Preventive measures, like the Violence Against Women Act (VAWA) are the only cure for PTSD
A few weeks ago an article in the Scientific American Twitter stream caught my eye. EMDR (Eye Movement Desensitization and Reprocessing) once again debuted as a "promising new treatment" for PTSD. EMDR, which has been repeatedly called "promising" over the last two decades, works only about as well for PTSD as other psychological treatment modalities with which it competes, primarily cognitive behavioral therapy (CBT) and exposure therapy. These so-called trauma focused treatments (TFT) all garner similar results. TFT have large effects in clinical trials, with two important caveats: 1) the enthusiasm of their various advocates bias the study results towards the treatment the researchers prefer; and, 2) they are effective for a significant number of carefully selected PTSD patients. The sad truth, however, is that current short-term treatments are not the solution for most patients with PTSD. Trial criteria often exclude those with comorbid disorders, multiple traumas, complex PTSD, and suicidal ideation, among others. Even when they are included, comorbid patients drop out of treatment studies at a much higher rate than those with simple PTSD, a problem that has implications for clinical practice.
The large majority of those with PTSD also have other psychological disorders (commonly, substance abuse, depression, and anxiety disorders) and many of these patients have complex PTSD, which is both harder to treat, and more prone to relapse (see Fig. 1). Those who suffer from both PTSD and substance abuse (64%-84% of veterans, for example) often perceive the disorders as "functionally correlated." Similarly, depression and PTSD are mutually reinforcing; each compounds the symptoms of the other. Both substance abuse and depression are notoriously difficult to treat, and harder to treat when comorbid with PTSD. Multiple studies document the long-term failure of PTSD treatment for veterans, but there are fewer on the effectiveness of therapies in treating comorbid PTSD in civilian populations. Existing studies challenge the assumption that PTSD treatments effective for simple PTSD, are also effective for combined PTSD and substance abuse, or PTSD and depression.
Effectiveness in clinical trials is usually measured by the extent to which clinical symptoms of PTSD have diminished, but those may not be the most useful measures for patients. PTSD symptoms are recurrent and even at subclinical levels, reintegration may be difficult for patients and daily functioning may remain impaired. To measure effectiveness accurately, clinical trials should adopt additional outcomes, like daily functioning (also see here and here), if they are intended to cover all dimensions of disorder as described in the DSM. Effective treatment of long term cases is necessary for comprehensive rehabilitation of difficult-to-treat patients: those with comorbid PTSD; those who have been repeatedly re-traumatized; and those whose environments place them at continuing risk of new trauma. Short-term TFTs are regularly prescribed by the VA, and yet, VA studies indicate that the majority of veterans treated for PTSD are still in treatment four years later (see Fig. 2). The military and VA want a quick fix, but that's not what they're getting.
Though the military tried to deny the ubiquity of PTSD for many years, prevalence studies made it impossible. Mental illness is the leading cause of hospitalization for active duty troops, and accounts for a larger share of troop indisposal than its next competitor (injury and poisoning). The majority of mental health cases in the military have a PTSD component. Prevalence of the disorder is affirmed in the public sphere, where an endless stream of sympathetic portrayals of veterans with "invisible wounds" can be found in literature, on film and television. The U.S. military spends more money on PTSD research and treatment than any other funder, and with good reason: 8%-20% of veterans suffer from PTSD. Estimates vary widely, as in most claims surrounding PTSD, but that's a range of between 1.75-4.5 million vets with the disorder, and our continual wars ensure a steady stream of new cases.
The lure of a quick and enduring fix for PTSD is hard for the military to resist since they stand to benefit greatly from a cure. They would surely like to save the $1.5 million per soldier they believe PTSD will ultimately cost them. They are also concerned about troop strength. If PTSD is portrayed as endemic and chronic in soldiers, rather than as a rare and short-term consequence of war, qualified civilians may be reluctant to enlist, and the military will have a hard time convincing their families that it can keep soldiers safe. In the Iraq and Afghanistan wars, the military has lowered the number of troops in combat by increasing tour length high and encouraging soldiers to extend and repeat their tours. Fewer soldiers are spending more days in combat than ever before: 20% of the soldiers deployed in Iraq and Afghanistan have served three tours; more than 50,000 have served four or more tours. The math is simple: more combat exposure means that a higher percentage of active duty troops and veterans will get PTSD. Without a cure, there's no way to stem the tide.
