Sunday, February 18, 2007

PTSD: Treating The Numbers, Not The Soldiers

According to the United States Department of Veterans' Affairs--as its information page reads this morning, at least--Post Traumatic Stress Disorder (PTSD) is defined as:

An anxiety disorder that can occur following the experience or witnessing of a traumatic event. A traumatic event is a life-threatening event such as military combat, natural disasters, terrorist incidents, serious accidents, or physical or sexual assault in adult or childhood. Most survivors of trauma return to normal given a little time. However, some people will have stress reactions that do not go away on their own, or may even get worse over time.

Insofar as the government's asserts, some 60% of men and 50% of women (overall, both military and civilian) experience a traumatic event at some point in their lives. Assuming, of course, that all traumatic events are reported or somehow noted--which of course they aren't--one can still be forgiven for being alarmed that such a staggeringly high number of human beings are at risk for developing PTSD. And of course, many human beings do heal on their own, handling trauma in ways that don't threaten the safety and well-being of themselves and those around them; they work through the shock, terror, grief, flashbacks, and sense of needing to be on guard at all times, and with time and support, they return to a point where they can sleep a reasonably normal length of time without waking from re-enactment nightmares or go to a noisy, crowded place without feeling overcome by irrational waves of fear or violent urges.

For far too many who've witnessed war's indescribable tragedies firsthand, though, the notion of healing is itself a phantom concept, a dream. From The Real Cost Of War (currently at Playboy Online):

Burgoyne had been brought into the hospital by one of the other soldiers in his unit after he had been found doubled over in his bunk, having tried to kill himself with an overdose of antidepressants. The attempted suicide, plus the lack of expression in his eyes and his "rapid cycling behavior" from rage to grief and back to rage, were the symptoms of a dangerously ill man. Koroll sensed he was looking at a severe case of post-traumatic stress disorder, the clinical term for someone who continues to experience trauma long after the event has passed. This reexperiencing of the original event can take the form of insomnia, flashbacks, paranoia, panic attacks, emotional numbness and violent outbursts.

These symptoms are treatable, Koroll knew. If he could transfer Burgoyne to a safe, comforting environment, the young man might be restored over time to full health and capacity. That meant getting the soldier out of the dusty chaos of the Kuwaiti Army base, where he was temporarily stationed after a bloody tour in Iraq, and sending him to a hospital in Germany where he could rest on clean white sheets in a quiet room in a first-class psychiatric facility.

It was Koroll's job as the on-duty nurse to make the decision about whether to evacuate Burgoyne. He was ready to do it based on what he'd seen. But he needed to ask one final question before he could order the evac in good conscience.

"So," Koroll said, "right now, at this moment, do you have thoughts of harming yourself or others?"

Burgoyne, he remembers, looked up through those flat, vacant eyes and said quite clearly, "Yeah. Yeah, I do."

Koroll picked up the soldier's chart and wrote in a clear hand, "Evac."


As it turns out, Burgoyne had not been evacuated to Germany as Koroll had ordered. According to Koroll, a colonel in Burgoyne's command pressured the hospital to allow Burgoyne to return to America with his unit, the Third Infantry Division, which was to be one of the first units lionized for its heroism in leading the fight north to Baghdad. "He's a hero. He should be with his men" is how Koroll remembers the explanation coming down to him. After he returned to Georgia, Burgoyne, according to his mother, spent a few minutes in an Army hospital, spoke briefly to an Army psychiatrist and then was released from medical supervision. Exactly two days later Burgoyne attacked a fellow soldier in the woods near Fort Benning, Georgia, killing him with 32 stab wounds from a three-inch blade and then burning his body with lighter fluid, because, as he explained at his subsequent murder trial, "that's how we disposed of bodies in Iraq."

Sadly, this story is not unique, but rather, is representative of the frighteningly under-reported problem of PTSD. More troubling than the fact that this serious anxiety disorder--and its devastating effects and costs--is shamefully under-reported in the media is the reality that it is all too often underreported within the Unites States military. Underreported, minimized, ignored, misdiagnosed, and, most frighteningly, untreated (my bolds).

