Healing Combat Trauma

Veterans, PTSD and Suicide: The Overlooked Element of Contagion

This is an article I'd first started writing two years ago now. I did the research, and located the main, most often-cited study's principal investigator, long since retired, and asked him to confirm whether the trend is still true, though he first published it back in the 1970s. He affirmed that it was. What it is is an important and often-overlooked "connection" that will make more sense when we start describing it. It also fits into the category of things where the information is out there, but for some reason is also strangely ignored. Another instance was a few years ago, when the military kept saying, "We don't know what PTSD is tied to"; essentially, "we have no idea." Yet at the time, and this goes back several years now, I was able to read through the existing literature and learn, PTSD is tied to combat exposure. In other words, the more combat, the greater the chances of developing PTSD. And I wrote about it, here, at the time the military was saying, in essence, we don't know what it's linked to.

So it isn't that that wasn't known...it's that no one was paying attention to what was out there. (And these days, several  years later, they ARE admitting publicly that more exposure = greater chance of developing PTSD. But it does make me laugh a little bit to hear that now, thinking, we were talking about it here well before that was being said publicly. And not because of some strange prophetic abilities on our part; just from reading the available literature, and drawing what seemed like obvious conclusions.)

There's the old saying that "those who refuse to learn from history are condemned to repeat it." Well, much of what's known about PTSD has been known for decades now, with another fair part of the knowledge base has been increasing exponentially. I read an article the other day about a Harvard-trained psychiatrist who worked at the V.A. in Boston during the Vietnam war, and was "shocked" to learn that there wasn't a single book on war trauma in the library there. Today, one would hope, that situation has changed quite a bit. 

But to the point at hand...

As I read through my Twitter feed today (you can follow us @HealingPTSD on Twitter), I noticed several suicides being Tweeted by various sources. One was that of Mel Turpin, a former All-American basketball player and NBA star, dead at 49; and then the troubling news, especially to us in the veterans community, of a Marine Corps veteran, James F. Popkowski, 37, who apparently died in a "suicide-by-cop" or armed confrontation outside the V.A. in Bangor, Maine. (See those stories linked here and here, as well as a longer quasi-obituary of Popkowski, here.) At first the headline said only "an armed man" had died in a confrontation with police near a local VA -- and as soon as I read that, I hoped -- but yet somehow knew -- that it would be a veteran, with a painful story of his own. Later the news matured to show that in fact he was a veteran, who was struggling with this illness (cancer) and its treatment. But the fact he was a veteran and committed suicide reminded me instantly of the news from the last few days, where the Seattle Times did such a good job covering the suicide of a veteran with PTSD from Whidbey Island, Orrin McClellan. (I wrote about Orrin's life and death here and here.) So many suicides in the media, and superstitious types tend to think those run in threes -- though technically McClellan's death was in mid-May, with the coverage of it in the media happening over the last few days.

I need to branch off in two different directions here, to cover this material. 

One is to talk about the V.A. suicide's statements about his own condition, because veterans with PTSD and their family members may recognize their own veterans in those words. And the other is to introduce something very different, which is the effect that media coverage of suicides has on "successful" suicide attempts by others during the same general news cycle, especially young men (who are, after all, the majority of those who serve.) 

On that second point, as the military has generally speaking tried and failed to lower the suicide rate lately, I haven't seen much recognition (OK, any) of the idea that suicides are to some degree contagious. There's quite a bit of medical literature on the subject...and it's been documented in studies around the world, starting in the 1970s, that suicides reported in the news will have a demonstrated effect on increasing suicide attempts from specific populations who hear the news. Since suicide is a broad category -- many single-car or single-motorcycle accidents are also suicides -- and the military attempts periodically to crack down on motorcycle safety, etc., it would also be wise to enlarge the conversation to not only what other methods qualify as suicides, but also to take a look at how one suicide making the news can, depending on how it's portrayed, have an effect on increasing the number of other suicides that take place in the same general time frame, especially among those prone to committing suicide, because of depression and other factors. And we haven't even mentioned yet here the effect that some prescribed pharmaceutical medications can have on increasing suicidal thoughts.

(While it's somewhat unlikely that Popkowski, in Maine, was reading the Seattle Times' coverage of Orrin McClellan's death -- one, we never know; and two, in the age of the Internet, geographical barriers have disappeared and the news is instantaneous -- especially if you include other social media, like Facebook and Twitter, which can serve as additional sources of the same news. We're so much more wired now than when these studies first started being done, so we can't assume Popkowski didn't read the Seattle Times coverage, even though it's most likely that he didn't. For the sake of this argument -- because if it didn't happen with this case, it surely does with others, let's pretend that Popkowski did spend some time over the last few days reading the coverage of McClellan's suicide on the Internet.)

There's enough material to cover here that I need to go as far as I can with it now and then circle back around to it again soon. We'll introduce the science (below) but also cover what Popkowski said about his failing health, because his words will resonate with other veterans, who struggle not with cancer but with PTSD.