This obsession with a cure seems admirable, until one examines some of the models the military has embraced: virtual reality (a variation on the computer games the military has used to dehumanize the enemy); drugs like propranolol, which erase memory and possibly a soldier's conscience; and injections that block normal nerve response in physically healthy patients. Compared to these, alternative and poorly validated treatments (e.g., neurofeedback, mind-body medicine, acupuncture, healing touch, loving kindness meditation) for which taxpayers foot the bill look positively benign.
Military and pharmaceutical interests converge: the former wants quick or easy fixes, and the latter wastes no time in peddling the pharmaceutical flavor of the month, whether it's sertraline, paroxetine, fluoxetine, venlafaxine, risperidone, clonidine, diazepam, lorazepam, alpralozam, duloxetine, propranolol, prazosin, yohimbine, cortisol, quetiapine or gabapentin. In 2012, "the Pentagon spent more on pills, injections and vaccines than it did on Black Hawk helicopters, Abrams tanks, Hercules C-130 cargo planes and Patriot missiles--combined"; drug sales to the military doubled between 2001-2011. The military's hope is that a combination of drugs and short-term TFT will prove more effective than either alone. Between 2001-2011, the Defense and the VA combined spent $791 million on Risperidone, a drug that turned out to be no more effective than placebo for treating PTSD. Just last year, the Army finally changed its long-standing policy of prescribing benzodiazepines for soldiers with PTSD because the drugs are highly addictive, and they worsen PTSD symptoms. The Army supplements TFTs with pharmaceutical cocktails, often administered seemingly at random.
The pharmaceuticals the military dispenses so freely are often tested by the very companies that produce them, just as treatments that originate in the military are also tested by the military, the VA and other medical arms of the U.S. government. The resources and research of both pharmaceuticals and the government greatly exceeds those of organizations with no conflict of interest. The flood of documentation they generate on PTSD creates the impression that military treatments and pharmaceutical solutions are supported by the weight of evidence, even when they are not. This evidence, in turn, leads civilian institutions to adopt PTSD treatment strategies that originated in the military, and also can determine the decisions made by insurance companies.
Insurance companies, like pharmaceutical companies and the military, have a vested interest in short-term treatments to cure PTSD: the shorter the treatment, the lower the cost. Insurance companies will cut costs even when it means that patients will require more expensive treatments in the long run. Insurance companies place caps on benefits; many will pay for 10-20 mental health visits per year, and no more. Insurance companies will have to cover mental health care under the Affordable Care Act, which singles out behavioral treatments as particularly deserving. But there is no indication that longer-term treatments will receive more support under the ACA than they did previously. Insurance companies will continue to cover TFTs (CBT, exposure and EMDR), and reject longer-term treatments, and they will back up their decisions with evidence from clinical studies supported by the military and the drug industry.
The convergence of pharmaceutical and military interests, and the funding nexus they create, has ensured that the focus of PTSD research and treatment continues to be military veterans, despite the fact that military veterans comprise only 15% (at minimum) or 40% (at maximum) of the approximately 11 million adults and adolescents who suffer from PTSD in the U.S. (No reliable numbers for children exist.) The military medical complex has a history of coming up with psychological theories and treatments, which are transferred to the civilian world, even though treatments for veterans may not meet the needs of survivors of other traumas.
