Healing Combat Trauma

William P. Nash, M.D.

William P. Nash, M.D., is an active duty Captain in the U.S. Navy Medical Corps, with nearly thirty years of active military service. He is a graduate of the University of Illinois, College of Medicine, in Chicago, and of psychiatry residency training at Naval Medical Center, San Diego. In addition to leading two Navy SPRINT crisis response teams, he has directed two Navy psychiatry residency training programs, and has served as the Director of Clinical Services of the hospital ship USNS MERCY. CAPT Nash has been stationed with the Marine Corps since 2000, including deploying to Iraq in 2004 with the 1st Marine Division as a psychiatrist embedded with ground combat forces. He was awarded a bronze star medal for his service in Iraq in support of combat operations there. Since October, 2005, CAPT Nash has been stationed at Headquarters, Marine Corps, in Quantico, Virginia, where he directs and coordinates combat/operational stress control policies and programs for the United States Marine Corps. He is an Assistant Clinical Professor of Psychiatry at the University of California, San Diego, and has co-edited a book with Charles R. Figley, Ph.D., released in late 2006, entitled Combat Stress Injury.

Senators Harkin and Feingold Introduce Veterans Suicide Tracking Bill

Senators Tom Harkin (D-IA) and Russ Feingold (D-WI) on April 23rd introduced a bill requiring the Department of Veterans Affairs ("VA") to track veteran suicides.  The "epidemic" of veterans' suicides has been in the news recently, both because of the Federal court case being waged in San Francisco this week and next by veterans rights groups against the VA, and because of the recent CBS News investigation into the same.  It turns out the CBS report's high numbers were accurate; and documents produced during the trial implicate the VA's chief psychiatrist, Ira Katz, M.D., Ph.D., in attempting to suppress the true figures.  Various groups have called on Katz to resign.  The proposed legislation, entitled "The Veterans Suicide Study Act" would require the VA to report to Congress how many veterans committed suicide since 1997; and the VA would continue to issue reports annually.  For more information about the bill's introduction, click here.

Aspen Institute Forum on PTSD and Iraq Veterans

Thanks to the miracle of the Internet, the full program from last fall's Aspen Institute's Health Forum on PTSD and Iraq War Veterans is available on the Web.  The program was entitled, "From the Front Lines: Post-Traumatic Stress Disorder and the Legacy of Iraq," and it featured panelists Charles Figley, Ph.D., combat veteran Georg-Andreas Pogany, Jennifer Vasterling, Ph.D., and Barbara Romberg, Ph.D..  Click here for the link to the video, or just watch it below.

Georg-Andreas Pogany

Georg-Andreas Pogany is a retired Sergeant First Class (SFC) and Operation Iraqi Freedom Veteran. After obtaining a bachelor's in criminology from the University of South Florida, he enlisted in the U.S. Naval Reserve. In 1998, he switched services and enlisted in the Army, where he trained as a nuclear, biological and chemical warfare specialist. In 2003, he was deployed to Iraq as part of a Special Forces unit. There, he became incapacitated by toxic drug levels from the anti-malarial drug Lariam/Mefloquine. He was sent to Fort Carson, Colo., where he was diagnosed with a related brain injury. He received treatment and shortly thereafter was honorably discharged.

Since his retirement from the Army, he has worked as a veteran's and active duty service member advocate on health care, combat stress, and military justice. He created and manages "J1W2," Just One Wounded Warrior, which connects veterans and active duty service members with mental health care professionals.

Barbara V. Romberg, Ph.D.

Barbara V. Romberg, Founder and Executive Director of Give an Hour, is a licensed clinical psychologist who has been practicing in the Washington, D.C., area for 16 years. She specializes in the diagnosis and treatment of children.

Dr. Romberg has spent her career interacting with and coordinating services within large systems, including school districts and mental health clinics. In addition, for many years, she served as an adjunct faculty member at George Washington University, where she trained and supervised developing clinicians. She received her PhD in clinical psychology from the University of Maryland in 1991.

Concerned about the mental health implications of the Iraq War, Dr. Romberg founded Give an Hour in 2005. Give an Hour is a nonprofit organization that is creating a national network of mental health professionals who are providing free services to U.S. troops, veterans and their families.

Editor's note: For a link to Give an Hour, click here.

Jennifer J. Vasterling, Ph.D.

Jennifer J. Vasterling serves as the Chief of Psychology at the VA Boston Healthcare System and as a clinical investigator within the Behavioral Sciences Division of the National Center for PTSD.

Dr. Vasterling also is a Clinical Professor of Psychiatry and Neurology at Tulane University School of Medicine. She obtained her PhD in clinical psychology from Vanderbilt University in 1988. Trained as a clinical neuropsychologist, Dr. Vasterling's research has centered on furthering understanding of the cognitive and emotional changes that accompany war-zone deployment and post-traumatic stress disorder.

Her recent work includes a longitudinal study examining neuropsychological and emotional outcomes of the Iraq War. This effort is unique in that it tracks the mental health of deploying soldiers, starting when they are deployed and following them after they return from Iraq.

Charles R. Figley, Ph.D.

