Healing Combat Trauma

From the Canadian Side of the Street: A Military Author's Take on Veterans Suffering from War and PTSD

One of the many blessings of the new media -- social media like Facebook -- are the interesting, talented people one meets within that. One such person is Bonnie Toews, a Canadian former journalist and novelist with a longtime background in writing about the military. I forwarded her an article from the Montreal Gazette last week about social workers quitting because of burnout in Canada, meaning that fewer will be available to serve returning veterans with PTSD, and this is what she wrote on her website in response:

Outrageous failure of government assistance to returning Afghanistan vets

"It is wonderful that we celebrate the lives and courage of fallen soldiers when they are repatriated to CFB Trenton and paraded down the Highway of Heroes, but the question that is never answered: who looks out for the returning vets? Especially those whose minds, bodies and spirits have been shattered on a continual rotation of tours through the past eight years.

It is disgusting and absolutely unacceptable to hear that Canada's Veterans Affairs is cutting back on social workers because WWI and WWII vets are dying off. 

Excuse me, but Canada has a whole new generation of vets who have served in Afghanistan for eight years. By next year it will be nine years. The war in Afghanistan has lasted longer than either world war in the 20th Century and soldiers have been repeatedly rotated through three and four tours because our forces aren't large enough to handle a deployment this long and this demanding. These vets and their families need help to mend their lives back together. 

Kevin Dougherty in Montreal's newspaper, The Gazette, writes that soldiers suffering from Post Traumatic Stress Disorder can wait up to four months before seeing a social worker, a necessary step to integrate them back into society and return them to the labor market. 

Why? Because federal social workers each have a caseload of 40 clients to their provincial counterparts, who carry a caseload of 20 clients each. There are not enough social workers to contend with the need, and under such strained resources, these caregivers burn out, depleting veterans' social services even further. 

People forget that soldiers returning home are not the only victims of the wars they've fought. So are their loved ones, families and friends. They need as much social assistance as the soldiers themselves. Those coming home are forever changed. They have experienced things the rest of us can't imagine. They carry this psychological burden for the rest of their lives. 

In 1994, in Rwanda, I was briefly introduced to that world of theirs. I was one of the few North American journalists covering the massive humanitarian effort following the genocide against the Tutsis and moderate Hutus in Rwanda. One peacekeeper after another told me what they saw, incomprehensible mass slaughter with no human respect whatsoever and they were forced to observe because the UN didn't give them the mandate or size of force to quell the madness. Soldiers trained to fight and defend forced to stand down. Can you imagine the helpless rage they experienced? Yet, when I came home, I faced the same apathy from friends, co-workers and the public as they did. My husband proudly explained that I had been in Rwanda and time and time again I was asked, "Did you go there on holiday?" 

People didn't even know what was going on, and were indifferent when I chose to explain. I, like so many soldiers, learned not to talk about it because no one really cared to listen. 

This time the public must get behind their vets and demand the social services they deserve and need. This is the most important tribute we can give our returning vets for the sacrifices they've made on behalf of our country."

 -- Bonnie Toews. A longtime journalist reporting for logistics and private security magazines and now a novelist, speaks out for the victims of genocide and war, from the peacekeepers and coalition forces trying to save suppressed peoples to the children and innocent civilians caught in the crossfire of opposing powers, ideologies and cultures. Current writing "Trilogy in Treason." Member of Military Writers Society of America, American Authors Association and ACFW. Her website is linked here.

Editor's note: Find us on Facebook, here; follow us on Twitter @HealingPTSD.

Provider Burnout among Combat Stress Healthcare Practitioners

It's been interesting to follow the Tweets from the conference at Mass. General Hospital this Friday and Saturday, on the "Complexities and Challenges of PTSD and TBI." It sounds like it was a great conference. One of the items that stood out to me was the statistics being shared about provider burnout. Check these out:

"Not enough social workers, therapists, etc. to help all the people who need help."

"146,000 mental health providers in U.S. Medical Command (MEDCOM),...a huge centralized training that's re-assessed annually for improvements...now (with) significant training resources in place to help providers manage stress." 

