Healing Combat Trauma

PTSD Drugs: Better Living through Chemistry, or Purely Popping Pills for PTSD's Psychological Ills?

There was a story in the news recently about four young combat veterans in West Virginia, all seemingly in decent physical condition beforehand, who nevertheless all died in their sleep recently.  Besides combat PTSD, one thing the vets all had in common was the cocktail of drugs they were taking: Paxil, Klonopin and Seroquel.  (The Charleston, West Virginia Gazette-Mail reported this story on May 24, 2008 - it's linked here.)  An investigation is pending, but the story obviously raises the question: what are vets with PTSD being prescribed, and is it really working, or what's best?  (Continue reading, and you'll learn more about those specific medications as well.)

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Where to go for information about PTSD medications?  Here are a few, carefully-chosen selections, and their pros and cons - as appropriate:

Jonathan Shay, M.D., Ph.D., well-known VA psychiatrist and outstanding veterans advocate, has written before about medications used to treat combat PTSD, and his impressions of them.  He wrote the material for a lay audience, in the version that's kicking around on the Web, in several different locations, and although it has been quoted by many as gospel, it's more than 12 years old by now (first published in 1995), and that's much too much time that's elapsed to consider that information really current. (The Dr. Shay list, "About Medications for Combat PTSD,"  is linked here.)  So that information is interesting for background -- and particularly for Dr. Shay's explanation of how things work and/or what makes a good PTSD medication, and what doesn't -- it out of date and should not be considered current. 

There's another list on the Web -- a table, really -- that's much more current (2006), and it lists the drug names, brand names, and how the drugs are thought to work with PTSD.  That list is linked here.  It may be a little difficult to read if you're coming to the topic cold, but perhaps not.

Some other suggestions:

If you have access to a public library or academic library, you can check out the PDR -- the Physician's Desk Reference -- and read up on a drug's profile, side effects, warnings, etc.  But since you're already on the Web, we can assume, reading this -- try going to PDRHealth.com, linked here-- and read up on the prescription drugs prescribed for PTSD.  Of the three drugs mentioned earlier, Paxil is linked here; Klonopin is linked here; and Seroquel is linked here.  You can also do a straight search for any OTHER drug used in PTSD treatment, or one with possible interactions with a drug used for PTSD, at the same site, by searching within prescription drugs by name (e.g., Zoloft, Chantix, etc.), at the general search interface, linked here.

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But the information in the PDR, whether on the Web or in the desk reference, is going to dry and technical, though worth reading -- pretty much exactly like the fine print that's packaged with the medications themselves. What you're probably going to want to know more about is what in software is called "the user experience" -- how other patients like you have experienced the medications.  For that you will need to turn to some other sources.

For what amount to "user reviews," try PsychCentral, or Revolution Health, both of which have increasingly robust user communities who will comment on their own experiences of the medications.  (Of course, not all their users taking medications for PTSD have PTSD from combat trauma, so be aware that their cases may be substantially different.)  Combined with the technical information about the drug's effects, side-effects and warnings (see links, above), it might be helpful in creating a broader picture of what the user experience is like:

Dr. John Grohol's PsychCentral website:  Paxil (Paroxetene) is linked here; Klonopin (Clonazapam) is linked here; and Seroquel (Quetiapine fumarate) is linked here. A general search through the medication library is linked here.

AOL Founder Steve Case's Revolution Health:  Users in the "User Community" provide "Community Ratings" on various medications.  The items on Paxil, Klonopin, and Seroquel are linked here (click on any of those hyperlinks to take you to the community ratings), or, use a more generic search here, and look for the tab beneath that says "Community Ratings." (We will be blogging more about Revolution Health shortly.)

Don't forget books as well.  Mark Goulston, M.D.'s Post-Traumatic Stress Disorder for Dummies (2007), linked here, is very recent, and contains a whole chapter entitled, "The Role of Medication in Treating PTSD".

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You'll also want to learn as much as you can -- though this is primarily your healthcare provider's reponsibility, yet it's in your best interests to care about this as well -- about possible interactions, if you're taking a number of medications; as well as thinking through carefully whether the risks involved are ones you want to agree to, such as the potential that a medication -- bizarrely enough, prescribed for PTSD or depression -- may actually increase risk of suicide. (An example of news coverage about this is linked, here.)  Strange, and perhaps unavoidable, but true.