The interests of the majority of those with PTSD have been neglected in comparison. This is unsurprising to those who know the long history of the effort to list PTSD in the DSM. As I wrote over a dozen years ago, in Worlds of Hurt, the efforts of women's advocates had been rejected, despite the massive amount of evidence they'd assembled and shared with the psychiatric establishment. The long term psychological effect of rape and incest, like the earlier discovery of chronic stress disorder in Holocaust survivors, was not granted the status of a unique psychiatric diagnosis. It was only after returning Vietnam veterans joined together into a massively politicized antiwar faction that the medical establishment and the VA bowed to veteran and public pressure to establish the PTSD diagnosis. In the ensuing decades, although some attention has been paid to other traumatized populations, veterans have continued to get the lion's share of the attention, funding and treatment, although they are a minority group among survivors.
The Department of Veterans Affairs acknowledges that women are more than twice as likely as men to develop PTSD (10% for women; 4% for men, a number that includes all male veterans). They note that women experience sexual assault more often than men do, and that sexual assault results in higher rates of PTSD than many other traumas. The Justice Department's Office of Violence Against Women and the CDC have recently published the following statistics (2012-2013):
1 in 10 teens will experience dating violence
1 in 6 women, and 1 in 19 men will experience serious stalking at some point in their lives. (This is stalking so severe that the victim felt very fearful or believed that she or someone close to her would be harmed or killed.)
1 in 3 women has experienced domestic violence; 63% of those women have suffered from PTSD.
Nearly one in five women (18.3%) have been raped at some time in their lives.
46% of Native American women have been raped, victimized by physical violence, or seriously stalked
80% of female victims were first raped before they were 25; almost half were raped before age 18.
Women with disabilities are more likely to experience more severe forms of violence, for longer periods, and by more perpetrators than women without disabilities.
Intimate partner homicides account for 14% of all homicides in the US, and researchers estimate that for every victim of domestic violence who has been killed, nine are nearly killed.
In contrast, combat in war happens far away from the majority of Americans, in a country most of us will never see. The events that cause PTSD in soldiers and veterans take place of sight and earshot of most of us. Perhaps it is because the psychological costs of combat are paid only a relative few volunteers, who serve in far away lands, and whose actions are condoned by law, by tradition, and by myth, that we can accept (and rationalize) the physical and psychological wounds they receive on our behalf. Except for a few military psychiatrists who think (and quite a few generals who hope) they might be able to use drugs to circumvent PTSD by short-circuiting a soldier's ability to perceive violence as traumatic, most Americans are resigned to the apparent truth that PTSD is one of the prices many, many soldiers will pay for going to war. At least in theory, we owe them care and support as a debt of gratitude for what they sacrificed to keep us free.
But domestic and sexual violence against women are perpetrated in our own homes and sometimes in our own beds. They affect one in three of women (mothers, daughters, sisters, friends, lovers). Significantly reducing PTSD in the female population would first require us to name the factors that cause violence against women, and then to make rational and radical changes in the legal, social, and economic systems of the country in which we live. The majority of U.S. residents would need to change their beliefs and attitudes, and modify their actions to significantly reduce violence against women. As exhausted feminists are the first to testify, knowledge doesn't bring about change: the desire and the will to change brings about change.
An excellent example of PTSD prevention born out of effective political change is the Violence Against Women Act (VAWA), first authorized by Congress in 2000, then renewed in 2005. Between 2000-2005, the U.S. government provided $3.2 billion in funds to prevent violence against women. Since then, the government has spent between $500-625 million a year to support a wide variety of prevention programs. A November 2012 Department of Justice Report on intimate partner violence records a steep drop in 1999-2000, when the VAWA was enacted. Since then, the level of domestic violence (while still quite high) has held steady, at a far lower level than it average in the 1990s (see Fig. 3). Its stability between mid-2000 and 2010 demonstrates that the level of domestic violence does not track that of other violent crimes, which dropped, and then peaked sharply, and then dropped again in the same time period.
But the drop may not be permanent. Renewal of the Act was blocked by Republicans in 2011. It is again before the House of Representatives, after passing in the Senate. As I write, the Republicans have just proposed a weaker version of VAWA than the Senate approved. This version strips out the expansions that would offer more protection to lesbian, bisexual and trans women, and to Native American women. If the Act does pass the House, it will be because women constituents have pressured Republican representatives to capitulate to their demands, and their victory will provide aid to hundreds of thousands of American women. VAWA, however, is a holding action rather than a victory, as the statistics and incidents like the recent rape in Steubenville demonstrate: rapes, and their cover-ups and rationalizations, still happen frequently on the community level, with willing participation at the highest and lowest levels of responsibility. More structural intervention is necessary, if we want to see another decline in the rate of domestic abuse and other crimes of violence against women.
