235 U.S. soldiers returning from Iraq who completed both a Post-Deployment Health assessment and a Post-Deployment Health Reassessment, with a median of six months between the two.
The main outcome measures were a positive screen for PTSD, major depression, alcohol abuse or misuse, or other mental health problems, as well as referrals for and use of mental health services.
They found that at the second assessment soldiers reported more mental health concerns and were referred at significantly higher rates compared with their immediate post-deployment assessment.
The authors found that soldiers indicated more mental health distress on the reassessment than on the first screening, and were referred at higher rates.
National Guard and reserve soldiers were also more than three times as likely as active soldiers to be referred for mental health concerns at the second assessment, when referrals from employee-assistance programs were included (36.2% versus 14.7%, odds ratio for reservists: 3.29, 95% CI: 3.19 to 3.40, P<0.001).
When the authors combined data from both and from employee assistance referrals, they found that clinicians had identified 20.3% of active soldiers and 42.4% of reservists as either needing referral or already being under care for mental health problems.
They also found that although soldiers frequently reported alcohol concerns, few were referred to an alcohol treatment program, and that most soldiers who used mental health services did so on their own, without a referral, even though the majority sought care within 30 days of being screened.
In addition, although soldiers were much more likely to report PTSD symptoms on the reassessment rather than on the initial screening, 49% to 59% of those who had PTSD symptoms identified on the first screening had improvement of symptoms by the second screening, and there was no direct relationship of referral or treatment with symptom improvement.
“Rescreening soldiers several months after their return from Iraq identified a large cohort missed on initial screening,” the investigators wrote. “The large clinical burden recently reported among veterans presenting to Veterans Affairs facilities seems to exist within months of returning home, highlighting the need to enhance military mental health care during this period.”
They noted that the reported increases in interpersonal conflict underline the lack of available services for the families of returning soldiers, and the higher rates of referral at second assessment for reservists may reflect concerns about their ongoing health coverage.
The research was funded by an intramural program of the U.S. Army Medical Research and Materiel Command at Fort Detrick, Md. The authors reported no conflicts of interest.
Additional Anxiety & Stress Coverage
Primary source: Journal of the American Medical Association
Source reference:
Milliken CS, et al “Longitudinal assessment of mental health problem
REFLECTIONS:
I find myself trying to imagine what the factors are
that contribute to the significant increase in symptomatic vets after
the second six month later screening. I am thinking that there is likely a halo
effect of feeling relief immediately upon returning (thus a crazy time
to test and to come up with conclusive
results) vis a vis being alive, excitement for reunions with loved ones,
reduction of fear experienced during deployment, and possibly a desire
to believe one is all right or will soon become so This intrigues me as
do statistics about greater incidence of mental health issues with
reservists. I am on-goingly sad about the lack of appropriate services
for these veterans and their families. When I think about Vietnam vets and the care and support that
they never got I am even more aware of their feeling the anguish and
hopelessness that led so many of them to suicide. It ultimately feels
like we are mistreating these men throughout the process:
- they enlist because the system convinces them that the military will
make things better for them, which has been a terrible lie since at
least the start of the current wars
- they face an enemy they cannot identify using weapons they cannot
defend against, including IED’s and suicide bombers.
- they are on an impossible and totally thankless mission to bring
democracy to folks who cannot stand one another and our military
- they come back from the above scarred emotionally and psychologically,
at least, with profound therapy needs – as is true for their family
members
- the care they are offered is inadequate and often does not take into
consideration their needs or else they receive no care
- they suffer from PTSD and other mental health conditions that we do
not want to acknowledge in the numbers they are presenting themselves
and they also fear the stigma our society will place upon their
reputations if they seek therapy/support.
And, most terrifyingly, those in power exhibit no learning about
the huge mistreatments of the past…
The numbers really don’t reflect the families’ experience & often trauma. I’ll just take this opportunity to share that my godson, whose dad was in Iraq (Navy Reserve of all things) suffered at age 13 mightily: depression, aggression, bordering upon suicidal tendencies & I think these kinds of struggles don’t even make it (barely ever) into the mainstream. At 16, he’s still not entirely comfortably “on track” although thankfully his dad is home safe & actually sound.
Thanks so much for sharing this incredibly important point. Yes, other family members suffer and it is not even showing up as a blip on the radar. I keep thinking that if we really thought about and came to know the real cost of war – let alone a war of aggression like the current one complete with an army of occupation – we would not allow our leaders to immerse our country in war after war. Then I remember that some 15 million of us did our best to stop this one and somehow we were co-opted and it happened in spite of our efforts. But your point is another essential one in painting the full picture of what war does. I am thankful, as I know you are, that your godson’s father is home and intact. I know we both are mindful of all of those fathers, husbands, sons and brothers who aren’t and will never be…
Hi Tom,
And mothers, sisters, daughters, wives who will never be …
I agree with you both. Also this reminds me of PTSD from rape and abuse. I don’t know statistics, but I think often that people do ok for awhile and then it hits them. Often people don’t deal with abuse or rape until much later – especially when it happens to us as kids.
I wonder if some of the difference of reserve and national guard vs regular service members is that from the regulars, they more expected to be in combat? This is total conjecture and not from my experience or reading … just thinking out loud.
Let’s face it too, once people start going to drugs and alcohol to take the edge off reentry, that often causes problems in itself – often including for family members too. I am so glad Sarah raised the issues of family members!!
It is so frustrating!!
~ Diane Clancy
http://www.dianeclancy.com/blog
Thank you for your words from the heart, Diane. I think you are correct in comparing what happens to the returning vets to other kinds of trauma victims. Susan just had a 7 year old girl testify in court to abuse that occurred when she was 5. The judge thought she did an incredible job accessing memories and articulating them, but, much to Susan’s amazement and chagrin, the jury, three of whom were close in age to the 19 year old alleged perpetrator, found him innocent. Susan is completely convinced that he did what he was accused of and is heartsick that this girl had to not only experience the initial trauma, but also undergo reliving it and testifying about it, only to have the man who hurt her so badly go free. I feel similarly about those who brought this war upon these veterans. Their lives remain untouched by the trauma they so heartlessly caused to befall these men and women and those who love them. And the same was tragically true during the Vietnam War.