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Use caution whenever evaluating information about medications, especially as a non-professional, but at the same time, don't "just" believe what a healthcare provider tells you: be sure to check it out for yourself or your family member, at reputable sites like the ones mentioned above.  Your health is in your hands, so while you want and should actively solicit the expert advice of healthcare providers familiar with PTSD -- and don't settle for less :-), at the same time, YOU are the one who's going to be bearing the brunt of anything that goes wrong, so be sure to do your own due diligence and figure out what the possible side-effects, interactions, and unpleasant experiences might be for you, before you commit to a course of treatment.  You and your healthcare provider can be partners -- that's the new model -- not just "master" and "servant," or "priest" and "parishioner."  Take an active, informed role in your own healthcare, particularly where medications are concerned. 

Healing Hands: Cranio-Sacral Therapy, Veterans and PTSD

Before we leave off talking about Complementary and Alternative Medicine (CAM) therapeutic strategies for dealing with PTSD (usually, in addition to other approaches, not instead of other approaches) -- as we have been discussing lately on this blog, an index to which is linked, here -- it's important to mention one other therapeutic technique: Cranio-Sacral Therapy, developed by Dr. John Upledger (pictured at left).  You'll have to go elswhere -- like the Upledger Institute's website, linked here -- to learn more about the practice -- it would take too long to explain here, because there are several schools of thought on why it might work, and it's a fairly esoteric practice to begin with.  But...an important but...it is a bodywork therapy, akin to massage but not the same as massage, which has shown some effectiveness in improving the symptoms of PTSD.   Digging around on the Upledger Institute's site may help you learn about who practices it in your area of the country, but that is unlikely to be a completely comprehensive list.

For those who believe -- and it surely isn't everyone who does, but many do -- that the physical body "stores" trauma, craniosacral therapy attempts to "release" the stored trauma through the very light, deft touch of the craniosacral therapist.  Not everyone who's been through trauma wants to "talk about it," or "take medications for it" -- for those who are comfortable with a massage-like experience, craniosacral therapy is an opportunity to see if trauma can be cleared, lightly or substantially, using a different method.  (Rumor has it that the Navy and/or the Marine Corps, on the West Coast, is experimenting with using craniosacral therapy to treat PTSD -- more news as that develops.)

Dr. Upledger, and another West Palm Beach, FL-area craniosacral therapist, who I have known for years, and who used to practice together, worked in a novel program years ago to treat Vietnam veterans who were struggling with the effects of PTSD.  In their program were a handful of veterans and at least one medical nurse who had served during Vietnam.  The treatment program allegedly helped some, didn't help some others, and had at least one anomaly as a result: a patient who died in an unrelated car accident, soon after he reported to his family, unfortunately, how much relief he was gaining from the program.  So the results were mixed, but in general, more positive than negative.  (There was even some interest from a famous Hollywood filmmaker, who shall remain anonymous, but who's a big fan of veterans and the Vietnam experience, in filming the experience of veterans undergoing the treatments, but that created controversy for the program, and the idea was eventually dropped.)

Years later, Dr. Upledger did more work with other veterans, and at least one of them, Steve Shumelda, LMT, an ex-military guy with injuries of his own, including PTSD -- was so impressed by the treatments that he gave up whatever he was doing for a living before, and studied craniosacral therapy instead.  He has a practice in South Florida now, and has written about his experience with craniosacral therapy.  You can read more about the Upledger Institute's work with veterans and PTSD, here.

Dr. Upledger has apparently done a video that is available via his Institute on PTSD and veterans and craniosacral therapy.  You can contact their office to see about purchasing a copy.  For additional resources to read up on the topic of craniosacral therapy, veterans and PTSD, click here for a separate blog entry we did recently that consolidates a few in one place.  To read about Vietnam veteran and former Navy corpsman Steve Shumelda, LMT's experience with PTSD and craniosacral therapy, click here.