Studies that MEDCOM has done indicate that provider "burnout" is approximately "35% among deployed psychiatrists," "20% in deployed psychologists," "15% in deployed social workers," and "26% in non-deployed." (Source: LTC Graeme C. Bicknell, PhD, LISW, LTC, MS, Deputy Chief, Behavioral Health Division US Medical Command.)

We've written about "Caring for the Caregivers" frequently on this website, most recently here, in a post entitled, "Too Long a Sacrifice Can Make a Stone of the Heart:The Tao of Self-Care." Acknowledging provider burnout is another aspect OF "caring for the caregivers." The takeaway? Combat stress injures troops AND mental health providers; servicemembers and practitioners alike need stronger support. 

(There's a great article by Charles Figley on the topic, "The Art and Science of Caring for Others without Forgetting Self-Care, linked here, suggested by one of the readers on the Facebook site for this website, which is linked here.)

Editor's note: You can follow the PTSD Conference, now over, on Twitter, @PTSDConference; and you can follow this website on Twitter @HealingPTSD.

Prevention Talk and Prescriptions Apparently Not Doing It: Army and Marine Suicides Both Up

"The grand essentials of happiness," Allan Chalmers wrote, "are something to do, something to love, and something to hope for." Those words echoed in my mind yesterday when I met a remarkable woman vet in Seattle, who ten years ago was homeless, suffering from MST and PTSD. (Today she's a vital, contributing member of her community, solving problems for herself and other veterans in need, on a large scale.) 

We were talking about suicide prevention, a cause close to her heart, because she'd lost a daughter to suicide, and recently a friend as well (Orrin McClellan, who we wrote about recently on this site.) We were talking about suicide, and how Army and Marine numbers are still up, despite prevention strategies. She said, pointedly, that she'd learned that veterans (and others) who are struggling with suicide need "three things" in their lives to keep from killing themselves. What they need are: "a reason to live, a way to live, and a purpose to live for."

Salon magazine had an excellent but gut-wrenching article earlier this week by Mark Benjamin called "A Predictable Suicide at Camp Lejeune," subtitled, "A doctor warned that mental health care for violent, disturbed Marines was inadequate. Sgt. Tom Bagosy proved it." The story profiled the violent death of Marine Sgt. Tom Bagosy, 25, on the way out of the Deployment Health Center. (Bagosy leaves a wife and two children.) Less than a year ago, Salon had run another article by Mark Benjamin about a Marine Corps psychiatrist, Dr. Kernan Manion, and his specific, whistle-blowing warnings about the inadequacy of mental health care at Camp Lejeune -- warnings he took all the way to the president, and seemingly for which he was fired a few days after voicing them. (Here's the link to that earlier article, including his warnings.)

Marines initiated a new suicide prevention program last year; but suicides have only increased. They lead the services at this point. Army numbers are up as well. According to a report released Thursday, and carried on CNN, 32 soldiers killed themselves in June, "the highest number in a single month" since Vietnam. Twenty-one of of the soldiers were active duty, 11 were inactive Guard or Reserve; and seven of them killed themselves while deployed. A quote from the article, "Army officials admit they still haven't answered the question of why troops are committing suicide at a record rate."

While Marines sometimes mock the Army's slogan of an "Army of One" -- preferring instead to focus on the group -- the reality is, both branches are seeing heavy combat and neither one is excelling at helping troops not commit suicide. New programs get trotted out, new initiatives, new videos. But none of them are getting the job done: not alone, not together. Troubled troops and veterans are simply not listening; or not hearing what they need to hear. And what would that be?

Well, Mass. General Hospital is having their second annual conference right now on the "Complexities and Challenges of PTSD and TBI," and they're doing a great job "Tweeting" the speakers' points in real time. Here are a few excerpts of note, starting with a crucial one: "Only 30% of troops self-identify as needing help before committing suicide -- despite all the proactive intervention points." And again: Only 42% of troops who screened positive for mental health problem actually sought help from doc or spiritual advisor." PTSD is initially difficult to distinguish in troops because upon their return home, "initial relief and euphoria" at being back can mask it. But over time,"After 8-10 weeks and adjusting to a different life schedule at home, symptoms start to present."