According to the article in the Portland, Maine Press Herald today, Popkowski, who had undergone a stem cell transplant for his cancer back in 2003 at the National Institutes of Health, struggled valiantly with the effects of the cancer and its treatment (both difficult), as well as sleep problems, depression and the like. In a letter to the editor of the magazine "New Scientist" back in 2008 he wrote,

"Suicide is like a little devil, always on my shoulder and always tempting me. Concern for the care of my three dogs after I am gone, my dogs being the only things I feel anything resembling passion for, is the only thing I think that has kept me from pulling the trigger on the loaded pistol, which rests next to my pillow."

He continued,

"The best way to describe the mental and emotional issue is that I am numb and passionless. Nothing brings joy or pleasure. I graduated magna cum laude with a (Bachelor of Science degree) in computer info systems and business management in just three years. Now, I cannot mentally focus enough to read a newspaper."

He added,

"I have lost count of the number of sleep aids NIH and my local VA have tried. Like the anti-depressants, none have worked."

And he described leaving his bunker, in terms that a veteran with PTSD would understand, only for brief forays out to re-provision with groceries and return, if his health even allowed him that. He wrote:

"For weeks at a time I will only leave my house once, and only briefly at night, to buy groceries and other supplies. Most of the time, the only time I drag myself into the shower, is when I have to go into town to buy groceries."

---

Now, we hope that no veteran ever crosses the bridge to suicide in his or her lifetime, and especially is not discouraged enough reading news of how another distressed veteran felt to contemplate it. Please use the resources at your disposal, including hotlines, buddies, and compassionate others as lifelines to not give up hope, because there IS hope, and you can get better. But for the rest of us, we need to keep pushing on with this narrative because there's something to learn here, including for decisionmakers who wonder about how better to educate about suicide prevention. This is where the element about the notoriety/publicity level of a suicide influences other at-risk populations.

To the science on this.

• Back in 1977, in the journal Science, DP Philips showed that "motor vehicle fatalities" (including "suicides by motor vehicle") increase in the time frame "just after publicized suicide stories." From the abstract: "The average increase in motor vehicle fatalities is 9.12 percent in the week after a suicide story. The more publicity given to the story, the greater the rise in motor vehicle deaths thereafter. This rise apparently occurs because suicide stories stimulate a wave of imitative suicides, some of which are disguised as motor vehicle accidents."
• In 2006, an Australian journal, Social Science Medicine, published a similar study, further demonstrating the "relationship between media reporting of suicide and actual suicide." They studied data on "4,635 suicide-related items appearing in Australian newspapers and on radio and television news and current affairs shows between March 2000 and February 2001. The study found that 39% of media items were followed by an increase in male suicides, and 31% by an increase in female suicides. Media items were more likely to be associated with increases in both male and female suicides if they occurred in the context of multiple other reports on suicide (versus occurring in isolation), if they were broadcast on television (versus other media), and if they were about completed suicide (versus attempted suicide or suicidal ideation). Different item content appeared to be influential for males and females, with an increase in male suicides being associated with items about an individual's experience of suicide and opinion pieces, and an increase in female suicides being associated with items about mass- or murder-suicide." They concluded, "Further research on this topic is required, but in the meantime there is a need to remain vigilant about how suicide news is reported. Mental health professionals and suicide experts should collaborate with media professionals to try to balance 'public interest' against the risk of harm."
  
• Versions of the original study were repeated over and over in the intervening years, and 30 years later, in 2007, the International Journal of Epidemiology published a study which showed "the influence of media reporting of the suicide of a celebrity on suicide rates," where a male television celebrity in Taiwan committed suicide, followed by a wave of somewhat "copy-cat" suicides among young men. (The "celebrity" element may initially confuse, but think of it this way -- it's a well-publicized suicide when it happens, which means it reaches most of the target audience. It also happens, according to other studies, when non-celebrities commit suicide. The distinguishing factor is how well publicized the suicide is/how much media attention or coverage is given to it. The more coverage, the more people know about it, including those in somewhat fragile populations.) Back to the study's results: "After controlling for seasonal variation, calendar year, temperature, humidity and unemployment rate, there was a marked increase in the number of suicides during the 4-week period after media reporting (relative risk = 1.17, 95% CI 1.04-1.31). The increase was in men (relative risk = 1.30, 95% CI 1.14-1.50) and for the individuals using the same highly lethal method (hanging) as the TV  actor did (relative risk = 1.51, 95% CI 1.25-1.83). However, the age groups in which the increase occurred were younger than the age of the celebrity. CONCLUSIONS: The extensive media reporting of the celebrity suicide was followed by an increase in suicides with a strong implication of a modelling effect. The results provide further support for the need for more restrained reporting of suicides as part of suicide prevention strategies to decrease the imitation effect."
• Also in 2007, a study was conducted in Taiwan around the fact pattern of the same television celebrity's suicide and published in the Journal of Affective Disorders. It attempted to define the "influence of media reporting of a celebrity suicide on suicidal behavior in patients with a history of depressive disorder," and what it found was "Among 438 depressive patients exposed to the media report, 38.8% reported an influence on subsequent suicidal behaviors, including 24 (5.5%) with a suicide attempt. The risk of such influence was highest among patients in a severe depressive state just prior to the media report (adjusted OR 7.81, 95% CI 3.28-18.59). Such influence on a subsequent suicide attempt was highest in patients with a most recent suicide attempt within one month prior to the media reports (adjusted hazard ratio 11.91, 95% CI 3.76-37.72)." The authors concluded, "This study has provided more convincing evidence suggesting negative influences of media reporting of a celebrity suicide on subsequent suicidal behaviors among depressive patients. Particular attention in terms of potential negative media influences should be paid to patients who are younger and currently depressed and have made a recent suicide attempt."
• This year (2010), another Taiwanese study took a look at suicide rates after media reporting of another celebrity suicide, this time a female singing star. Their premise was that "Suicide attempters are known to be vulnerable to the influence of media reporting of suicide events. This study investigates possible influences of media reporting of a celebrity suicide on subsequent suicide attempts and associated risk factors among suicide attempters." In their study, "Sixty-three suicide attempters registered in a surveillance system of Taipei City Suicide Prevention Center were assessed using a structured interview soon after media reporting of the suicide of a young female singing star." Their results? "Forty-three (68%) respondents had encountered with the suicide news. Among them, 37% reported being influenced by the media reporting on their subsequent suicide attempts." Most hard-hit by the news? "Men (adjusted OR 6.36, 95% CI 1.29-31.44) and younger age groups (adjusted OR 4.93, 95% CI 1.04-23.45) were more susceptible to the media reporting." And the authors concluded, "This study has provided further evidence for suicide imitation among vulnerable people encountered with media reporting of celebrity suicide, and for the need to actively restrain reporting of suicides to decrease the imitation effect."