Charles R. Figley, Ph.D. is Director and Professor, Florida State University Traumatology Institute, and Editor of Traumatology (Sage Publications). He has published nearly 200 scholarly papers and 19 books since 1973. His first book, Stress Disorders among Vietnam Veterans: Theory, Research, and Treatment (Brunner/Mazel, 1978), is recognized as the first comprehensive analysis of the immediate and long-term psychosocial consequences of war on the combatants. This was followed by Strangers at Home: Vietnam Veterans since the War (Praeger, 1980). His latest book, with Navy Captain and psychiatrist William Nash, is Combat Stress Injury (Routledge, 2007). He is a former Vietnam veteran and Marine who has worked closely with all branches of the military to help combatants and their families and those who care for them (corpsmen, medics, nurses, physicians, social workers, psychologists, chaplains, and their superiors who evaluate them). The Green Cross Academy of Traumatology, which he founded in 1995, is working with other NGOs to help returning veterans and their families.

For a link to Dr. Figley's home page at Florida State University, click here.  For a downloadable copy of his c.v., click here.  For a link to the Traumatology journal, click here.

Four Reasons Veterans Don't Get Their Benefits

I had a wonderful conversation on Thursday with the local Veterans Service Officer ("VSO"), who's the sole point of contact for 11,000 veterans in the local area, and 34,000 family members, total.  We had a great and wide-ranging discussion, about many things that concern veterans, but one point he made really stood out.  He said something pretty remarkable about why veterans don't take more advantage of the benefits they're entitled to.  (This veterans service officer says the population he serves is composed of WWII veterans, and those from the Vietnam War, the Korean War, peacetime, and the Gulf War -- which includes OIF/OEF veterans -- in that order, rather than predominantly OIF/OEF veterans.  But still, it's illustrative...)  He says the top four reasons veterans don't take advantage of the benefits -- health, educational and otherwise -- that they're entitled to are that:

1. They don't know that the benefits exist;
2. They don't think they'd qualify;
3. They don't know how to apply for the benefits, or assume that applying would be a real "pain in the butt";
4. They rationalize that there are others "worse off than me."  He says he hears that about once a week.  Very noble, truly, but not great when it comes to getting the benefits that service has entitled them to.  As the officer said, enthusiastically, "The veterans have EARNED those benefits!  The sacrifices they've made...!"

More about this conversation later...

58 Bills before 110th Congress Reference PTSD

According to the Congressional legislation-watching website, Thomas, there are 58 bills making reference to PTSD before the 110th Congress.  Click here for a link to the Thomas site, and type in "PTSD" to pull up the current list.  (The Thomas website is a public service of the Library of Congress, with an implied reference to Thomas Jefferson.  Click here for a link to the full Thomas site.)  Both houses of Congress, the House of Representatives and the Senate, have committees devoted to Veterans Affairs.  Periodically, those committees publish reports of their activities.  If you go to a page on the Thomas site, you are able to search for those reports, which are updated regularly.  Click here for that link, and then check the boxes for Veterans Affairs committees within the House and Senate.

Citizen Journalist Dad Uploads the Damning Ft. Bragg Barracks Video: "Ask Them to Fix This!"

A stunning video, shot by a returning combat veteran's dad, and uploaded to YouTube by him, shows the deplorable conditions awaiting his son in the barracks at Fort Bragg, North Carolina, after 15 long months in Afghanistan.  The screen capture to the left is a soldier plunging a clogged bathroom drain, on a bathroom floored filled with inches of standing water and raw sewage.  Ft. Bragg's living conditions, at least as shown in this video by a suitably outraged father, bring to mind those at Walter Reed, profiled by the reporting team at the Washington Post last year.  The Fayetteville Observer has weighed in with an article on the conditions at Fort Bragg, prompted by the release of this video, and they're asking for answers, too.  Do yourself a favor and watch what one citizen journalist did to document the conditions facing some returning military.  We are not remotely giving them the care that they deserve.  And it's shameful that public pressure has to be brought to bear, by videos like this, before conditions are improved for returning servicemembers. When you think of all the challenges they've been through, which are more than enough to process and decompress from, the last thing they need it to be "greeted" with hospitality like this.  If this is how we treat our returning soldiers, what hope can they have that we as a country really care about their welfare -- mental, emotional, physical and spiritual.  These pictures speak louder than words.  Watch the video, below.  The article in the Fayetteville Observer is linked here; with follow-up linked here, and three full days later (cough, cough) on CNN, linked here.  (It's great to scoop CNN on a blog ;-).  (Military.com has not covered it yet, but ideally they will, and soon.)  Over time, of course, we can expect to see follow-up, and damage control, and spin -- and eventually, one hopes, actual change.

Editor's Note: the video was uploaded by Edward Frawley, the father of a sergeant who served with the Army in Afghanistan, as part of Charlie CO 2/508 82n Airborne.  His son returned to the U.S. on April 13, 2008, and is living in the dilapidated barracks on base.