This fits right in with the stories you hear from people coming back, that they don't want to talk about it or think about it (PTSD); they just want to get on with their lives, and fit right back in to where they were before. It's later on, when this adjustment doesn't work, that things get more stressful. High unemployment can't help: veterans' unemployment is significantly higher, in the recession, even that the national average. And troops have gone from being highly focused on the battlefield and engaged in their warrior purpose to losing that and perhaps not being able to replace it immediately with another. They've also gone from a high level of camaraderie with their buddies often to being quite geographically separated from those they were close to when deployed. Marriages and family life can be rocky as well. The relationship they were dying to get back to on the battlefield may have evaporated by the time they got home; or not make the adjustment intact. Again from the MGH conference: "78% of marriages end in divorce for first-time deployment troops."

Against all these backdrops of difficulty -- and an awareness that the "gold standard" of treatment is still talk therapy and psychopharmaceuticals -- the problem persists, compounded by sleeping pills that can be dangerous, and the ever-present self-medication strategies of alcohol and street drugs. It's hard to get the formula right for the correct medication(s) at the correct dosage(s), and until that happens, veterans frequently talk about feeling numb, in a stupor, not feeling like themselves, etc. Vets don't necessarily want to talk about what they've been through -- except perhaps with one another, and even then, not that much -- and ignorant questioning about how many people they've killed while they were over there, etc., just exacerbates the problem. So enough of the bad news...of which there is plenty...what can vets possibly do to increase their chances of surviving and adjusting? Because I highly doubt it's gonna be another prevention video or poster that does the trick, however well-meaning.

If everyone wants an easy answer, maybe they won't like this. But it seems to be that it's time to return to replacing one purpose (warrior) with another (warrior on the homefront), and putting some time and thought, effort and resources into what that will be. One veteran who made the transition from serving to the fire department, felt he literally replaced his one purpose, and one set of buddies with another; and that "substitution of purpose," as it were, was what helped him survive. But not every vet will be so lucky, or have or make that opportunity. 

If we take a look back at the Chalmers quote that opened this discussion, what are the three "grand essentials" for happiness (i.e., well-adjustment) that he cites? Something to do, love and hope for. And what are the three things that help a vet prevent suicide, according to the suicide counselor vet? Three very similar things: a reason to live, a way to live, and a purpose to live for. Veterans are warriors...and cast aside from their purpose, without an effective way to replace that immediately, it's possible they flounder. As a society, as those who "support" our troops -- whether professionally or personally -- what can we do to make sure that they have all three? With a little reflection, we can see where they had them in combat. Something to do (be a warrior); something to love (family, country, buddies, the mission); and something to hope for (winning; getting back home alive; reuniting with family and friends; keeping your buddies alive). What I suspect, sadly, is that from those adrenaline-charged heights, life on the home front, potentially unemployed, over-medicated, and disconnected from family and friends, there can become a time when there's not enough "reason" to live; there's not enough way to live; and there's definitely a loss of purpose to live for.

A better use of resources than more videos, etc., though would be: focusing on what would it take to give veterans their purpose back? And not entirely how could be do it for them, but how could they join in that mission themselves? Every veteran affects the lives of 50 other people, minimum; so whatever happens with them back on the home front is a ripple effect. Let's focus some energy on the topic of continuing life with a purpose; versus watching on with sadness and despair the continuing tragedy of young vets (and older) taking their own lives. They've given too much; and they deserve so much better. So while pep talks on prevention and prescription pharmaceuticals don't seem to be doing the total job when it comes to suicide prevention, maybe it's time to bring back talk about purpose -- and how to continue that successfully, after the deployment is over and the uniform is hung up for the time being.