Mind Body Medicine: Healing the Wounds of War

When I started this blog over two years ago now, I was hoping that somehow James S. Gordon, M.D., and the Center for Mind-Body Medicine which he founded in Washington, DC, would somehow get involved in the prospect of bringing mind-body medicine to the troops.  Gordon is a Harvard-trained psychiatrist, with impeccable credentials, who has a lifetime interest in expanding patient care into new areas, particularly Complementary and Alternative Medicine (CAM), and mind-body medicine in particular.  (Mind-body medicine is a shorthand way of re-combining the two "halves" of medicine perhaps unjustly sundered in an arbitrary Cartesian mind-body split.  Much of Eastern thought, rather than Western, never saw them divided at all.)  In a previous lifetime, where I interviewed luminaries in the natural medicine field, Gordon was a favorite interviewee - smart, genial and with a very forward-thinking grasp of what mind-body medicine could accomplish.  Gordon, who was featured in the Bill Moyers series on PBS, Healing and the Mind, was a frequent lecturer at the Smithsonian Institution in Washington, DC, and for years had served as the head of the White House Commission on Complementary and Alternative Medicine.  He is also a Clinical Professor in the Departments of Psychiatry and Family Medicine at Georgetown University Medical School.

But more to our purposes, when war broke out in Kosovo, he and the Center for Mind-Body Medicine (CMBM) took their methods into the region, creating a program called "Healing the Wounds of War," to help war-torn schoolchildren and their caregivers manage the trauma they had undergone, through a sustained, devastating conflict.  What I was hoping -- and I kept checking the CMBM website periodically to find out -- was that they would leapfrog off their successes with PTSD in Bosnia and Kosovo, and Israel and the Middle East, and develop something geared to PTSD in servicemembers, and the conflicts in Afghanistan and Iraq.  For years, nothing was obvious (yet), but here's some of their success with children in Kosovo.  Notice what symptoms the program helped with, how impressive the statistics are, and make the conceptual leap to how this might help with combat veterans and/or their families:

The clinical efficacy of the CMBM program with traumatized children has been repeatedly demonstrated. In a pilot study in which high school teachers in the Suhareka region of Kosovo used the CMBM model, levels of posttraumatic stress disorder in high school students were reduced from an average of 88% to 38% in only six weeks (read the research, published in Journal of Traumatic Stress, April 2004, linked here). Participants have also reported the following documented effects of CMBM trainings, including: the alleviation of their own stress and trauma; decreases in anxiety and depression; increased optimism; decreased anger; and increased capacity to help others.

You can read more about the program's specific successes, here.  Or, you can read a general overview of the program and what's involved, here.  You can also read Dr. Gordon's bio, here.

Mind Body Medicine: Healing the Troops

We've talked about James S. Gordon, M.D.'s Center for Mind-Body Medicine and their successes in "Healing the Wounds of War" recently on this blog, and the wait to see if they would revamp this program to address the needs of PTSD and the troops.  Finally, at long last...The Center for Mind-Body Medicine's program for Healing the Troops, informational material linked here.

From their website:

The Center has created a program of training in mind-body medicine and on-going support for physicians and mental health professionals working with veterans returning from Iraq and Afghanistan as a first step to providing veterans with a powerful and healthy approach to dealing with the stress of war and to enhancing their resiliency.

This program will be a significant focus at our Fall 2008 Mind-Body Medicine training, for which we have received funding to bring 20 military healthcare professionals on scholarship. We are seeking additional funding for this important effort.

Also from their website:

The Center for Mind-Body Medicine has developed a trauma relief program utilizing mind-body skills including biofeedback, relaxation, guided imagery, meditation, drawing, and breathing exercises that has been used successfully around the world.

This program, which is presented in small educational groups, has the advantage of enhancing veterans’ capacity to help themselves while mobilizing social support crucial to full recovery. The Center has used this program to assist in population-wide healing efforts in war-torn and traumatized regions around the world, including Bosnia, Kosovo, Macedonia, Israel and Gaza , and in the United States with NYC firefighters post-9/11 and in post-Katrina Louisiana.

Further information about the 2008 conference is linked here. Dr. Gordon's bio is linked here.

"Give an Hour" Helps Fill Veterans Counseling Gap

Give an Hour -- the foundation that matches member psychogists and counselors with veterans and their families in need of counseling at no charge -- to fill the currently unmet gap in mental health services, has been in the news recently.  (You can learn more about Give an Hour's founder, Barbara V. Romberg, Ph.D., in her bio, linked here). It's truly fantastic to see this public-spirited act of service on the part of Give an Hour; at the same time, it's a shame that private industry, so to speak, has to jump in to fill the unmet gap of mental health care -- the need for which care is an entirely predictable "soft cost" of going to war.  Nevertheless, good stuff, and very altruistic and forward-thinking on the part of Dr. Romberg and her organization.

