Healing Combat Trauma

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.

Veterans, PTSD and Suicide: The Overlooked Element of Contagion

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

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

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

But to the point at hand...

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

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

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

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

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

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

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

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

He continued,

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

He added,

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

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

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

---

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

To the science on this.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I love who I was.

Why did I do this to myself?

Was it war?

Did I implode from all the shit I saw?

Or was it something else?"

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

Why did I let myself

Get so lost?

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

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

Quotable Quotes -- Former U.S. Senator Bill Bradley on PTSD

Former U.S. senator Bill Bradley (D-NJ), NBA Hall of Famer, and Rhodes Scholar, had this to say in a commentary published in Vanity Fair today about PTSD. The occasion was the premiere of the Tom Hanks/Steven Spielberg/HBO miniseries, "The Pacific," about U.S. Marines in the Pacific during World War II, also getting screened privately at the White House today.

Bradley thinks there are several things that the president and the first lady should be thinking about while they watch the miniseries. One of those topics is PTSD. Says Bradley:

"Both The Pacific and Band of Brothers focus on the horrors of the war and the emotional trauma that a soldier or Marine can endure. P.T.S.D. should be treated with as much seriousness as a gunshot wound. If the president is going to send tens of thousands more troops [into combat], he also needs to consider the emotional payload. With suicide rates up among veterans -- accounting for 20 percent* of all suicides among Americans -- the government must dedicate more money to support programs for our returning troops."

Editor's note: If 8,000 veterans kill themselves every year, conservatively, and the national suicide rate is close to 34,000, according to the NIMH, the percentage of suicides who are veterans is closer to *25%. They also represent almost 50% of the homeless population. So yes, please, let's do that...and sooner rather than later...

(The full commentary is linked here.)

More Numbers to Remember: 3 Then, 7 Now

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

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

Let's Hope This Isn't More "Blame the Victim" Thinking on Combat Veterans with PTSD, But...

A recent medical study, published in the British Medical Journal and reported on Friday, suggests that "the risk of combat-related post-traumatic stress disorder (PTSD) increased by two- to threefold in military personnel who had significant mental or physical problems before deployment, according to a study of 5,400 veterans."  In other words, those who were vulnerable beforehand, were even more susceptible to PTSD than their peers.  Hmmmn.

It's always interesting, and is going to stay interesting, to contemplate what, if any, predictive or predisposing factors there are for who develops later develops combat-based PTSD and why.  At the very least, this study throws yet more analysis into the mix, in a story that will continue developing for years.

According to the BMJ, the conclusion of the study was that:

"Low mental or physical health status before combat exposure significantly increases the risk of symptoms or diagnosis of post-traumatic stress disorder after deployment. More vulnerable members of a population could be identified and benefit from interventions targeted to prevent new onset post-traumatic stress disorder."

The study, which was supported by the U.S. Department of Defense, reported that:

"More than half of post-combat PTSD diagnoses involved veterans who ranked below the 15th percentile in mental or physical health at baseline, Cynthia LeardMann, of the Naval Health Research Center in San Diego, and colleagues reported online in BMJ.

"We have identified an at-risk population whose functional health seems to predict vulnerability to PTSD after combat deployment," the authors said. "In theory, such a population could be targeted for PTSD prevention programs, early intervention after exposures to stress, or even protection from stressful exposures, when possible."

The findings came from the Millennium Cohort Study, which has accumulated data on military personnel since 2001, before the wars in Afghanistan and Iraq. Investigators collected follow-up data from June 2004 to February 2006.

A previous report based on the study suggested that combat exposure -- as opposed to deployment -- significantly increased the risk of new-onset PTSD. Building on that observation, the authors examined the association between baseline mental and physical health and the risk of new symptoms or a diagnosis of PTSD.

The current analysis involved 5,410 combat veterans who completed baseline and follow-up questionnaires. The questionnaire includes a 17-item self-report measure of PTSD symptoms.

Baseline health status was determined by participants' scores on the mental and physical summaries of the SF-36V (veterans) health survey. A new PTSD diagnosis was based on DSM-IV criteria (derived from the questionnaires) or self-reported physician diagnosis.