One Marine Reflects on His Battle with PTSD

Back in January, The Marine Corps Gazette published the account of one Marine's own struggle with PTSD.  The Marine was 1st Staff Sergeant Travis N. Twiggs, and the article was called "PTSD: the War Within - A Marine Writes about His PTSD Experience."  Twiggs had four deployments with OIF/OEF: one to Afghanistan, and three to Iraq.  He writes fairly bluntly about what his experience with PTSD was like; how it crept up on him; what the process of admitting that he had it was like; and what he did to recover from it.  He also writes a postscript about what his like has been since then.  I've tried to contact Twiggs several times and the Marine Corps Gazette, to see about getting permission to reprint Twiggs' story on this blog; but haven't heard anything back.  That makes me concerned that perhaps the end of the story isn't as positive as it seemed it was going to be; but I hope that I'm wrong about that.  Twiggs' writing his story about his own fight with PTSD is a very powerful thing.  While many veterans obviously suffer from PTSD, not many have come forward to really talk about what it's like to have had it, and to have made progress in overcoming it.  That's why Twiggs' story is so valuable.  It also has the added benefit of being a story by a combat veteran to other veterans -- with all the shared camaraderie and empathy that implies. I hope things continue to go well for Twiggs -- his example and his openness can really be helpful to other veterans who are suffering from combat trauma.

Some items that stand out from his story:

• A triggering point: arriving back in the U.S. after his third deployment, and being greeted by the families of the two Marines who were killed in action on his tour at the homecoming for his battalion.  It seems to have pushed to the forefront of his mind the question, "Why them, why not me?" which is classic for people to ask.  "From then on my life began to spiral downward," he says.
• At another point he describes being back from the front: "When I arrived back in the States, it was as though I had never left. All of my symptoms were back, and now I was in the process of destroying my family. This was all taking place because I did not understand what was happening to me. My situation worsened, if you can believe that. I started neglecting my work, and my answer for everything was alcohol."
• In other point, he describes with great poignancy the real battle within himself: "The true horror of war is coming home without all of your Marines, because at some point you have to look at yourself in the mirror and wonder, “Did I give them my all?” “Did I train them to the best of my ability?” I could not answer yes to either question. I still can’t and wonder if I ever will." (That last point also makes me concerned about how fully he's been able to put this in the past; it's probably still far too difficult to - and there's definitely no shame in that.)

Another constructive part of the article is the recommendations he offers as a layman, about what he believes helped his PTSD, and what might help others.  Here are the majority of things he says he learned from the experience, that he can recommend to others:

• Medication alone will not calm PTSD symptoms. Therapy is a must, and it has to be done with others who have experienced the same war or conflict. In other words, veterans of Operation IRAQI FREEDOM should not be undergoing therapy with Vietnam or Operation DESERT STORM veterans. The symptoms are the same, but the time periods are different.
• Alcohol and pills don’t mix. The Marine/sailor should never be told that moderate alcohol consumption is acceptable.
• It is okay to mourn those you’ve lost, but remember, they don’t want you to be sad. They want you to celebrate their lives.
• PTSD is not a weakness. It is a normal reaction to a very violent situation.
• I firmly believe that a lot of my [subsequent] problems were caused by overmedication. The medication affected my judgment and my ability to cope with the true issues that haunted me. I also have since suffered from a seizure, which is believed to have occurred from the same cause. So, ensure that the Marines/sailors know that it is okay to question the amount of medications they are taking and why.
• Place more emphasis on the post-deployment health questionnaire all Marines/sailors have to fill out before leaving theater. I remember Marines being told that if they marked “yes” to anything, it would cause problems with their taking leave. They don’t know that PTSD is not even noticeable until they come home. Marines/ sailors should fill out these questionnaires honestly when they get back in garrison, and they need to know that it is okay if they are experiencing difficulties readjusting.
• Leaders should sit down with their Marines/sailors prior to releasing them for leave and cite different examples of PTSD so that they know what to expect and how to recognize the symptoms. When they return from leave, leaders should get them enrolled in as many schools as they can. Regardless of whether they can get them into the schools or not, leaders should set up a well-planned schedule for them.

Wherever you are, Travis Twiggs, best wishes for your continued health and healing.  Thanks for being strong enough to write this; thanks for sharing it with your fellow combat veterans. 

Editor's Note: A copy of the original article is linked here; a PDF copy of it on the Web is also linked here.

Acupuncture May Help PTSD Sufferers

Acupuncture May Help Symptoms of Posttraumatic Stress Disorder

A pilot study by researchers at the University of Arizona's Department of Psychiatry shows that acupuncture may help people with posttraumatic stress disorder. Posttraumatic stress disorder (PTSD) is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat.

Michael Hollifield, M.D., and colleagues conducted a clinical trial examining the effect of acupuncture on the symptoms of PTSD. The researchers analyzed depression, anxiety, and impairment in 73 people with a diagnosis of PTSD. The participants were assigned to receive either acupuncture or group cognitive-behavioral therapy over 12 weeks, or were assigned to a wait-list as part of the control group. The people in the control group were offered treatment or referral for treatment at the end of their participation.

The researchers found that acupuncture provided treatment effects similar to group cognitive-behavioral therapy; both interventions were superior to the control group. Additionally, treatment effects of both the acupuncture and the group therapy were maintained for 3 months after the end of treatment.

The limitations of the study are consistent with preliminary research. For example, this study had a small group of participants that lacked diversity, and the results do not account for outside factors that may have affected the treatments' results.

