After a rather intense two months of long-form work, I’m so far behind on blogging I don’t know where to start. Forget the last two months and move on? Probably the best move. But beforehand, I want to note a few developments along major lines of interest. I’ll start with PTSD.
Amid the stagnation on combat PTSD, the summer brought news of new programs from the UK and US militaries aimed to answer the call for more effective treatment for rising rates reported in vets of the wars in Iraq and Afghanistan. Mind Hacks was one of several blogs to report and comment on a new Royal Marine program called TRiM, or Trauma Risk Management. The Times and other outlets covered a program being launched this October by the US Dept of Defense.
I’m not sure how much I have to add to these, other than noting (as others have) that neither of these programs is peer-reviewed (though they’re based roughly on peer-reviewed methods), and neither should be seen as anything approaching a full solution. I’m glad to see these programs and expect they’ll help some soldiers. But not many, I fear, at least in the US, for the program proposed has no real hope of overcoming the other problem with our response to war-related distress here.
And that problem (again, in the US) is that neither the PTSD establishment nor the VA is seriously trying to answer — and indeed, they are trying to ignore — the two obvious questions that should be asked:
1. Why are rates in US soldiers and vets higher than in other countries?
2. Why is the US combat vet population the only one in which PTSD rates and diagnoses increase as time passes after service? (Civilians studies have repeatedly shown that likelihood of developing PTSD decreases steadily and significantly as time passes after the traumatic event. Only in US combat veterans does likelihood of reported symptoms and diagnosis increase with time.)
Those are the two great anomalies of the US experience — and they scarcely go examined in most papers and statements, much less VA or DOD policy or practice. (A recent paper out of the UK does look at these issues.) Sometimes the researchers do backflips to try to try to answer those questions without mentioning the possibility that something in our culture or the VA’s response could be contributing to the problem. Here’s Karen Seal, lead author on a study published in the Am J of Public Health a few weeks ago that found rates increasing with time in vets of our wars in Iraq & Afghanistan:
Dr. Seal attributed the rising number of diagnoses to several factors: repeat deployments; the perilous and confusing nature of war in Iraq and Afghanistan, where there are no defined front lines; growing public awareness of PTSD; unsteady public support for the wars; and reduced troop morale. She said that “waning public support and lower morale among troops may predispose returning veterans to mental health problems, as occurred during the Vietnam era.”
Dr. Seal said often it takes more than a year for symptoms of PTSD to appear and diagnosis to be made. She said, “The longer we can work with a veteran in the system, the more likely there will be more diagnoses over time. It sometimes takes time, given the stigma associated with mental illness, before we are able to break through the barriers and have patients tell us what is happening.”
The key sentence here is “”The longer we can work with a veteran in the system, the more likely there will be more diagnoses over time.’” The many ways in which the VA’s response — both in the clinic and in its absurd disability structure — can discourage healing and encourage a faulty diagnosis of PTSD are well-documented. I recently had an Army captain buttonhole me and volunteer that the entire response to returning soldiers feeling any sort of distress all but begs them to declare themselves traumatized rather than troubled. A leading Australian PTSD researcher who worked for 6 weeks with returning US vets at Walter Reed said essentially the same thing. Yet the iatrogenic powers of such a response go ignored in Seal’s attempt to explain why a vet’s chance of diagnosis increases with time spent in the care of the VA.
Meanwhile, as I’ve noted before, both the press and the military continue to ignore a study suggesting that we could cut PTSD rates in half by simply not deploying the 15% of soldiers who score lowest on measure of overall health we’re already giving them.
We can throw all the money we want at PTSD and continue to hire lots of therapists at the VA. But we won’t get anywhere until we start asking why the PTSD problem takes such a unique course here in the U.S.
Update 9/3/09: The speculative answers to these questions (i.e., why rates apparently so uniquely high in US soldiers) in the comments make me fear I was too subtle. Much of the answer is in the way this country, and the VA, responds to combat-related stress. For an exploration of that answer, see my Scientific American story “The PTSD Trap” looks at the issue in depth. I’ll soon be posting a longer version here.