The analysis showed that 7.3% of the participants had new-onset symptoms or a diagnosis of PTSD at follow-up by DSM-IV criteria. When self-reported physician diagnosis was included, the rate increased to 8.6%.

The authors stratified the participants into three groups according to mental and health status scores: below the 15th percentile, 15th to 85th percentile, and above the 85th percentile.

Combat veterans who scored below the 15th percentile of the mental summary had a relative risk of PTSD of 3.51 compared with those in the 15th to 85th percentile.

A score below the 15th percentile of the physical summary more than doubled the risk of PTSD (RR 2.22).

Overall, 58% of new PTSD diagnoses involved combat veterans who were below the 15th percentile for either summary.

Subgroups at increased risk for new PTSD symptoms or diagnosis included:

• ≥3 combat exposures during deployment, 2.60
• Women, 2.33
• Current smokers, 1.56
• Non-officers, 1.77
• Reserve/National Guard members, 1.85
• Army veterans, 2.04"

Editor's Note: The full reference is: LeardMann CA, et al "Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: Prospective U.S. military cohort study."  The full citation is: BMJ 2009; 339: DOI:10.1136/bmj.b1273. For the link to the full article, click here.

A Look in "The Mirror" -- Great Britain Seeing War Trauma Now in 3 Years, Not 13 As Before

Because Americans are notorious for paying little attention to things that happen elsewhere, even among other English language-speaking countries, here's some news from Great Britain's tabloid-esque "The Sunday Mirror" today about their soldiers' battles with PTSD on the homefront -- soldiers who served in Iraq and Afghanistan.  For the link to the article, called "War's Silent Victims," by Rupert Hamer, click here. (The tabloid nature of the newspaper explains the fairly breathless writing style, but let's hope the facts and the reporting are accurate nonetheless.)

Points worth mentioning from the article include:

"Alarmingly, the charity [Combat Stress, see below] say[s] the figures are just the "tip of the iceberg" and add that the rate at which soldiers are developing the condition has accelerated. Usually it takes 13 years for cases of post-traumatic stress disorder to develop in veterans.

But psychiatrists at Combat Stress's pioneering centre say the men and women now being treated have come forward after just THREE years.

Also:

Dr Walter Busuttil, a consultant psychiatrist at Combat Stress, said: "What we are seeing now is just the tip of the iceberg.

"Because there has been no proper study of post-traumatic stress disorder among troops in this country we have no idea of the true scale of the problem.

"The same thing happened in the US after Vietnam. The Government tried to dismiss the disorder as a myth - then the whole thing exploded. Now when I speak to my colleagues in America they tell me: 'You are going through your Vietnam'."

And finally:

Dr Busuttil, 49, a psychiatrist in the RAF for 16 years, says the Government has covered up the severity of the conflicts from the public.

"The worst thing for a serviceman or woman is to come back from a war and for people not to have any idea what they have been through.

Editor's note: For a link to Great Britain's charity, Combat Stress, click here.  To find them on Facebook, click here. We've written about them before on this blog, but according to their website, "Combat Stress is the leading charity specialising in the care of British Veterans who have been profoundly traumatised by harrowing experiences during their Service career and who are suffering from poor mental health as a result."

"It Was Loyalty to Your Buddies That Kept Men Going" -- The Wet Bond of Blood, Civil War Style

A few months ago we blogged about an interesting, little-known WWI-era poem, written by Robert Graves for Siegfried Sassoon, called "The Wet Bond of Blood," about the brotherhood men forge in combat. (That post is linked here.)

From the news this past week comes a related story in the L.A. Times, talking about the work of Dora Costa and Matthew Kahn, a husband-and-wife research team at UCLA, who have been delving into 41,000 Civil War records of the Union Army to find out what makes some soldiers "stay and fight on a brutal battlefield," and others "desert and flee." Their new book is called "Heroes and Cowards: The Social Face of War."

According to the L.A. Times,

"The book's thesis is that serving in a homogenous Army company, particularly one of volunteers recruited from the same region, reduced desertion rates in the 1860s. Patriotism played a role in keeping soldiers at the front lines, according to the book, but more important factors were sticking with buddies of similar backgrounds and avoiding a bad reputation back home.

