A Call to Better Treat PTSD in Our Military Veterans
None of our fellow Americans are more deserving of respect and concern than our military personnel. Amidst the political gridlock and a polarized electorate, perhaps, this is the one topic that can bring our country together. So, why haven't we done more to tend to their wounds of war -- lost limbs, injured brains and traumatized psyches -- particularly those injuries that are psychological in nature?
Almost one-third of all service persons in the ongoing Afghanistan and Iraq conflicts suffer from post-traumatic stress disorder and its complications of suicide and addiction. Our veterans are more than twice as likely to commit suicide than their peers in the civilian population -- and the rates are rising. Between 1999 and 2010, the overall suicide rate among males in the U.S. was 19.4 per 100,000, and 4.9 per 100,000 for females. The current rate for military personnel is 38.3 per 100,000 males and 12.8 per 100,000 females; at one point, more soldiers were dying from suicide than from enemy combatants.
[See: 9 Things to Do or Say When a Loved One Talks About Taking Their Life.]
It has long been known that war produces overwhelming psychological stress and can indelibly alter a person's brain function and mental state. Soldiers who enter military service perfectly normal are somehow never the same again after a firefight, an IED explosion or the sustained stress of repeated deployments -- even though they have no apparent physical injury. The constellation of symptoms that characerize PTSD -- a diagnostic term that was coined following the Vietnam War and described in earlier wars as "Soldier's Heart," "Shell Shock," "Battle Fatigue" and "Combat Neurosis" -- include anxiety, hypervigilance, insomnia, irritability and flashback memories of varying levels of intensity.
Despite PTSD's long history and the rising number of soldiers affected due to the ever more powerful weaponry and lethality of warfare, there has been limited progress in the medical understanding and ability to treat PTSD. Military medicine made extraordinary advances in the 20th century, when rates of severely injured combatants went from 80 percent dying to over 80 percent surviving between World War I and the Iraq and Afghanistan wars. Moreover, medical research has successfully confronted seemingly impossible challenges from human disease within lesser spans of time.
There is no better example of this than AIDS, which first appeared in the late 1970s as a mysterious disease with a fatal outcome. The government responded to an urgent cry for help by the gay community and their advocates and mounted a furious research campaign to find its cause and develop treatments. As a result, researchers identified the human immunodeficiency virus in 1983 and introduced the first medication, AZT, in 1987. Subsequently, treatments such as antiretroviral and protease inhibitor drugs -- and then their combination in "triple therapy" -- have turned a deadly scourge into a chronic illness with which people can live normal lives. In little more than a decade, AIDS went from a mysterious plague to a treatable, and in some cases even curable, illness. We currently see similar heroic efforts in research being made for cancer, Alzheimer's disease and autism, which begs the question: Why hasn't the same been done for the terrible affliction of those who valiantly defend our country?
There are three reasons. First, the idea of psychological weakness is antithetical to military culture with its ethos of aggression and invulnerability -- so military leaders were reluctant to recognize and accept its existence. In the interim, many soldiers were accused of cowardice, in some cases punished and even executed, for their infirmity. Second, mental disorders are not tangible and have no visible physical signs. Hence, they are not seen as real and are often ignored or minimized. Third, PTSD was considered to be a military problem and thus the responsibility of the Departments of Defense and Veterans Affairs.
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Consequently, the National Institutes of Health did not prioritize PTSD research and fund biomedical researchers at academic medical institutions to address this problem. Most funding for PTSD research was provided through the VA and to researchers at VA hospitals; we have already heard many reports of how the VA did not optimally serve our nation's veterans. The combination of the first two reasons created an ambivalence that diminished the motivation to launch an all-out effort to solve the mystery of PTSD, and the third did not engage the best and brightest scientists.
Two grievous errors are apparent in this scenario. One is that just because there is no physical lesion associated with PTSD, that doesn't mean it's not a real medical condition that can be distressing and disabling. The other is that psychological trauma is not limited to the military but also occurs in the civilian population to victims of violent crime, natural disasters and other forms of experiential trauma. Therefore, PTSD affects the entire population and should concern the entire biomedical research community.
Of the 265 disorders described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, aside from substance use disorders, only PTSD has a known cause: psychological trauma. Moreover, it is one of the few mental disorders that can be modeled in animals. Therefore, its pathology can be studied in the laboratory, and treatments can be developed to alleviate the symptoms of people who have PTSD and potentially prevent its development in those who regularly go into harms way, such as first responders and military personnel.
[See: How to Find the Best Mental Health Professional for You.]
The first step is for the VA to convene a task force of leading scientists to develop a strategic plan to do the same thing that was done for AIDS: elucidate the pathological basis of and develop treatments for PTSD. Next, Congress must allocate funding to support the necessary research to be carried out under the auspices of the NIH. The NIH Office of the Director would be responsible for monitoring progress and reporting to the president and Congress. This effort would be sustained until sufficient progress has been made to alleviate the psychological wounds of war. The final step entails empaneling a network of medical centers to provide specialized services for PTSD in addition to the VA Hospitals, plus establish mechanisms for reimbursement.
With Veteran's Day right around the corner, and with a new president and Congress about to take office, what better time for our elected officials to redress this historic health disparity, which has been endured for far too long by those who have placed themselves in harm's way to defend our country?
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Jeffrey Lieberman, MD, is a nationally-renowned psychiatrist at Columbia University College of Physicians and Surgeons, where he is the Lawrence E. Kolb professor and chairman of the Department of Psychiatry -- the largest department of psychiatry in the United States. He also directs the New York State Psychiatric Institute and is psychiatrist-in-chief of the New York Presbyterian Hospital. Dr. Lieberman is a past president of the American Psychiatric Association and is a member of numerous scientific organizations. In 2000, he was elected to the National Academy of Sciences Institute of Medicine. He is the author of "Shrinks: The Untold Story of Psychiatry" (Little Brown & Company, March 2015). The opinions expressed here are his own.