In a related side note, apparently mental health plummets when distressed individuals can't "do" to solve their situations with personal effort. There's been talk in the news lately about mental health issues soaring in the Gulf states after the BP eco-disaster, and that money needs to be set aside to help with those; but in that, there's also discussion of what happened after Hurricane Katrina. Apparently, after the hurricane hit, those affected started immediately to do what they could to restore their lives. (Think of all the news footage we've seen of residents after large-scale disasters, sawing up downed trees, hauling lumber to shore up makeshift housing, etc.) What's now surfacing anecdotally are stories about while this busy-ness after the disaster was therapeutic for people -- helped them to get their minds off the tragedy by putting themselves back to work -- when FEMA came through and made everything grind to a halt while they inventoried the situation -- people's grief and despair rose up in waves, with nothing to "do" to distract them.

Much is made of the "adrenaline rush" of combat, and how it's very hard (hmmn, likely impossible) to match that in civilian life -- but at the same time, there's also definite "purpose" -- of getting the job done, of keeping your buddies alive, etc. After combat...it's suddenly very quiet, and boring by comparison. "War is hell, but peace is boring!" some veterans joke. Cast adrift without the shared common and energizing purpose of combat, in their early 20s, veterans need quickly to find something to "do" that matters to them -- something they can live for, love and enjoy, that satisfies them and makes life worth living. Sadly, far too many people are checking out when they can no longer find a reason to live, and in tragic stories like that of Marine Sgt. Tom Bagosy, or Orrin McClellan, you get the impression they don't feel like they had any other choice. Tragic. Not just for them, but for the people they left behind, whose lives will also forever be marked by this experience. Such a tremendous loss...and possibly, preventable: If not for them, at least for some others. Let's try.

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.

June 27, 2010 is "National PTSD Awareness Day"

Amazingly enough -- and suddenly, because the U.S. Senate just passed it -- tomorrow is "National PTSD Awareness Day." Even MORE amazingly, the text of the resolution is very veteran-focused (yippee!).

Here's the full text of the bill. Enjoy! My only quibble is that the numbers seem a little on the low side, but mebbe not. (Actually, the advocacy group Veterans for Common Sense, led by veteran and former VA bureaucrat, Paul Sullivan, lists the numbers as much higher. See link here for current information.)

And, of course, a focus on treatment through integrative medicine would also be nice. It alludes to, but does not mention directly MST (military sexual trauma), which plagues women and men in the Armed Forces AND which unfortunately also leads directly to PTSD. The combination is often too much to bear. With all those caveats, it's still a great bill, and we appreciate any and all emphasis on the topic, as beneficial to veterans, their loved ones, their caregivers, decision-makers, and the general larger community of humankind. 

Thanks especially are due the Vietnam veterans, who never gave up (you're still out there, I know! patiently waiting for it to be your turn; the media, for highlighting the problem and ensuring that greater awareness might result in better options for veterans and their communities; veterans' families, loved ones and employers, for not giving up on the veterans in their midst; and the legislators, who passed this bill and in so doing, created more national focus on the post-deployment adjustment difficulties of those who served. Thank you!

RESOLUTION

Designating June 27, 2010, as ‘‘National Post-Traumatic Stress Disorder Awareness Day’’.

Whereas the brave men and women of the United States Armed Forces, who proudly serve the United States, risk their lives to protect the freedom of the United States and deserve the investment of every possible resource to ensure their lasting physical, mental, and emotional wellbeing;

Whereas 12 percent of Operation Iraqi Freedom veterans, 11 percent of Operation Enduring Freedom veterans, 10 percent of Operation Desert Storm veterans, 30 percent of Vietnam veterans, and at least 8 percent of the general population of the United States suffers from Post-Traumatic Stress Disorder (referred to in this preamble as ‘‘PTSD’’);

Whereas the incidence of PTSD in members of the military is rising as the United States Armed Forces conducts 2 wars, exposing hundreds of thousands of soldiers to traumatic life-threatening events;

Whereas women, who are more than twice as likely to experience PTSD than men, are increasingly engaged in direct combat on the front lines, putting these women at even greater risk of PTSD;

Whereas—

(1) from 2003 to 2007, approximately 40,000 Department of Defense patients were diagnosed with PTSD;

and

(2) from 2000 to 2009—

(A) more than 5,000 individuals were hospitalized with a primary diagnosis of PTSD; and

(B) more than 500,000 individuals were treated for PTSD in outpatient visits;