"Loyalty to comrades trumped cause, morale and leadership. But loyalty to comrades extended only to men like themselves -- in ethnicity, social status and age," the authors wrote."

For example,

"Through statistical analysis, the authors developed a formula in which group loyalty in those Union regiments was found to have counted twice as much in preventing desertion as a soldier's ideology, and six times as much as their unit leaders' popularity. For example, Company D of the 36th Regiment contained neighbors and relatives from Worcester County, Mass. The men, mainly mechanics and artisans, saw heavy action and no desertions.

In contrast, Company B of the 47th Regiment from New York was a more diverse lot, including men from cities and farms, along with laborers who were paid to substitute for conscripts. Its desertion rate was 16 percent."

"Cohesion" in military units is a topic even experts like Jonathan Shay, M.D., Ph.D. have spoken about as vital and essential for morale, and for the prospect of some form of healing taking place also in community.  As the article's author remarks, "Unlike the Civil War army, American units today are ethnically and geographically diverse. Yet the military has learned to reinforce the bonds gained in training, and usually rotates entire units in and out of war zones rather than fill in for casualties with new soldiers as it did during the Vietnam War, the professors said."

Interestingly, the book's authors are economists, not sociologists. The data they surveyed, and the ways they worked with the source material might also be useful for others to evaluate as well.  One of the recent, though debated, conclusions of PTSD research is that ethnic minorities are at risk for suffering from PTSD at greater rates than the general population.  There are various hypotheses proposed as to why, and no general agreement as yet about why this might be.  (See "PTSD among ethnic minority veterans," from the National Center for PTSD Research, linked here, for more on this subject. Also Professor Hedley Peach's research with the Australian Vietnam veterans studies as well, previously discussed on this blog.)

(Here's a look at the source material and their techniques for analyzing it, from the same L.A. Times article:)

"They used Internet databases as well as copies of antique paper documents written in the elegant penmanship of 19th-century government clerks. They applied the statistical tools of economic analysis to history, a cross-disciplinary technique increasingly popular in academia. Through those archives, the authors examined service records, ages, birthplaces, prewar occupations, battlefield deaths and prisoner-of-war interments among 35,000 white and 6,000 black Union soldiers. They also tracked census and pension information going back in some cases to 1850 and as far forward as 1910. Similar Confederate records were not available, they said. And to estimate pro-Union sentiment among the troops they studied, the researchers examined support for President Abraham Lincoln¹s elections in the soldiers' home counties."

Dora Costa, one of the book's authors called the source material they used, the Union Army's war records, "a fantastic laboratory for studying how do men behave under extreme stress." For that very reason, I hope other authors and scientists will mine this same trove of information.  The book's authors come up somewhat blank on one of the most fascinating themes of all.  During the Civil War, "the most ideological of U.S. wars," Costa remarked, "it was loyalty to your buddies that kept men going.id. "But we don't know why there was this loyalty."

Answering that question, we might want to turn to Graves' poem for Sassoon, mentioned above, or the thoughts of America's premier wartime journalist, Ernie Pyle, who we've also talked about at length on this blog.  From last summer -- the author of "Ernie Pyle's War," describing Pyle's authentic empathy for the soldier beside him, so well-conveyed in print:

"He knew, too, that it was neither God nor Flag nor Mother that impelled a pimply faced kid to risk, to lose his life in an obscene adventure.  He did it for the kid next to him; he couldn't let him down.  They needed one another so bad."

In "Heroes and Cowards," Costa and Kahn were surprised to learn that the average Union desertion rate was only about 10%, on average.  Says the L.A. Times, "Given the horrific conditions, it is surprising there was so little desertion," Costa said. That was especially true since fewer than one-half of those who deserted were caught, punishment often was not very harsh and execution extremely rare."

In the absence of any other, better sociological explanation, it just goes to underscore the "wet bond of blood" -- or what Pyle referred to as "the powerful fraternalism of the ghastly brotherhood of war."

What Would Hope Regained Do for Combat Veterans?