Michael Hollifield, Nityamo Sinclair-Lian, Teddy D. Warner, and Richard Hammerschlag, "Acupuncture for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial." The Journal of Nervous and Mental Disease, June 2007.

Rand Study Estimates PTSD Figure is 1 in 5

One In Five Iraq and Afghanistan Veterans Suffer from PTSD or Major Depression

Nearly 20 percent of military service members who have returned from Iraq and Afghanistan — 300,000 in all — report symptoms of post traumatic stress disorder or major depression, yet only slightly more than half have sought treatment, according to a new RAND Corporation study.

In addition, researchers found about 19 percent of returning service members report that they experienced a possible traumatic brain injury while deployed, with 7 percent reporting both a probable brain injury and current PTSD or major depression.

Many service members said they do not seek treatment for psychological illnesses because they fear it will harm their careers. But even among those who do seek help for PTSD or major depression, only about half receive treatment that researchers consider "minimally adequate" for their illnesses.

In the first analysis of its kind, researchers estimate that PTSD and depression among returning service members will cost the nation as much as $6.2 billion in the two years following deployment — an amount that includes both direct medical care and costs for lost productivity and suicide. Investing in more high-quality treatment could save close to $2 billion within two years by substantially reducing those indirect costs, the 500-page study concludes.

"There is a major health crisis facing those men and women who have served our nation in Iraq and Afghanistan," said Terri Tanielian, the project's co-leader and a researcher at RAND, a nonprofit research organization. "Unless they receive appropriate and effective care for these mental health conditions, there will be long-term consequences for them and for the nation. Unfortunately, we found there are many barriers preventing them from getting the high-quality treatment they need."

The findings are from the first large-scale, nongovernmental assessment of the psychological and cognitive needs of military service members who have served in Iraq and Afghanistan over the past six years. The RAND study is the first to comprehensively assess the current needs of returned service members from all branches of the military.

Researchers concluded that a major national effort is needed to expand and improve the capacity of the mental health system to provide effective care to service members and veterans. The effort must include the military, veteran and civilian health care systems, and should focus on training more providers to use high-quality, evidence-based treatment methods and encouraging service members and veterans to seek needed care.

Since October 2001, about 1.6 million U.S. troops have deployed to the wars in Iraq and Afghanistan, with many exposed to prolonged periods of combat-related stress or traumatic events. Early evidence suggests that the psychological toll of the deployments may be disproportionately high compared with physical injuries.

Tanielian and project co-leader Lisa Jaycox headed a group of 25 RAND researchers who conducted a three-pronged assessment of the needs of returning service members: a national survey of those who had served in Iraq and Afghanistan to assess their psychological and cognitive injuries; economic modeling to estimate the cost not only of providing needed treatment, as well as the costs associated with lost productivity and suicide; and an assessment of treatment services that are available to service members, as well as barriers to treatment.

Researchers surveyed 1,965 service members from 24 communities across the country to assess their exposure to traumatic events and possible brain injury while deployed, evaluate current symptoms of psychological illness, and gauge whether they have received care for combat-related problems.

Service members reported exposure to a wide range of traumatic events while deployed, with half saying they had a friend who was seriously wounded or killed, 45 percent reporting they saw dead or seriously injured non-combatants, and over 10 percent saying they were injured themselves and required hospitalization.

Rates of PTSD and major depression were highest among Army soldiers and Marines, and among service members who were no longer on active duty (people in the reserves and those who had been discharged or retired from the military). Women, Hispanics and enlisted personnel all were more likely to report symptoms of PTSD and major depressions, but the single best predictor of PTSD and depression was exposure to combat trauma while deployed.

Researchers found many treatment gaps exist for those with PTSD and depression. Just 53 percent of service members with PTSD or depression sought help from a provider over the past year, and of those who sought care, roughly half got minimally adequate treatment.

"If PTSD and depression go untreated or are under treated, there is a cascading set of consequences," Jaycox said. "Drug use, suicide, marital problems and unemployment are some of the consequences. There will be a bigger societal impact if these service members go untreated. The consequences are not good for the individuals or society in general."

Service members report many reasons for not seeking treatment. Many are worried about the side effects of medication or believe that family and friends can provide more help than a mental health professional. Even more reported that they worried seeking care might damage their career or cause their peers to lose confidence in their abilities.

The RAND report recommends the military create a system that would allow service members to receive mental health services confidentially in order to ease concerns about negative career repercussions.

"We need to remove the institutional cultural barriers that discourage soldiers from seeking care," Tanielian said. "Just because someone is getting mental health care does not mean that they are not able to do their job. Seeking mental health treatment should be seen as a sign of strength and interest in getting better, not a weakness. People need to get help as early as possible, not only once their symptoms become severe and disabling."

Researchers also found an urgent need to train more mental health providers throughout the U.S. health care system on delivering evidence-based treatments to service members and veterans. While many opportunities for treatment exist for active-duty personnel, there is no system in place to monitor the quality of those services to ensure they are getting the latest science-based forms of treatment.

The Department of Defense's newly created Defense Center for Excellence for Psychological Health and Traumatic Brain Injury may provide a historic opportunity to change the culture of psychological health within the military and to promote and monitor the use of high-quality care to service members. The RAND report provides information that the center could use to pursue these objectives through the use of innovative care models and performance measurement techniques.