It's also true that young men -- the dominant demographic of who the all-volunteer military is these days, though approximately 11% are women -- are more prone to suicide than other age groups. Back to the science:

• According to statistics from a fact sheet on youth and violence provided by the CDC, "In 2005, 17% of high school students seriously considered attempting suicide, and 13% made a plan about how they would attempt suicide during the 12 months preceding the survey." (The reference cited is CDC. Youth Risk Behavior Surveillance - United States, 2005.  Morbidity and Mortality Weekly Report 2006; 55 (SS-5): 1-112.)
• Similarly, according to the CDC, "approximately 14% of all deaths among children and adolescents aged 5-19 years result from suicides."  The numbers climb according to age ranges, with younger children having the fewest, and older children the most.  Suicided ages 10-14: 283.  Suicides ages 15-19: 1,700.  (The reference cited is CDC, National Center for Injury Prevention and Control, Office of Statistics and Programming. Web-based Injury Statistics Query and Reporting System (WISQARS). Online at http://www.cdc.gov/ncipc/wisqars/. Accessed September 6, 2007.)

There's more that we could talk about here -- responsible reporting guidelines about suicide, when disseminated and implemented, seem to have the effect of reducing the number of copycat suicide attempts after a successful publicized suicide (a study in Austria shows that) -- but the intended effect here, which we can elaborate on in future posts, is to introduce the idea that one publicized suicide by, say, a veteran, can also most likely encourage an increased number of suicide attempts, some of them successful, by members of at-risk populations, such as young/depressed/men. Do any of those words correlate with anyone who might be suffering from PTSD, or taking medications that might also increase suicidal thoughts? And we haven't even added into the mix the effects of alcohol, which many PTSD sufferers self-medicate with, and how that would affect suicidal thinking. There's much, much, much more to talk about on this topic -- not just here on this site but nationally -- but we hope this dense, rather convoluted post has at least gotten you thinking about not so much that we need to protect veterans with PTSD from seeing or reading the news, which might contain an item about another veteran's suicide -- but that suicides can almost go in waves (read the literature on prison populations, etc. for this), where one suicide spurs others in the same population -- because publicity surrounding a suicide has the unintended consequence of increasing suicidal tendencies in other affected people. Since many, many veterans with PTSD are to a degree on edge already...it might be good to realize the effect that reading about another veteran's demise could have on an already depressed, stressed or demoralized individual.

And since the larger goal for all of should be preventing suicides among PTSD-injured veterans, it's highly worth having this conversation.

Anatomy of a PTSD Suicide: Orrin McClellan Was "Only Halfway Home" from War

"Happy families are all alike," wrote Leo Tolstoy, the famous Russian novelist (and combat veteran), in the opening lines of "Anna Karenina," adding, "every unhappy family is unhappy in its own way." And certainly few families are unhappier than those who've lost someone they love deeply to suicide, as Orrin McClellan's parents have, who've recently lost their Airborne soldier son to the aftermath of PTSD.

We wrote about Orrin McCllelan yesterday, the 25-year-old OEF veteran who took his own life in May of this year. The article, "Anatomy of a Suicide: OEF Veteran Orrin McClellan, RIP from PTSD," is linked here. The underlying Seattle Times article, also from yesterday's paper, is very good, and combines multimedia with the telling the story of McClellan's all-too-short life and struggle. It also documents the pain and suffering McClellan's parents are going through.

There is no "purple heart" for PTSD. There is no "war memorial" that lists those who died by suicide from PTSD, even when combat was the most likely explanation. And maybe there should be... But in the meantime, all we can do is try to reconstruct what we can find about who Orrin McClellan was in the 25 short years he was here.