I was in a conversation the other day with a Vietnam era psychologist, who I respect and admire a great deal, but who was nonetheless giving me static for the way I talked about "hope" in a previous blog post, as it concerned combat veterans.  "You talk about it as though it's an abstract, but then immediately move into talking about its RESULTS," he said (I'm paraphrasing.)  Rrrright.  And that would be exactly the point.  Hope is a great and a necessary thing -- but our goal here is to find ways to get over combat trauma, to the extent possible -- at least to reduce its effects on veterans -- and in that regard, yes, we're all about the results.  Are there any?  And what can those be?  Because if they're legitimate at all, in the vacuum of hope-lessness and despair created by a complete lack of reasonable solutions, let's figure out what those are, and let's try them out.  Are combat veterans game?  Many are.

Here's something I ran across the other day, in the middle of a [draft] journal article.  The author was talking about a type of therapy he used -- a therapy he's famous for developing, and which has been around and in use for decades -- on combat veterans, mostly from the Vietnam era, and the results he was able to achieve with them.  I have some inside knowledge of his program, but this was the first time I'd read something in print about it.  In the middle of quite an extensive article, charting this result and that, he happened to mention the results of one of the tests he did on the 22 vets, both before and after the two weeks of treatment.  This is what he wrote:

"Scores on the Beck Hopelessness Scale fell from an average of 11 before treatment to 3 following treatment.  In clinical practice, scores of 9 or more are used to indicate serious hopelessness.  A score of 4 is expected in the general population.  The veterans went from having pre-test scores characteristic of hopelessness, suicidal ideation and predictive of suicide attempts, to having scores typical of the general population.  Thirteen veterans had scores above 9 before treatment, one had a score above 9 after treatment. (That individual's score had dropped from 17 to 10.)  Nineteen out of 22 scores dropped; two remained the same (scores of 1 and 2); and one score increased [negligibly] (from 4 5o 5).  Marked decreases in pessimism are indicated, and it seems safe to conclude that the treatment group felt considerably more hopeful at the program's conclusion."

Do you see what's embedded in that, if true?  In two weeks of treatment, combat veterans with PTSD that went back decades started feeling better to a degree, on average, better than the general population?  That's remarkable...

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So I ask you, what would HOPE do for veterans today, and their families?  It's pretty clear that when it comes to suicide, people are able to go forward with the act because they've given UP hope.  (That's why the Beck test, for example, is able to link the two: hopelessness and suicide, both ideation and attempts.)  We've seen in previous blog posts how the "focus" of a suicidal person becomes narrower -- it's not that they "don't love their family" or "aren't thinking about the consequences to others," they simply have narrowed their focus down to an either/or choice, and the rest of the considerations, no matter how otherwise dear, are simply "not in the picture." 

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Now it's entirely possible that the veterans in the above-mentioned program didn't functionally "stay" that perky and optimistic, and that's why more follow-up studies, such as retests at longer intervals, would have contributed more information worth knowing.  Many times, at the end of a program, irrespective of what type of program it is, participants feel most buoyed and optimistic about future performance, lighter about their burdens, and more likely to discount the negative effect of future obstacles they may encounter.  However, even so it's significant to note how good those scores seemed to be, given the great degree of difficulty the same participants had having hope beforehand.

It's not just veterans -- it's also their families.  How often do family members say things like, "But you were only in the war for two years...how can you let it affect you for the whole rest of your life?"

If combat veterans are able to access health care that adequately deals with their symptoms, and reduces their symptom load to a manageable extent, and gives them back HOPE -- they will have the ability to resume their lives with some degree of normality, and prevent any number of negative consequences that come from NOT having hope, from having given up.  The tremendous societal costs from combat trauma we have to start understanding not only affect the veterans involved -- they affect their families, the communities in which they live, future generations, etc.  Veterans with hope -- who get their hope back -- will be functional and integrated into all aspects of their lives, and actively participate in their various roles as spouses, parents, employees, citizens, etc.  Veterans who lose hope, and who we do not help to regain hope, will lose out.  And this loss will affect them first, and then like the ripple effect of a pebble thrown into a pond, concentric circles of effect will spread out from them to others in their lives: their immediate families, their workplaces, their schools, their communities, even future generations in their families.