Researchers suggest special training programs are needed to instruct mental health providers in the military, veterans and civilian health systems about the type of evidence-based treatments needed by service members. Only providers with such training should be eligible to treat service members and payment programs should be retooled to reward providers who use science-based treatments.

"It's going to take system-level changes — not a series of small band-aids — to improve treatments for these illnesses," Tanielian said.

The RAND study estimates the societal costs of PTSD and major depression for two years after deployment range from about $6,000 to more than $25,000 per case. Depending whether the economic cost of suicide is included, the RAND study estimates the total society costs of the conditions for two years range from $4 billion to $6.2 billion.

The RAND study also estimates that about 320,000 service members may have experienced a traumatic brain injury during deployment — the term used to describe a range of injuries from mild concussions to severe penetrating head wounds. Just 43 percent reported ever being evaluated by a physician for that injury.

While most civilian traumatic brain injuries are mild and do not lead to long-term impairments, the extent of impairments that service members experience and whether they require treatment is largely unknown, researchers said. In the absence of a medical examination and prognosis, however, service members may believe that their post-deployment difficulties are due to head injuries even when they are not.

One-year estimates of the societal cost associated with treated cases of mild traumatic brain injury range up to $32,000 per case, while estimates for treated moderate to severe cases range from $268,000 to more than $408,000. Estimates of the total one-year societal cost of the roughly 2,700 cases of traumatic brain injury identified to date range from $591 million to $910 million.

The report is titled "Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery." The full report and several summaries are available at http://veterans.rand.org/.

The project, jointly conducted by RAND Health and the RAND National Security Research Division, was sponsored by a grant from the California Community Foundation.

RAND Health, a division of the RAND Corporation, is the nation's largest independent health policy research program, with a broad research portfolio that focuses on quality, costs and health services delivery, among other topics.

The RAND National Security Research Division conducts research and analysis for the Office of the Secretary of Defense, the Joint Staff, the Unified Commands, the defense agencies, the Department of the Navy, the U.S. intelligence community, allied foreign governments and foundations.

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Jonathan Shay, M.D., Ph.D.

Jonathan Shay, M.D., Ph.D. has been a staff psychiatrist at the Department of Veterans Affairs Outpatient Clinic, Boston since 1987, where his only patients have been combat veterans with severe psychological injuries. In 2007, he was awarded a MacArthur Foundation "genius grant" for his work with veterans.  Shay is the author of Achilles in Vietnam: Combat Trauma and the Undoing of Character (1994) and of Odysseus in America: Combat Trauma and the Trials of Homecoming (2002), the latter of which has a foreword authored jointly by US Senators John McCain and Max Cleland.

Between September 1, 2004 and August 31, 2005, Dr. Shay was Chair of Ethics, Leadership, and Personnel Policy in the Office of the US Army Deputy Chief of Staff for Personnel, and earlier was Visiting Scholar-at-Large at the US Naval War College (2001) and performed the Commandant of the Marine Corps Trust Study (1999-2000).

Jonathan Shay received a B.A. (1963) from Harvard University and an M.D. (1971) and Ph.D. (1972) from the University of Pennsylvania.  For a link to his bio on the MacArthur Foundation site, click here.  For an interesting bio of Dr. Shay that was published some years ago in the New York Times, go here. 

Marines and the Stigma of Mental Health Issues

If you haven't done so already, you owe it to yourself to read the excellent article published recently in The Nation, called "Denial in the Corps."  The author, Kathy Dobie, did another great piece for GQ recently, which we blogged about here.  (That entry was entitled, "Superb Writing about a Vietnam Vet's PTSD and Subsequent Nervous Breakdown.")  Kathy Dobie is a superb writer, who crafts an excellent narrative -- every sentence in the Nation piece is worth reading, and both informs and moves the story along.  Regrettably, the story is a painful one to tell, about how Marines haven't yet fully risen to the challenge of taking care of their own who have been used up, broken down, or shattered into pieces by their experience at war.  Three paragraphs are the sum of the story:

"According to civilian and military defense lawyers, mental health professionals and veterans' advocates, the trajectory of [one of the Marines profiled]'s postdeployment life, with untreated PTSD leading to misconduct and then punishment, is all too common in the Marine Corps. A marine endures one, two, even three tours in Iraq, serves honorably and well, but returns suffering from combat trauma and starts to drink or abuse drugs or becomes violent at home, and suddenly finds himself ostracized, punished and drummed out of the Corps with an other-than-honorable or bad-conduct discharge. A history of service is tarnished, and the marine is denied benefits--even the treatment necessary to recover from combat trauma--and left with only a bitter sense of betrayal. A Corps review in 2007 of 1,019 other-than-honorable discharges issued to combat veterans during the first four years of the Iraq War found that fully a third of the discharged marines had evidence of PTSD or another combat-related mental illness. Lt. Col. Colby Vokey, the Marine Corps's legal defense counsel for the western United States, estimates that of all the Iraq combat veterans his office defends, one-third have PTSD or another combat-stress mental health issue. Many of these clients have served at least two tours in Iraq.