Digging around on the Web, we can find out much about who McClellan was. The exercise becomes less macabre, or voyeuristic, than the assembling of an online shrine to the memory of someone we never knew, who's now too soon gone. There are the two online journals that McClellan kept, at MySpace and LiveJournal. There is his photo stream on Flickr. There is an obituary by a caring friend, who attended his memorial service. There is McClellan's listing at an online dating service, "Hot or Not," which he set up when he was in Afghanistan, and elsewhere pans with the single word, "whatever." There are some videos that a friend shot of him, who mourns his passing and wishes he had captured a few more shots of McClellan while he was still alive. There are the photos and the poems that his family shared with the Seattle Times, that are part of the original article. And there is a truly beautiful video about his deployment to Afghanistan, called "They Carry," that McClellan himself pieced together, shown on YouTube, and set to music: not heavy metal, but classical...He uploaded it in late September, 2007, after he got back from Afghanistan, and it carries the interesting descriptor: "this generation's wars from eyes on the ground...the faces and names are placeholders. those who were there remember. the rest can only watch." WELL worth viewing...

His interests, as he discloses them on one of the two online journals he kept, are nothing out of the ordinary: places he's been, music he likes, hobbies: "airborne, american beauty, army, dave barry, death cab for cutie, flickr, glen phillips, haruki murakami, italy, langley, lava lamps, led zeppelin, military, muse, orbital, photography, pink floyd, quentin tarantino, seattle, the big lebowski, toad the wet sprocket, vicenza, washington, whidbey island."

There's his brief description of the key dates and places in his short life, again from an online journal:

"Born in Milwaukee, WI. But home is between the Cascades and Olympics on the Puget Sound. Grew up in Langley, on Whidbey Island, Washington. Enlisted in the Army in late '03, started Basic in Feb '04, Airborne School that June, got to Italy that July, and to Afghanistan Mar '05. Getting out Feb '07."

(In September of 2007, he uploaded the excellent video, "They Carry," of his time in Afghanistan.")

And then there are the news items about him, focusing on an arrest, locally. And what look like three court cases: in July of 2008, January of 2009, and September of 2009, listed on King County Superior Court's website.

In July of 2008, he was in the local paper, for assaulting some cops at a concert, allegedly threatening to kill them, gouging one of their eyes, and basically asking for them to shoot him. In October of 2008, he's back in the news locally, after being acquitted of assaulting and threatening police officers in the earlier event. He spent time as an inpatient at the VA for PTSD. He also lived too far away to make regular treatment a likelihood, and getting there, via a ferry trip and highway driving on I-5, was triggering.

His parents, who describe themselves as self-employed and dedicated (i.e., more available than most) seem to be doing everything in their power to help him, but he is melting down. The previous article, yesterday, describes some of the symptoms of his raging PTSD. The two articles in the local papers also detail the attempts his family made to get him help.

In one of the articles, his mother is quoted as saying, "We must not stop with research and development of the healing of visible wounds and helping the veterans become whole with prostheses for severed arms and legs. We have a responsibility to get just as expert at healing the inner wounds of the body, mind, emotions and spirit.”

She also goes right to the heart of the matter when she says, also quoting from those articles, "Our military is well-versed at training our sons and daughters to be experts in weapons, combat and killing, and distrust of the other, but they fail to complete their warrior training of our troops by failing to train them in the skills of regulating the emotional responses of the body, mind and spirit after experiencing the traumatic horrors and terrors of war, and in the skill of reintegrating into families and communities.” 

When she talks about her son's difficulties, she is very clear: "Our son, only halfway, came home from the war; half of him is still fighting over there, within his body, mind, heart and soul,” Gorman said. “Every day, all the time.”

Unfortunately, on May 18, 2010, Orrin McClellan lost that fight. And his family, and everyone concerned about combat veterans and PTSD in America, grieves with them.

Anatomy of a Suicide: OEF Veteran Orrin McClellan, RIP from PTSD

The Seattle Times has an article in yesterday's paper about a young Whidbey Island OEF veteran who unfortunately killed himself in May of this year. Orrin Gorman McClellan served with the 173rd Airborne Brigade Combat Team in Afghanistan in 2005-2006. He took a lot of photos of his experience in Afghanistan, and he also wrote, poignantly, about his experiences as a soldier in an online journal, where he wrote every day. (The article doesn't reveal the location of that journal.) In what's known in the journalism biz as a "package," the article also has two multimedia presentations included with it: a video of his parents leafing through a book they're putting together of poems Orrin wrote, linked here, and a video narrated by his parents of some of his photography from Afghanistan, linked here. "I've become numb," McClellan writes, "but not comfortably so."

It's wrenching watching his parents in the videos sit side-by-side on the couch, in a tableau no doubt repeated across America, as the parents of the approximately 18 veterans a day who kill themselves must do, trying to make sense of why Orrin had to go, and still actively grieving, trying to come to terms with their own loss. In Orrin's case, his mother is a social worker, who the article says specializes "in the treatment of traumatized individuals." Of course, not even a mother with this background can necessarily save her son, which only adds to the tragedy. It says his mother even "took a counseling job with the Whidbey Island NAS and helped her son navigate through the VA system." He was retired with a 100% disability due to PTSD. The article quotes the mom as saying that as a community, we all need to listen better to our vets. And practice "deep listening" to their stories of what they've gone through.