From a press release:

The American Psychiatric Foundation, Lilly Foundation And Give An Hour Join Forces To Provide Mental Health Care To Iraq And Afghanistan Veterans

Heeding the call of a growing public health crisis -- the unmet mental health needs of returning soldiers and their families -- Give an Hour (GAH) and the American Psychiatric Foundation (APF) announced a major expansion of a nationwide effort to help U.S. veterans returning from Iraq and Afghanistan.

GAH and APF, the philanthropic and educational arm of the American Psychiatric Association (APA), will be using a $1 million grant from the Lilly Foundation to recruit and educate volunteer mental health professionals, who will become part of a network aiming to bridge the gap in mental health services for soldiers returning from service, as well as their families. Among troops returning from Iraq and Afghanistan, approximately 40 percent of soldiers, a third of Marines, and half of the National Guard members report psychological problems, but mental health services are in short supply.

"This all-volunteer effort provides badly needed support to help our veterans, many of whom come home with mental health needs," said U.S. Representative Steve Buyer (R-Indiana), Ranking Member, House Committee on Veterans' Affairs. "I applaud the hard work of Give an Hour, the American Psychiatric Foundation, and the Lilly Foundation, which are stepping up to help those who have selflessly served."

Efforts will be made to create a large, national, volunteer network over the next three years to address postwar mental health issues such as post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), drug abuse, anxiety and depression.

"This grant will allow us to get out the message that help is available. We want to normalize what our military personnel and their families are experiencing and support the sacrifices that they are making by providing critical mental health support at no cost," said Barbara V. Romberg, Ph.D., founder and president of GAH. "We will be educating the military community and broader public about these mental health needs in hope of helping veterans keep their lives and families intact."

GAH is recruiting mental health professionals to volunteer one hour each week for a minimum of one year to provide direct services in person, by phone or in consultation with schools and community organizations that serve the military community. Services are wide-ranging and include marital and family therapy, substance abuse counseling and treatment for PTSD. APF brings strong ties to the psychiatric community and is actively encouraging psychiatrists to join the network.

"This grant will help us reach our goal of recruiting 10 percent of the 400,000 mental health professionals in the United States by 2015 to assist in this effort," said Dr. Richard K. Harding, M.D., president of the APF. "It is an ambitious goal, but we are confident it can be achieved."

The Department of Defense (DoD) is making an unprecedented attempt to encourage personnel to seek mental health treatment, but a significant increase in demand, in some areas, has forced the rationing of services, created long waiting lists and limited individual counseling sessions. In addition, some members of military families such as parents, siblings and unmarried partners do not qualify for care through the Veterans Administration or DoD but are affected nonetheless by the mental health of the veteran.

"We're privileged to be able to give something back to our troops, but we know there's still much more to be done," said Steven Paul, M.D., executive vice president for science and technology and president of Lilly Research Laboratories. "Lilly is fully committed to assuring that the best possible medicinal treatments are available, but unfortunately, we also know that having access to the best care -- in this case mental health services -- is essential."

About Give an Hour
Give an Hour is a nonprofit 501(c)(3), founded in September 2005 by Dr. Barbara V. Romberg, a psychologist in the Washington, D.C., area. The organization's mission is to develop national networks of volunteers capable of responding to both acute and chronic conditions that arise within our society. Currently, GAH is dedicated to meeting the mental health needs of the troops and families affected by the ongoing conflicts in Iraq and Afghanistan. Give an Hour now has approximately 1,200 providers across the nation and continues to recruit volunteer mental health professionals to its network. For more information or to volunteer to become part of the effort, please visit http://www.giveanhour.org.

About The American Psychiatric Foundation
The American Psychiatric Foundation is the charitable and educational subsidiary of the American Psychiatric Association. The mission of the foundation is to advance understanding that mental illnesses are real and can be effectively treated. For more information, please visit the foundation's web site at http://www.psychfoundation.org.

About Lilly
Lilly, a leading innovation-driven corporation, is developing a growing portfolio of first-in-class and best-in-class pharmaceutical products by applying the latest research from its own worldwide laboratories and from collaborations with eminent scientific organizations. Headquartered in Indianapolis, Ind., Lilly provides answers -- through medicines and information -- for some of the world's most urgent medical needs. Additional information about Lilly is available at http://www.lilly.com.