The factors leading to the abandonment of combat-broken marines are both cultural and operational. The Marine Corps is the youngest, most male, most junior and least married of all the services. Sixty-six percent of the troops are 25 or younger; 13 percent are teens; and 39 percent hold the rank of private, private first class or lance corporal. Fewer than 7 percent are female. The Corps's deeply macho culture, which values stoicism in the face of pain and disdains "weakness," makes it hard for marines to seek help. Judith Broder, a civilian psychiatrist who treats Iraq and Afghanistan vets, says, "They all know of stories where buddies have asked for help and have been ridiculed by the chain of command or given some kind of treatment that is not really adequate and told they have to go back."

This harsh culture is exacerbated by the relentless tempo of training and deployment, which pressures commanders to quickly replace broken marines with deployable ones. "You read the Marine Corps values and you'll find that anybody that gets hurt isn't courageous or doesn't have honor," Judith Litzenberger, a civilian defense lawyer and twenty-one-year Navy veteran, explains. "That's how the marines interpret it: 'I went to Iraq and I didn't whine and I didn't claim that I had a mental disorder, and damn well marines don't do that--we suck it up.' And it has to be that way because they have a mission that's bigger than the number of people they have. They can't spend all their time taking care of people who have mental disorders. They've got to wash them out quickly and move on."

There are institutional benefits for washing them out quickly and moving on, and the articles goes on to suggest what those are.  At its most extreme, it's ultimately all about the money.  One retired Air Force colonel, in charge of medical operations in the Air Force's European headquarters, who is quoted in the story, cuts right to the point: "Every kid that gets kicked out with PTSD is gonna be a lifetime of disability payments for the government. Every kid who gives up and kills himself, nothing."

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The trouble is, though, the thing that gets people in this predicament -- PTSD -- is war itself.  Marines and other servicemen and women aren't creating PTSD -- they're developing it, from and in combat.  And combat at a level -- longer tours, more deployments, less time between tours -- that is just unprecendented.  Rather than preparing for the logical outcome of that -- more PTSD cases, a greater need for care -- and PLANNING on and for that -- the tendency seems to be, still to some degree, to blame the participant, and refuse to acknowledge the greater problem -- or the link between the two: combat and PTSD.

A current and disturbing example, surfaced on this blog, is the case of Lance Corporal Eric Acevedo, accused of murdering his former girlfriend in Saginaw, Texas, in what certainly "seems" be a PTSD-related event.  We dug a little bit into his background, and found the extent of the combat he'd seen in the Marines, and what had happened on his tour.  (Read about that here.)  Even found the great, iconic photograph of him, in the Marine's own photo archives, pictured above.  What happened?  WIthin three days, the Marines had removed all trace of Eric Acevedo from their publically-searchable archives.  No photo, no attached story, no reference to the memorial service he attended (where the photo by Heidi Loredo was taken), where ten of his fellow Marines who died in Fallujah were honored.  All references to Lance Corporal Eric Acevedo -- VAPORIZED.  As though he no longer existed; or had in fact, never existed.  What disturbs me the most about this is the simple, brutal fact.  If Lance Corporal Eric Acevedo, a three tour Marine, ended up with PSTD, no matter what he did AFTER he had it -- it's clear where he got it, and how.  For the Marines to distance themselves like that from him goes against all the Three Musketeer-ing sentiment we usually associate: the all for one, and one for all stuff that gets so many guys (and gals) through their unbelievably rigorous training, and in and out of battle.  It creates a terrible impression, too: that while the Marines may be all for one another, on the battlefield, so long as it's a reasonably level playing field; but is the top brass really all for the average Marine?  Only time will tell, but if the Eric Acevedo story is any indication, the perspective is, get in trouble and you're expendable.  In fact, we never knew you.

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The Marine Corps's legal defense counsel for the western United States, Lieutenant Colonel Vokey, quoted in the Nation article says prophetically: "The problem is I don't think the system accounts for these folks with PTSD. There's got to be another way to handle this without lumping them in with every other marine who commits misconduct. They were fine when they went to Iraq, we broke them, this is what combat did to them, and I think we should feel some responsibility for what happens to them." Absolutely; that's EXACTLY the point.

PTSD Complicates Healthcare, Increases Utilization and Costs

PTSD ASSOCIATED WITH MORE, LONGER HOSPITALIZATIONS AND GREATER MENTAL HEALTH USE

Boston, MA—Researchers from Boston University School of Medicine (BUSM) and Boston Medical Center (BMC) have found post-traumatic stress disorder (PTSD) is associated with more hospitalizations, longer hospitalizations and greater mental healthcare utilization in urban primary care patients. These findings appear in the current issue of Medical Care.

Prior studies suggest that trauma exposure and PTSD have considerable impact on health care use and costs. Most of this research, however, has focused on male veterans and female sexual assault victims but the impact on healthcare use in other populations is uncertain.

The researchers interviewed a sample of primary care patients to examine overall prevalence of traumatic exposure and select behavioral health outcomes in addition to PTSD, including major depression, substance dependence and chronic pain. The interview included demographic questions, the Composite International Diagnostic Interview (version 2.1 PTSD module), the Chronic Pain Definitional Questionnaire, the Patient Health Questionnaire (to measure depression) and the Composite International Diagnostic Interview-Short Form (for drug and alcohol dependence).