Given the inevitability of psychological scarring in intense, prolonged conflicts, it is odd that the two bureaucracies most responsible for the mental health of American troops -- the Department of Veterans Affairs and the Department of Defense -- have taken steps to downplay the psychological toll of the war. According to sources I spoke to in the Pentagon and former officials in the VA, DOD and VA doctors are being pressured to limit diagnoses of PTSD in order to save the military money and manpower. The DOD's official medical policy toward PTSD was recently amended to include new criteria making it a virtual certainty that many soldiers who exhibit symptoms of the disease will not be diagnosed. And the VA itself has been quietly working to arrive at new, stricter formulations of PTSD -- contradicting those of the American Psychiatric Association -- that would allow the agency to diagnose far fewer cases.

"Some people would argue that it's malicious and intentional, but to me it's a reflection of the military mind-set," says Steve Robinson, a 20-year veteran of the Special Forces who recently became a full-time policy advocate. "The Department of Defense is not a health care provider. It couldn't do the right thing if it wanted to because of how much money it would cost and how many doctors it would take. It's a matter of capacity. The number of people seeking care versus the number of doctors available to provide that care nationwide across the whole armed services is out of whack."

In the four years since Koroll's diagnosis of the young soldier was ignored, the anti-PTSD-diagnosis movement (for lack of a better phrase) within the military has grown, as evidenced by, among other things, the hard numbers. The Department of Defense (DOD) reports diagnosing approximately 2,000 cases of PTSD a year, but according to a study by Army researchers that was published in The New England Journal of Medicine, PTSD rates are between 10 and 15 percent for soldiers in Iraq and Afghanistan; this translates to PTSD cases numbering between 13,000 and 20,000. (The study also notes, disturbingly, that only 23-40% of those veterans diagnosed with anxiety disorders and other psychological afflictions even seek treatement.) And according to figures obtained after repeated requests by Playboy, the evacuation rates for PTSD-afflicted soldiers--for example, those from January to July 2006, showing only 716 soldiers evacuated from Iraq for PTSD--fall well below the predictions of statistical models. As reporter Mark Boal notes:

If the military diagnosed even half the cases in Iraq and Afghanistan that are thought to exist, the evacuation figures would be closer to 5,000 a year.

For their part, military officials deny any attempt to minimize or underplay the impact and magnitude of the situation. This despite published forecasts that the cost of America's current involvement in the Middle East will soar beyond even the stratospherically high numbers around which most of us have just begun to wrap our heads; this despite officials having gone on record with--and been roundly criticized for--statements like that of Pentagon undersecretary David Chu, in a January 25, 2005 article in the Wall Street Journal:

WASHINGTON—With the wars in Iraq and Afghanistan badly straining its forces, the Pentagon is facing an awkward problem: Military retirees and their families are absorbing billions of dollars that military leaders would rather use to help troops fighting today.

Congress, pressured by veterans groups, has in recent years boosted military pensions, health insurance and benefits for widows of retirees. Internal Pentagon documents forecast that the lawmakers' generosity since 1999 will force the federal government to find about $100 billion over the next six years to cover the new benefits.

"The amounts have gotten to the point where they are hurtful. They are taking away from the nation's ability to defend itself," says David Chu, the Pentagon's undersecretary for personnel and readiness.

As I read the profoundly upsetting Playboy article referenced throughout this post, I thought about my freshman economics class at Florida, which was taught by one very entertaining and sharp-witted professor named Dr. Denslow. "Guns and butter," he said one day, actually plunking a box of unsalted butter sticks alongside a plastic toy grenade-launcher on his lecturn. "Guns and butter. The money stays the same, so how are you going to spend it--on guns, or on butter?"

Bombs or bodies? Mines or minds? Futilities or futures?

(Also at Ezra's place.)

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