From Give an Hour's website:

Our Mission
Our mission is to develop national networks of volunteers capable of responding to both acute and chronic conditions that arise within our society. Our first target population is the U.S. troops and families who are being affected by the current military conflicts in Afghanistan and Iraq. Give an Hour is asking mental health professionals nationwide to literally give an hour of their time each week to provide free mental health services to military personnel and their families. Research will guide the development of additional services needed by the military community, and appropriate networks will be created to respond to those needs. Individuals who receive services will be given the opportunity to give an hour back in their own community.

Our Focus
Our organization is currently focusing on the psychological needs of military personnel and their families because of the significant human cost of the current conflicts. Over 1.6 million troops have been deployed in Afghanistan, Iraq, and the Persian Gulf since September 11, 2001. Nearly 550,000 of these troops have been deployed more than once. According to the U.S. Department of Defense, as of May 15, 2008, nearly 4,600 American troops have died in Iraq and Afghanistan. Roughly 32,875 U.S. troops have been injured during these conflicts.

In addition to the physical injuries sustained, countless servicemen and servicewomen have experienced psychological symptoms directly related to their deployment. According to a RAND report released in April 2008, over 18 percent of troops who have served in Iraq and Afghanistan--nearly 300,000 troops--have symptoms of post-traumatic stress or major depression. At the same time, about 19 percent of service members reported that they experienced a possible traumatic brain injury. And let us not forget: millions of Americans belong to the families of these servicemen and servicewomen. Spouses, children, parents, siblings, and unmarried partners of military personnel are all being adversely affected by the stress and strain of the current military campaign.

Our military leaders are well aware of the human cost of this campaign. Indeed, they are attempting to address the psychological needs of the troops through a variety of programs within the military culture. Unfortunately, the tremendous number of people affected makes it impossible for the military to respond adequately to the mental health needs in its greater community. For example, according to the RAND study, only 43 percent of troops reported ever being evaluated by a physician for their head injuries. Moreover, returning combat veterans suffering from depression, anxiety, and post-traumatic stress disorder (PTSD) are not routinely seeking the mental health treatment they need. RAND also reports that only 53 percent of service members with PTSD or depression sought help over the past year.

A major barrier preventing military personnel from seeking appropriate treatment is the perception of stigma associated with treatment. Many fear that seeking mental health services will jeopardize their career or standing. Others are reluctant to expose their vulnerabilities to providers who are often military personnel themselves, given the military culture’s emphasis on strength, confidence, and bravery. Servicemen and servicewomen might be more inclined to seek help if they know that the services provided are completely independent of the military. By providing services that are separate from the military establishment, we offer an essential option for men and women who might otherwise fail to seek or receive appropriate services.

We are also offering services to parents, siblings, and unmarried partners who are not entitled to receive mental health benefits through the military. Although these individuals may have access to mental health services through other means, they are less likely to seek the help they need and deserve if that help is difficult to find or costly. Our goal is to provide easy access to skilled professionals for all of the people affected by the current war. The participating mental health professionals offer a wide range of services including individual, marital, and family therapy; substance abuse counseling; treatment for post-traumatic stress disorder; and counseling for individuals with traumatic brain injuries. Whether it is a young military wife who is anxious because her four-year-old has had nightmares since her husband’s deployment or a father who is struggling to cope with his son's loss of a leg as a result of an explosion in Iraq, both will receive the assistance they need to move through their experience. The healthier the support system for the returning troops, the lower the risk of severe or prolonged dysfunction within these military families.

Our Plan
Give an Hour is reaching out to the military community in several ways. As a member of America Supports You, a Department of Defense program that provides opportunities for citizens to show their support for the U.S. Armed Forces, we are identifying individuals involved in post-deployment processing of returning troops. We are developing collaborative relationships with the commanding officers of returning troops so that these officers are aware of and comfortable with the services we provide. We are also working closely with a number of veterans service organizations to promote our services directly to the family members of troops. Furthermore, we are working with individuals affiliated with Walter Reed Army Medical Center in Bethesda, Md. We are also collaborating with the Veterans Administration to distribute information about our services through Vet Centers across the country.

Finally, we are promoting our services to the military community and the public through a media campaign that includes print, television, and radio coverage. In fact, our founder and president, Dr. Barbara Romberg, has been interviewed in national media outlets from the Washington Post to NPR's Diane Rehm Show, Ladies' Home Journal, and HD Net's World Report.

Give an Hour recruits mental health professionals in several ways. We have been endorsed by the American Psychiatric Association and the National Association of Social Workers and are seeking endorsements from other major mental health organizations. Only licensed mental health professionals are included in the network. Licenses are verified. Non-licensed pastoral providers may be included in the network as long as they meet other criteria, including membership in professional organizations. In addition to coordinating with national organizations, we also recruit mental health professionals through professional publications and Web sites.