Among the participants, the researchers found that 80 percent had one or more trauma exposures. Compared to participants with no trauma exposure, subjects exposed to trauma were significantly more likely to be males, unmarried, have substance dependence and depression. They also had more mental health visits than those with no trauma exposure.

Among the participants, 22 percent had current PTSD. Compared to participants without PTSD, those with PTSD were significantly more likely to be female, to have an annual income of less than or equal to $20,000, have substance dependence and depression. PTSD participants also had more hospitalizations and mental health visits.

According to the researchers, among urban primary care patients PTSD is associated with greater health care use: both mental health visits and hospitalizations. “Unexpectedly, trauma exposure by itself was not associated with increased healthcare utilization apart from mental health visits, a finding which was attenuated after adjusting for PTSD,” said lead author Anand Kartha, MD, an assistant professor of medicine at BUSM. “This may be due to the fact that the non-traumatized to whom we are comparing the traumatized patients, have complex social milieu leading to high utilization,” added Kartha.

“PTSD has a cost beyond the specific mental health symptoms,” said senior author Jane Liebschutz, MD, an associate professor of medicine and social and behavioral sciences at BUSM and a primary care physician at BMC. “PTSD may be on the causal pathway between trauma experiences and negative health consequences. These findings are relevant in light of the PTSD prevalence not only in our returning veterans, but in areas of urban poor,” she added.

This study was supported in part by the Robert Wood Johnson Foundation and by the National Institute on Drug Abuse.

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Editor's Note: Anand Kartha, M.D., the study's main author, served a two year fellowship (2003-2005) at then Veterans Admininstration Hospital in Boston, Massachusetts, where his healthcare systems area of focus was "predictors of re-hospitalization/Utilization of health care resources in post-traumatic stress disorder."

A Good Librarian is a Wonderful Resource

Lori Sekela, collection management librarian at the U.S. Army War College, who we've blogged about earlier, just produced a second, updated edition of her previous work, "Post-Traumatic Stress Disorder and the Military: A Selected Bibliography."  She reports that it was just released this week by the U.S. Army War College Library and is available for downloading online at http://www.carlisle.army.mil/library/bibs/PTSD08.pdf. 

The Table of Contents reveals the breakdown of her selected bibliography.  The big categories are "General Resources," "PTSD Related to Age, Gender or Ethnicity" (a live topic, in my opinion), and another great subset, "PTSD and Disability Claims."  The publications and resources cited all look to be officially-sanctioned, so they're on the conservative side, but for anyone who's doing research on the subject and wants to know where to look, this is a tremendous place to start.  Thank you, Lori!  A link to our earlier post about her work is here. 

Editor's Note: the U.S. Army War College is located in Carlisle, PA.

Fred D. Gusman, M.S.W.

Mr. Fred D. Gusman, M.S.W. is an internationally recognized figure in the mental health field. Mr. Gusman's expertise in the arena of traumatic stress is based on the firm foundation of his own military service coupled with his 30 years of clinical, research, and consultative experiences in the field of traumatic stress, combat stress, PTSD, disaster mental health services, and mental health programs development. He is an expert educator, clinician, program administrator and developer, and is a frequently sought after consultant to those in the field of traumatic stress. His knowledge base is informed by a noteworthy career and varieties of roles and experiences. Mr. Gusman pioneered and developed the nation's first residential rehabilitation programs for men and women veterans at the Veterans Affairs Palo Alto Health Care System (VAPAHCS). Under his vision, guidance, and leadership, the programs have served thousands of veterans during the course of the last thirty years. In addition to this role, he has been called upon to serve in diverse capacities for the Department of Veterans Affairs, National Institute of Mental Health, Department of Defense, American Red Cross, Federal Governmental Committees, in numerous community and state programs throughout the country and in Europe, and in numerous natural and man-made disasters, e.g. September 11th terrorist attack on the Pentagon). During the last two years, Mr. Gusman has provided numerous consultations and clinical trainings to various branches of the Department of Defense such as: Marine Corp Community Services (MCCS) staff and Marine Corps Family Services staff (various US mainland sites); the National Guard (Hawaii's 29th Infantry Brigade) and their families, and; Army personnel at Hawaii's Schofield Barracks-Soldier Retransition Center and the Family Retransition Center. Finally, Mr. Gusman is a collaborator on various research studies and author/co-author of numerous research and clinical publications.

Finally, Some Good News

The Washington Post has an article in Thursday's paper about some positive improvements being made to patient care at Walter Reed. The article is entitled, "The Young Lions of Able Troop," and the subtitle is, "to the cadre on the front lines of improving care at Walter Reed, the challenge can rival combat."  Indeed.  The story, which is written by Steve Vogel, profiles the efforts of Army Major Steven Gventer and others to encourage the injured troops under his care to get the help they need, and most importantly, to help take care of one another.  It's an interesting story about what amounts to proactive case work being done by the military, with their injured soldiers undergoing treatment at Walter Reed, and it represents very much of an improvement -- seemingly something to be replicated elsewhere.  Read the story.  It's rare to find some encouraging news on this front -- this really qualifies.  The article is linked here.

