The Corpus Callosum

Support the Troops

A recent study indicates that the lifetime cost of medical
care for
Iraq and Afghanistan veterans will be greater than the cost of the war
to date.  We really have no choice, but it is going to cost
us.  A lot.  Of course, the ones really paying are
the troops themselves.  From Medscape (free registration
required).

href="http://www.medscape.com/viewarticle/565407">High
Rate of PTSD in Returning Iraq War Veterans

Bob Roehr

November 6, 2007 (Washington, DC)

Estimates of the rate of posttraumatic stress disorder (PTSD) among
veterans returning from Iraq range from 12% to 20%. With deployment
topping 1.5 million this summer, and the Department of Veterans Affairs
(VA) having treated more than 52,000 persons, the greatest effect of
those mental health issues has yet to be experienced. These problems
and interventions were presented here at the American Public Health
Association 135th Annual Meeting.

Evan Kanter, MD, PhD, staff psychiatrist in the PTSD Outpatient Clinic
of the VA Puget Sound Health Care System, said that estimates are for a
minimum of 300,000 psychiatric casualties from service in Iraq, to this
point, with an estimated lifetime cost of treatment of $660 billion.
That is more than the actual cost of the war to date ($500 billion)…


This is the kind of thing that makes me doubt that we are reducing the
deficit.  It is a hidden, partly unfunded, liability.

Complicating this is the fact that no one knows the best way to provide
care for veterans with PTSD.  A recent analysis by the
Institute of Medicine, href="http://www.nap.edu/catalog.php?record_id=11955">Treatment
of Posttraumatic Stress Disorder: An Assessment of the Evidence

concluded that there is a lack of evidence for the efficacy of most
treatments.  From their href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11955">summary:

The committee reviewed 53 studies of pharmaceuticals
and 37 studies of psychotherapies used in PTSD treatment and concluded
that because of shortcomings in many of the studies, there is not
enough reliable evidence to draw conclusions about the effectiveness of
most treatments.  There are sufficient data to conclude that
exposure therapies — such as exposing individuals to a real or
surrogate threat in a safe environment to help them overcome their
fears — are effective in treating people with PTSD.  But the
committee emphasized that its findings should not be misread to suggest
that any PTSD treatment ought to be discontinued or that only exposure
therapies should be used to treat PTSD.

They concluded that exposure therapy can work.  However, that
is a circumscribed type of treatment that helps with avoidance behavior
and autonomic overreactions related to specific reminders of the
trauma.  PTSD generally includes a much broader range of
symptoms.  Reducing just those symptoms is helpful, but I
suspect that in most cases, it is not going to return a person to a
state of wellness.  

The IOM study was designed to provide guidance to policymakers, not
clinicians.  Thus their main recommendations are for Congress
to authorize more funding for research, and for researchers to do a
better job of designing their studies.  

To clarify, they found many of the studies to be questionable:

The committee identified 90 studies that met its
criteria for trials from which it could anticipate reliable and
informative data on of PTSD therapies.  However, several
problems and limitations characterize much of the research on PTSD
treatments, making the data less informative than expected. 
Many of the studies have problems in their design or how they were
conducted, and high dropout rates — ranging from 20 percent to 50
percent of participants — reduced the certainty of several studies’
results.  Moreover, the majority of drug studies were funded
by pharmaceutical firms and many of the psychotherapy studies were
conducted by individuals who developed the techniques or their close
collaborators.  Further investigation is needed to know
whether these treatments would produce the same results if tested by
other researchers and in other settings. 

Studies funded by drug companies are not useless, but we do need to be
appropriately cautious about relying on them.  

Additionally, the study of treatment for PTSD presents some significant
challenges.  One such challenge is the high dropout rate, as
mentioned above.  

In addition, the research has not taken into account
potential differences in the effectiveness of treatments for subgroups
such as those with traumatic brain injury, depression, or substance
abuse; nor have studies examined the effects in ethnic minorities,
women, and older individuals.  Many studies excluded
individuals with concurrent health problems such as depression and
substance abuse, raising questions about whether the results apply to
the many PTSD sufferers who have multiple conditions.

Patients rarely come in with a narrow set of problems.  There
is heterogeneity in the symptom profiles as well as the concurrent
conditions.  Furthermore, there is more that one type of
trauma:

The vast majority of people who experience the
disorder also have other concurrent conditions, such as alcoholism,
depression, drug use, or anxiety disorders.  Sexual assault
during military service is another factor that can lead to PTSD among
service members…

…In addition, the research has not taken into account potential
differences in the effectiveness of treatments for subgroups such as
those with traumatic brain injury, depression, or substance abuse; nor
have studies examined the effects in ethnic minorities, women, and
older individuals.  Many studies excluded individuals with
concurrent health problems such as depression and substance abuse,
raising questions about whether the results apply to the many PTSD
sufferers who have multiple conditions.

As noted by Retired Doc, href="http://mdredux.blogspot.com/2007/10/there-are-no-average-patients.html">there
are no average patients.  One
thing I would add is that, not only are all the patients different, but
they all have different psychosocial environments, which change as the
patient changes.  In psychiatry, there are no truly controlled
experiments.  We have control over the interventions, but we
do not have control over the environment.  It is like doing a
chemistry experiment when the control solution is in a different room,
and someone keeps messing with the thermostats and the lights, perhaps
even sneaking into the room and adding a little something to the mix.
 

Cynics might say that if we can’t consistently demonstrate efficacy of
treatment, then we should just give up.  But do we really want
to give up on the folks we sent off into war?