What makes the article good, from this reader's perspective, is that it positions Orrin McClellan's death against the backdrop of the statistics of veterans suicides across the country, and then projects how those statistics affect Washington state, where the Seattle Times is based, and where Orrin lived. Eighteen deaths of veterans a day, the number of suicides approximating deaths in combat this year -- these are shocking statistics, but like so many others, we become numb to them over time. Bringing it closer to home, those same statistics mean of the almost 36,000 OIF and OEF veterans from Washington state, a dozen would be lost to suicide. In 2010, Orrin McClellan was sadly one of that number.

(Army veteran Chris Loverro, who served with the Stryker brigade from Fort Lewis, Washington, did a poignant video of his own about PTSD and suicide in the life of a veteran. We've shown it in a recent article, linked here.)

McClellan's mother, Judith Gorman, says that her son never really came all the way back home, because of his PTSD. Retired Army General Eric Shinseki, now head of the VA, is also quoted in the article, as ruminating -- perhaps not about McClellan's death in particular but about veterans' suicides in general -- that he often asks himself, "Why do we know so much about suicides, but so little about how to prevent them?" That's a fabulous quote, but it's also quite a profound question.

Edwin Shneidman, the so-called "father of suicidology" -- who ironically got his start leafing through files at the VA, reading suicide notes of veterans -- is someone we've written about a fair amount on this site. He's also known as the originator of the concept of a "psychological autopsy," where someone, reasoning backwards from the fact of the a person's death, tries to reconstruct the extent and timing of the stressors in that person's life, to determine how and why it became too much for them (the "when" having already been determined.)

I'm not sure, but I would hazard a guess that, other than the families of veterans who commit suicide, who are directly involved, there isn't much of an effort made on a larger level to reconstruct what stressors became unbearable in the lives of those who kill themselves, during or after military service. Perhaps a broader study into this, a la Shneidman's methods, would produce important or helpful conclusions.

McClellan's story is in many ways all too typical...except for the social worker mother, and the wonderful legacy he left behind in the poems he wrote and photographs he took. He struggled, as many veterans with PTSD do, with drugs and alcohol, with trying to fit back into his life, with impulse control, with hypervigilance, with nightmares, with combining alcohol with prescription medications, with grief and perhaps blaming himself over the deaths of two close friends. And he struggled with long drives to the VA, which was located quite a distance from his home.

His parents sound like amazing people, who tried so hard. They even established a Veterans Resource Center, on the island where they lived, "to offer referrals, networking and other assistance," to help other veterans in addition to their son. In the wake of his son's death, they may also publish a book of his writings, to raise awareness about PTSD.

Digging around on the Web, especially within social media, it wasn't hard to find some of McClellan's thoughts. He had two journals where he kept his writings, one on MySpace and one on LiveJournal. I've chosen not to link to them, to protect his privacy in case that's an issue. But in one he quotes from T.S. Eliot's famous poem, "The Hollow Men," which closes with the memorable lines about "this is how the world ends, not with a bang but a whimper."

It also contains an entry from September of 2008, while McClellan was actively struggling with PTSD, but a full year and a half before he ended his life. In an entry called "What the hell happened to me?" he writes:

"I read some entries in my journal from two years ago" 

[2006, the end of his Afghanistan deployment and beyond]

I love who I was.

Why did I do this to myself?

Was it war?

Did I implode from all the shit I saw?

Or was it something else?"

Questions really with no answer. He goes on for a bit more, and then concludes with the poignant question:

Why did I let myself

Get so lost?

RIP Orrin McClellan, gone too soon, and comfort to your family and your friends.

Editor's note: The photo is of a point on Whidbey Island, a thoroughly beautiful place in Washington state.

"The Hell of War Comes Home" Almost Nets Reporter a Pulitzer Prize

The Pulitzer Prizes in journalism were announced today. A semi-finalist in the "local reporting" category was Dave Philipps of The (Colorado Springs) Gazette for" his stories on the spike in violence in a battered combat brigade returning to Fort Carson after bloody deployments to Iraq, leading to increased mental health care for soldiers."

Go here to read the series, "The Hell of War Comes Home." The link goes to the first installment in the series; other installments are linked to that initial article. There's also video.

Recent Women Vets with PTSD Use Mental Health Services Differently, Not Enough -- Study Says

According to a recent item published by Boston University's School of Public Health, younger women combat veterans with PTSD under-utilize specialized mental health treatment programs provided by the VA. Just why this is the case hasn't been determined yet, but the study highlights some interesting results  -- and in any case it's progress that the needs of this special population (women combat veterans) are being studied. From the press release:

"Younger women veterans with substance abuse problems, post-traumatic stress disorder and other mental health diagnoses were significantly less likely to utilize specialized Veterans Health Administration (VHA) mental health services in 1999, after the first Gulf War, than their male counterparts, a study led by BUSPH researchers has found.

Veterans of recent conflicts have been shown to have significant mental health needs," says the study, published in the journal Women's Health Issues. "Examining the effects of gender on disease burden and health care utilization in this growing group of veterans is important."

The study found that younger women (under 35) were significantly less likely to use mental health services in comparison to men. However, middle-aged and older women were more likely to use the services than men."