The Washington Post Wins Pulitzer Prize for Its "Walter Reed and Beyond" Series

On Tuesday it was announced that the Washington Post won a total of six Pulitzer Prizes this year, including one for its outstanding series on Walter Reed, by the reporting team of Dana Priest, Anne Hull, and photographer Michel du Cille.  The Post series won the Pulitzer's public service medal "for documenting in vivid detail the substandard treatment for wounded soliders and poor living conditions marked by cockroaches and mold."  The series, wrote the Post, "sparked a political uproar, prompting Defense Secretary Robert M. Gates to fire Army Secretary Francis J. Harvey, and a presidential commission later recommended numerous changes."  The link to the story about the Post winning the six Pulitzers is here.  The link to the Post's complete series of stories and photography called "Walter Reed and Beyond" is here.  Well-deserved congratulations to journalists Priest and Hull, and photographer du Cille, on a groundbreaking and vitally necessary series.

Actor and Vietnam Vet Produces Film about PTSD

Military.com has an item today about a new movie, Soldier's Heart, by actor and Vietnam veteran, Brian Delate.   In Military.com's blurb about their interview with Delate they say, "Vietnam veteran and accomplished actor Brian Delate has released his vision of the challenges facing warriors upon their return in his movie "Soldier's Heart."  At a time where a handful of films are being released about the wars and the challenges faced by soldiers, from thoughtful documentaries, to bigger-budget Hollywood treatments for a mass audience, a movie like Delate's -- ostensibly, from someone who knows -- should be a welcome addition.  PTSD is a timely topic, and who better to tell the story than a veteran who's struggled with it himself, as Delate says that he has.  Sounds very promising, and relatable - and likely to make a difference.

The promotional material about the movie -- which looks like it could have used some help in the copywriting department -- is as follows:

"PTSD - sometimes you don't know you have it until your life falls apart.  Elliot (James Kiberd), a Vietnam vet with PTSD has held it together until participation in a documentary about the Vietnam War causes unacknowledged feelings about his experience as a soldier to surface, threatening his marriage to Linda (Cady McClain), alienating his best friend, Richie (Brian Delate) and damaging his career.  In this journey of the heart, PTSD forces Elliot to re-design his blueprint for living with courage and some humor as the truth of his war experience emerges, allowing him to gain a deeper understanding of himself as a veteran, his father as a World War II vet, Richie as a Vietnam vet, and to forge a stronger bond with Linda."

"Finally, a unique film about veterans as told by a veteran -- Soldier's Heart is about Vietnam vet Elliot's waking up to the present and his journey to a deeper self-acceptance -- with regard to the long term effects (PTSD) from the war and his relationships to his family, wife and friends.  Writer/Director and Vietnam veteran Brian Delate is also a veteran actor of film, stage and television.  If you are a veteran -- from any war or you know a veteran, this is a must-see movie."

A link to the film is here. A link to the podcast on Military.com, where writer/director (and actor) Brian Delate talks about his own war experiences, including how he dealt with his PTSD, is here.

Editor's note: Though similarly titled, this film is not the same as the PBS show on Frontline, called "The Soldier's Heart," which we blogged about earlier, here.

"Extra, Extra, Read All About It" -- Combat Trauma in the News

Reporter Alysa Landry has an excellent series of articles published in the Farmington, New Mexico newspaper, The Daily Times on combat trauma and PTSD.  Click here, here and here for the links to the stories in this three-part series, which is well worth reading.  The individual article titles are, "Combat That Never Ends," linked here; "The Front Lines Shift...Military Veterans Face Varying Battles," linked here; and "The Search for Combat Trauma Solutions," linked here.

A Poem for My Father

Medic! Medic!

I wish I could yell, and someone would come,

But they don’t

I call in air support but the pilots are all stricken too

The infantry has gone into the bunkers

MIA in their own wars like yours …

Forty years after ...

Under a hundred starry nights … stained with blood

Comrades lost, in the winds of Battles gone

In a war over there, in the napalmed jungles

Where Agent Orange still stains the ground

A million screams now silent,

Except those in your mind, which will echo

For all time

We are alone

And we fight the war, together, after you’ve come home

Medic! Medic!

You were wounded in the Nam

Spiritually, wounded, for a country that has forgotten what you’ve done

And what was done to you

Medic! Medic!

Nobody to help us, just you and me

You are wounded, and I your son, a warrior too,

Help you carry on

Though I have never seen the jungles

I am there with you

Fighting a war

In jungles of PTSD, anger, fits of rage

Flashback ...

Incoming, again!

You duck into your psyche until choppers pass

Ones you hear, though we are standing here in suburbia

Guns firing, shrapnel flying,

Once again ... it happens often

We go on, me carrying you, and you wounded

Through the battle under the blood stained heavens

Fighting the war together, the one they forgot

The war you still fight, I fight with you

Medic! Medic!

© 2007 by Jeremy Hogan, photojournalist, son of Jerry Hogan, a Vietnam veteran with longtime PTSD.  The photo is of Jerry Hogan.  Used with permission.

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Editor's Note: April is National Poetry Month.  We're initiating it with this poem, written by a son about his Vietnam veteran dad's experience with PTSD.