Monday, February 21, 2011

PTSD, Taking its Toll

In 2009, there were 380 cases of suicide among U.S. military service members—a number greater than the number killed in combat in Iraq and Afghanistan combined. Many believe that there is a direct correlation between the soaring number of cases of Post-Traumatic Stress Disorder (PTSD) and the sharp increase in suicides. And as military suicide percentages have finally passed civilian averages, the steady increase in cases is starting to set off alarm bells among military leaders. They are beginning to recognize that it is an issue they have to address actively, and in a whole new way. With the possible number of PTSD cases from the War in Iraq and the War in Afghanistan estimated to include up to 30% of all service members, the potential risk for even greater tragedy grows.

There are many reasons forwarded as potential causes for the increased suicide rate among service members. The War in Iraq and the War in Afghanistan are the longest on record, and the lengthened rotations and decreased dwell time—time at home between rotations—have been seen as major detrimental factors to the mental stability of service members in general. When added to the daily stresses of living and fighting in war zones, the risk of mental issues only increases.

Admiral Mike Mullen, chairman of the Joint Chiefs of Staff, speaking last year at the 2nd Annual Suicide Prevention Conference, said that the problem of suicides in the military was growing serious, was affecting all the branches of the military, and that increased deployment must be part of that equation. "I know at this point in time, there does not appear to be any scientific correlation between the number of deployments and those who are at risk, but I'm just hard-pressed to believe that's not the case," Admiral Mullen said.

PTSD is believed to stem from events in which the individual faces such overwhelming trauma that his or her mind is incapable of thinking or dealing with feelings normally. Those thoughts and feelings the individual had during those traumatic events later resurface, often causing the individual debilitating distress. PTSD, in previous conflicts referred to as “Shell Shock” of “Battle Fatigue,” is now known to affect people of all ages and backgrounds who have suffered severe trauma from a host of different causes: physical or sexual abuse, shootings, and floods or other natural disasters are some examples. It is thought that half of all Americans suffer some form of severe trauma during their lifetime. Although many are able to cope with the traumatic event, some 10% are not, and go on to develop PTSD. For women, the most common event that causes PTSD are rape and sexual abuse, while for men, combat is the most prevalent.

It is believed that there are a lot of stressors that service members may be subject to--well before a traumatic event--that set the stage for a more profoundly negative coping response. Dr. Craig Bryan, a psychologist who studies suicidal behavior and prevention, and advises the Air Force and Department of Defense on PTSD, feels that service members are often mentally weakened well before a major event happens. When interviewing troops, he said, their biggest complaint “wasn't the combat, seeing the dead bodies, shooting people, being shot, being injured. Yes, those were definitely important but what most service members talked about the most was the day-to-day benign stressors. It was the not being able to sleep in a comfortable bed, not having access to warm, cooked food, not being able to communicate with loved ones easily. Those day-to-day stressors slowly degrade their mental resources and their resiliency so that when big things happen -- the explosions occur, when the gun battles happen -- they don't have as much energy in their battery to get through that and that's where we started to see more of the problems."

Service members in Iraq and Afghanistan have often been subjected to many significant stresses: killing insurgents, or seeing comrades killed or wounded; the constant fear of being killed or injured—even if an IED (improvised explosive device) is not encountered on a patrol, the fear of one going off is constant; the sometimes dehumanizing policing orders that soldiers are ordered to carry out; and unintended civilian killings.

Clinicians look for three types of symptoms when diagnosing PTSD: unavoidable, distressing, vivid memories, dreams or re-living of the traumatic event; feelings of withdrawal or disconnect from others, loss of interest in life and loss of interest in activities; and increased agitation, anxiety, or panic attacks.

Although there is a growing knowledge base of PTSD, its causes and symptoms, its diagnosis can be quite difficult, in part due to the military culture itself. Service members often avoid shows of perceived weakness in general, and they tend to distrust medical personnel, viewing them as outsiders. They worry that being diagnosed with a mental illness would make them unfit for duty, or that it would negatively impact their military career, or planned careers after their military commitments are finished.

Further complicating PTSD diagnosis is the fact that many sufferers often have other disorders like depression or substance abuse that have some of the same symptoms of PTSD. In addition, symptoms of PTSD often surface much later, long after the traumatic events have passed and physical wounds have healed.

Until recently, veterans applying to Veterans’ Affairs (VA) for disability benefits and treatment for PTSD had to prove that a specific traumatic incident—a particular explosion, or combat event they were involved in, etc.—was the reason behind their disability. This would severely delay veterans’ gaining their disability status and access to treatment—sometimes up to years later.

It was only in July of 2010 that the VA changed its ruling about PTSD cases, no longer requiring such an onus of proof on the part of the veteran.

By the time service members and veterans do seek help, they are usually very distressed and are well into advanced stages of mental illness. They are already suffering intensely, are agitated, cognitively constricted, and have a general feeling of hopelessness. Interventions include psychoanalysis and medication. Often used in conjunction, both have been found to be successful to different degrees, with some difficulty in getting the right medication for the specific individual.

The different anti-depressents most often used in treating PTSD are Bupropion, Prozac, Zoloft, and Paxil. The antipsychotics most often used are Risperdal, Zyprexa, and Seroquel. They normally take 6-8 weeks to reach a therapeutic level, so for those already in acute distress, relief can still be a long way off. Also, the first drug prescribed might not work for the specific individual, and another drug has to be tried--and another 6-8 weeks must pass before therapeutic levels can be reached. Adding to this fact that the doses may be too high or too low, and a patient could be faced with many months with little or no relief and/or living through a rollercoaster of mental states. There have been a number of cases of suicide by individuals already being treated in the VA system.

Tragically, 75% of those that commit suicide have never sought help of any kind.

Douglas Murphy

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