Whereas PTSD significantly increases the risk of depression, suicide, and drug and alcohol related disorders and deaths;

Whereas the Departments of Defense and Veterans Affairs have made significant advances in the prevention, diagnosis, and treatment of PTSD and the symptoms of PTSD, but many challenges remain; and

Whereas the establishment of a National Post-Traumatic Stress Disorder Awareness Day will raise public awareness about issues related to PTSD: Now, therefore, be it

Resolved, That the Senate—

 (1) designates June 27, 2010, as ‘‘National Post-Traumatic Stress Disorder Awareness Day’’;

 (2) urges the Secretary of Veterans Affairs and the Secretary of Defense to continue working to educate servicemembers, veterans, the families of servicemembers and veterans, and the public about the causes, symptoms, and treatment of post-traumatic stress disorder; and

 (3) respectfully requests that the Secretary of the Senate transmit a copy of this resolution to the Secretary of Veterans Affairs and the Secretary of Defense.

Editor's note: And if you want to know why we do what we do, here it is. It can change someone's life. Here's how the Vietnam vet, Marine, subject of the "Eyewitness to Combat" section of this site, is doing after a year of addressing his 40-year solid case of chronic, severe PTSD. He came, he saw, he conquered. Other veterans can too. We give them HOPE. First awareness, then treatment, and the chance of getting their life back. (H)Oorah. (Here's the link.)

"The Brain at War" Conference in San Francisco

Last Thursday I had the opportunity to attend the third annual "The Brain at War" conference, put on by the NCIRE, The Veterans Health Research Institute, in San Francisco, CA. More on that later, because things are really busy around here right now. But it was a great conference, and the second excellent training I'd been able to attend, within the past 30 days. (The first being the superlative clinical training program in PTSD, put on by the National Center for PTSD in Menlo Park, CA. An article about that program is linked here.)

Some personal recaps and observations:

The Brain at War featured a number of interesting speakers, including Heidi Kraft, Ph.D., the author of "Rule Number Two," whose presentation was really the emotional anchor of the day. (Kraft now serves as the Deputy Director of the U.S. Navy Combat Stress Control Program.) She talked compellingly about her experience in Iraq, and in particular the events and emotions surrounding holding the hand of a dying Marine, who later became famous to the nation as Cpl. Jason Dunham, who was posthumously awarded the Medal of Honor. (He's also the subject of an excellent book, "The Gift of Valor," by Wall Street Journal reporter Michael Phillips.) 

Her speech was probably the first time, in almost five years of writing and editing this site, that I got to let the power of the stories I've heard, from various suffering servicemembers, vets and their families, really sink in. As Kraft told her story, of pain, empathy and loss, and the bond it built with Dunham's family, that continues to this day, I tapped into my own reserve of painful memories of stories I know, and couldn't stop crying. Looking around the large conference room, I saw I wasn't remotely alone in that, though; even men in suits were dabbing both eyes with their handkerchiefs and napkins. She also had a powerful, powerful poem that she wrote about the highlights and lowlights of the Iraq tour, called "The List," that she read to those assembled, and which is featured prominently in the book she later wrote, above.

There were many highlights of the program, including hearing from the National Guard about what they're doing to secure better mental health for their servicemembers, who don't have the same access that other branches do. The California National Guard has a good "Combat Stress Control" program, with handouts like this tip sheet, "Helping a Soldier Buddy in Distress," linked here. They've also got a superlative poster, "Never Let Your Buddy Fight Alone (against PTSD)" that emphasizes the importance of Guardmembers in one another's lives. An U.S. Army National Guard leader, Major Paul E. Gonzales, from Kansas' National Guard, talked convincingly about the challenges Guardmembers face after deployment, accessing mental health services, when they're frequently hours away from the nearest facility. 

Another true highlight was, through the miracle of Skype, hearing and seeing USAF Major Jennifer J. Hatzfeld, Ph.D., R.N., report in from Afghanistan about her tour of duty there and what it's been like. And Chris Loverro, a UC Berkeley grad now filmmaker, and part of the U.S. Army's Stryker Brigade from Ft. Lewis, Washington in Iraq, talked openly about his struggles with PTSD upon returning from war, and showed a short film he's made about the "Hidden Casualties" among veterans. The short film's message was raw and powerful, and hit home with many in the audience.

