Untreated Vets: A “Gathering Storm” of PTSD/Depression

Reports of 1 in 5 military service members returning from Iraq or Afghanistan with posttraumatic stress disorder (PTSD) and/or depression and rising suicide rates have led researchers and military leaders to warn civilian psychiatric care providers of a “gathering storm”¹ headed their way.

A RAND Corporation study released in April found that 300,000 individuals-18.5% of US service members who have returned from Afghanistan and Iraq-report current symptoms of PTSD and/or depression.²

Since October 2001, about 1.6 million US troops have been deployed to Iraq and Afghanistan. Of those with PTSD/depression, most will not be treated within the Department of Defense (DoD) or the Department of Veterans Affairs (VA) systems, Thomas Insel, MD, director of NIMH, told the press at the annual meeting of the American Psychiatric Association (APA).

“In both the RAND report and what we are hearing from the VA is the prediction that most of those people, about 70%, will not seek treatment from the DoD or VA, so we are talking about a gathering storm for the civilian sector, for the public mental health system,” he said.

Psychologist Lisa Jaycox, PhD, a senior behavioral scientist with RAND, told Psychiatric Times that there is a need to track the whole population, including those who are not receiving care from the DoD or VA, because psychiatrists and psychologists are likely to encounter these individuals in their practices in coming years.

Jaycox, along with Terri Tanielian, codirector of RAND’s Center for Military Health Policy Research, led a group of 25 RAND researchers who conducted a large-scale survey to assess psychological and cognitive injuries of returning service members. This group also analyzed treatment services and barriers and determined individual and societal costs related to PTSD and traumatic brain injury (TBI).

RAND’s nongovernmental telephone survey involved 1965 service members and veterans from 24 communities across the United States. Post-stratification weighting was used so that results accurately reflected the entire deployed population.

“This is the first study that tries to look at the size of the problem now, across everybody who has been deployed,” Jaycox said. “We had all 4 branches of the military, and with Reservists and National Guard as well as active duty, and we were able to look at all those people who are back in the US . . . whether it is just 1 month back or back as much as 5 years.”

Researchers also identified the subgroups most at risk. “Army soldiers and Marines were more likely to report PTSD and depression than individuals from the Navy and Air Force; people who are not on active duty (Reservists and those who have separated or retired) were more likely to have problems than [those on] active duty. Women, enlisted personnel, and Hispanics were more likely to report more problems than their counterparts,” Jaycox added.

But the single best predictor of PTSD and depression, she said, was the number of combat trauma exposures (eg, friend seriously wounded or killed) while deployed. The number of exposures generally increases with multiple deployments.

Colonel Elspeth C. Ritchie, MD, MPH, consultant to the US Army Surgeon General confirmed, during an APA meeting lecture, that “the rates of anxiety and depression are rising with multiple deployments, ranging from 12% with first deployment to 27% with third deployment.”

“This [increase] is concerning to us,” she said, “because the backbone of the Army is our noncommissioned officers, and about a quarter of them have at least significant symptoms of PTSD.”

“Ask patients if they are soldiers,” she advised psychiatrists. “Don’t assume that every soldier is young and male. There are old ladies like me in the military.”

Suicides and attempts

The RAND report indicated that individuals with PTSD/depression or TBI are more likely to attempt suicide. At the APA meeting, Insel warned, “if you think about . . . mortality from serious PTSD complicated by depression and substance abuse, it is quite possible that the suicides, the psychological mortality from this war could trump the number of combat deaths.” In mid-May, combat deaths reached 4564.

Suicide rates in 2007 among soldiers in both Iraq and Afghanistan, for instance, remained higher than historic Army rates.

“We don’t have the final numbers for last year, because every suicide is investigated to determine if it is an accident, homicide, or suicide,” Colonel Ritchie told APA attendees. “But we are anticipating that the suicide rate is going to continue to go up. Our baseline in the Army usually is between 10 and 12 per 100,000 [troops] per year . . . it is up to almost 20 per 100,000 per year. . . . The trouble is that our soldiers have access to loaded weapons. . . . And the most common precipitant for a suicide in our population is a Dear John or Dear Jane letter or e-mail. They [the recipients] become upset and distressed but don’t tell anybody. They go into the porta-potty and shoot themselves. This is a real challenge for us, because it is a sequence that is very hard to intervene in.”