As of May 2008 we have a redesigned Web site, expanded to include materials to guide visitors seeking services as well as reference materials to inform mental health professionals. Only mental health professionals trained and experienced to work with trauma victims will identify themselves as available to work with soldiers who have experienced combat. We are working with experts in the trauma field to prepare materials for our Web site and to find appropriate mental health professionals for recruitment.

The Eli Lilly and Company Foundation recently awarded Give an Hour, in partnership with the American Psychiatric Foundation, a major grant that will allow us to spread our message to the leaders of the mental health community in every state. 

We are recruiting volunteers from a number of organizations and institutions as well as through our Web site to assist us in the implementation of our program. Volunteers from retired military personnel to members of military families to concerned civilians throughout thte country are helping Give an Hour. Volunteers are checking licenses, distributing brochures, and coordinating community partnership opportunities for those troops and family members interested in giving back an hour to their own community.

Our Vision
Our primary focus will always be to attend to those in need by linking them to individuals in our society best equipped to respond effectively. In addition, we will develop research and educational programs to further promote the value and importance of a new kind of volunteerism. We hope to encourage an increase in shared responsibility for those citizens who are suffering. We need only look at the outpouring of aid and support following both the terrorist attacks of September 11, 2001, and Hurricane Katrina in August 2005 to see the potential we have to become a truly compassionate and united nation. And we need only look at the significant costs of the war in Iraq and the relief efforts for Katrina’s victims to see that federal and state governments are already strained beyond their means. We have not only the potential but the duty to help one another in times of need.

For more information, contact Barbara V. Romberg, Ph.D., Founder and President, Give an Hour.  Her email address is linked here.

Pick Up the Phone, Hon - That's the VA Calling!

In a seemingly odd, but -- one would hope -- nonetheless proactive move -- the Department of Veterans Affairs (VA) is now placing outgoing calls to in a nationwide campaign to inform and connect returning combat veterans with the services the VA provides.  The calls, which are being outsourced to a provider called EDS, are initiated by the VA and follow a very specific, and laudable intention,  In a PR blurb published on the Web at TCRNet, the following information was provided about the program:

The Combat Veteran Call Center is expected to make more people aware of health care and benefits eligibility for veterans of the wars in Iraq and Afghanistan. It’s the first task order awarded under the General Services Administration’s $2.5 billion USA Contact contract vehicle, according to EDS.

Calls to veterans began on May 1 and plans include reaching out to nearly 570,000 recent wartime veterans over the next six months. The campaign will initially focus on roughly 17,000 veterans who, based on their wartime injuries or illnesses, are considered candidates for care management.

The second phase will include contacting about 550,000 Operation Iraqi Freedom and Operation Enduring Freedom veterans who have not yet enrolled for VA health care services."

Additionally, "Officials at the company say EDS phone representatives will make initial calls to veterans to complete interview that will assess their needs. Representatives also will provide information about available VA health care services and benefits. Follow-up calls will also be completed to ensure that the veteran has had his or her needs met."

 

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At least one Veterans Service Officer I spoke with, while praising the existence of this program, also cautioned that its emphasis on prioritizing contact with OIF/OEF veterans over those of previous wars, could have the unintended consequence of creating friction between Vietnam veterans and Iraq and Afghanistan veterans -- groups which have been reasonably supportive of each others' existence, so far.  In fact, Vietnam veterans have been incredibly gracious about seeing that veterans of more recent conflicts get the help they feel was denied to them.  So any move that pits the two groups against each other in triaging care runs the risk of causing unnecessary friction and competition for what amounts to limited resources.  And speaking of limited resources -- although the proactive calling is in some ways a good idea (and positive PR for the frequently embattled agency) -- more and different solutions are desperately needed.  Examples include: hiring more psychotherapists, exploring treatments other than drugs and group therapy, making sure patients get seen quickly, expanding services to include outreach and education for family members, and freeing up some cash for paying private providers who are now giving their time for free, to make sure veterans get seen.  Oh, and eliminating the stigma of mental health care to career veterans, who are sometimes afraid to be seen for the impact it might have on their career advancement.  We're not even gonna mention the "shhh!!!" email here -- or the tendency to want to call PTSD by any other name including adjustment disorder -- there's enough about that in the news already.