Hidden Casualties from chris loverro on Vimeo.

(Army) Brigadier General Loree Sutton was in attendance at Thursday's program, and seemed to be an enthusiastic supporter of all things health and wellness related to the military and PTSD (and TBI). Sadly, in news that went over the wire yesterday, Sutton resigned her position as the head of the Defense Centers of Excellence (DCoE). See news item, linked here. The timing was significant: it's the same week that the privately-funded National Intrepid Center of Excellence for Psychological Health and Traumatic Brain Injury opened on the Navy campus in Bethesda, Maryland for the treatment of TBI and PTSD. Although the opening was a big deal -- and the fact that the money was raised privately also is -- apparently no cabinet members, no White House representatives, no senators and only two congressmen showed up. So the "war" ... on the brain... at war... appears to continue.

It was gratifying to see a certain portion of the event, as well as a small-group discussion afterwards attended by maybe a dozen participants, devoted to the discussion of integrative medicine and PTSD. (The discussion leader, an M.D., said she was also in the process of leaving the military.) Let's hope that despite the apparent setbacks and detours that progress can still be made on treating PTSD with integrative medicine. 

The building the conference was held in -- an A+ facility called "The Marines' Memorial Hotel & Club," in San Francisco's Union Square -- was fantastic. "Like the Harvard Club for Marines!" I exulted, to anyone who'd care. It's worth a return trip to San Francisco just to revel in the exhibits on each floor. (The food was also superb.) There's an excellent library on the 11th floor, many things on other floors I didn't get to see, but a true "draw" and it's quite powerful is the "Tribute Wall" on the 10th floor, Mezzanine, which honors the fallen heroes of every branch who have given their lives in the OIF and OEF campaigns. I'll probably have to reserve writing about that for another time, but I kept stealing away from the presentations to go back to that memorial, taking photos of the plaques commemorating those who died who were important to vets who are special to me. The memorial has black stone plaques, engraved with the servicemember's name, branch of service, and date of death, and they're embedded into the walls (the exhibit covers five walls by now, one full room and stretching outwards from that) roughly chronologically, vertically. There's a guest book in the room to sign, and also a guidebook, which must be updated regularly, listing servicemembers KIA by name, branch of service, and date of death. Once you find the date of death, you know approximately where their plaque on the wall will be located, and you just go looking for it. Pretty impressive, and moving, exhibit, giving honor to those to whom honor is very much due. (For more on that, see link here.)

Occupational Therapy and PTSD -- It Had Its Origins in WWI, with Shell Shock

April is "Occupational Therapy" month, and come to find out -- Occupational Therapy has an interesting past! It was founded in World War I as a way to deal with shell shock -- what PTSD was called at the time -- because it was thought that "doing" was therapeutic for injured veterans, not just "talking." I've been fascinated with this ever since I learned it from an OT with a specialty in mental health, who has practiced in and around the military for decades.

(If you know any veterans who have been injured, you've probably heard about occupational therapy for traumatic brain injuries (TBIs), amputations from IED blasts, etc. But PTSD? Wow. Who knew that it was founded as a discipline to address that!

On the hunt for more information about this topic, I uncovered the following. Carolyn M. Baum, Ph.D., the immediate past president of the American Occupational Therapy Association ("AOTA") presented testimony on post-traumatic stress disorder to the House Veterans’ Affairs Subcommittee on Health on April 1, 2008. Her testimony, "Post-traumatic Stress Disorder (PTSD) Treatment and Research: Moving Toward Recovery, "explained the unique contributions of occupational therapy in the treatment of PTSD and other mental health issues."

"Occupational therapy brings a third dimension to the system of care for PTSD. Medication and counseling, supported by occupational therapy and performance, is the approach that we recommend the VA adopt, she said."

Dr. Baum also promoted the role of occupational therapy broadly with the Veteran's Administration (VA).

(Inquiring minds want to know what happened with that...)