Suicides and suicide attempts have become a controversial issue for the VA. During a House Veterans Affairs Committee hearing last May, Lieutenant General James B. Peake (Ret), MD, VA secretary, cited a study by Han Kang, PhD, director of the VA’s Environmental Epidemiology Service. That study found that 144 of 490,346 service members who served in Iraq or Afghanistan and who left active service between 2002 and 2005 had committed suicide.³

Lieutenant General Peake testified that the number of suicide attempts by all veterans under treatment by the VA actually could be more than the 1000 per month previously reported. There may be regional variations and differences in data reporting by suicide prevention coordinators and others at the VA’s 153 hospitals.

In mid-May, the Veterans Affairs Committee formally requested data from the VA on the total number of veterans who have committed suicide or attempted to commit suicide-and on the number of veterans who have committed suicide or attempted to commit suicide while receiving care from the VA, among other statistics.

Brain injury

According to the RAND report, 19% of those surveyed (320,000 service members) reported that they experienced a possible TBI while deployed. As many as 7% reported both a TBI and current symptoms of PTSD or major depression, Jaycox said.

“What we don’t know yet is how many people are suffering from some long-term impairment related to those injuries, since we found that fewer than half [43%] had been evaluated by a doctor for that concussion or brain injury,” she said.

In her lecture, Ritchie urged psychiatrists and others to ask about TBIs. Individuals who have experienced mild TBI, she added, can have problems with behavior, attention, and concentration, and “we really need to be able to identify soldiers who are having symptoms of it.” Individuals exposed to a TBI, she warned, are more at risk for getting another TBI, and are, therefore, more at risk for permanent injury.

While screening tests are available for TBI, “no single test tells you definitively whether somebody has a head injury,” she said. The Military Acute Concussion Evaluation is used in theater, and the Automated Neuropsychological Assessment Metrics is used predeployment and after someone has an injury.

Treatment gaps

For those with PTSD/depression, RAND researchers found significant treatment gaps. Only 53% had seen a physician or mental health provider to seek help for a mental health problem in the past 12 months, and of those who sought care, roughly half received minimally adequate treatment.

“If PTSD and depression go untreated or are undertreated, there is a cascading set of consequences,” Jaycox said in a press statement. “Drug use, suicide, marital problems, and unemployment are some of the consequences.”

Societal costs of PTSD and depression for 2 years after deployment range from about $6000 to more than $25,000 per case, the RAND report indicated. Estimates of total society costs for the same period ranged from $4 billion to $6.2 billion, depending on whether the economic cost of suicide was includ-ed. If everyone needing care received evidence-based treatment, the savings could be as much as $1.7 billion.

Numerous recommendations were listed in the 492-page RAND report, including better organization of the array of mental health programs provided by the DoD and VA; monitoring service quality with widespread adoption of treatment guidelines for depression and PTSD and identification of screening tools and effective treatments for TBI; intensification of efforts to reduce stigma and barriers to care; and enrollment of the civilian sector in providing care that is evidence-based, that is sensitive to the unique aspects of military life and deployment, and that is adequately reimbursed.

“We need more psychiatrists in the Army,” Colonel Ritchie told APA attendees. There are some 120 psychiatrists in the active Army, serving about half a million active Army soldiers, she explained. Colonel Ritchie also encouraged mental health professionals to familiarize themselves with TRICARE and become providers. TRICARE is the health care program serving active duty service members, National Guard and Reserve members, retirees, their families, and others. It brings together the health care resources of the uniformed services and supplements them with networks of civilian health care professionals, institutions, and other providers.

The issue of stigma

Yet, even when treatment is available, service members often do not seek treatment, fearing it might damage their career or cause their peers to lose confidence in them.

New efforts to reduce stigma are under way, according to Jaycox and Ritchie. In May, DoD announced revisions to question 21 on the Questionnaire for National Security Positions, which asks if in the last 7 years, the respondent has consulted with a health care professional regarding an emotional or mental health condition or was hospitalized for such a condition. Currently, the person can answer no if the counseling was strictly related to adjustments related to service in a military combat environment.

Other steps to reduce stigma and encourage treatment cited by Ritchie include the Army’s chain-teaching program to educate soldiers how to recognize and respond to PTSD; combat stress control teams to bring front-line assistance to soldiers; Battlemind training to prepare soldiers for the stresses they face in combat and when returning home; and Military One Source, a 24-hour, toll-free hotline to enable soldiers or their families to arrange for civilian mental health counseling without charge.

References:

References
1. Insel T. Statement during a press briefing at the 161st annual meeting of the American Psychiatric Association; May 3-8, 2008; Washington, DC. http://www.medpagetoday.com/MeetingCoverage/APA/tb/9345.
2. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corp; 2008. http://veterans.rand.org.
3. Peake JB. Testimony before the Committee on Veterans’ Affairs, United States House of Representatives; May 6, 2008; Washington, DC.