Women are not the only population to suffer disproportionately from violence and, hence, from PTSD. Look again at the figures above, and you'll note that close to half of Native American women have PTSD, as compared to a third of American women in general. Higher rates of PTSD are evident in communities with high rates of violence, low-income communities with poor social support, populations with a high rate of incarceration, and other markers of social and economic disadvantage. Poverty and racial oppression increase the likelihood that an individual will experience one or more traumatic events; PTSD then lowers the life chances of the individual who suffers it. Thus, a seemingly unrelated circumstance, such as unequal sentencing for possession of crack cocaine vs. powder cocaine (especially when it takes place in an environment of unequal policing, prosecution, and sentencing) can have a significant effect on the level of PTSD in a community where a large number of male residents have served time for possession. Much human-caused trauma is systemic, rather than exceptional. Those of us who want to treat PTSD in the U.S. need to ask ourselves how best to treat PTSD in community under siege, where we're attempting to help patients who were probably traumatized before, and are quite likely to be traumatized again.
The answer is that we may not be able to do so effectively. For many patients, we may only be able practice a form of battlefield medicine as we advocate for structural change and funding for preventive measures. Most short-term therapies require patients to be in a safe environment, as a prerequisite to effective treatment. The safety requirement immediately excludes a large segment of the population with PTSD. Economic barriers are also difficult to surmount, since even after all provisions of the ACA go into effect, many Americans will still be be un- or underinsured. And if they are insured, many cannot afford the required co-payments for therapy, or may not be able to continue therapy beyond the low number of allotted sessions.
Even if a patient gains access to short-term treatment, only a minority will find significant, long-term relief. For the majority, short-term treatment should be considered a bridge into long-term care for a chronic disorder. Claims to treatment effectiveness should not depend primarily on abating clinical symptoms, but on reintegrating the patient, and on improving and maintaining the patient's ability to function in daily life. The clinical symptoms of survivors may fluctuate, but function is a life-long problem for the majority of them, even when their PTSD symptoms may be subclinical.
If our goal is to lower the burden of PTSD in the long term, we must first of all devote resources to supporting and advocating violence prevention. This means preventing the gun violence that is pervasive in both urban and rural settings; passing and funding more legislation like VAWA, so that all populations that suffer disproportionately from violence are served; and, addressing the inability of the police, the courts, and the prisons to effectively serve victims, ensure their safety, and rehabilitate perpetrators
Finally, we need to look at war trauma from a more comprehensive perspective. We need to assess the effects of long-term psychological trauma on both civilians and soldiers, as well as the social and financial burdens imposed by PTSD even after peace is declared, and weigh them in the decision to commit U.S. troops to battle. If we use the VA's very reasonable figures for treatment cost ($4,000/year for continuing treatment), and assume that 80% of the 11,00,000 Americans with PTSD have comorbid disorders, we're talking about $35.2 billion a year, to treat about 8.8 million people (veteran and civilian) on an ongoing basis. This is more than we spent to support the Marine Corps in 2012 ($29 billion). But a 5% cut in the 2012 Department of Defense budget of $707 billion would cover it. Ending even one of our wars would make it possible for the government to fund long-term therapy for those with chronic PTSD, at the same time it would slow the rate at which new cases of PTSD were generated.
There is no quick fix for PTSD. There is only the slow fix: stopping violence before it starts. Whatever treatments you advocate and provide, if you aren't working to prevent violence, you aren't working to cure PTSD.
The author gratefully acknowledges the assistance of J?rgen Barth, Ph.D., of Institute for Social and Preventive Medicine, University of Bern, who generously shared his knowledge of clinical treatments and research study design. If there are errors in the essay, they are doubtless mine and not his.