In terms of specialty mental health services, women veterans under the age of 55 were significantly less likely to use PTSD or substance abuse services. The authors speculated that women with substance abuse problems "may be averse to using male-dominated therapeutic groups," may seek treatment in general medical settings or may not seek treatment at all, as described in prior literature on women and substance abuse.

If underutilization of [substance abuse] services continues in newer women veterans, a significant percentage...may remain untreated," the authors cautioned.

The researchers said the underutilization of specialized PTSD services by younger women could be due, in part, to the fact that a significant proportion of PTSD in female veterans is associated with a history of military sexual abuse: "Women with a history of military sexual trauma may not feel comfortable either in mixed-gender groups or using services in which treatment is oriented primarily toward combat-related PTSD.

Overall, a higher percentage of women veterans than men utilized outpatient mental health services, other than the specialized PTSD and substance abuse programs. The study also found that women veterans who used VHA services had a higher prevalence of mood/anxiety disorders and bipolar or psychotic disorders than their male counterparts.

The researchers said that, if the utilization trends found in the study persist, an increasing number of women veterans with significant mental illness and comorbidity could be expected to rely on the VHA for care.

They said their findings highlight the complexity involved in crafting mental health services for the new wave of women veterans."Further research is warranted as to how to address the complex needs for specialty mental health services in this newly emerging group of veterans," they said.

They noted that examining gender differences alone, without taking age, diagnosis and other factors into account, may not provide an adequate picture of women veterans' mental health service needs."

Source: "The Insider," from Boston University's School of Public Health, June 29, 2009. Submitted by Lisa Chedekel.  Link is here.

More Numbers to Remember: 3 Then, 7 Now

A newspaper article reports today, "In the Vietnam war, for every soldier killed, three came home wounded. In Iraq, for every soldier killed, seven come home wounded." Those are some substantial numbers...and I wonder if they're even accounting for PTSD in them, which is often considered an "invisible wound," and one which shows up usually after the fact.  The numbers could be even that much higher...

Roughly 5,000 killed to date -- 35,000 wounded (by that estimate) -- and for every veteran, another 50 people who he or she affects (see Fred Gusman comment about that, which we blogged about earlier -- linked here).  If we add the number killed and the number wounded together, then multiply the 50 each veteran affects directly in his or her life, that's 2 million Americans affected by veterans' sacrifices.

Feel Like Just a Number / War's Psychic Toll

The New York Times has a good op-ed piece today by Bob Herbert, entitled "War's Psychic Toll," linked here.

One point he makes, in the wake of the shooting deaths at Camp Liberty, is that:

"The fallout from the psychic stress of the wars in Iraq and Afghanistan has been vast, but there was no reason for its destructive effects to have surprised anyone. There was plenty of evidence that this would be an enormous problem. Speaking of Iraq back in 2004, Dr. Stephen C. Joseph, who had been an assistant secretary of defense during the Clinton administration, said, “I have a very strong sense that the mental health consequences are going to be the medical story of this war.”

He also further clarifies a point that a number of people have been making over the last several years, which is that an all-volunteer military concentrates the inevitable "psychic toll" of warfare into too few combatants on our side.  Herbert writes:

"Because we have chosen not to share the sacrifices of the wars in Iraq and Afghanistan, the terrible burden of these conflicts is being shouldered by an obscenely small portion of the population. Since this warrior class is so small, the same troops have to be sent into the war zones for tour after harrowing tour.

As the tours mount up, so do the mental health problems. Combat is crazy-making to start with. Multiple tours are recipes for complete meltdowns."

We've already seen, in previous blog posts, how more combat => more opportunities for PTSD. The relationship is direct.

At some point, with the same people serving multiple deployments, being injured becomes a numbers game.  And increasingly servicemembers who keep going back, if they've managed to avert injury so far, become concerned that their luck can't hold out forever.

A Recon Marine, with multiple deployments under his belt -- some would say, the toughest of the tough -- headed back to Afghanistan on Monday.  "I'm scared," he told his friends and family, unashamedly.  War is a dangerous game, and multiple deployments wreaks havoc on those who go, and those who stay behind and wait.

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In the old Bob Seger song about working on an assembly line, "Feel like just a number," he sang, "I feel like just another / Spoke in a great big wheel / Like a tiny blade of grass / In a great big field."  Seger insists he's gonna "cruise out of this city / Head down to the sea / Gonna shout out at the ocean / Hey its me!" "I feel like a stranger / A stranger in this land," he sings.  "I feel like a number / But I'm not a number / I'm not a number -- Dammit, I'm a man! / I said, I'm a man."

I recall a conversation with another Marine, who between tours of Vietnam, had a premonition that he wouldn't survive his second tour.  What worried him even more than the dream was that everyone he knew who'd had a dream like that, and shared it with his buddies, subsequently was killed.  This Marine talked it over with his dad, a heavily-decorated Army officer, who told him, in sort, to buck it up and suck it up and go back -- because if he didn't, he'd be running from every other experience like this in his life.  Well, the premonition had a lot of weight to it -- he was shot multiple times and almost died, and took years to recover from his injuries. So we know that the Recon Marine in today's story, headed back to Afghanistan, does have something to be worried about -- even if he hasn't had a dream like this.