Far from being an abstraction, I believe HOPE is pretty central to the whole concept of "healing combat trauma."  We've got to help combat veterans to hang on and have some, and they themselves have to believe it's possible to get better.  Then we have to make sure we're connecting them with the very resources that can deliver the results.

In the News: Two Articles Worth Reading Recently

Two articles worth reading that have been in the news recently:

"How the VA Abandons Our Vets," by Joshua Kors, in The Nation, linked here; and the poorly-headlined but otherwise worthwhile"Military Town Newspaper Challenges U.S. Military on Murder of Military Women," by Ann Wright, in TruthOut.org on the Web, linked here. 

Kors' article talks about the recent veterans' class-action lawsuit against the VA, fought in Federal court, and WHY it was necessary -- and there are some interesting and unexpected points, which didn't show up elsewhere in enough detail.  The biggest one is about the "fuzzy math" the VA employs to calculate claim times, and how this uniformly works against veterans (no pun intended on the "uniformly" thing.) It also confirms a longheld impression on my part that a veteran who struggles intensely with the mammoth difficulty of being his or her own advocate in the process, and ends up committing suicide, is actually counted as a "victory" for the VA, who calls their claim "resolved" in the time it took them to kill themselves.  In other words, fellow veterans killing themselves while waiting for their claims to be resolved actually makes the VA look "better and faster" at resolving claims, if you can believe that.  Yikes.  Talk about a system that needs to be overhauled and addressed...

Another great point Kors makes is that "someone" already attempted -- but was fired for her efforts.  That "someone" is Frances Murphy, M.D., who in 2004, according to Kors, "helped draft the Mental Health Strategic Plan, a blueprint for overhauling the VA.  The plan called for 256 changes to the organization, among them: installing a tracking system to stay in touch with suicidal veterans, creating rehabilitation programs that involved veterans' families, and streamlining the benefits process to resolve wounded veterans' immediate needs."  However, after expressing her frustration in public (to mental health providers) about the barriers the VA erects to veterans' speedy care, and how this causes veterans to suffer additionally and unnecessarily -- she was summarily fired.

Read the Kors piece to understand what wounded veterans have to go through, and how unfair it is; and to get a better picture on the fuzzy math that's employed to make things seem much better than they are.

The Ann Wright piece talks about military wives and women servicemembers murdered recently by other servicemembers, and mainly serves to remind us of how this is a problem that isn't going away.  The "news peg" for her article is a recent editorial in the Fayetteville, NC Observer -- Fayetteville is close to huge Army and Marine bases -- called "Our View: Military Domestic Violence Needs More Aggressive Prevention" (speaking of odd word choices).  That editorial is linked here.  The editorial references a recent vigil to memorialize the murdered women locally.

In conjunction with the Helen Benedict material and the other writings on Military Sexual Trauma, blogged about recently, here -- this is a topic worth keeping in the forefront of our minds.  Collateral damage from combat trauma? Or just crimes committed by otherwise sick individuals who happen to be in the military?  Either way, "more" needs to be done about this terrible problem.  (A similar and related topic is the "non-combat deaths" one we discuss from time to time, which can sadly be what's used to describe what more actually is a victim's suicide or a "domestic violence" type murder, of one servicemember by another.) We're just about to add a series of blog posts about domestic violence, and why it's important to leave when you're at risk, but ideally how to do so in a way that preserves your life.  Look for that shortly.

About the authors:

Joshua Kors is an investigative reporter for The Nation, where he covers military and veterans' issues. He is the winner of the National Magazine Award, George Polk Award, IRE Award, National Headliner Award, Casey Medal, Mental Health Media Award, and the Military Reporters and Editors Award.  He was also a finalist for the Michael Kelly Award, Tom Renner Award, Harvard's Goldsmith Prize for Investigative Reporting, and the American Bar Association's Silver Gavel Award.

Ann Wright is a retired US Army Reserves colonel with 29 years of military service. She also was a US diplomat who served in Nicaragua, Grenada, Somalia, Uzbekistan, Kyrgyzstan, Sierra Leone, Micronesia and Mongolia. She is the co-author of "Dissent: Voices of Conscience," profiles of government insiders who have spoken and acted on their concerns of their governments' policies.