Here are her remarks in full:

Statements of Carolyn M. Baum, Ph.D., OTR/L, FAOTA, Immediate Past President, American Occupational Therapy Association, and Professor, Occupational Therapy and Neurology, Elias Mitchell Director of the Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO; David Matchar, M.D., Member, Committee on Treatment of Post-Traumatic Stress Disorder, Board on Population Health and Public Health Practice, Institute o Medicine, the National Academies, and Director and Professor of Medicine, Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC; and Mark D. Wiederhold, M.D., Ph.D., FACP, President, Virtual Reality Medical Center, San Diego, CA; Accompanied by Gerald M. Haase, M.D., Founder and Chief Medical Officer, Premier Micronutrient Corporation, Nashville, TN.

Statement of Carolyn M. Baun, Ph.D., OTR/L, FAOTA:

Dr. Baum. Thank you, Mr. Chairman, Members of the Subcommittee, for giving me the opportunity on behalf of the American Occupational Therapy Association to discuss issues regarding post traumatic stress disorders.

You introduced me, so I will bypass that. I also am the Professor of both Occupational Therapy and Neurology at Washington University School of Medicine.

Occupational Therapy (OT) has had a rich history providing services to veterans dating back to World War I. Occupational therapists help wounded warriors return to their military responsibilities or transition into civilian life. We do this by helping them set goals, develop strategies to accomplish their goals, and gain the skills that allow them to achieve the maximum level of participation and independence.Occupational therapy perhaps is best known for its work in rehabilitation services after stroke, loss of vision, physical injury, including amputations, and traumatic brain injury, but occupational therapists also treat individuals with stress-related disorders that result in mental and cognitive impairments as well.

OT plays a unique role in helping veterans recover from PTSD as they serve as key members of the team, that along with physicians and psychologists who use medication and counseling, the occupational therapist employs performance strategies that support the veterans in achieving success in their performance in daily activities.

Actually, it is in these daily activities that it is possible to observe the problems veterans are having with multi-tasking, with sequencing of tasks, with their safety, with their judgment, and actually identifying the cognitive fatigue which has a very important need for consideration.

These are all problems that require strategies for individuals to overcome.

The effective treatment of PTSD and the return of veterans back into their work, their family, and community lives really requires an integrated system of care that includes assessment, goal setting, treatment, and learning to self-manage life with PTSD.

Rehabilitation does not stop when veterans are discharged from hospitals or medical care. It must be provided along a continuum addressing community reintegration, social reconnections, and work accommodations. All these are areas in which occupational therapists play an important role.

Veterans with PTSD often have difficulty in their daily lives and avoid activities because they result in anxiety or fear or even anger. Consider, for example, a soldier who is driving on routine patrol when a road-side bomb explodes. Upon returning home, the veteran might experience flashbacks of that event triggered simply by driving.

The therapist might use simulated or virtual reality driving experiences or even actual driving experience in a controlled environment to help the veteran extinguish or reframe the negative stress reactions.

Therapists also work with veterans to help them manage issues related to PTSD such as depression, mild head injury, or concussion, and substance abuse by helping them develop strategies to reengage in daily life that are meaningful for them and their families. Having the families involved is particularly important because we know the importance of social support to individuals recovering from PTSD.

The unique contribution of occupational therapy is highly valued by the Army for their combat stress control. The Army model deserves additional attention from the Veterans Administration and the Subcommittee because it fully recognizes occupational therapy's contribution as a member of the team by adding the performance component to the medication and counseling provided by other team members. We recommend the VA consider and adopt the Army model.

The Veterans Administration has made significant strides in preparing to meet the needs of veterans, but work remains to be done. There are only 750 occupational therapists in the entire VA system. While both the Veterans Administration and the Department of Defense guidelines for PTSD exist and include occupational therapy, it is the experience of our members that the inclusion of occupational therapist varies from site to site. This variation does not ensure full access to effective treatment.

The American Occupational Therapy Association encourages the Committee to look at this issue. From the consultation with AOTA's members within the VA, we have heard that they are struggling to maintain the quality of care for which they are known because of increased demand for rehabilitation services and gaps in staffing.