Ultimately, whether he and servicemembers like him think of themselves as "just a number" in the larger war machine or not, their more pressing concern, with multiple deployments in harm's way, is whether this time their number is going to be up.  And let's hope it won't be.  But of course, for society at large -- who stays behind -- the broader public health worry is that even if these warriors come home relatively "unscathed" -- in body, more likely than in mind -- their struggle with dealing with the after-effects of combat will just have begun.

Editor's note: To listen to the Bob Seger song mentioned above, on YouTube, click here.

Puget Sound Veterans Hospital Tries Meditation for PTSD

The Seattle Times reports in today's paper that a veterans hospital in the Seattle area is trying a version of mindfulness meditation for combat veterans with PTSD.  The article is called, "Seattle hospital teaches meditation to troubled vets," by Michelle Ma.  The eight-week course, which has been held for a year, has proved to be of some value to veterans, and current plans are to study the effects more in-depth. 

The article in the Seattle Times is linked here.

For links to other posts we've done about mind-body medicine, including meditation, and PTSD, click here.

PTSD, Suicide and the Primary Importance of ... Sleep

There's a great article in today's San Antonio Express-News by Sig Christenson, called "War Lingers, GI Suicides Rise."  (The article is linked here.)

It quotes my favorite, retired Veterans Affairs psychiatrist, Jonathan Shay, M.D., Ph.D., and it quotes him on, among other things, the absolute primary importance of SLEEP, which we've talked about many times on the blog before. (Click here for a link to those posts, many quoting Shay himself.)

Quoting Christenson's article, from today:

"The armed services' high operational tempo for the past decade definitely is part of the problem, said (Jonathan) Shay (M.D., Ph.D.). Though alcohol abuse “is a major risk factor,” he said the military's rapid training and deployment cycles short-change troops on the one critical ingredient to good physical and mental health: sleep.

“I've been agitating for years the importance of getting truly realistic policy on sleep,” Shay said. “This is a slow slog because it is so contrary to the macho culture and so contrary to the self-sacrificial culture, which sees self-care like sleep as self-indulgence.”

Let's recap some absolute basics about sleep:

• It's absolutely necessary for mind and body healing, and down regulation of bodily systems;
• It's vital for decision-making and mental health. Studies on drivers who operate on lack of sleep of sleep show that it impairs functioning to the level of alcohol intoxification.
• It's hard to get in a war zone, for any number of reasons: from the operations that go on for days and nights at a time, to the noises of combat, etc.;
• It's hard to get after combat, thanks to nightmares, hypervigilance and arousal, and often the desire to avoid sleep (which brings on intrusive memories, nightmares, night sweats, and the like);
• Chronic lack of sleep impairs mental, physical and emotional health;
• And yet without adequate, nightly sleep -- how is healing going to take place?

There's a great story told about beloved Marine veteran, Travis Twiggs, who we've written about in other contexts.  Apparently his nickname was "War Pig," and it was given to him during a tour of duty at Guantánamo Bay, where after being up for umpteen hours straight, and finally getting a break, he had fallen into such a heavy sleep that he couldn't be roused, and a passing a general had stuck over his sleeping form a sign that said, “Here Lies the Mighty War Pig.”

I know another hardcore combat veteran and former Marine who came with me once to a program that was designed to help people learn how to sleep better.  He bitched and moaned while we were there, quite a bit, about how this wasn't really suited to combat veterans like himself, but whatever -- he persevered, and tried what they had to offer.  The next day, after he flew home, I worried about him because I hadn't heard how he was doing. A day later, he called me back. "I came home and slept for 31 hours straight," he said.  "I hadn't been able to sleep more than two hours at a time since before I left for Vietnam." So my guess is that the method was of some help to him ;-) But imagine not sleeping for more than two hours at a time?  How well would you be able to heal?

Editor's note: Read the rest of the articles we've included about sleep, from previous posts, linked here.

Travis Twiggs: The Un-Happy One Year Anniversary of Combat PTSD's Perhaps Most Visible Death

Just a brief note to mention, it was one year ago today that Travis Twiggs passed from this earth, by his own hand, the veritable poster boy of combat-based PTSD.  It also marks his brother Willard's passing, who left this earth with Travis, apparently by Travis' hand.  It's an absolute tragedy, for any number of reasons -- from the family members and friends the Twiggs brothers leave behind -- to the fact that Travis, personally, was making an impact as a Marine who broke the code of silence, so to speak, and spoke openly about his PTSD.  Twiggs wrote about his ordeal in the January, 2008 issue of the Marine Corps Gazette, in an article that has been widely circulated, and is still available on the Web.

Travis Twiggs' suffering was something that really stood out to me -- perhaps because of his very willingness to speak openly about his struggles, something Marines.Just.Don't.Do.  We actually broke the news of his death on this blog, before the mainstream media had reported on it -- and in fact, the early reports were wrong on the facts but widely repeated, making the damage that much more painful.  (He and his brother were reputed to be hardened criminals, for example, which they were not, although they had been -- at the last -- involved in a carjacking, as part of their initially ill-fated but ultimately successful desire to end their lives.  In fact, Twiggs was a much-decorated Marine with multiple combat tours behind him, who had recently met the president, and whose Marines (and his family) deeply loved him.  His brother, Willard, was well-loved as well.  A year later, not a day goes by that people don't find this site out of a search they're doing for Travis or Willard; and in the days after their death, searches for Willard were almost as popular as those for Travis, though Willard was obviously shyer and less well known. And these tragedies were not the only ones the Twiggs family suffered in a very short amount of time: their beloved grandmother also passed away within days of the Twiggs' brothers' deaths. Hard, hard times for the Twiggs' family, and for all those who loved Travis and Willard.

It's hard to explain my own involvement in this saga except to say, I had a bad feeling about how Travis was really doing, without even knowing him, just based on reading what he wrote, and how it didn't seem to add up.  So the month before, without realizing he'd already been confined to an inpatient PTSD program at Bethesda Naval Hospital, and was therefore unable to answer, I repeatedly tried to get ahold of him and/or the Marine Corps Gazette, which had published his somewhat optimistic article months before.  When neither would reply, I started to really worry that something was amiss.  Then when the first news reports came out of the National Park Service about the "armed, tattooed and dangerous" Twiggs brothers, involved in a carjacking, I just knew it had to be Travis, and that things had somehow gone terribly wrong. Hoping to offset the "bad news" (and mistaken news" about who Twiggs really was -- not a lifelong criminal, but a decorated Marine, who everyone loved, who'd struggled mightily with PTSD -- I went out on a limb, and wrote, as I realized he was dying, what became a "PTSD obituary" to this at the time unknown Marine, who'd undoubtedly died from the consequences of his uncured, but not untreated PTSD.

In the days that followed, as I waited for any national attention to be focused on his case -- none was -- the blog here received heavy, heavy traffic, as those who loved Travis and his brother came to essentially pay their respects, much as I had tried to myself, and also tried to come to terms with the brothers' passing.  Over time, various reporters kicked into gear and started covering the Twiggs' story in lengthy pieces. (I had to put the "use with attribution" notice up on this blog when one reporter spent, no joke, 40 hours mining this site, without acknowledging where he got his information.  Ugh.) Richard Ruelas wrote about the saga for the Arizona Republic (the brothers had died in Arizona), Bill Finnegan's at the New Yorker magazine, and there was a two-part series in the New Orleans-based Times Picayune. CNN, to its discredit, never once mentioned the brothers' passing.  I think once they missed the initial window, it was too embarrassing to catch up, but to this day, they never have, whereas pretty much everyone else has had something to say about it -- or them.

While many, many aspects of being the one to break this story -- on a blog, not in a newspaper or a wire service -- have been exceedingly frustrating, I'll spare you my angst on that one.  The blessings have also been there -- getting to "meet" online and sometimes in person, some of the key players in the brothers' lives, and have them express their appreciation for what I did to help to humanize their brothers, while the rest of the print world was essentially doing the opposite (at least initially). I'm still concerned for how Travis' wife, now his widow, Kellee, to whom the news of Travis' whereabouts and obviously his death, came about as a shock, as well as for the Twiggs' parents, whose loss of two sons at once is just incalculable.

In the New Age-y world, people do talk about being careful about what your intention is, and how your intention will carry the day.  Without going into what "intention" means, overmuch, it can be simplified to say, whatever the vision is of an outcome, that you carry in your heart, or that you express to the world.  In this case, it was very, very clear.  Back exactly a year ago today, as Travis Twiggs and his brother were in their last moments, and time was running out, I wanted the world to NEVER FORGET who Travis Twiggs was, and what the legacy of unresolved PTSD looks like.  If ever there were a poster child for PTSD, it was Travis Twiggs.  He took the first step when he told the world his secret in that powerful, much-read article in the Marine Corps Gazette, when he broke the silence for his Marines, and the rest of OEF/OIF veterans.  What I held in my heart that day -- despite the professional disappointments that may have followed -- was that when people thought of PTSD, they would think of Travis Twiggs.  And given that his legacy is still very much alive, one year later, I do believe that intention accomplished exactly what it was supposed to.

As Twiggs himself said, he was willing to come forward and talk about what he went through, because he wanted no other soldier, sailor, airman or Marine to suffer like he had -- in silence.  With his death, and that of his brother, unfortunately for the much-beloved Twiggs brothers, but mercifully for the rest of us -- it's a conversation we will all keep having.  RIP, Travis and Willard Twiggs. You are not forgotten.

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Editor's note: The original blog entries about Travis Twiggs from a year ago are: "One Marine Reflects on His Battle with PTSD," linked here (before his death); "PTSD -- "The War Within" -- Claims Another Victim," linked here; "RIP Travis N. Twiggs, USMC PTSD Sufferer," linked here; "The Ballad of Travis Twiggs," linked here; "Travis Twiggs' Suicide - Only Questions Remain," linked here; "The PTSD Obituary for Travis Twiggs," linked here; "Bleeding Green with PTSD," linked here; "Twiggs' Wife: 'The PTSD Drove Him Crazy'," linked here; "The Tragic Last Days of Travis 'T-Bo' Twiggs," linked here; "Travis Twiggs' Widow, Kellee, Puts a Human Face on the Suffering of PTSD," linked here;and, finally, "SSgt. Travis Twiggs - Well-Loved U.S. Marine and Hurting PTSD Hero - the Update," linked here.