The most important issue is to ensure that veterans receive the services they need to recover and reenter community life, able to care for themselves and others, able to work and make contributions to their families and communities. If the VA has staffing problems, they should look for, and contract with, community programs to provide the services that the veterans need.

Just as you discussed earlier with Colonel Hoge, there is also a need to study the effectiveness of complex interventions, medications, counseling, and I would ask for consideration to add the third leg to the stool, the importance of daily life performance.

Research should seek to understand the relationship of quality of life to PTSD symptom severity, disability, treatment outcomes and cost. The problem begs for an interdisciplinary translational clinical study.

Mr. Chairman, I have made additional recommendations in my written testimony, but I want to highlight a couple of issues for your Subcommittee's consideration.

To increase the numbers of occupational therapists within the Veterans Administration, we would urge that the Subcommittee consider expanding the Student Loan Repayment Program to ensure that the VA remains an attractive employment option because there is a real supply and demand issue for OTs right now and that would draw people to the VA services.

Salaries in the VA appear to be lower than other healthcare settings. The Bureau of Labor Statistics estimated in 2006 that the average salary in California for occupational therapists was $73,000. Right now the Palo Alto Polytrauma Rehab Center is offering $50,000 for two new positions that have been vacant since last July.

New positions continue to be added across the country, but salary will continue to be an issue, and AOTA urges the Subcommittee and the VA to attend to salary, recruitment, and retention issues.

Mr. Chairman, in conclusion, I want to reiterate that occupational therapy has expertise in the treatment of functional impairments resulting from a broad range of conditions faced by veterans, including PTSD. Occupational therapy should be explicitly included on treatment teams to address the every-day life issues of veterans and their families through the phases of recovery and community reintegration.

Thank you very much for the opportunity to provide testimony to the Subcommittee. AOTA looks forward to working with Congress and the VA to meet the needs of our veterans. And I would be happy to answer any questions. Thank you.

[The prepared statement of Dr. Baum appears on p. 45.]

Mr. Michaud. Thank you very much, Dr. Baum.

Editor's note: The source for the testimony is linked, here.

Martin Luther King Jr Had a Dream for Combat Veterans, Too

Martin Luther King Jr., from a speech delivered exactly one year before he was assassinated in Memphis, Tenn.:

"This business of burning human beings with napalm, of filling our nation's homes with orphans and widows, of injecting poisonous drugs of hate into veins of peoples normally humane, of sending men home from dark and bloody battlefields physically handicapped and psychologically deranged, cannot be reconciled with wisdom, justice and love." -- Martin Luther King Jr, speech at Riverside Church in New York City, April 4, 1967. 

Editor's note: A link to the online text and audio of his full speech is here.

43,000 Troops Found "Unfit to Serve": Non-Deployable but Sent Anyway?!

Several weeks ago I watched a wonderful Bill Moyers interview on PBS with Oliver Stone, noted filmmaker and Vietnam veteran. The whole interview was great, but a figure Moyers used at the beginning was just stunning -- for the implications it has for soldiers with PTSD and their families.

Moyers said:

"...I read a report based on military records which revealed that from 2003 to 2008 some 43,000 troops had been sent to Iraq and Afghanistan despite having been classified as "non-deployable" for medical reasons. In plain English, they weren't healthy enough to go, but were sent, anyway."

Yowser. It's hard to imagine a circumstance in which being considered unfit to serve for medical reasons, and being deployed anyway, improves your situation. It sounds like all it would do is reinforce the difficulties you were already having, or pile more trauma on top of the pre-existing trauma.

Additionally, troops who have fought in Iraq, when they're deployed next to Afghanistan, find that to be a completely different experience. So Afghanistan for them isn't "more of the same," it's new and different, with all the challenges that implies.

(See news report from November 29, 2009, entitled "Afghanistan, Iraq: Different Wars -- U.S. Soldiers: Afghanistan War Dramatically More Difficult, Challenging Than Iraq," linked here.)

Editor's Note: For the link to Bill Moyer's Journal and his excellent interview with Oliver Stone, shown on December 4, 2009, click here.)

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.

---
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.